Isle of Wight Clinical Commissioning Strategy Strategic Priorities for Health Service Development 2014-2019 Final Document June 2014 Isle of Wight Clinical Commissioning Group Strategy 2014-2019 CONTENTS Foreword .................................................................................................................................. 4 1 EXECUTIVE SUMMARY .............................................................................................. 5 2 INTRODUCTION ............................................................................................................ 7 2.1 CCG Priorities .......................................................................................................... 8 3 FIVE YEAR HEALTH AND SOCIAL CARE VISION .............................................. 10 4 HEALTH NEED AND CALL TO ACTION ................................................................. 12 5 4.1 CCG contribution to delivering the Health and Wellbeing Strategy ............... 12 4.2 Demographics ........................................................................................................ 13 4.3 Health Inequalities ................................................................................................. 13 4.4 Call to Action .......................................................................................................... 16 4.5 Consultation............................................................................................................ 17 WHERE ARE WE NOW?............................................................................................ 19 5.1 Benchmarking to other areas .............................................................................. 19 5.1.1 Emergency Admissions ................................................................................. 20 5.1.2 Planned Care .................................................................................................. 21 5.1.3 Prevention ....................................................................................................... 22 5.1.4 Mortality ........................................................................................................... 23 5.2 Primary Care .......................................................................................................... 25 5.3 Mental Health ......................................................................................................... 25 5.4 Quality ..................................................................................................................... 25 6 WHAT HAVE WE ACHIEVED SO FAR? ................................................................. 27 7 WHERE DO WE WANT TO BE? ............................................................................... 29 8 7.1 Objective 1: Improved Health and Social Care Outcomes ............................. 29 7.2 Objective 2: People have a positive experience of care ................................. 31 7.3 Objective 3: Person centred provision ............................................................... 31 7.4 Objective 4: System Sustainability...................................................................... 31 7.5 Objective 5: Employers of Choice ....................................................................... 32 7.6 Service Transformation ........................................................................................ 32 SERVICE TRANSFORMATION – OUR PRIORITIES FOR IMPROVEMENT ... 33 8.1 Self Care and Self Management ......................................................................... 33 8.1.1 Self Care and Self Management Vision and Expected Outcomes ......... 33 8.1.2 Self Care and Self Management Strategic Objectives ............................. 34 8.1.3 Self Care and Self Management System Reform ..................................... 34 8.2 Primary Care .......................................................................................................... 35 8.2.1 Primary Care Vision and Expected Outcomes .......................................... 36 Page 2 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 8.2.2 Primary Care Strategic Objectives .............................................................. 36 8.2.3 Primary Care System Reform ...................................................................... 37 8.3 8.3.1 Integrated Care Vision and Expected Outcomes ...................................... 37 8.3.2 Integrated Care Strategic Objectives .......................................................... 38 8.3.3 Integrated Care System Reform .................................................................. 38 8.4 Urgent Care ............................................................................................................ 39 8.4.1 Urgent Care Vision and Expected Outcomes ............................................ 39 8.4.2 Urgent Care Strategic Objectives ................................................................ 40 8.4.3 System Reform ............................................................................................... 40 8.5 9 Integrated Care ...................................................................................................... 37 Supporting people to improve their Mental Health ........................................... 41 8.5.1 Mental Health Vision and Expected Outcomes ......................................... 41 8.5.2 Mental Health Strategic Objectives ............................................................. 42 8.5.3 Mental Health System Reform ..................................................................... 42 8.6 Other Service and Priority Areas ........................................................................ 43 8.7 Key Enablers .......................................................................................................... 44 DELIVERY ..................................................................................................................... 46 9.1 Governance and Monitoring ................................................................................ 46 9.2 Partnership Working.............................................................................................. 48 9.3 Workforce Strategy................................................................................................ 49 9.4 Estates Strategy .................................................................................................... 50 9.5 Contractual Levers ................................................................................................ 50 9.6 Financial Position .................................................................................................. 50 9.7 Risk Management.................................................................................................. 50 Appendix A – Glossery of terms B – References Page 3 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Foreword Welcome to our Clinical Commissioning Strategy for 2014 to 2019. We are facing unprecedented challenges as public sector organisations and we have to ensure we can support increasing demand with more limited resource. By working together with our colleagues in the Isle of Wight Council, Isle of Wight NHS Trust, primary care and the third and independent sectors, and by consulting with the public, we have identified our priorities as set out in this document. We have also created a vision for the future that will enable us to transform our services to meet this increasing future demand. This requires strong leadership, effective partnership working and a commitment to deliver change. Our success will be measured on the delivery of this service change and improved health and care outcomes for our Island population. Dr John Rivers, Chair, NHS Isle of Wight Clinical Commissioning Group The Clinical Commissioning Group has a governing body, we are: Dr John Rivers Chair Dr Ian Reckless Secondary Care Doctor Helen Shields Chief Officer Mark Rawlinson Registered Nurse Loretta Outhwaite Dr Joanna Hesse Chief Finance Officer GP Executive David Newton Lay Advisor (PPI) Fred Psyk Lay Advisor (Finance & Audit) Our other GP Clinical Executive members are: Dr Anitha Rani Ande GP Executive Dr David Isaac GP Executive Dr Sarah Bromley GP Executive Dr Peter Coleman GP Executive Page 4 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 1 EXECUTIVE SUMMARY The Isle of Wight Clinical Commissioning Group (CCG) Vision is “Commissioning high quality, integrated and sustainable services”. We feel this Clinical Commissioning Strategy sets out what we need to do to achieve this, and deliver our contribution to the achievement of our Five Year Health and Social Care Vision as agreed with the Isle of Wight Council, and the Isle of Wight NHS Trust. Our strategy reflects the views and priorities of our membership (the Isle of Wight GP practices), our health and social care partners, the third sector, our patients and the general public. It also reflects areas for improvement as demonstrated in the various benchmarking analysis that has been undertaken. The conclusion is a set of priorities which we feel will improve the health and social care outcomes for the people of the Isle of Wight while living within the resources which are available. Our priorities are: Self Care and Self Management Supporting people to stay healthy and have healthy lifestyles Educating people to manage long term conditions Making information and guidance readily available Supporting the third sector to deliver programmes of prevention and support Assistive technologies Falls prevention Primary Care Services Primary care as part of integrated locality teams supporting vulnerable and older people Improved premises and IT systems Supporting formal federations/collaboration of member practices Supporting workforce reconfiguration Integrated Care Integrated care delivered by locality teams Risk stratification and case management Personalised Care Plans Seven day a week access to services Supporting frail older people Supporting people living with dementia Anticipatory care Urgent Care Urgent care coordination centre Crisis response services Direct access GP beds Acute GP service Better access to urgent care within Primary Care Page 5 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Supporting People to improve their Mental Health Reduced stigma and discrimination with parity of esteem Prevention and early intervention Improved recovery and enhanced Mental Health Reablement Suicide Prevention Child and Adolescent Mental Health Services Other Services Areas and Key Enablers Children Planned care Safeguarding Information technology Workforce development and cultural change Carers Patient engagement Page 6 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 2 INTRODUCTION The key messages are: We will commission services focussed on quality, access, innovation and value for money. We will ensure that Island people are involved in the planning of our services and are fully empowered in their own care. We will deliver improved health outcomes and a reduction in inequality. We will move to a model where we are commissioning services jointly with the Isle of Wight Council. Services will be commissioned to ensure Island health care provision is sustainable within the resources available. Services will be people centred and delivered in the environment which best meets their needs. Our commissioning priority areas are: Self care and self management Primary care services Integrated care Urgent care Supporting people to improve their Mental Health This document is the third Clinical Commissioning Strategy for the Isle of Wight Clinical Commissioning Group (IOW CCG). It builds on our priorities highlighted in our previous documents, and it also reflects the work we have been doing with our key partners to create a new five year Health and Social Care Vision for the Isle of Wight. The joint aim of the IOW CCG, IOW NHS Trust and the IOW Council is to promote longer, healthier and more independent lives for the people of the Isle of Wight. Primary, secondary, and social care, all have individual contributions to make to this, but we recognise our overall effectiveness and efficiency is dependent upon developing a highly integrated model of care. The services that are delivered need to focus on prevention and self-management and be of the highest standards of safety and quality which can be delivered within the resources we have as an Island. One of the national drivers that will support these changes is the Better Care Fund. By 2015-16 we will have greater pooled funds for commissioning between the CCG and Council which will support the commissioning of integrated services. Year on year more services will be commissioned through this fund. We have consulted with our stakeholders, both directly and through the My Life A Full Life (MLAFL) process, who have confirmed that they support our strategic Page 7 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 direction. This document sets out those priorities and gives an overview of what we plan to do to improve services and make transformational change to ensure the whole health and social care system is sustainable going forward. 