CKWCB-12-186f_North_Kirklees_DCO_Report_Cluster_Board_Report_Sept_2012__final__NKCCG

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Report Author: Chris Dowse, Shadow Accountable Officer, NHS North Kirklees CCG

Report to: CKW Cluster Board 27th September 2012

Subject Summary Actions Quality and Safety

Quality is a key governance priority for North Kirklees, recognising the role of CCGs in creating a culture which supports continuous improvement. As a subcommittee of the Cluster Board the governing body has the responsibility for scrutinising and gaining assurance in relation to the three domains of quality; safety, effectiveness and experience and the role of the Quality and Safety Group is to provide this assurance to the governing body. The group receives regular reports which collate information about quality, safety and experience from various sources.

Patient Safety

Early Supportive Discharge In December 2011, the MYHT were awarded provisional accreditation at Level 2 hyper acute (including acute and rehabilitation), subject to a number of improvements being made within the next six months. The decision made by the reviewers was that further assurance is needed in order for the stroke service to be fully accredited. They noted that great progress had been made towards the development and implementation of the panel’s recommendations. This included the improvement in SALT

SHA informed of ESD plans and commencement date.

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capacity, 24/7 stroke specialist assessment and 6 week/6 month follow-up arrangements. However, there were concerns from the reviewers where further action is required before full accreditation is awarded:

• Recruit to the two new stroke/neuro consultant posts and align job plans to allow delivery of a 24/7 service. It was confirmed that the interviews for these posts are being held in September with an intended start date of December 2012;

• Recruit to vacant SALT posts, although it is recognised that the national shortage of therapists has inevitably impacted this area of the workforce;

• Lack of progress in developing and implementing a solution for Early Supported Discharge care for Dewsbury stroke patients. It was confirmed by North Kirklees CCG that Locala will deliver this service from 1 October 2012, operating as an early implementer, while the full review of rehabilitation services is completed.

The monitoring of the actions is through the Stroke Management Group, which includes commissioner representation. A further visit is scheduled for December 2012 to ensure that the consultant posts have been filled, and the Quality Review Group will receive an update in January 2013. HSMR The NKCCG Quality and Safety Group scrutinised the MYHT HSMR action plan during its August meeting. Currently the

The group escalated two issues from the Quality and Safety

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high level data suggests:

• Palliative care coding has fallen from 94% to 58%

• HSMR for non-elective admissions are likely to rebase as outliers

NKCCG has a GP on the MYHT HSMR task and finish group. The group identified that patient transfer coding issues mean that HSMR rates are having an impact in terms of coding for the DDH site.

Paediatric Diabetes Peer Review (March 2012)

Dewsbury- No immediate risks were identified, but serious concerns were raised regarding access to a named psychologist, adequate support from CAMHs and insufficient dietetic support. Some concerns identified were common with Pinderfields/Pontefract, but others included the need to establish weekly MDT meetings, implementation of key worker policy and the routine introduction of Multiple Daily Injections (MDI) at diagnosis in line with best practice. Areas of good practice identified included:-

• Impressive reduction in HbA1C levels;

subgroup to the MYHT Executive Contract Board. Firstly, concern that the action plan was led by a service matron (this has now been changed to the Medical Director) and secondly the action plan focussed on coding rather and needed to be strengthened in terms of auditing compliance of care delivery against standards; such as the timeliness of IV antibiotic administration for patients with suspected pneumonias. This will be made more explicit in future versions of the action plans.

It was agreed that an action plan would be developed to capture the work being progressed, which would be presented as additional assurance to the next Quality Review Group. This would also be shared with children’s commissioners.

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• Piloting and developing the paediatric template on SystmOne;

• Increased target for the number of children using pumps.

The August Quality Review group were assured that a number of actions are being taken to address the concerns identified. Some of these have been completed – including thirty minute slots for every child and an additional dietetic post advertised – and others are ongoing. The key action is the development of a business case to secure additional resource for the dietetic cover and administrative support.

The process is being managed through the Diabetes Network and Children and Young People’s NSF Task Group, and commissioners meet with the paediatric team every six weeks

Experience

MYHT Outpatient and Inpatient Experience

The MYHT Composite Action Plan which includes inpatient and outpatient survey results was reviewed by the August NKCCG Quality and Patient Safety group. It was agreed that due to the size of the document it would be more beneficial to review the key areas at the next governing body meeting to discuss with clinical board members.

