Thursday 1st October 2015

CCG Clinical Commissioning ForumCCG Clinical Commissioning Forum

THE OUTLOOK

OCTOBER 2015

MONEY• CCG good position and done lots – but where next?• December - 3 year CCG allocation?• New capitation formula – impact and pace of

change???• New requirements in Planning Guidance?• CCG growth could be 0• New capitation formula for primary care• PMS reviews – money stays in CH primary care• NHSE primary care budget decreasing

LOCAL ECONOMY• Doing OK

• Collaboration and work of local GPs• No deficits so far…

• £32m Non recurrent schemes to evaluate• Tough in provider land – no let up on money,

performance and quality ->deficits? • In year and recurrent cuts to Public Health• LA cuts brutal

CCG CONTRACTS – 15/16Contract Recurrent Non

recurrentTotal

FHV 276 1058 1334

Mental Health 385 385

maternity 259 259

Vul Childrens 1000 1000

LTC 1512 1874 3386

EOLC 160 160

Extended hours 840 840

Duty doc 1485 1485

2432 6417 8849Clinical commissioning is recurrent; phlebotomy and anticoag = new recurrent

contracts with Homerton and Confederation

CONFLICTS• Direct and indirect financial• Reputational• Loyalty

• Please score evaluation bids with professional integrity for patient benefit

PROCESS FOR CCG CONTRACTS

THE FUTUREWHATS THE LEAST WORST

OPTION?

THE PERSPECTIVE FROM COMMISSIONING

NHS POLICY

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No top down reorganisation – permissive not prescribed!

DEVOLUTION IN LONDON

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ACO/VANGUARDS

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LOCALLY…•“Leaders summit – working together and understand each others issues•New models of care/vanguards•Financial challenges for LA •Enthusiasm from providers to pilot integration

CCG & Confederation•Maintain NHS commissioning responsibility – not delegate to LA•One Hackney is a building block

PILOT DEEP INTEGRATION?

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A PERSPECTIVEPROS ISSUES• Head of steam/pilot opportunity

• Providers already working together via One Hackney

• Reduce transaction costs in providers and commissioners

• Agree to move away from PBR and tariff – understand costs

• Provider savings by working together

• Collective responsibility

• Make best use of Hackney £

• Transparency

•City

•Non Hackney care – (£70m)

•Shrinking budgets – CCG; Social Care; Public Health

•Whats in and out (?Children social care, specialist, core GP contract)

•Political influence

•?Clinical voice

•?Patient voice

•Making tough decisions on how to share the £

•Incentives to keep down referrals

•Organisational form to allow the delegation

•Residual commissioning function

•Procurement

•Patient choice

•Regulation and oversight

ALTERNATIVES

DO NOTHING WORK AS INEL

•Keep heads down and stay as we are•Chaos around us?

•CCG within Inner North East London•As well as local cost pressures add in Barts Health deficit.•Loss of City & Hackney perspective and focus

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If went for pilot•Is there common understanding and agreement•Use pilot to explore what it means

•Describe the journey, steps and principles•Decision points along the way – stop/go

•Formal partnership and delegated budget go hand in hand – cant do one without the other•More transparency and alliance contracts in 16/17 building on One Hackney•More join up between Public Health and CCG

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Dr Kathleen WenadenGP Clinical Lead for Diabetes

City and Hackney CCG

Current serviceDiabetic Centre: DSN’s/DieticiansAccess to specialist advice – Diabetes advice

lineQuestions: how do you feel DSN’s/Diabetic

Centre model is working?Is it mainly insulin focused?

Lipid/Hypertension Mx?Annual review with DSN’s?Diabetic Care Plans?Comments?

Current IssuesStill low on prescribing of high intensity statinsHypoglycaemia: esp elderly people on

SU’s/insulin – should be aiming for 8-9% depending on co-morbidity

(as agreed by European Society of Geriatricians, and American Geriatric Society).

Will be trying to reach a local consensus with John Robson, CEG in Newham/TH/City & Hackney.

END

Developing a primary care strategy – Developing a primary care strategy – discussion at the Clinical Commissioning discussion at the Clinical Commissioning

ForumForum1st October 20151st October 2015

• In April 2015, C&H CCG asked its Primary Care Quality Programme Board to develop a strategy for Primary Care for the next 1-3 years.

• We have consulted with: • Our patients and the public• Our members• Local stakeholder organisations (C&H LMC, NHSE, C&H GP

Confederation, voluntary sector)• Our consultation has told us that the strategy should be congruent

with the following principles….