2.1 CCG Priorities Self Care and Self Management Supporting people to stay healthy and have healthy lifestyles Educating people to manage long term conditions Making information and guidance readily available Supporting the third sector to deliver programmes of prevention and support Assistive technologies Falls prevention Primary Care Services Supporting innovation in the delivery of care through locality based urgent care centres Primary Care as part of integrated locality teams supporting vulnerable and older people Improved premises and IT systems Supporting formal federations/collaboration of member practices Workforce reconfiguration Integrated Care Integrated care delivered by locality teams Risk stratification and case management Personalised Care Plans Seven day a week access to services Supporting frail older people Supporting people living with dementia Anticipatory care Urgent Care Urgent care coordination centre Crisis response services Direct access GP beds Acute GP service Supporting People to improve their Mental Health Reduced stigma and discrimination with parity of esteem Prevention and early intervention Improved recovery and enhanced Mental Health Reablement Suicide Prevention Child and Adolescent Mental Health Services Other Service Areas and Key Enablers Children Planned care Safeguarding Information technology Workforce development and cultural change Carers Patient engagement Page 8 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 By choosing these priorities it does not mean other services are not important, even if not reflected in this document, but it does mean we will be giving emphasis to these areas. The MLAFL programme has been a catalyst for change bringing together our organisations to deliver a significant programme of changing cultures, attitudes, and behaviours. The focus has been on person centred and community responses to ensure people receive coordinated care and support. This has now developed into a conceptual model which is bigger than the initial programme and reflects how we need to work across all services and organisations. Section 3 sets out the vision, objectives, and principles, and aims of working together and with others to improve services. The vision was developed following the MLAFL workshops and CCG Strategy workshops with our stakeholders and reflects the messages that our staff, patients and other stakeholders were telling us. This has now been adopted formally by the CCG, Isle of Wight NHS Trust and Isle of Wight Council and is being widely disseminated through the organisations. This strategy is about how we translate the Health and Social Care vision into reality from a CCG perspective. It should be read alongside the Island’s Health and Wellbeing Strategy, and the Isle of Wight NHS Trust’s Beyond Boundaries Clinical Strategy. Integral to this process is: Clinical leadership and clinically driven commissioning Joint commissioning with our partners in the Isle of Wight Council Collaborative working with all of our stakeholders. Figure 1: System themes and priorities identified in the MLAFL workshops Page 9 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 3 FIVE YEAR HEALTH AND SOCIAL CARE VISION Vision Person centred, coordinated health and social care Objectives Improved health and social care outcomes. People have a positive experience of care. Person centred provision. Service provision and commissioning is delivered in the most efficient and cost effective way across the whole system, leading to system sustainability. Our staff will be proud of the work they do, the services they provide and the organisations they work for and we will be employers of choice. Principles and Aims of working together and with others to improve services To work towards better integration and coordination of care across all sectors of health and social care provision within statutory deadlines. To reduce bureaucracy, improve efficiency and increase capacity to meet future demands for services. To work towards one Island budget for health and social care which makes the best use of resources. To ensure all care will be person centred, evidence based and delivered by the right person in the right place and at the right time. To jointly ensure that that our resources are focused on prevention, recovery and continuing care in the community. To jointly ensure that people are supported to take more responsibility for their care and to be independent at home for as long as possible reducing the need for hospital admission and long term residential care. To continually improve the quality of our care and improve the experience of people in contact with our services within available resources. To ensure partnership working across all sectors, including the third sector and independent sector. To develop our workforce to enable our staff to have to have the right knowledge, skills and expertise that is appropriate to their role. To encourage staff to work beyond existing boundaries to support system wide innovative delivery of care. To work towards a fully integrated IT system across primary, secondary and social care with appropriate access for staff. To jointly commission services with outcome focused contracts, which incentivise positive change in providers of services. To recognise the importance of communities and act to ensure we listen to Island people in the planning of services and responding to their concerns. To share information in an open and transparent way to enable decision making across the organisations. Page 10 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Figure 2: How the health and social care system will look and feel from a patient perspective. Patient outcomes captured at the MLAFL workshops held in 2013. Page 11 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 4 HEALTH NEED AND CALL TO ACTION The key messages are: 4.1 The population of the Isle of Wight shows an aging demographic profile, with the incidence of dementia set to grow significantly. There are large numbers of people with long term conditions. The major causes of poor health and premature death continue to be circulatory, respiratory diseases and cancer. Lifestyle is a significant contributing factor and preventable causes of poor health and health inequalities include smoking, alcohol misuse, physical inactivity and obesity. Mental health and wellbeing is as important as physical health. There are rising expectations in terms of what and how services are delivered. We need to rethink where and how services are provided. Costs of providing care continue to rise and this is set against health allocations not keeping up with inflation and demand and local authority resources being cut. Call to Action demonstrates that doing nothing is not an option and major service transformation will need to take place. CCG contribution to delivering the Health and Wellbeing Strategy The CCG actively contributes to the delivery of the Health and Wellbeing Strategy (HWS) which has the aims of: Together we want to make a difference to people’s lives on the Island by: Ensuring Children and Young People have the best possible start in life Helping and supporting people to prepare for old age and to manage long term conditions and disabilities Enabling people to make healthy choices for healthy lifestyles Building and sustaining economic growth for the Island and supporting improved employment opportunities Making the Isle of Wight a better place to live and visit This document and the HWS reflect priorities identified through the Joint Strategic Needs Assessment (JSNA), which sets out the significant facts relating to the demographic, social and environmental context within which the strategy is set. It also provides a comprehensive analysis of the Island’s current health and wellbeing. Page 12 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 4.2 Demographics The current population (2012) of the Isle of Wight is around 139,000. The population is growing slowly but aging fast compared to England, the growth rate is about 0.26% per year. It is the population structure which is changing over time that has the most significance to planning our health services. The structure sees the greatest overall change in elderly males, a group not often effectively engaged in preventative help and self-management. This aging profile has implications for age related long term conditions (LTCs) as while the burden of LTCs is currently greatest in the 65-74 age group, by 2025 this will be greatest in the 75-84 age group, increasing demand on health services where there may be less people to undertake a caring role. See figure 3. Figure 3: Age profile of the Isle of Wight. 2011 2031 90+ 85-89 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 90+ 85-89 80-84 IW male IW female England 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 20-24 15-19 10-14 5-9 0-4 5 % 4.3 4% 3% 2% 1% 0% 0% % of total Male 10-14 5-9 0-4 1% 2% 3% % of total Female 4% 5% 5% 4% 3% 2% 1% % of total Male 0% 0% 1% 2% 3% % of total Female 4% 5% Health Inequalities Inequalities in health status and outcome are closely associated with inequalities in the wider environment, as reflected in the national Index of Multiple Deprivation. Higher levels of deprivation are associated with higher prevalence of diseases that shorten life expectancy and healthy life expectancy. The Island ranks among the 40% most deprived local authorities in England. Against a background of modest deprivation within a dispersed rural population there are some geographically defined areas with a higher concentration of those on low incomes, poor housing, poor access to services and consequently poorer health. These are in parts of Newport, Ryde and Ventnor. There are inequalities in average life expectancy between electoral wards, for the combined period 2009-2011 there was a 12.2 year difference between the best and worst areas for males (Ventnor & South Wight 89.1 years, The Bay 76.9 years). For women the difference is smaller but still statistically significant at 4.6 years (Ventnor & South Wight 86.3 years, West & Central Wight 81.7 years). Health inequalities on the Island are marked and reflected in mortality from the major diseases, lifestyles and behaviours associated with them. The Isle of Wight mortality rate is lower (i.e. better) than the rate for England, and similar to the mortality rate for the South East. Although life expectancy is Page 13 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 increasing, ‘healthy’ life expectancy is not increasing at the same rate. The main causes of mortality are cancer, cardiovascular disease and respiratory disease. Over 45,000 people are currently estimated to have one or more long term conditions (LTCs) such as coronary heart disease, stroke, diabetes, chronic obstructive pulmonary disease (COPD) and dementia. The number of people with one or more LTCs is predicted to increase by 5.1% between 2011-2018 (an additional 2,500 people). This reflects the growing and aging population. We have identified that it is the number of people with three or more conditions who will need targeted support. This group of people is predicted to rise by 30.2% from 8,600 to 11,300 people between 2011 and 2018. The aging population profile enables us to predict the prevalence of dementia. The number of Island residents living with dementia is projected to increase by 21% from 2012-2020. This is an increase of approximately 500 people during this timespan. Mental health status and a sense of wellbeing is an important determinant of overall health. It is estimated that over 16,000 Island people will have common mental health problems. The high rates of claimants for incapacity benefits/employment support allowance that have a mental health problem correlates to the areas of deprivation. One of the key aims in the Health & Wellbeing Strategy is to give every child the best chance in life. We know 20% of the 0-17 year olds live in poverty and 44.1% do not experience good emotional health. There are problems of obesity, smoking, teenage pregnancy and alcohol consumption, which are detrimental to children’s health. The CCG will work with Public Health to support addressing these areas. Figure 4: Morbidity and Mortality comparisons Page 14 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Crude Mental Health prevalence - Isle of Wight and its ONS Peers: 2011/12 Blackpool PCT Torbay Care Trust Isle of Wight NHS PCT Southampton City PCT Great Yarmouth & Waveney PCT Portsmouth City Teaching PCT England Cornwall UA & Isles of Scilly PCT Hampshire Primary Care Trust 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 Crude prevalence rate (%) Sources: Quality and Outcomes Framework as at end of July 2012 accessed via NHS Information Centre Copyright © 2011, The Health and Social Care Information Centre, Prescribing Support Unit. All rights reserved. DSR Mortality Rates for Deaths in 65's and over by condition per 100,000 65+ population 2009/11 IOW Directly standardised rate all cause mortality per 100 000, 65+. Directly standardised mortality rate from circulatory causes, ICD: I00-I99 per 100 000, 65+. Directly standardised mortality rate from cancer, ICD: C00-C97, 65+ Directly standardised mortality rate from coronary heart disease, ICD:I20-I25 per 100 000, 65+. Directly standardised mortality rate from respiratory causes, ICD:J00-J99 per 100 000, 65+. Directly standardised mortaliy rate from stroke, ICD:I61I69 per 100 000, 65+ Directly standardised mortality rate from chronic obstructive pulmonary disease, ICD:J40-J44 per 100 000, 65+ England Better Similar Better Similar Similar Similar Better 0 1000 2000 3000 Data Source: WMPHO DSR = Direct Standardised Rate DSR Rate per 100,000 65+ population Population estimates based on 2011 census based population multiplied by three Similar indicates no significant difference against the national average / Better indicates a better (healthier) rate 4000 Page 15 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 4.4 Call to Action NHS England has launched a campaign named ‘Call to Action’ which is about engaging the public in the issues facing the NHS, developing a national vision to deliver change and ensuring all NHS stakeholders, the public, patients, and staff are involved in the redesign process. The key message is that there is a funding gap of about £30 billion nationally by 2020/21, and that doing nothing to transform services to address this issue is not an option. The messages tailored to the Isle of Wight health system from Call to Action were discussed at our stakeholder events in September 2013 and this helped inform determining our priorities. Figure 5: ‘Call to Action’ campaign Over the next five years emergency admissions could be responsible for an additional expenditure of £650-720k per annum; resulting in an additional £3.4m spent in 2017/2018. Acute healthcare costs for the Isle of Wight Clinical Commissioning Group have increased by 17% since 2008/2009; rising from £5.2 million per calendar month to £6.1 million per month in 2012/13. The Island has the highest recorded prevalence of Dementia in the UK for 2011/12 There has been a 66.5% increase in patients registered with Dementia from 2006/07 to 2011/12 There is still an estimated 1,245 people living with Dementia on the Island without a diagnosis It is predicted that there will be a