The group agreed that the report is useful to look at in future

Key points from the document are being escalated to be included in the MYHT Outline Business Case; particularly to ensure that and OBC includes Outpatient appointments for all specialities being available on the DDH site; access to Outpatient services being increased to six days per week and MYHT operating a

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planning and ways forward.

2011 Staff Survey (MYHT) Further to discussion at ECB in May 2012, the Quality Review Group received information on the following areas:

• The disaggregated position for the question on

whether staff would recommend the Trust as a place to work or receive care and treatment.

The information shows that 49% of staff agree or strongly agree they would be happy with the standard of care provided if a friend or relative needed treatment; and 43% would recommend the Trust as a place to work. The data was also split by service area and showed a range of 59-29% for the first question and 73-7% for the second. The lowest specialty for both questions was women’s services. The key findings for different sites will also established whether the transfer of community services had impacted on the results compared to previous years.

Of the 38 key findings, staff in community services scored lower for 7 compared to the hospital sites and higher for 14 areas, which indicates that the community services have not impacted negatively on the results and the overall survey results are lower than last year

fully functioning choose and book system.

The Quality Review Group expressed concerned about the first area and agreed to ensure ECB challenge the impactof the actions being implemented following the survey results when the paper on the Making it better together programme is presented.

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Effectiveness

Performance reported in the performance report and the dashboard National Lung Cancer Audit-

The National Lung Cancer Audit was considered at the NKCCG Quality and Safety Group. Areas of significant interest are as follows;

63.1% of patients are seen by a clinical nurse specialist which is below the recommended 80%

Surgical resection is below the national average of 12.2% at 11.6%

There is currently an on-going issue with late presentation of lung cancer across the Yorkshire Cancer network

Access to a clinical nurse specialist is a significant issue due to insufficient numbers of suitably experienced staff

It was also noted that there is an issue with transfers of patients between Mid Yorkshire to Leeds NHS Trust and it was agreed that this would be discussed further with the Cancer lead and feedback at the next meeting.

CQC Compliance

Discussion was had about access to clinical nurse specialists and it was agreed that the CCG Cancer Lead would be tasked with triangulating this information with that from the Yorkshire Cancer Network and the PH observatories to understand what this data is telling us for patients in North Kirklees and then agree further action needed.

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The CQC performed an unannounced inspection in July to Ward 2 at Dewsbury District Hospital and Maternity Services at both DDH and the Pinderfields Site.

Following this inspection a formal warning has been issued to Mid Yorkshire regarding serious concerns on Ward 2 where issues with treatment of patients with regard to dignity and respect and also staffing issues. (CQC Outcome 1- Respecting and Involving people who use services- Major concern; CQC Outcome 13- Staffing- Moderate concern.)

During this inspection Maternity Services on both sites were found to be fully compliant with the Essential Standards as set by the Care Quality Commission.

A remedial action plan has now been put into place, which has included the closure of Ward 2. This has been scrutinised by the Heads of quality for NKCCG and NHSWCCG and has discussed in further detail at the August Executive Contract Board.

On the 6th

of September 2012 the CQC inspected Gate 40 (day case unit) at Pinderfields hospital against the following Essential Standards (CQC Outcome 1- Respecting and Involving people who use services; Outcome 4- care and welfare of people who use services, Outcome 8- Cleanliness and Infection control and Outcome 10- safety and suitability of

Remedial action plan continues to be monitored via the ECB

Verbal update to be given to the board.

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premises)

All other compliance reports relevant to North Kirklees are included in the performance report being presented to the Cluster board.

National Audit of Psychological Therapies for SWYPFT

The National Audit of Psychological therapies for SWYPFT, where discussed at the NKCCG Quality and Safety group in August.

It has been reported that SWYPFT were rated in the bottom 25% of services when benchmarked against other national services. However SWYPFT have stated that the services have progressed since the audit and that the findings do not reflect the current position.

The group reviewed the action plan provided by SWYPFT and noted the report.