A vision for Primary Care

These are the aims we want to achieve for City and Hackney:

Be in the top 5 CCGs in London in terms of quality

Be an attractive place to work for existing and new primary care staff

Delivery of safe services

Services that are resilient by being productive, efficient, safe and value for money

Services that are of high quality and offer comprehensive patient support

Services that are accessible

Reduce health inequalities

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Planned Care Headline Commissioning Intentions

Community services:

•Increase capacity of community gynae, ENT and dermatology

•Develop a community based minor eye conditions service jointly with Islington CCG

•Implement community post operative wound care service and develop a shared plan with HUH to improve leg ulcer clinic care

Cancer:

•Review service level agreement between HUH and Bart’s Health for Acute oncology service

•Review with two week wait/cancer office capacity with HUH to manage existing referrals and in view of new NICE guidance

•Direct Access colonoscopy with triage

•Stratified follow up – prostrate, breast, colorectal – (building on Time to Talk?)

Misc:

•Work with HUH to deliver a tier 3 weight management service

•On behalf of PHE, commission a new service for latent TB testing from primary care

•Review of Bi-lingual Advocacy service

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Summary of Prescribing Programme Board’s Commissioning Intentions

• Reduce the inappropriate use of antipsychotic, antidepressant, anxiolytic, hypnotic and antiepileptic medicines in people with learning disabilities 

• Increase the number of medication reviews carried out by a Practice Support Pharmacist (PSP), prioritising the following high risk patient groups:

• Patients who have frequent hospital admissions

• Patients on compliance aids

• Patients in nursing homes

• Patients requiring domiciliary medication review

• Patients on polypharmacy

• Patients on high risk drugs which require shared care

• Patients with diabetes

• Patients on high dose inhaled corticosteroid

• Consider the introduction of Medicines Reconciliation for patients with CKD 3-5 who have been referred by practices 

• Increase GP uptake of IT prescribing tools e.g. electronic formulary, antibiotic app and MUST Tool

• Deliver Respiratory Training for GPs and Practice Nurses by PSPs and ACERs Nurse

• Improve our sustainability by supporting interventions to reduce medicines waste e.g. charitable recycling of returned medicines

• Supporting the uptake of dressings supply through the dressings optimisation scheme

• Support prompt implementation of national warnings and local Formulary agreements

• Ensure that practices are supported in undertaking Antimicrobial Training

• Continue to engage with practices at the annual prescribing visit and through the CCG medicines management newsletter

• Continue to ensure that the CCGs expectations of HUHFT, ELFT and NHSE with regards to all commissioning intentions related to prescribing and medicines management are addressed and the outcomes monitored regularly.

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Summary of Urgent Care Programme Board’s Commissioning Intentions for 2016/17

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Primary Care:

•Monitor the delivery of the Duty Doctor scheme to ensure patients with urgent care needs are being treated in the appropriate setting

•Work with the provider to increase population coverage for extended hours to ensure an equitable service is delivered for all patients in City and Hackney

•Implement the recommendations from the out of hours review to ensure we have high quality sustainable primary care out of hours as well as in-hours

•Support the delivery of the newly developed ParaDoc pathway to ensure complex, frail and elderly patients are treated at home when appropriate to do so

•Engage our community pharmacists in the overall urgent care strategy ensuring patients are sign-posted to appropriately and accordingly

•Continue to explore opportunities for working across the new urgent and emergency care network to ensure patients accessing urgent care are treated by the right clinician, first time everytime.

Secondary Care:

•Continue to work with the local acute trust to ensure the A&E department continues to meet the 4hr performance target

•Explore opportunities to develop ambulatory care models that improve the patient journey, experience and outcomes

•Maintain the Primary Urgent Care Centre as a service for patients with urgent care needs that can be treated by primary care clinicians

Community Crisis response:

•Continue to support the delivery of the Integrated Independence team and its links with urgent care access points, ensuring patients in are treated by the right clinician when in crisis

•Monitor the delivery of the action plan to engage care homes and housing with care schemes with the overall crisis response pathway

Emergency Care:

•Work with associate commissioners to ensure LAS performance continues to improve for its urgent and emergency/Red1 cases

•Engage LAS with continued work to refer into City and Hackney’s community crisis response pathways

•Ensure on-going referrals to the newly developed ParaDoc pathway, to improve experience for patients with complex health needs

Communications and engagement:

•Continue to work with our patient groups and patient representatives to raise awareness around the right care at the right time everytime including self care, primary care and urgent and emergency care when in crisis.