further 21% increase in registered dementia prevalence between 2012 and 2020. This is an increase of approximately 500 people over the timespan. Challenges will the health and care services face in the future on the Island? During 2008/2009, 30% of admissions for Isle of Wight CCG residents were associated with patients suffering from 1 or more long term conditions; this has increased to 47% in 2012/2013. As disease diagnosis, identification and coding improve we can expect this statistic to shift greatly. Around 80% of the deaths from major diseases, such as cancer, are attributable to lifestyle risk factors such as excess alcohol, smoking, lack of physical exercise and poor diet. 59% of admissions for Isle of Wight CCG residents are associated with patients aged 65 and over. Emergency admissions for patients aged 65 and over are responsible for 67% of acute emergency bed days. Patients admitted for an emergency under the age of 65 have a length of stay between five and sixteen days on average; for patients aged 65 and over, length of stay is typically between ten and twenty five days. In 2021 it is projected that 22% of the Isle of Wight’s population will be aged 70 and over. In real terms this equates to an additional 9,000 residents; an increase from 23,000 in 2011 to 32,000 in 2021. Page 16 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 4.5 Consultation The CCG ran three workshops in September 2013 for stakeholders. The three workshops were as follows: Healthcare provider organisations including clinicians and other key stakeholders such as the local authority, and other representatives of the Health and Wellbeing Board Third sector, patients, and patient and carer groups Primary care including GPs, Practice Managers and Practice Nurses Representatives of the CCG’s Governing Body, Clinical Executive, Commissioners and Clinical leaders were present at all three workshops. At the workshops we presented posters with ‘Call to Action’ themes, benchmarking data and progress against the 2012-14 Strategy. Presentations were given on key areas: Call to Action/Context for the workshops My Life A Full Life Mental Health Strategy Primary Care The CCG used the following information to develop its understanding of the Island health economy and inform our stakeholders: Joint Strategic Needs Assessment – review of the population level indicators of demography as well as indicators of disease prevalence combined with predictions for the numbers of patients to be treated by 2020. Benchmarking – a review of various reports including national Audit Office reports, Outcomes Analysis, Commissioning for Value. The analysis identifies opportunities for improvements in the health system. Financial assumptions – our assumptions of the Isle of Wight health economy financial position. Local knowledge – collective knowledge of clinical leaders, commissioning managers and our stakeholders. This identifies known pressures and concerns in the health system. Participants then worked in groups to consider the presentations and current priorities which were agreed and prioritised at previous strategic workshop events and they identified other areas for consideration. Personal feedback forms were also available. Overall there was significant support for the strategic priority areas and the strategic direction. There was much greater recognition of the issues facing primary care including the shortage of general practitioners and there was a clear message that the public sector organisations should become more integrated. The outcomes of the workshops, consultation on MLAFL and Mental Health strategies, were the drivers for developing the Five Year Health and Social Care Vision and form the basis of this strategic plan for the CCG. The final public and key stakeholder consultation was undertaken on the draft Strategy during April/May 2014. There was support for the strategic direction and where appropriate the document has been amended to reflect comments. This includes stronger reference to children, and safeguarding included as a general priority. A final consultation response document is published on the CCG website. Page 17 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Figure 6: CCG Existing Priorities 2012-2015 General Priorities Service Specific Priorities Self help and support Long Term Conditions Carers Adult Mental Health Case Management People with dementia and their carers Integrated care Frail older people Assistive Technologies equipment Urgent care Development of the workforce Improving customer focus Improving Communication, Coordination and Consistency Increase the awareness of vulnerable people Emotional health and wellbeing These existing priorities were determined at a previous strategic priority workshop where the priorities had to meet the following criteria: Would reduce health inequalities. Would provide the right intervention to the right patient at the right time. Would improve the patient experience of healthcare. Would support the maintenance of sustainable and viable provision of services for the Island. These criteria are reflected in the slightly revised priorities as set out in this document. Page 18 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 5 WHERE ARE WE NOW? The key messages are: 5.1 The CCG has used a variety of information to inform the development of its key priorities including CCG, Public Health and Adult Social Care outcome indicators. Generally, comparative measures show that the Isle of Wight Health and Social Care System is performing well. Benchmarking has shown there is scope for improvement in various areas in under 75, mortality rates from coronary heart disease and cancer, emergency admissions for children with lower respiratory tract infections and lipid management. Quality reports and financial benchmarking indicate there needs to be improvement in the quality and design of adult mental health services. We need to support adult social care to support people living independently and reduce admissions into residential care. Primary care on the Island is of high quality but is under pressure from increasing demand. Benchmarking to other areas The CCG has considered a variety of reports to compare Island services to services in other areas. This includes measures of access, activity, outcome, quality and value for money of services. This has helped in identifying where opportunities for improvement are and help determine our priorities. The Isle of Wight is generally a very high performing health system but there are some very specific areas where it needs to improve performance to improve health outcomes and patient experience. It also needs to transform services to meet future demand, with a reducing financial allocation, if it is to continue achieving good outcomes. The diagram on the next page shows high level indicators from the NHS Outcomes Frameworks, the Public Health Outcomes Frameworks and the Adult Social Care Outcomes Framework. The comparison to the cluster is other coastal and countryside areas. Each leg shows that where the point is further from the centre it represents better performance. For example, patient experience of GP services is very good. The dots show a comparison of the Island to all Local Authorities in England and the grey circle in the middle is the England average. The only area where the Island is underperforming from these measures is permanent admissions to care homes for people aged 65+. Page 19 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Figure 7: Isle of Wight summary spider diagram 5.1.1 Emergency Admissions Various benchmarking reports suggest the Isle of Wight emergency admissions, i.e. non-elective admissions are lower than the national average, so although there is scope to reduce emergency admissions further, there is not the same level of opportunity as other geographic areas. Figure 8: Emergency admissions for acute conditions that should not normally require hospital admission. 2500 Emergency admissions for acute conditions that should not usually require hospital admission - Directly standardised rate for all ages per 100,000 population (July 2012 - June 2013) Rate 2000 1500 1000 500 0 CCGs Page 20 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 5.1.2 Planned Care Overall the CCG has a good record of performance for NHS constitution targets. The CCG benchmarking shows that planned care benchmarks are low in most areas and NHS Comparators 2012/13 show that: Length of stay elective for inpatient admissions is lower than the national average – national rate 3.1 days, IOW rate 2.6 days. Outpatient follow up to first attendance ratio is lower than the national average – National rate 2.1, IOW rate is 1.5 The IOW CCG has significantly fewer elective admissions (inpatient and daycase) than the national average. The standardised rate for the CCG is 68.0 and the national rate is 116.3. The admission rate is also lower than the average of similar PCTs (CCGs) in the Coastal and Countryside ONS cluster group, which has a rate of 124.2. There needs to be an improved understanding of this particularly low position. Figure 9: Total inpatient and daycase admissions per 1000 population 2012/13 Source: NHS Comparators. A clinical area where the CCG has identified the need for action is endoscopy. The IOW has a population profile that is older than the national average. However, even when this age profile is taken into account, the total number of endoscopies carried out is higher than the national average. The expected rate of increase in the need for endoscopies is estimated at 60% between 2011/12 and 2016/17. As endoscopies are increasingly clinically indicated for diagnosis and treatment, the CCG has recognised there is a need to invest in these procedures to provide effective care for IOW patients whilst managing demand along planned care pathways. Page 21 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 5.1.3 Prevention From Commissioning for Value and analysis of outcomes it appears that primary care on the Island needs to improve its management of lipids (cholesterol). The diagram below shows that the Island has not been as effective as other areas in reducing cholesterol levels of patients with coronary heart disease and particularly those with diabetes. Figure 10: Lipid management Patients with CHD whose last measured cholesterol is 5 mmol/l or less Reported percentage of CHD patients whose last measured cholesterol is 5mmol/l or less (as measured within the last 15 months). Diabetic patients whose last cholesterol was 5mmol or less The percentage of diabetic patients whose last cholesterol was 5mmol or less 2011/12, per CCG. Page 22 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 5.1.4 Mortality The Summary Hospital-level Mortality Indicator (SHMI) gives an indicator for each hospital trust in England whether the observed number of deaths within 30 days of discharge from hospital were higher than expected, lower than expected or as expected when compared to the national baseline. The IOW NHS Trust is in Band 2 where the mortality rate is as expected. It is at the higher (worst) end of band 2 but its position is improving. An action plan is in place to improve outcomes and this is regularly monitored by the CCG. Figure 11: Summary Hospital-level Mortality indicator The table below provides an overview of the SHMI values at the main providers: Provider Observed Expected Value IOW NHS Trust University Hospital Southampton NHS Foundation Trust Portsmouth Hospitals NHS Trust Salisbury NHS Foundation Trust 901 2879 817 2920 1.1026 0.9861 Banding (13) 2 2 3076 1120 2943 1032 1.0452 1.0848 2 2 Page 23 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Figure 12: Our overall performance (CCG Outcomes Indicator Set, Source: Health & Social Care Information Centre) (Position as of June 2014 from available data) For varicose veins there were an insufficient number of admissions which met the criteria. Page 24 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Our Overall Performance The Isle of Wight CCG is in the top national decile for the following indicators: Excess under 75 mortality rate in adults with serious mental illness. Infant mortality. Unplanned hospitalisation for chronic ambulatory care sensitive conditions. Emergency readmissions within 30 days of discharge from hospital. Under 75 mortality rate from liver disease. Patient experience of GP out of hours services. Emergency admissions for acute conditions that should not usually require hospital admission. The top 11% to 25% of CCGs nationally for: Potential years of life lost (PYLL) from causes considered amenable to healthcare: Males. Neonatal mortality and stillbirths. Total health gain as assessed by patients for elective procedures : Groin hernia. Under 75 mortality rate from respiratory disease. Emergency admissions for alcohol related liver disease. Total health gain as assessed by patients for elective procedures : Knee replacement. Potential years of life lost (PYLL) from causes considered amenable to healthcare: Females. Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s. The top 26% to 50% of CCGs nationally for: Under 75 mortality from cardiovascular disease. Employment of people with long term conditions. The bottom 11% to 25% of CCGs nationally for: Total health gain as assessed by patients for elective procedures: Hip replacement. The bottom 26% to 49% of CCGs nationally for: Under 75 mortality rate from cancer. 5.2 The bottom 10% of CCGs nationally for: Emergency admissions for children with lower respiratory tract infections (LRTI) (High admissions). Primary Care Primary care services on the Isle of Wight are and have been of high quality for many years, with high patient satisfaction and good outcomes. Our analysis shows that we have a good standard of GP care locally. Our challenge in this area is a stable but shrinking workforce in GP surgeries as approximately one third of GPs are due to retire in the next five years, and GP recruitment that is challenging and likely to remain so in the next two years. We have a cohort of highly qualified and motivated Pharmacists and Opticians who are entrepreneurial and have a track record in providing services to patients above and beyond their basic contract. We need to continue to develop and harness that willingness to innovate. 