Maintaining Quality & Safety – ‘How to’ handover guide

The Quality and safety group received the action plan and legacy document in response to the National Commissioning Board guidance spelling out to maintain quality through the transition between PCTs and CCGs.

Concerns were raised over the number of patients initially being referred being seen face to face and how many patients are receiving phone consultations. This has been escalated to the next SWYFT Quality Board for a response.

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The report sets out the process the CKW cluster will take to handover to the CCGs in March 2013.

Safeguarding children

CQC/Ofsted Inspection of Safeguarding Children Action Plan

The CQC/Ofsted inspection of Safeguarding and Looked After Children’s Services began on 3 October 2011 and the joint inspection report published on 18 November 2011. The CQC report on the outcome of the Integrated Inspection of Safeguarding and Looked After Children’s Services in Kirklees was published on 21 December 2011.

An action plan to address the recommendations in the CQC report has been developed and submitted to NHS North of England and the CQC on 3 January 2012. The action plan has been monitored through the Quality & Safety Sub Group and evidence collated accordingly.

Health Visitor Placements The SHA has allocated the Trust 27 student placements for the next academic year and commissioners expressed a level of concern about the risk associated with the increased level of placement required when the current service has capacity constraints. It was confirmed that the SHA’s formula for allocation had been challenged by commissioners, in an attempt to support the Trust and ensure adequate service delivery continues.

The Quality and Safety Group and Quality Boards have initiated challenge to three providers in relation to the quality of evidence they have submitted as assurance they have completed their actions. The Quality Review Group agreed to receive the risk assessment at the October meeting and scrutinize the actions identified to mitigate the

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The Trust confirmed that they will be able to accommodate the 27 placements and a full risk assessment has been undertaken to mitigate any associated risks. The risk assessment has been revisited since the change of nurse leadership within the new integrated care division and a number of alternative actions suggested.

risks associated with accommodating the student placements

Performance The 18 weeks RTT admitted pathway performance for NHS Kirklees at MYHTs has slightly increased from May’s position. May was 85.9% and June's validated data is showing 87.9% against a standard of 90%.

18 Weeks RTT

The projected July 2012 position for the admitted pathway is 90.76%, and 92.38% excluding plastics, both projected to achieve above the 90% standard. The specialties not achieving the 90% standard individually for June for NHS Kirklees and all providers are; Trauma & Orthopaedics 89%, Neurosurgery 50% , ENT 82%, Gynaecology 89%, Oral Surgery 80%, and Plastics 89%. The overall MYHT 18 week position is as follows;

The 18 week recovery board continues to meeting on a weekly basis, scrutinising both the backlog position and the in month performance of all 18 weeks Operational Standards. The focus is at speciality level ensuring that the recovery plan is on track and issues identified at the earliest stage. Commissioners agreed that in order to reduce the backlog position, the in month admitted performance

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Admitted; • 90.65% projected performance for current month admitted position • Specialties projecting below 90% are at present ENT, Plastic Surgery and Urology • 632 admitted waiters above 18 weeks (11%) • 251 admitted no patients above 18 weeks • 98 trip overs to book for current month (18 week yes pts) • 679 projected month end above 18 week position Non admitted; • 971 non admitted waiters above 18 weeks (5%) • Month to date position is 96.8% completed performance • Specialties projecting below 95% are at present ENT, Gastroenterology, Neurology, Orthopaedic and Plastic Surgery • 1558 TAL’s of which the longest wait is 22 weeks in Ophthalmology • 5209 follow up’s pt’s outstanding who were due prior to the current month (review backlog) Incomplete combined; • 93.5% combined overall incomplete 18 week position.

Mental Health

The Q1 position shows the number of people on CPA as 157, and the number of people followed-up within 7 days of discharge was 147, resulting in a Q1 performance of 94% achievement against a plan of 100%, but, the national minimum standard is 95%, however, this does not alter the

would suffer as a consequence and that it was accepted that 90% would not be achieved until the start of Quarter 2. Un-validated July data projects that the 90% standard will be achieved. SWYMHT has launched an internal investigation.

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'traffic light' performance assessment in this instance. The reason for the under-performance was owing to the Care Co-ordinator and the Lead Manager being on annual leave at the same time.