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Integrated Care Programme Board’s Commissioning Intentions

We will reduce delays in discharge from hospital• No more than 3% of medical beds will be occupied by patients who are ready for discharge. • We will commission sufficient capacity of NHS services to support effective discharge, particularly continuing

healthcare and neuro rehabilitation services We will commission more proactive community care for frail patients

• Co-ordinated around their needs and delivered by new multi-disciplinary teams comprising health, social care and the voluntary sector: One Hackney and the Integrated Independence Team

All integrated community services (nursing, therapy and multidisciplinary services) will work in quadrants aligned to GP practices

• They will adopt a common approach to implementing care plans• Care across these services will be co-ordinated by a named lead professional for each patient.

There will be effective transitions into community settings and good communication • The lead named professional will be aware when patients are admitted • Plans will be enacted with integrated community services as soon as possible during admission

Elderly patients will spend less time in hospital • All community services will be aiming towards reducing emergency bed days for elderly patients

There will be better access to end of life care services for patients • Patients will be identified as approaching end of life where appropriate• Patients will be supported to express their wishes about care at end of life (these shared where appropriate) and

supported to die in the place of their choice• There will be better communication between secondary and primary care about prognosis and conversations about

this

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Maternity Programme Board Commissioning Intentions

October 2015

Summary of Maternity Programme Board’s Commissioning Intentions

• Improve pre-conceptual care and early identification of medical and social risk through implement of an Early Years contract to be delivered via the GP Confederation.

• Early booking (by 10 weeks) to improve outcomes of pregnancy.

• Continuity of care in the antenatal and postnatal periods.

• Ensure a high quality safe service, with the aim of reducing neonatal and maternal morbidity and mortality.

• Ensure women have a good experience of care throughout the antenatal, perinatal and postnatal periods.

• Ensure parents can help to shape maternity services in City and Hackney through listening to patient’s feedback.

• Improve the uptake of the flu and pertussis vaccinations.

AIMS WHAT WILL BE DIFFERENT? HOW CAN WE DELIVER THIS THROUGH OUR PROVIDERS?

• We want to ensure women have a good experience of care throughout the antenatal, perinatal and postnatal periods.

• We want to ensure parents can help to shape maternity services in City and Hackney through listening to patient’s feedback.

• We wish to strengthen our excellent Maternity Services Liason Comminttee (MSLC) so it can engage with more families in City and Hackney and empower parents to demand the best possible care.

• Increase the response rates of the Friends and Family test so we can accurately monitor patient experience.

• Review complaints to ensure themes are identified and mitigated wherever possible.

• Ensure women are given adequate information about choice of birth, with the aim of increasing numbers of low risk women delivering in the mid-wife led birth centre and at home.

• Have a rolling programme of ‘Walk the patch’, whereby the MSLC gain feedback from users of the service to help inform our commissioning intentions.

• Social Action for Health have been commissioned to work with the MSLC to improve recruitment of members and engagement with local families.

• We will build on the CQUIN improving the response rates to the Friends and Family test.

• We will regularly review complaints at the Maternity Programme Board.

• The Homerton are considering running the ‘Whose Shoes’ programme to help gather more user feedback.

Improving Women’s Experience

AIMS WHAT WILL BE DIFFERENT? HOW CAN WE DELIVER THIS THROUGH OUR PROVIDERS?

• Improve pre-conceptual care to improve outcomes of pregnancy

.

• All women should be offered opportunistic pre-conceptual care.

• Women with chronic diseases should have their condition and medication optimised prior to conception. Diseases requiring good pre-conception care include:

Diabetes Hypertension Asthma Epilepsy Mental health Thyroid disease Rheumatological conditions Obesity Mental health illnesses

• Women with complex medical/obstetric history or with more than one chronic disease should be referred to the pre-conceptual clinic at the Homerton.

• Commission Confederation to provide pre-conceptual care for women with the following conditions:

Diabetes Hypertension Asthma Epilepsy Mental health Thyroid disease Rheumatological conditions BMI >35

• Homerton: (via tariff)-pre-conceptual clinics for complex patients-obstetric advice service

• ELFTPerinatal Mental health support for women taking

medications as treatment who may be planning a pregnancy

Identify ways women can be referred or signposted to support (preconception pathway)

Pre-Conceptual Care

AIMS WHAT WILL BE DIFFERENT? HOW CAN WE DELIVER THIS THROUGH OUR PROVIDERS?