5.3 Mental Health The CCG has concerns regarding the quality of some mental health services on the island. Several Care Quality Commission (CQC) reports have highlighted that patient experience and outcomes are not as good as they should be and work is taking place to rectify these issues. Encouraging the IOW NHS Trust to link with a high performing mental health provider from the mainland and ensuring high quality clinical leadership within the mental health services will be a priority for the CCG to ensure these issues are addressed. 5.4 Quality The CCG will work with providers of services to ensure the patient’s experience of healthcare is positive and that they continue to receive care that is safe and effective. The CCG actively involves patients and carers in the design of services and listens to concerns over quality and monitors trends in complaints. The CCG Page 25 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 studies CQC reports and monitors provider action plans that result from these. It also undertakes its own visits to provider services to audit quality and it monitors complaints. Soft intelligence is gathered from the knowledge and experience of GPs. Key indicators of quality are regularly examined and specific areas are targeted for improvement. Figure 13: Example of key quality measure where improvement is required Measure Mortality (SHMI) Pressure Ulcers (Grades 3&4 All) Serious Incidents Requiring Investigation – new in month Current Position 1.1026 (Oct 12 – Sept 13) (IOW NHS Trust) 68 (2013/14) 85 total (2013/14) (IOW NHS Trust and IOW CCG combined) Target 2014/15 <1 Grade 3 – 50% reduction Grade 4 – 0% reduction for Hospital, 50% reduction for Community. Monitoring on a monthly basis – no target set 5 total (2013/14) MRSA Percentage of emergency readmissions within 30 days Friends and Family Test: Improved outcome score IWNHST (A&E / Inpatients) (IOW NHS Trust and IOW CCG combined) 4.39% (2013/14) (IOW NHS Trust) A&E 68.7 Inpatients 70.7 Zero cases in year <3% Improvement in scores (Q4 13/14) (IOW NHS Trust) Page 26 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 6 WHAT HAVE WE ACHIEVED SO FAR? The key messages are: Our previous priorities remain a priority because although significant progress has been made in all the areas, more needs to be done to improve patient outcomes. We have made significant progress against what we said we would do in: - Dementia services - Crisis/Urgent Care Response - Falls Prevention - Self Help - Community Rehabilitation - Heart Failure and COPD care pathways We need to do more against what we said we would do particularly in: - Carers Support - Integrated Locality Working and Case Management - Mental Health services - Improved services for children with Attention Deficit Hyperactivity Disorder and Autistic Spectrum conditions In our previous strategies we set out what the priorities were following previous stakeholder engagement. We have made excellent progress in either delivering our priorities or working towards them, but we recognise we still have a significant amount of work to do to achieve the outcomes we wish to see. Priority Self Care and Self Management What we have achieved Self help groups and services identified and mapped across the Island. Third Sector supported to run numerous LTC self help groups. Support Group Development Officer commissioned. Café clinics being piloted across the Island. Type 2 Diabetes education developed for patients. Supporting Carers Joint carers strategy published (2013). Male carers group set up. Training and support offered to carers. Case Management More effective case management. Improved case management of complex rehabilitation patients. Integrated Care My Life A Full Life Programme established. Trusted assessment across organisations. Services working towards an integrated model e.g. Mental Health Reablement. Locality model for Health and Social Care in development. Assistive technology and equipment Wider use of assistive technology. Various pilots in place for telemedicine e.g. chronic obstructive pulmonary disease (COPD), heart failure, telecare for people with a learning disability and mental health need. Significant additional investment in community equipment to increase availability Development of the workforce McKenzie training for all contracted physiotherapy providers to support management of musculoskeletal conditions. Training of GPs Page 27 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Support for Mental Health staff in ensuring NICE compliance. Support to trained nursing home staff to get access to training in St. Mary’s. Supporting staff to understand the needs of people with dementia. Improved training in primary care for COPD. Communication, coordination, consistency and customer service. Compassion in Care incentive scheme within NHS Trust to improve quality of patient experience. Living with long term conditions Patient Advisory Group set up. Single point of access for Rehabilitation Services. Risk stratification tool rolled out across GP practices. Revised Heart Failure Pathway implemented including commissioning an additional Specialist Nurse. COPD pathway reviewed and revised. Stroke pathway significantly improved. Home oxygen service improved. Supporting people to improve their Mental Health Reviewed service specifications across all Mental Health services to reflect NICE guidance of best practice through payment by cluster. Improved rehabilitation pathway to support recovery. Supporting people with more severe mental illness to gain access to psychological therapies. Supporting people and their carers to live with dementia. Improved diagnosis rates so people can access help and support. New dementia Outreach service to support people in care homes and their own home. Redesign of Memory Service Care Pathway and re-commissioning of service to enable Cognitive Stimulation Therapy and Community Memory Groups run by Age UK. Reduction in anti-psychotic drug prescribing. Supporting Frail Older People Independent survey of patient/family experience for NHS funded continuing care clients. Anticipatory Care Plans being offered to people and rolled out across the Island. Falls Prevention services in place and training being rolled out across the island. Falls pathway reviewed and new models of service being developed. Incentive schemes put in place to improve quality of care in care homes. Urgent Care Further development of Urgent Care Co-ordination Centre to include social services adult duty team and Wight Care. Major review undertaken of service. Further ambulatory care clinics in place. Community Crisis Response agreed and being piloted. Improved links between Ambulance Service and Wight Care to ensure most appropriate service responds to need. Acute GP Services taking referrals from primary care being piloted. GP direct access to residential care beds and direct access to nursing home beds being piloted. Other Areas Winterbourne View recommendations implemented for people with a learning disability. Palliative care for children via virtual hospice in the community. Improved local inpatient facilities to support children with severe mental illness. Better early assessment for families to access services needed in early pregnancy. New care pathways for children to support maximum care in the community. Improved major trauma pathway. Implemented Personal Health Budgets for Continuing Healthcare patients. Page 28 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 7 WHERE DO WE WANT TO BE? This section sets out our objectives in achieving the Five Year Health and Social Care Vision. Our key messages are: 7.1 We will achieve our objectives as set out in our Five Year Health and Social Care Vision: - Improved health and social care outcomes - People have a positive experience of care - Person centred provision - Service provision and commissioning is delivered in the most cost effective way across the whole system leading to system sustainability - Our staff will be proud of the work they do, the services they provide, and the organisation they work for; and we will be employers of choice. Our stakeholders during consultation have helped us define our objectives and determine our priorities. We will deliver national requirements for improved services. Objective 1: Improved Health and Social Care Outcomes In the NHS Outcomes Framework 5 categories of outcomes are described. We want to prevent people from dying prematurely with an increase in life expectancy for all sections of society. We want to make sure that those people with long term conditions, including those with mental illness, get the best possible quality of life. We want to ensure patients are able to recover quickly and successfully from episodes of ill health or following an injury. We want to ensure patients have a great experience of all their care. We want to ensure that patients in our care are kept safe and protected from all avoidable harm. In addition NHS England has set out three more key measures for improvement. Improving health Reducing health inequalities Parity of esteem (treating mental health issues as equally as physical health issues) The outcomes on the Isle of Wight are generally good. However we have asked our clinical leaders to identify the areas where specific improvements in service areas will impact on the improvement of overall outcomes. These are listed in the table opposite with our target ambitions. Data analysis from benchmarking in Section 5 has been considered to inform our target areas, and we have tried to apply the national outcome measures. Page 29 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Priority Outcome Ambitions for 2018/19 (See Appendix A: Glossary) Outcome Ambition Baseline Measure Target 2018/19 Preventing people from dying prematurely National measure – Potential years of life lost per 100,000 population 1801.2 1687.8 National measure – Average score for improving health related quality of life for people with a long term condition Helping people to recover from ill health or following injury 70.40 74.73 National measure – Composite measures relating to emergency admissions Ensuring people have a positive experience of care 1183.9 Enhancing the quality of life of people with long term conditions National measure – Patient experience of GP out of hours services Patient experience of hospital care Treating and caring for people in a safe environment National measure – Patient safety incidents reported (medication errors) Improving health No national measure GP Care 3.80 1121.4 GP Care 3.69 Hospital Care Hospital Care 146.9 142.2 No nationally set – local target only No current national measure or trajectory. Area to be improved Under 75 Mortality from Cardiovascular disease Atrial Fibrillation Lipid Management Diabetes Under 75 mortality from cancer Earlier cancer detection (lung/breast/colo rectal) Number of people with personal care plans Diagnosis of dementia Improving access to psychological therapy. Improving recovery from fragility fractures Integrated rehabilitation and reablement services. Crisis response services Emergency admissions of children with lower respiratory tract infections Reduction in pressure ulcers Adult Mental Health services Integrated care People treated with dignity and respect Improved communication People empowered to make decisions Percentage of medication patient red alerts with Intervention intervention response reported Response to the CCG. (2014/15 Improved safeguarding only) MRSA 20% Clostridium Difficile No current national measure or trajectory. Self help and support Page 30 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Reducing inequalities No national measure Parity of esteem No national measure 7.2 No current national measure or trajectory. No current national measure or trajectory. No current national measure or trajectory. No current national measure or trajectory. Adult mental health services Improving health checks for people with a learning disability Mental Health Reablement Adult mental health services Objective 2: People have a positive experience of care Quality care covering effectiveness, experience and safety is central to commissioning of healthcare. We will ensure our providers of care implement recommendations from the Francis Report; Transforming Care: A national response to Winterbourne View Hospital; and the Berwick Review into Patient Safety. We will ensure our providers services have: The right staff with the right skills to care for our patients at the right time. A system wide organisational development programme to deliver cultural change through the MLAFL programme. Systems to report and learn from safety incidents. Measurable year on year improvement in patient experience and innovative ways of gathering feedback. Care staff who adopt and demonstrate the six C’s: Care, Compassion, Competence, Communication, Courage and Commitment. This will be supported through contractual requirements. That vulnerable people are safeguarded. 7.3 Objective 3: Person centred provision This objective is fully addressed in Section 8 where we consider how we will transform services to meet the needs of individuals. Central to this is: Empowering individuals to support themselves. Developing models of integrated care around the individual. Targeting vulnerable people with both proactive services and crisis response services. Ensuring access to the highest quality of urgent care. Improving access and choice. Improving support for carers. 7.4 Objective 4: System Sustainability In Everyone Counts Planning for Patients 2014/15 to 2018/19, NHS England has identified that any high quality sustainable health and care system will have the following six characteristics in five years: A completely new approach to ensuring that citizens are fully included in all aspects of service design and change and that patients are fully empowered in their own care. Wider primary care, provided at scale. A modern model of integrated care. Page 31 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Access to the highest quality urgent and emergency care. A step-change in the productivity of elective care. Specialised services concentrated in centres of excellence. In our vision statements we wish to see service provision and commissioning delivered in the most efficient and cost effective way across the whole system and through this plan we will deliver these requirements and achieve our objectives. 