Smoking Quitters

The most up to date complete data is for 2011/2 year end. The annual target was not achieved, although performance in the final quarter was significantly increased within both the intermediate service and the specialist service resulting in a total of 2,251 quits against a target of 2,677. It should be noted that only a small percentage of quitters access NHS stop smoking services. Successes in reducing smoking rates in recent years means that it is those most addicted and those least likely to want to quit who the services are now trying to engage. The Intermediate service target accounts for 80% of the Kirklees target with the Specialist Stop Smoking Service the remaining 20%.

Complete data for Q1 2012-13 is not yet available due to the delayed reporting system for the Intermediate Advisor service.

Various initiatives to address activity are being developed, these include: an audit of the pharmacy LES and voucher scheme activity and a review of the GP LES in order to identify priority pharmacies/practices to engage and work with (links have been made with GHCCG & NKHA Respiratory Lead around this); work with dental contracting to explore ways to increase take-up of the dental LES; and a pilot PbR project with up to 3 voluntary/community organisations.

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Choose and Book

Performance for Kirklees is slightly above the Regional average of 52.1%, and National average of 51.3%, standing at 54.0% for July. This is however a decrease on the April position of 55.5%. The under-performance is a combination of issues which include migration of practice computer systems with resultant short-term reduction in use, and periods of unavailability of slots.

Information to Patients

Nationally, there is a very small number of practices utilizing certain parts of the functionality in respect of this indicator: Within NKCCG, no practices as yet, provide patients with:- • Direct access to test results; • Direct access to Letters; and

The CCG Choose & Book Lead Manager is activity working with individual practices to improve the low utilisation rates.

NK CCG choose and book champion is currently working with practices to understand the issues that practices are experiencing.

Appointment Slot issues (ASI) are being addressed by the MYHT contract Management Group and assurance as been given the ASI percentage currently above 30% against a national standard of 5% will start to reduce as a consequence of the 18 week underperformance being back on track.

A point to note is that the current

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• Direct Access to Full patient record. NHS Kirklees IT lead, and the data quality team, are increasingly beginning to raise the patient access agenda at Practice Managers meetings, the SystmOne User group, and with the CCG’s IT clinical leads and will continue to provide support to enable the further roll out of this type of functionality.

major IT clinical systems only have limited functionality available and we are awaiting development of patient access functionality of both the GP clinical systems, SystmOne and EMIS.

The Governments 10-year Information Strategy, is that patients will be able to view their GP record online by 2015 that over time will extend to all health records held by all Providers.

Actions to take this outcome/measure forward, is to be discussed and agreed at the September Executive Committee Meeting and to enable the informed decision making process, a copy of the outcome/measure technical guidance, Overview paper and Position Statement, is enclosed with the Performance Report.

Finance, QIPP and Contracting

Finance

• August Financial Position balanced, and forecasting achievement of financial targets at year end.

• Currently reviewing plans for non-recurrent investment in year to support delivery of transformational work

Governing body task and finish group to decide how best to present and manage practice level budgets for 2013 onwards

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streams.

QIPP

• QIPP plans in place for 12/13, monitoring being done using Performance + system. Forecasting achievement of overall total at year end.

Risks

• Risk that MYHT financial position is not able to be managed by the Trust itself without the support of commissioners.

• Failure to deliver the required level of QIPP over the next 3 years.

• No specific financial items escalated. To note that the CCG (and F&P) reviewed re-ablement and the joint investment plans previously agreed with Local Authority. Additional investment of £285k (shared with GHCC) agreed in mobile response service, funded from the national re-ablement allocation.

Items escalated from F&P Group

Contracting

Current pressures on our contracts continue to be, as before,

Completion of assurance process on 12/13 schemes followed by planning rounds for 2013/2016 starting October 2012.

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within emergency activity. The increased activity is based on both last year’s data and against our plan. Emergency spells at MYHT continue to grow and at month 3 flex are 16% above planned levels.

Any Qualified Provider Assessment of the AQP suppliers of Adult Hearing Services has now concluded and letters have been sent to successful and unsuccessful suppliers by the regional Qualification Centre of Excellence.