• Safe, joined-up antenatal and postnatal care delivered by a woman’s GP and named midwife with input from obstetricians when required

• Early identification and referral for medical and mental health conditions

• Medical and mental health conditions managed in a timely and appropriate way

• Improve uptake of healthy start vitamins

• Increase aspirin prescribing• Improve uptake of flu &

pertussis vaccinations• Early identification of

vulnerable families, including relationship difficulties, safeguarding issues and adequate support provided

Patients who present to their GP when first pregnant will•receive advice on diet, smoking, alcohol and healthy start vitamins•have their BP and BMI checked•be prescribed aspirin if indicated•have a social psychological and medical risk assessment undertaken•have medical issued addressed, including increasing levothyroxine if necessary, full medication review, assessing asthma, reviewing their mental health•be referred on for antenatal care in a timely manner using pan-London referral form to share all relevant information with secondary care•be referred for specialist services if indicated, e.g. perinatal mental health, primary care psychology, public health or specialist midwives, FNP, medical obstetric clinics, bump buddies, benefits advice, Family Action, relationship counselling•All pregnant women will be screened for depression and referred on for further care if necessary

Confederation•Introduce a payment for ‘First contact appointment’, i.e. when women first present pregnant to GP•Confederation and Maternity programme board could produce a pack for GPs to give women containing:Advice leaflet including signposting to further information and important numbers Healthy start vitamin formForm for free prescriptions/dental careInformation on local services and antenatal classesTailored information for women e.g. FNP, mothers health support group.

•Continue with GP 16 week check and adding in:Depression screeningMedication reviewPrompt for flu vaccination

•Continue with regular meetings with midwives

Antenatal Care (part 1)

AIMS WHAT WILL BE DIFFERENT? HOW CAN WE DELIVER THIS THROUGH OUR PROVIDERS?

• Safe, joined-up antenatal and postnatal care delivered by a woman’s GP and named midwife with input from obstetricians when required

• Good communication between professionals

• Early booking (by 10 weeks gestation) to improve outcomes

• Preparation for parenthood and introduction to health visiting service

• Women will be booked by 10 weeks gestation (if they present early enough) in the appropriate place, e.g. for low risk women in a community clinic, for high risk women in the medical obstetric clinic, for vulnerable women by public health midwives.

• Women will receive continuity of care throughout the antenatal and postnatal periods (definition of continuity TBC)

• Women will receive high quality targeted antenatal education

• Vulnerable families will have joint antenatal and postnatal visit by their midwife and Health visitor

• Women will be screened for CO levels (smoking)

• Improved communication between health care professionals

Homerton (via tariff):-Booking by 10 weeks (when referred before this time)-Continuity of care by midwife-Obstetrician input where required-Public Health Midwife -Obstetric advice service- CO screening CQUIN Others:-Joint midwife and health visitor antenatal and postnatal visit for vulnerable women-Targeted Antenatal classes – monitoring outcomes and evaluating programmes and reviewing the mental health messages/content.

Antenatal Care (part 2)

AIMS WHAT WILL BE DIFFERENT? HOW CAN WE DELIVER THIS THROUGH OUR PROVIDERS?

• Reduce stillbirths

• Reduce neonatal morbidity and mortality

• Reduce maternal morbidity and mortality

• Promoting normality including increasing deliveries in birth centres and at home.

• Ensure timely admission and timely access to pain relief

Many changes have been implemented at the Homerton in response to the external review of the 5 recent maternal deaths and the recent CQC inspection. The impact of these changes will be monitored.

Areas focused on will included:

•Recognition of the deteriorating patient •Escalation of the unwell patient•Staff competency and training•Timeliness and quality of investigations in to serious incidence•Ensure learning from significant events are embedded into practice•Ensure access to interpreter and advocacy services •Review of performance data and increase its use in identifying poor performance and areas for improvement

• Completion of action plans from maternal death reviews and the CQC inspection.

• Auditing and reviewing changes which have been implemented to ensure they are embedded in practice.

• Monitor the timeliness and quality of significant event reporting.

• Benchmarking against and implementing London Strategic Clinical network (LSCN) toolkits

• Evaluation of the enhanced CTG training (funded by NRF)

• Build on 15/16 CQUIN that aimed to increase births at home and in the birth centre

• Continue to use patient feedback to assess admission and pain relief timings

Intrapartum Care: high quality and safe service

AIMS WHAT WILL BE DIFFERENT? HOW CAN WE DELIVER THIS THROUGH OUR PROVIDERS?

• Continuity of care in postnatal period

• Early identification of vulnerable families, including relationship difficulties, safeguarding issues, mental health conditions, domestic violence.

• Follow up of difficult pregnancies or difficult early years to plan subsequent pregnancies for improved outcomes

• Women will receive community postnatal care from their named midwife.