7.5 Objective 5: Employers of Choice The CCG values its staff and now has an excellent new headquarters from where people work. The CCG has an organisational development plan and is committed to supporting training and education to enhance the skills of the staff. The CCG has competent, committed staff and is already an employer of choice. 7.6 Service Transformation The CCG developed a comprehensive Clinical Commissioning Strategy 2012-14 following extensive consultation with stakeholders and the public, which it refreshed for 2013-15. The priorities that were developed then remain our priorities now. The focus has changed slightly within the priority areas and we have grouped them into different headings and added primary care, but the overall aims of our service transformation remain the same. These are fully set out in section 8. Figure 14: 2014-2019 Priorities Page 32 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 8 SERVICE TRANSFORMATION – OUR PRIORITIES FOR IMPROVEMENT Our key messages are: 8.1 If we are to deliver improved outcomes, higher quality services and improved patient experience with diminishing resources, major service transformation needs to take place. In five year’s time services will look and feel different from now with a real shift from hospital acute services to primary, community and social care based services. Through numerous self care and self management initiatives people will be empowered to live healthy lifestyles and take responsibility for their own health. Primary care will be accessed in different ways and GP’s will have access to system wide records. Patients will get seen the same day for urgent care, but not necessarily by their GP. The GP will be central in the coordination of care for complex vulnerable patients. Seamless integrated care will be the norm with individual needs central to the way in which people work. There will be a range of services for people who need urgent care. Individuals will get rapid access to care and treatment in the most suitable cost effective environment. People with a mental health need will get parity of services to support them have a meaningful and good quality of life and support their recovery. We recognise the importance of other factors in achieving transformation: - Information technology - Workforce development and cultural change - Patient engagement - Support for carers Self Care and Self Management This is a major programme of integrated projects within the MLAFL programme. The programme is being taken forward with the Isle of Wight Council and third sector and has five major areas of work. 8.1.1 Self Care and Self Management Vision and Expected Outcomes The overarching outcome is to ensure people are supported to stay healthy and have the knowledge to effectively manage any long term condition they are living with. People will be supported to understand what information is available and how to access it. Page 33 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Information and advice will be readily available, kept up to date and be in various formats. People will be supported and encouraged to live healthy lifestyles as part of healthy communities and will take responsibility for their health. The health, social care and voluntary sector workforce will have been equipped with the skills to enable people help themselves. Electronic personal care plans will be widely used across the Island. Patient Vision “My health, support and care are directed by me, are well co-ordinated and work well together. I am supported to take more responsibility for my care and be independent at home reducing my need for hospital admissions and long term residential care. I will, if I wish, be involved in all aspects of service redesign and change. All the services I can receive will be centred on me, evidence based and delivered by the right person in the right place and at the right time, seven days a week. I will be able to access support from the third sector and independent sector as well as health and social care providers.” 8.1.2 Self Care and Self Management Strategic Objectives Supporting self care and self management is essential if future demand on health and social care services is to be addressed. The impact is more medium and long term, but unless we reduce the burden of disease and demand of services the health system will not be sustainable. Our strategic objectives are: To reduce levels of preventable disease such as type II diabetes and coronary heart disease. To support the development of healthy communities which support healthy lifestyles. To equip people with the skills and knowledge and motivation to manage a long term condition to reduce demand on health and social care services. To improve people’s quality of life. 8.1.3 Self Care and Self Management System Reform Information, Advice and Support – there are numerous activities which are being supported which encourage self care, particularly in the third sector. A development officer has been appointed to support the development of condition specific self help groups and this work will continue. Various schemes have been piloted through a LTC prospectus which has encouraged innovative ideas such as the West Wight ‘Living with a LTC Café’. Where these schemes are evaluated to be effective, it is hoped longer term funding will be available. We will continue to offer opportunities for the third sector to bid for funds through the MLAFL prospectus coordinated through Community Action Isle of Wight on our behalf. Information Hub and Directory of Services – the third sector has received lottery funds to support the development of Isle Help. The aim is to bring together disparate sources of information from the Isle of Wight Council, health, third sector, etc, so there is one place which will have a significant range of up-to-date and credible information. This will link to the Council Directory of Services and the Health Directory of Services through 111. We will continue to actively support this initiative. Page 34 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Personal Care Plans – we are seeking an electronic solution through Eclipse so that all people with long term conditions and others who will benefit from personal care plans can have one. The personal care plans are important to help people determine how they want to live their lives, what outcomes they wish to achieve, how they can be supported to do this and if they find themselves in a crisis what they need to support themselves and get the appropriate help. Healthy Communities and Healthy People – lead via Public Health, but linked very closely to the programme, this is exploring what makes a community a good place to live and how we encourage healthy lifestyles. There are various programmes supported by the CCG such as weight management. Development of the Self Care mind set – this is aimed at the development of staff with various training initiatives to ensure they have the knowledge base and skills to encourage and motivate individuals to take more responsibility for their own physical and mental health. This includes many staff undertaking “Healthy conversations training”. This will also include schemes to support our staff to have healthy life styles. Evidence shows that self care interventions work when grounded in people’s day-to-day lives and therefore support and outcome goals need to be tailored to individuals. Professionals can support people by promoting self-confidence and self care by helping people to better understand and accept their conditions, and develop skills to manage them. Figure 15: Continuous strategies to support self management Focus on self-efficiency Motivational interviewing Care plans Patient held records Telephone coaching courses Goal Setting Activity group education Behavioural change Information provision Online courses Group education Electronic information courses Self-monitoring Written information Focus on technical skills Falls Prevention – we will continue to support and develop the falls prevention service and the falls pathway. Key within this is the widespread use of the falls risk assessment and the medical review of people frequently falling. 8.2 Primary Care The CCG uses the term primary care to describe the services provided by GPs, pharmacists and opticians. It is an area of complex partnership working involving the CCG, the IOW Council and the Local Area Team of NHS England each of whom hold particular contracts with this sector. The CCG firmly believes that it has a key coordinating role in primary care ensuring this partnership working is improving services for local people and that the commissioning framework within which primary care operates is working effectively and delivering against key targets and expectations. Page 35 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Patient expectation of the service from primary care is increasing, as more patients wish to receive medical help at times convenient to them. Patients wish to stay in their own homes and be independent for as long as it is safe to do so, and there is a need for primary care to provide holistic and responsive services particularly for frail and older people and those with complex health needs. 8.2.1 Primary Care Vision and Expected Outcomes By 2019, patients will think less about primary care as their “GP practice” and more of a seamless system of care across the Island providing a range of services that they can access that meets their needs. Patients will access primary care through a variety of means, increasingly in an electronic manner. Where they need to be seen or interact with a health professional this will be facilitated seven days a week. Telephone, e-mail and Skype–type consultation will become more prevalent and acceptable. Premises and IT systems will be fit for purpose, supporting professionals to manage people effectively with record systems that can be accessed by appropriate professionals. People with urgent on the day needs will have those needs met, but not always with a face to face appointment with a GP. Other professionals and other technologies will be in place to support people to achieve the care they need. Patients with complex and long term conditions will experience more joined up and coordinated care. Patients will be at the centre of the care they receive, with their GP surgery working as part of an integrated locality team working with them to provide care and support. Primary care will be working with patient groups to tackle health inequality and support deprived communities to make rapid progress towards equality of outcomes. Patient outcomes in primary care will continue to improve, as professionals increase their skills and knowledge. Patient Vision “I very rarely need to visit my GP practice, because the majority of my interaction with the practice can be done electronically and I am very effective at managing my condition myself with support from the practice. When I do need to be seen, I can access appointments easily and quickly and be treated without delay.” 8.2.2 Primary Care Strategic Objectives Primary care has a number of strategic objectives which will inform the detailed delivery from 2014 to 2019. These are: Supporting innovation in the organisation and delivery of care for patients who are acutely unwell as well as those requiring longer term support for chronic disease. Supporting infrastructure development in relation to premises and IT which will sustain innovation, quality and patient satisfaction. Increasing the available workforce and resources for primary care and support improved work-life balance for those staff affected by the challenge of longer days and seven day a week working. Maintaining high levels of patient satisfaction with primary care services. Maintaining the high quality of care that patients receive, ensuring that the CCG delivers its statutory requirements to support continuous quality improvement. Page 36 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 8.2.3 Primary Care System Reform The CCG will support member practices who wish to develop partnerships with other providers of healthcare (whether other primary care or in other sectors) to deliver services to patients in novel ways that respond to patient needs and expectations. The primary care strategy is in development but this includes: Supporting the development of formal federations/collaboration of member practices, cooperative arrangements or merger. Supporting innovation through letting contracts to reflect new ways of working across multiple practices and across different types of provider. Supporting workforce development to enable staff groups to undertake extended roles. Supporting the development and purchase of new technology which allows staff to work remotely and across multiple sites and be able to access the information they need to provide the best care. Supporting workforce recruitment and retention providing a coordinating office for marketing opportunities to train and work within primary care on the Island. Enabling culture change within providers which will ensure that changes are sustainable and spread across the Island. NHS England is in the process of developing a strategic commissioning framework for primary (GP) services. The CCG will review and respond to that strategy once it is published, working closely with the Health and Wellbeing Board and the CCG membership. 