The procurement processes for prioritised Any Qualified Provider services are now drawing to a close. The governing body received an update and agreed recommendations covering the following key areas:

AQP procurement for Adult Hearing Services (Cluster-wide), MRI (Cluster-wide), Non-Obstetric Ultrasound (Cluster-wide) and Psychological therapies (Calderdale only) has followed a nationally-coordinated process.

Following national checks and regulatory assessment, service-specific review of providers has been carried out for CKW by assessment teams involving clinical, quality, service and contract/management leads from across the four CCGs.

A standard national assessment framework has been used throughout, together with an electronic assessment tool that has ensured compliance and maintained an audit trail of the

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process. The overall process has been supported and monitored throughout by the relevant regional Qualification Centre of Excellence.

Adult Hearing Services: Procurement process has concluded. Successful and Unsuccessful bidders have been notified. Successful bidders are being contacted to finalise contracts and agree mobilization.

Diagnostics: NOUS and MRI: Advert window has closed. Assessment is at advanced stage.

IAPT: Advert window has closed. Assessment is underway.

The expected contract value to each new supplier is likely to be less than £100k for the contract period (to 31st March 2013). However because of the uncertainty associated with introducing new suppliers, a cautious assumption of value up to £250k has been agreed with Ian Currell when considering appropriate governance routes and to ensure compliance with Standing Financial Instructions. This means that each new contract will be signed by a Designate Chief Officer and either Cluster Chief Executive or Cluster Director of Finance.

The expectation is that CKW will meet the DH requirement for three AQP services to be operational by end September 2012.

Governance and Risk Risk

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NHS North Kirklees CCG continues to present all high level risks to the governing body on a monthly basis. In addition each month a Head of Service presents all of their service risks. In July the quality and safety risks were presented and in August the Finance risks were presented. NHS North Kirklees CCG has 15 risks logged on the risk register; 2 of these scoring above 15.

• Risk that MYHT financial position is not able to be managed by the Trust itself without additional financial support from commissioners over and above the level of income earned by the Trust from delivering services.

• The transformational workstreams for unplanned care do not deliver the required change and financial benefit to mitigate the increase in demand and the impact of the trusts’ clinical services strategy.

In addition there is a significant risk that NKCCG will breach its HCAI objectives due to present trajectory. In 2012/13 (NKCCG) the National HCAI objective for MRSA bacteraemia is no more than 10 cases in 2012/13. Seven MRSA bacteraemia cases reported in Kirklees residents - 1 April - 10 August 2012.

Development of the Governance Processes and Structure

Further to the last update, the following items have progressed within governance arrangements for North Kirklees;

• Committee Structure now agreed by SMT • Governing Body structure has been approved by the

Clinical Commissioning Executive

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• Draft Terms of Reference have been shared with Internal Audit Colleagues for review

• Strategic Objectives have been approved by the governing body

• A draft constitution has been shared with management colleagues and shared with the governing body on Friday 7th

• A session has been arranged with the governing body to commence the population of the Assurance Framework, this will be led by Internal Audit colleagues.

September 2012

Managing the transition and workforce

Authorisation

Wave 4 surgery took place on 13 September. Wave 1 lessons learnt conference call 18 September. The CCG will submit its application in line with the planned timescale of 1st November. The CCG has held and attended multiple stakeholder meetings and events with patients and the population. Overwhelming interest to our advertised meet and greet sessions has created the need to hold multiple events with our stakeholders. Feedback from the voluntary and charity sector 'speed dating' event 5 September, has been extremely positive and the CCG will be taking forward these new relationships to work together towards achieving the vision. 360 survey period is in progress, opening on the 10 September and closing on the 5 October 2012. Regular development sessions take place for the CCG, governing body and management team. Dedicated coaches

Submit application on the 1 November 2012. Further stakeholder events: 19 September, 10 October.

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have been engaged for managers, board members and the team. Future sessions to ensure compliance and development include:

• Equality and diversity • Safeguarding adult and children • Strategic planning • Preparation for assessment

Risk in relation to delivering authorisation has been reduced through the implementation of a dedicated project manager into the team. Authorisation risks are presently zero and one issue is being managed, resource being moved from supporting the CCG without notification had a detrimental effect on delivery of a key strategic document. A remedial action plan is in place and progressing to plan. The memorandum of understanding with public health has been agreed and will be signed off through Audit and Governance committee in September and CCE in October. Key strategic documents such as Equality and Diversity and PPE and Communications are in final draft stage ready for approval by the end of October.