• Women will have a comprehensive 6 week check by GP and be sign posted on to other services as required.

• Mental health assessment (including depression screening and referral on for further care if necessary).

• Vulnerable families will receive a joint midwife and health visitor visit to formally hand over care

• Vulnerable women requiring extra support will be referred on to ‘bonding with baby’ programme

• Improve breastfeeding support

Confederation:-GPs to continue to provide 6-week postnatal appointment Homerton:-Extend continuity to postnatal period so women see their named midwife antenatally and postnatally-Joined-up comprehensive breast feeding strategy including evaluation of volunteer project and ensuring community access to breastfeeding drop in support Others:-Evaluate ‘Bonding with baby’ programme- Evaluate Breastfeeding peer support programme and implementation of baby friendly standards - Evaluate mothers health support project -Joint midwife and health visitor postnatal visit for vulnerable families to ensure handover over of care-Mapping existing postnatal group offer to ensure evidence based mental health support messages are embedded.

Postnatal Care

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Summary of Mental Health Programme Board’s Commissioning Intentions 2016/17

•Mental Health Alliances will be expanded bringing secondary care, primary care, third sector and local authority providers together in a sustainable funding model, which incentivises outcomes, integration, quality and innovation based on shared aims and shared outcomes.

•Enhanced Primary Care services will continue to transfer higher numbers from secondary care services based on a recovery model, following the recent service redesign and expansion of the service.

•In line with the Crisis Concordat, the interface between organisations, including primary care, secondary care, NHS 111, third sector, police and ambulance services will be improved to create a more responsive and better integrated crisis pathway

•CAMHS: new funding will improve eating disorders pathways and transform services to improve links with schools and children’s social care and to continue to address early intervention and family support

•IAPT services: we will continue to hit our access target and will work on improving recovery.

•Dementia: we will maintain our prevalence identification and promote support for patients and carers through funding the Altzheimer’s society workers and we will work through the dementia alliance to ensure efficient pathways, avoiding duplication of service.

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Long Term Conditions Commissioning Intentions 2016-17

Planned

Scheme Current Funding Future funding

Revised version of core LTC contract

Mixed

(£1,512,000 recurrent,

£949,699 non-recurrent)

Requesting recurrent funding

Community heart failure re-procurement

Recurrent Recurrent

Hypertension re-modelled pathway

Recurrent Recurrent

PotentialScheme Current Funding Future Funding

LTC contract “time to talk” and “time for cancer Non-recurrent Requesting recurrent

Further development of virtual renal service Non-recurrent Requesting recurrent

Exercise on referral (specialist input) Within PH offer Requesting non-recurrent

Neurology – service review Recurrent Recurrent

Social prescribing roll out Non-recurrent Requesting recurrent

Stroke – support for people with high care needs after hospital

Nil Potential request for non-recurrent

Early adopter site for pre-diabetes lifestyle intervention

Nil No direct cost implications

Further peer support programmes for LTCs Non-recurrent Potential request for non-recurrent

Personal health budgets – continued roll-out Within existing budgets

No change

Learning disabilities – care reviews and support into volunteering/employment

Nil Potential request for non-recurrent

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Summary of the Children’s Programme Board Commissioning Intentions

• Improve transition pathway for children aged 12-18 years (up to 25 years for children with Special Educational Needs) to provide seamless care , preparation for adult health services, and early identification of medical (including mental health) and social risk.

• Continue to invest in the Children's Community Nursing team extending the service hours and assessing the need for a 24hr service.

• Combine the GP Antenatal contract and the GP Vulnerable Children's contract into a Children's and Families Primary Care Support Contract.

• Continue to commission improved identification and management of children’s long term conditions in primary care

• Ensure a high quality safe service, with the aim of reducing unscheduled care and referrals to hospital services by establishing a range of interface paediatric services / ways of working. Through greater access to specialist advice, development of joint pathways and guidance, and a structured programme of education, there will be enhanced support in primary care, informing increasingly empowered children, young people and their families. Monitoring will include audits, internal review and benchmarking.

• Establish a programme of education across secondary and primary care to support the management of children in primary care / out of hospital, and to enhance the confidence of staff. This will be underpinned by improved access to documented pathways / referral and service information.

• Establish consistent approaches to obtaining and measuring feedback of care in primary, community and hospital settings from both children / young people and their families.

• Ensure children and families can help to shape children's services in City and Hackney through listening to patient’s feedback, via a strong Children's and Families Forum

• Continue the review of children’s community health services to ensure clarity of outcomes and alignment with new national and local policy

• Support the uptake of childhood immunisations .

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