8.3 Integrated Care Delivering seamless, integrated care with multidisciplinary teams working across health and social care is a key ambition as set out in the overarching vision. This is a very ambitious plan and will need to be phased over several years to ensure we test out models and get it right for our Island population. Where it is appropriate, integrated services will be locality based, but for some services it may be appropriate for them to be Island wide due to diseconomies of scale. We already have some locality based services and primary care is working in three localities. Over the next five years we will review each service to test out the benefits of integration and where it is proved beneficial we will develop plans for integration. Integration may reflect more shared care between secondary and primary care, as well as primary care, community and social care. 8.3.1 Integrated Care Vision and Expected Outcomes The vision for integrated care is where multi-professional teams work together to meet the needs of individuals in a timely and efficient way. This is based on trusted assessment, respect of specialist skills, avoidance of duplication and a clear focus on delivering the outcome for the individual. The outcomes we are aiming to achieve are: People get quicker access to services. Services are tailored to the needs of the individual and are co-ordinated to ensure the most appropriate staff deliver the care in a joined up way. People’s experience of services is positive and they feel supported. Page 37 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Patient Vision “If I need a range of help and support this will be coordinated by a named person who I trust to help me achieve my goals. I will only get asked questions once, because my care plan developed with me gives all the information required to the people delivering my care. I do see a range of people both health and social care and the voluntary sector, but they work together in a way that meets my needs. It has allowed me to stay at home, where otherwise I might have had to live in residential care.” 8.3.2 Integrated Care Strategic Objectives All care will be delivered in an integrated way if it is beneficial to do so. Where appropriate care will be delivered in localities by the integrated teams. By the end of the five years all services will have been reviewed to justify whether integration is the most appropriate model. If it is services will have been redesigned and new services commissioned. 8.3.3 Integrated Care System Reform Integrated Care for Vulnerable and Older People – About five percent of people with multiple, often complex long term conditions, who may also be frail and elderly, have specific needs which need well organised integrated care and a senior lead clinician taking responsibility to support them to live independently. The new GP contract from 2014/15 focusses on people over 75 and those with complex needs and it requires that there will be an accountable GP for people over 75. Integral to this is systematic risk profiling and the Adjusted Clinical Groups (ACG) tool will be used by all practices to identify patients who will benefit from intervention. We will ensure that integrated health and social care teams will be developed that can meet the needs of these frail older people and those with complex needs. The teams will be locality based and work with a group of practices ensuring that primary care and the accountable GP is central to the individual in meeting their needs. The approach will be comprehensive, seven days per week and they will work with other services as required. They will co-ordinate care in accordance with the personal care plan from lifestyle support, social care, primary care, community care, rehabilitation and hospital episode co-management. The delivery of this will be phased over the next two years. As part of this work the CCG is supporting the Good Neighbourhood schemes and a Care Navigator pilot. Integrated Rehabilitation and Reablement – The CCG has already commissioned a comprehensive community health based rehabilitation service which is delivered in the three localities following a central triage of referrals. This ensures that people get the right rehabilitation in the right environment whether hospital bed, community bed, or their own home. During 2014 a review of this service will be undertaken to consider how it can be better integrated with the local authority reablement service to ensure seamless provision, regardless of which point the person has entered the service. Figure 16: Rehabilitation/Reablement options for service delivery Intensive hospital based rehabilitation Community rehabilitation beds (Nursing homes) Local Authority Resources Centre Rehabilitation or reablement in the home Page 38 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 The aim will be to have integrated rehabilitation and reablement teams based in localities which will closely work with the other locality teams. Supporting People and their Carers to live with Dementia – We are considering this service within our integrated care section as it is essential that people with dementia get good integrated care across all sectors. Supporting people with dementia remains a key priority and the CCG remains committed to achieving compliance with NICE guidance (2010). The CCG also remains committed to improving diagnosis rates; as early diagnosis enables access to treatment, education, and support. The CCG is working on a new Joint Strategy for people with dementia which will be available in 2014 following consultation. This will inform the detailed direction for the services. However, it is very important that services for people with dementia are integrated or closely aligned to the teams for frail and older people as people often have complex co-morbidities which include dementia. The voluntary sector has a very important role to play as part of the integrated care and the CCG is committed to working as part of the locally developed Dementia Alliance and supporting the development of dementia friendly communities. End of Life Care – The CCG is undertaking a comprehensive review of end of life care in 2014 to inform the future direction of service. Integrated care is essential for end of life care and this includes integration with the Earl Mountbatten Hospice. Multi-disciplinary teams which link with other locality based services will ensure patients are supported in their choice of care and place of death. Anticipatory care planning is central to this so that all professionals/carers who may be involved in the care of the older or dying person are aware of and respect patients’ wishes as they move towards the end of their life. Having an anticipatory care plan which is agreed by the individual or the family where there is no mental capacity, means that decisions whether to treat or give palliative care are much clearer when crisis situations arise and people’s wishes are respected. 8.4 Urgent Care Improving access to emergency urgent treatment and care results in better outcomes for patients and improves the efficiency of services. There are numerous schemes across health and integrated health and social care which are being developed to improve urgent care pathways and prevent unnecessary admissions to hospital and residential care. 8.4.1 Urgent Care Vision and Expected Outcomes The overarching vision for urgent care is a system which has a range of services which enables people who have an urgent need for treatment or care to get rapid access to services and be treated in the most safe, suitable and cost effective environment. The outcomes we are aiming to achieve are: Improved high quality cost effective urgent care pathways. Eliminating all avoidable emergency admissions to hospital. Ensuring people are able to be cared for at home where appropriate to avoid admission to residential care where possible. That A&E, Ambulance and Communication Hub services are cost effective. Page 39 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Patient Vision “If I have a crisis due to deterioration in my LTC I will get a rapid assessment of my needs ideally at home or in the hospital one stop clinic. My personal care plan will give any professional who supports me knowledge of my wishes about how I wish to be treated. Where possible I would like intensive support at home to get me well again and living independently, but if I am too ill for this I wish to be treated quickly and efficiently in hospital so I can go home again with suitable support as soon as possible.” 8.4.2 Urgent Care Strategic Objectives The strategic objectives of the system are: To put in place an integrated range of service options which enable high quality cost effective care. To deliver urgent care as close to home as possible. 8.4.3 System Reform Acute Primary Care Led Services – Our aim is to ensure GPs are supported to manage patients in the community if there is no need for hospital level care. We are currently piloting two schemes to determine their benefits to patients and whether they are cost effective. Acute GP referral scheme – within this scheme additional GP support is available in the walk in centre so that GPs calls regarding possible admission of patients to hospital can be triaged and dealt with in the most appropriate way. Admission may be required, but in many cases rapid assessment and access to diagnostics; and time to coordinate services around the patient can avoid an admission. GP Direct Access beds to residential care – this scheme has been piloted in residential care homes and is currently being piloted in nursing homes. GPs have direct access to contracted beds if they feel a patient has deteriorated and needs more care than can be delivered at home. The GP will manage the medical needs of the patient with this additional support on a short-term basis. It is hoped these schemes will be successful and be fully implemented by 2016. Urgent Care Co-ordination Centre – The ‘Hub’ as it is often known, is located at the St Mary’s site. This contains ambulance, 999 response, patient transport coordination, 111 response, adult social care rapid response team, Wightcare alarms and the rehabilitation co-ordination centre and District Nursing co-ordination centre. A review undertaken in 2013 highlighted that the service (999/111) is very expensive but there are significant benefits from its location and co-ordination. Our aim is to work with the IOW NHS Trust and Adult Social Care to continue to expand services in the hub but ensure they deliver these services in a more integrated and costeffective way. Walk in Centre and Urgent Care delivered by Primary Care – In section 8.2 we discussed the need to transform primary care services. This includes reviewing how patients get access to primary care services particularly when they need urgent primary care review. The walk in centre (Beacon) at St. Mary’s is very popular with Page 40 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 patients, particularly those based around Newport and healthcare staff. Although desirable the service is currently not cost effective as the CCG pays additional costs (Island Premium) for A&E services and NHS England already pays for GP services, so the walk in centre is an additional cost. During 2014/15 the CCG will consult widely with stakeholders regarding the future of the walk in centre and whether an alternative locality based model could be more accessible and more cost effective. Crisis/Response service – The Island is currently piloting a crisis/rapid response service which is a multi-agency response for people in need of urgent care, but not acute medical care. The aim is for the service to be delivered seven days a week, with a comprehensive assessment of need taking place within 4 hours of request. Dependent on need the service would offer support for up to 72 hours or refer the person on to relevant services. The service is linked into other community services and can refer directly as required. Referrals are accepted via various agencies. The service will be evaluated later in 2014 to ensure it delivers its objectives, but subject to evaluation it is expected that this will be made permanent. One Stop Clinic (Ambulatory Care) – the CCG will commission more rapid access to tests and investigations as well as consultant advice and opinion. Six common conditions are currently being managed through ambulatory care clinics, a further group of conditions have been identified as areas to be developed over the next couple of years. Outpatient Home Parenteral Infusion Therapy – This is a relatively new service aimed at delivering a range of Intravenous services in the community. This is for stable patients who don’t otherwise need hospital care. Over the next 5 years as the service is consolidated it is expected that this service will expand to a wider group of patients. 8.5 Supporting people to improve their Mental Health The national mental health strategy ‘No Health, without Mental Health’ (2011), sets out a number of national priorities for mental health services. The CCG and IOW Council have developed their own joint ‘No Health without Mental Health’ Strategy (2014) and Suicide Prevention Strategy (2014), to reflect national requirements and local needs following extensive consultation with service users and other stakeholders. The CCG continues to recognise the importance of improving mental health and wellbeing and mental health services particularly supporting the recovery model and improved patient experience. The challenges within services remain and continued development needs to demonstrate significant improvement. Mental health will therefore be a major area of focus for the CCG and we expect major transformation of the service completed by 2019. 8.5.1 Mental Health Vision and Expected Outcomes The priorities set out in the ‘No Health without Mental Health’ Strategy are as follows: More people will have good mental health by finding ways to reduce loneliness. More people with mental health problems will recover as there will be quicker and easier access to diagnosis and care. More people with mental health problems will have good physical health by ensuring physical health checks for hard to reach and vulnerable groups. More people will have a positive experience of care and support through prompt access to specialist services. Page 41 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Fewer people will suffer avoidable harm as we will support families and communities to keep themselves well and build self-confidence. Fewer people will experience stigma and discrimination as they are helped to build confidence and resilience, and we positively promote mental health. Patient Vision “When I enter the Reablement pathway, I expect to be treated with empathy, respect and dignity by the mental health professionals I encounter. I expect to be supported by professionals who have the right skills and who focus on my recovery, in a setting which suits me and my needs and that I am supported to make my own decisions about my recovery. I expect to see the same staff members as far as is possible and if I need another service this is arranged without unnecessary assessments. I expect to be supported to achieve a life that is productive and meaningful despite my mental health problem. I expect my life story, fears, hopes, and social circumstances to be located at the heart of my recovery plan and to be equipped with the necessary self-understanding and resources to minimise relapse.” 8.5.2 Mental Health Strategic Objectives Mental Health has a number of strategic objectives which will inform the detailed delivery of the vision from 2014-2019. To see a reduction in the twenty year gap in life expectancy for people with a mental health problem compared to those who don’t have one. To change the culture within mental health services to ensure people are empowered to help manage their own illness and get prompt access to specialist services when they need them. To enable more people with a mental health problem have a meaningful and good quality of life through improved recovery. 8.5.3 Mental Health System Reform The majority of the mental health services are provided by the IOW NHS Trust. The CCG will support the Trust to partner with a high performing mental health organisation to bring greater expertise in the form of clinical and managerial leadership to the Island. This will be essential if the system reform within mental health services is to be achieved. Service Redesign in Mental Health Clusters – This is a national way of contracting for mental health services which is helping drive service redesign into 21 clusters of care which will deliver more appropriate services where cost is linked to outcome. The clusters are linked to NICE guidance of best practice. There will be a more integrated community focussed model of care which is delivered in conjunction with the IOW Council and third sector. Redesign of Reablement Pathway – This service is being redesigned in conjunction with the IOW Council to ensure we have a fully integrated service. Patients will continue to have an option to have residential support if required, but there will be much more focus on support to live independently with ‘wrap around’ services in place and increased hostel and housing solutions available. More effective recovery based services will enable more patients to remain on the Island Page 42 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 or be transferred back from specialist mainland placements sooner, to enable them to be closer to friends and family. Support to Mental Health patients in Acute Hospitals – We will be scoping and if appropriate, implementing the RAID programme (Rapid Access Intervention and Discharge) in the acute hospital setting. This is aimed at reducing inappropriate admissions, improving care planning during acute admissions, reducing length of stay and ensuring good discharge planning. This will require more specialist mental health professionals to be available to support individuals with mental health needs in hospital. One of the aims of this is to ensure parity of outcome, to those with primarily physical illnesses. Improving Access to Psychological Therapy (IAPT) – The IAPT service has been supporting people with depression and anxiety and supporting people back to work after a period of illness. We have been working to extend this for people with a long term condition and we will now be looking at how these can support people with more severe mental illness. Whole Life Support for Children and Adults with Autistic Spectrum Disorder – Work has been going to support the development of these services. Although we have a pathway agreed for the services we need to ensure the delivery of the service is seamless and is delivering the health contribution to the achievement of goals within the Joint Autism Strategy (2013). 8.6 Other Service and Priority Areas Although the CCG is focussing on these priority areas, it does not mean other areas are not important. Below are other areas of work the CCG will be involved in. Children and Young People The strategic development of Children’s Services is led by the Children’s Trust with shared outcomes for Children and Young People, set out in the Children’s and Young People’s Plan. Through the Children’s Joint Commissioning Group, Children’s Services, NHS England, Public Health and the CCG will be committed to the ambition for children to live healthy lives, to this end we will be working closely with all partners to continue to focus on: Improving Child emotional health and wellbeing by developing the collaborative working with Social Services. Improving the pathways for Children with Attention Deficit Disorder and Autistic Spectrum Disorder. Developing the Education Health and Social Care Plans and Personal Budgets, responding to the Special Educational Needs and Disability (SEND) reforms. Acknowledging the important role that Schools play in the development of the plans, and the wider support in the prevention of illhealth. Working with our Local Authority colleagues to support the young carers who look after Adults with long term conditions at home, and recognising the impact this has on the young person. Ensuring timely medicals for Looked after Children and Adoption Medicals, including those placed out of Authority. Work with Health and Social Care and education colleagues to ensure smooth integration across all services. Page 43 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Children’s palliative care services including the further development of a community nursing service to support children and young people with end of life care and those with lifelong illness. Planned Care The CCG will continue to work with the IOW NHS Trust to increase efficiency to improve access, and reduce waiting times. We will explore more shared care initiatives with primary care so there are clear pathways and clarity of medical responsibility. We will continue to improve access to diagnostics. Safeguarding The CCG will continue to ensure effective leadership and governance for safeguarding across health services. We will actively work with our partners to ensure safeguarding vulnerable adults and children remain a priority across all services and this will be reflected in our contracts. 8.7 Key Enablers Information technology By 2019 the CCG aspires to have a single health record for patients registered with an Isle of Wight practice that can be viewed by the individuals and all professionals working with that individual. Building on the success of the system Vision 360 where out of hours GPs and consultants are able to see vital health information about Island patients, we will work with the public to develop a shared vision for use of health records and publish our information management and technology strategy by the end of 2014. Integration of the Isle of Wight health and social care system is also expected to be implemented over the next two-three years. Workforce Development and Cultural Change Development of the workforce whether NHS, Council, or third sector remains an important priority if we are to the have the right people with the right skills in the fast changing environment. Central to this will be cultural change across the organisations and where the focus is the need of individual patients. The MLAFL programme will lead the development of this across all organisations. Patients need to be involved in decisions about their care and the experience needs to be positive. There will be a focus on capturing both patient and staff experience and various methods will be undertaken to do this. The CCG will work closely with Healthwatch to get feedback on services. Communication, co-ordination and consistency and customer focus were 4 areas identified in our last consultation. We will continue to focus on these areas as part of workforce development and cultural change. Patient Engagement As we develop new services there will be increased emphasis on co-creation of services. The public, our patients, our stakeholders need to have the opportunity to be involved in the planning of services as well as being active participants in their own care. Page 44 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 We will continue to work with HealthWatch and take action on their reports and we have developed a “soft intelligence” reporting mechanism which actively takes note of patient feedback whether formal or informal and ensures the CCG is listening to public concerns about health services. Carers In 2013 we published the Joint Carers Strategy with the IOW Council. We are committed to implementing this and recognising the central and important role carers play in the care of family and friends. We need to ensure carers get the support they need to maintain their own health and feel supported themselves as well as those being cared for. This will include ensuring children and young people who undertake caring roles are supported. Page 45 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 9 DELIVERY The key messages are: The IOW health system faces challenges over the next few years particularly in relation to the amount of finance available to fund health and social care. The CCG has an ambitious delivery plan to achieve service transformation, improved outcomes and patient experience. Partnership and joint working across the system will be essential to deliver this transformation. There is a robust performance system in place to monitor delivery, but the risks of delivering wide scale change are high. The vision for health system is set out in the section 3. In order to deliver the vision and this strategy we need strong partnership working across the system and strong clinical leaders. The CCG is both transforming the way commissioning is undertaken and transforming the services it commissions. 9.1 Governance and Monitoring This document is one of a suite of four documents; the others are: CCG Operational Plan 2014-2016 CCG Delivery Plan 2014-2016 Better Care Fund Plan 2014-2016 The CCG Operational Plan and Delivery Plan are renewed annually and set out how the strategy will be delivered over a two year period. They are refreshed each year to take account of changes. The Delivery Plan sets out in more detail the outcomes to be achieved, the actions or milestones to achieve the outcomes, the person responsible and the planned achievement date. It also sets out investments and savings for each service area. Page 46 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 There is a clear system of performance monitoring within the CCG. Figure 17: Governance Structure NHS England Clinical Commissioning Group Membership Governing Body Health and Social Care Integration Group Joint Adult Commissioning Board CCG / LA CCG Clinical Executive Better Care Fund Health and Wellbeing Board Children's Trust Board Joint Commissioning Group Children CCG / LA / NHS England CCG Internal Performance Review Meetings Individual appraisal and objective setting My Life A Full Life Strategic Board The Governing Body is the body which monitors performance at a high level and seeks assurance that the outcomes, performance targets, contracts and strategy are delivered. However, in the CCG it is the Clinical Executive which monitors the detailed performance on a monthly basis. This includes activity, finance, key performance indicators and outcomes. Delivery of the strategy against its milestones is undertaken quarterly by the Clinical Executive by checking progress against milestones set out in the Delivery Plan. The Clinical Executive approve business cases and individual service strategies, which support the delivery of the commissioning key initiatives. The CCG is a membership organisation of the seventeen GP practices on the Island. It’s accountable for everything to the membership. Page 47 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Figure 18: Key priorities delivery schedule 2014-2015 2015-2016 2016-2017 2017-2018 2018-2019 Self Care Management Information advice & support & healthy communities Information Hub and Directory of services Falls prevention pathway Primary Care Improved access Federations of Practices Urgent Care Centres Integrated Care Integrated Locality Teams Integrated Rehabilitation & Reablement Dementia – compliance with NICE guidance Urgent care Acute GP services Urgent Care Coordination Centres Crisis Response service Mental Health services Redesign of services & effective delivery by clusters Reablement pathway Improved support update in acute hospitals Improved Autistic Spectrum Disorder service = Full Implementation 9.2 = Key Milestones = Ongoing Development Partnership Working The transformation agenda cuts across organisational boundaries. In particular the three public sector organisations – the CCG, IOW NHS Trust and IOW Council have to work together to deliver the vision. The organisations are so linked that any major change in one has consequences for the others. Two new structures will be in place. The Children’s Joint Commissioning Group and the Joint Adult Commissioning Board. The Children’s Board is a board of officers Page 48 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 which oversees the commissioning arrangements undertaken by the CCG and Hampshire Council children’s services on behalf of the IOW Council. The Joint Adult Commissioning Board is a Board of officers between the CCG and the Adult Social Care in the IOW Council. This board oversees all joint commissioning arrangements and the development of new joint commissioning of services. In 2015-16, the Better Care Fund is being introduced. This is a national requirement for a pooled budget to be in place to support integration. On the IOW we will use the mechanism to consolidate existing pooled budgets as well as use it to bring more and more services into a joint commissioning arrangement over the next few years. The CCG also believes in working with other stakeholders, including the independent and third sector. The CCG has used significant levels of grant funding to support the third sector providers in the delivery of the strategy. Where schemes are evaluated to be cost effective it will continue to strongly support this area. The CCG via the prospectus approach is also keen to develop innovative ideas and will continue to support pilots which test out innovation. The CCG together with the IOW Council will aim to ensure third sector services are more formally commissioned in future. All major priority areas and service development projects have planning groups which involve all our stakeholders, including providers and patients. Our Clinical Leads have an active and important role in the engagement of our local communities. The CCG will participate in the clinical networks and senates across Wessex which were newly established last year. It will also work closely with NHS England, which commissions other health services such as primary care (GP contracts, dentists, opticians and pharmacists), Specialist Care, and Offender Health. The CCG is also interested in co-commissioning primary care services with NHS England and is actively exploring this opportunity. In order to clearly articulate the impact of strategic plans on current health providers, CCGs across Southampton, Hampshire, Isle of Wight and Portsmouth will collaborate with NHS England to agree an explicit roadmap. This roadmap will detail how we will work with health and care providers and other stakeholders to describe the health provider ‘end-state’ in five years. This will ensure local CCG strategies are cross referenced and local implementation plans are, where necessary, coordinated. 9.3 Workforce Strategy The CCG has an Organisational Development Plan, but it needs to be also focusing on workforce development and considering the impact of the strategy on the future Health and Social Care workforce needs for the Island. It will work with providers to inform their workforce plans. The workforce development needs include, but are not exclusive to: increasing the number of GP’s; people skilled in caring for people with dementia; generic support staff who work within integrated locality teams. The Island also needs a system wide approach to improving recruitment, particularly of highly skilled specialist staff such as certain consultant specialities & GP’s. During 2014-15 a commitment is given to developing these plans. Page 49 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 9.4 Estates Strategy The CCG does not own any buildings, but as part of its strategy it needs to work with its key partners including primary care to ensure the implications of the Strategy are reflected in their plans, and that the estate is utilised effectively to ensure value for money. During 2014-15 the CCG will develop and ensure clarity on what the future implications will be and will produce an estates strategy by April 2015. 9.5 Contractual Levers Each year the CCG publishes its commissioning intentions on the website for the forthcoming year. This tells providers what we plan to do in more detail over the year in delivering our strategy. We strongly believe in using incentives both through the CQUIN process and local incentives to improve quality and effect service change and delivery. Performance and outcome targets are set and monitored. In this way we ensure we use the contractual process to deliver our strategy. 9.6 Financial Position The CCG has an allocation of £199,514k for 2014/15. Nationally the CCG allocation formula was amended in 2013, updating the 10 year old formula to reflect population, demographic and other changes and be equitable and fair across the country. The impact of this is significant for the CCG and it is indicating that the IOW CCG is over funded by about £35 million per annum. Figure 19: Local impact of CCG Funding formula Allocation 14/15 £’000s 199,514 15/16 £’000s 202,906 Target Allocation 164,342 167,297 Distance from target 35,172 35,609 Distance from target 21.4% 21.3% NHS England’s Board has adopted a pace of change policy to balance the need to address underfunding in services whilst not destabilising over target health economies. For the next two years the CCG will only receive growth equivalent to inflation. No information has yet been released on how the move to target will be achieved from 2016/17. This could have a significant impact on the delivery of the strategy and makes it even more important that service change is delivered. The CCG will be challenging the allocations formula on the basis of its unique position as an Island with significant diseconomies of scale, if it is to retain safe levels of services. 9.7 Risk Management The successful delivery of the CCG strategic priorities is subject to a wide variety of risk factors. Robust risk management processes within our governance structure are utilised to ensure risks are identified and mitigation strategies are implemented. The CCG Clinical Executive and Governing Body are informed about principle risks. Page 50 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 The overarching broad risks to the implementation of the Strategy are as follows: Risk Description Mitigation Controls The overall system’s financial risk is high. Financial risks include: Future impact of CC allocations formula. Reduction in management cost allowance. Council financial position. IOW NHS Trust financial position. Working very closely as a system to achieve service transformation and avoid destabilisation. Challenge to allocations formula based on evidence of need. Comprehensive savings programmes. Partners’ relationship and trust, where the challenge to each organisation is significant. There is a risk of organisations being protective and working against the best interest of the system. Set of principles for working together agreed. Open communication and sharing of issues. Formal and informal forums set up to discuss issues and agree delivery. Capability and capacity is a risk within organisations as the scale of the transformation stretches resources in terms of people and budgets. Strong programme management in place through the System Reform Board and MLAFL programme. Project support requirements identified and programme budget established. Joint commissioning strategies and plans do not deliver the scale of savings requested across the system. Continued performance management. Robust business cases. Contract levers and risk share arrangements. Page 51 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Appendix A Glossary of Terms Outcome Ambition Preventing people from dying prematurely National measure – Potential years of life lost per 100,000 population Baseline Measure 1801.2 Target 2018/19 1687.8 https://indicators.ic. nhs.uk/download/O utcomes%20Framew ork/Specification/N HSOF_Domain_1_S_ V2.pdf Direction Description Reduction The PYLL rate is calculated by weighting the number of ‘amenable’ deaths in a given year by the number of additional years the person who died might have expected to live in the presence of timely and effective healthcare. The average age-specific life expectancies for each five-year age band are used to weight the number of deaths in that age band to give the average number of years of life lost for that age band. The total number of years of life lost is summed for each age band and the result is expressed as a European age-standardised rate per 100,000 population. Plain English Description: The number of years of life lost by every 100,000 persons dying from a condition, which is usually treatable, measured in a way which allows for comparisons between populations with different age profiles and over time. https://indicators.ic.nhs.uk/download/Outco mes%20Framework/Specification/NHSOF_D omain_1_S_V2.pdf Enhancing the quality of life of people with long term conditions National measure – Average score for improving health related quality of life for people with a long term condition Units: total EQ-5D per 100 people with LTCs 70.40 74.73 Increase The indicator is based on the GP Patient Survey. Respondents are identified as having a longterm condition where answering ‘Yes’ to question 30 of the GP Patient Survey or select a long term condition in question 31. For all people who have stated in the GP patient survey that they have a long-term condition, health status is derived from responses to question 34 of the survey, which asks respondents to describe their health status using the five dimensions of the EuroQol 5D (EQ-5D) survey instrument: Mobility, Self-care, Usual activities, Pain/discomfort, Anxiety/depression. Answers to question 34 are described in terms of EQ-5D™ health states. For example, Page 52 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 if a person selected the best state for each domain, their EQ-5D™ health state would be described as 11111. All else equal, if the same person answered that they were ‘extremely anxious or depressed’, their health state would instead be 11113. The EQ-5D™ index has a maximum value of 1, which is assigned to patients who report the best possible health state for each of the five domains. Negative values imply a state of health worse than death. Plain English Description: This indicator measures health-related quality of life for people who identify themselves as having one or more longstanding health conditions. Health-related quality of life refers to the extent to which people: 1. have problems walking about; 2. have problems performing self-care activities (washing or dressing themselves); 3. have problems performing their usual activities (work, study etc.); 4. have pain or discomfort; and feel anxious or depressed. https://indicators.ic.nhs.uk/download/Outco mes%20Framework/Specification/NHSOF_D omain_2_S_V2.pdf Helping people to recover from ill health or following injury National composite measure – •Unplanned hospitalisation for chronic ambulatory care sensitive conditions •Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s •Emergency 1183.9 1121.4 Reduction Unplanned hospitalisation for chronic ambulatory care sensitive conditions Plain English description Indicator measures how many people with specific long-term conditions, which should not normally require hospitalisation, are admitted to hospital in an emergency. These conditions include, for example, diabetes, convulsions and epilepsy, and high blood pressure. Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s Plain English description This indicator measures how many young Page 53 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 admissions for acute conditions that should not usually require hospital admission •Emergency admissions for children with lower respiratory tract infections (LRTI) people (aged 0-18 inclusive) who have asthma, diabetes or epilepsy are admitted to hospital in an emergency. https://indicators.ic.nhs.uk/download/Outco mes%20Framework/Specification/NHSOF_D omain_2_S_V2.pdf Emergency admissions for acute conditions that should not usually require hospital admission Plain English description This indicator measures the number of emergency admissions to hospital in England for acute conditions such as ear/nose/throat infections, kidney/urinary tract infections and heart failure, among others, that could potentially have been avoided if the patient had been better managed in primary care. Primary care describes community based health services that are usually the first, and often the only, point of contact that patients have with the health service. It covers services provided by family doctors (GPs), community and practice nurses, community therapists (such as physiotherapists and occupational therapists), community pharmacists, optometrists, dentists and midwives. Emergency admissions for children with lower respiratory tract infections (LRTI) Plain English description This indicator measures the number of children (0 to 18 years) admitted to hospital in an emergency for some respiratory infections (bronchiolitis, bronchopneumonia and pneumonia). https://indicators.ic.nhs.uk/download/Outco mes%20Framework/Specification/NHSOF_D omain_3_S_V2.pdf Composite measure of avoidable emergency admissions Units: admissions per 1000 population. Numerator: total emergency admissions for any of the conditions considered avoidable. Denominator: total registered patients. Page 54 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Ensuring people have a positive experience of care National measure – Patient experience of GP and out of hours services Patient experience of hospital care GP Care 3.80 GP Care 3.69 Reduction Plain English description This indicator measures the proportion of people who report their overall experience of GP or out of hours services in the GP Patient Survey. Numerator: Total number of responses of either ‘fairly poor’ or ‘very poor’ experience across the two questions: -Overall, how would you describe your experience of your GP Surgery -Overall, how would you describe your experience of Out of Hours GP services Denominator: Total number of respondents to the survey questions http://www.england.nhs.uk/wpcontent/uploads/2013/12/stra-ophow-to-guide1.pdf Hospital Care 146.9 Hospital Care 142.2 Reduction Plain English description This indicator measures patient experience of inpatient care based on a selection of questions from the National Inpatient Survey. Numerator: Total number of ‘poor’ responses from 15 questions relating to the following areas: Access and waiting Safe, high quality, co-ordinated care Better information, more choice Building closer relationships Clean, friendly, comfortable place to be Denominator: Total number of respondents to the survey questions http://www.england.nhs.uk/wpcontent/uploads/2013/12/stra-ophow-to-guide1.pdf Page 55 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx Isle of Wight Clinical Commissioning Group Strategy 2014-2019 Appendix B Key References Isle of Wight Joint Strategic Needs Assessment 2011-2012. Available at: http://www.iwight.com/Council/OtherServices/Isle-of-Wight-Facts-and-Figures/JointStrategic-Needs-Assessment-JSNA NHS Outcomes Frameworks: Available at: https://indicators.ic.nhs.uk/webview/ Public Health Outcomes Frameworks. Available at: http://www.phoutcomes.info/ Adult Social Care Outcomes Framework. Available at: http://ascof.hscic.gov.uk/ NHS Comparators. Available at: https://www.nhscomparators.nhs.uk/NHSComparators/Login.aspx Page 56 of 56 K:\Corporate\Planning (working docs & guidance)\Strategy 2014-19\IW Clinical Commissioning Strategy June 2014 V5.docx
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