Workforce Transition

The sickness absence in Kirklees has dropped significantly down to 1.5% for July. This is well below the expected sickness

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rate for Commissioner Organisations which stands at 2.5%. Formal consultation has now commenced across the CKW Cluster with staff whose functions are destined to transfer to either a CCG or the West Yorkshire Commissioning Support Service. As part of the formal consultation, CCG structures were released for consultation on Monday 30th July 2012, with a deadline of 31 August for feedback to be received. The CSS structure was released for staff for consultation on Wednesday 22 August with a deadline of 7th

September for feedback.

The Department of Health’s pooling & matching policy was finally released on 1 August 2012. The joint local interpretation of the policy by CKW and Airedale, Bradford & Leeds Clusters was released to staff week commencing 13 August 2012. Pooling and matching in both the CKW and ABL Clusters is now scheduled to commence in September 2012, following the conclusion of the consultation on organisational structures.

NHS North Kirklees CCG Specific Information

Steve Brennan has been appointed as its designate Chief Finance Officer. Interviews were held on 6 September for the Secondary Care Doctor and Registered Nurse, appointees will be announced as soon as appointments are made. The interview for the designate chief officer will take place on 21 September.

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Lay member advertisements have now closed and short listing is due to take place next week. Draft structures were shared with employees of Kirklees and on the intranet on 4 September 2012. Ongoing discussions are in progress with the CSU in order to finalise a cost effective and value for money structure across the 2 organisations.

Transformation

Mid Yorkshire Health and Social Care Partnership Programme Board

North Kirklees CCG has agreed a set of principles which it will use to test developments on MYHT’s clinical services strategy in order to assure itself of the robustness and acceptability of the emerging options for service changes. These have been shared with MYHT. Detailed discussions are underway to test and support work on the planning assumptions for the Outline Business Case. In partnership with Wakefield CCG and MYHT, detailed analysis of the activity modelling that supports the service options continue. As CCGs we are clear about our responsibilities to fully understand the assumptions, baseline data and scenarios modelled. We continue to challenge these assumptions including those for capacity planning to ensure we have the right information to factor into our transformation programme.

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Transformation Programmes

Urgent Care The Urgent Care Transformation Board (for NKCCG and Wakefield CGG) met and agreed a direction of travel and ‘starter for ten’ projects to get the work underway. These include efficient streamlining at front doors to A&E (GP streaming, walk in, ambulances); rapid, clinical assessment and decision making in A&E; efficient and timely discharge; and, development of clinical dashboards for primary care. More work is being done to understand the detail behind the data we hold for urgent care which will help us accurately target our effort. Care at Home/Close to Home The first Workshop across the Mid Yorkshire economy has now taken place and the first Board meeting will be held on Friday 7th

September 2012.

Key discussion will be what can be developed as a single approach where possible across the partnership and also what can be developed at scale and pace to implement the changes required to meet the community requirements of the CSS.

Capacity to meet the timescales of the planning process for the MYH&SCP for the OBC.

Areas of risk

Analysis of urgent care data to inform Transformation Board agenda and influence winter planning via Operations Board.

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Earlier this year, and following considerable discussion with partners, Greater Huddersfield CCE approved a proposal to tender the tier 3 CAMHS service currently provided by CHFT. Both North Kirklees and Calderdale CCEs also approved this proposal and a procurement programme board for this exercise is now underway. This group is made up of representatives from across the 3 CCGs, and is chaired by myself.

CAMHS Tier 3

The advert for Expressions of Interest was placed on the Supply to Health website on 10 August, with pre-qualification questionnaires to be submitted by 10 September. It is anticipated that a recommendation on contract award will be brought to the Cluster procurement sub-committee in late December/January. Risks – all current risks have been identified and recorded on the CCG risk logs so they can be highlighted and managed.

The CCG has commissioned the ESD for Stroke service that will be operational from the 01/10/2012.

ESD for Stroke Care

Innovations within primary care: Primary Care Development

• Development of the primary care quality matrix. A wide

representation from primary care into the development of this matrix. An event has been organised with the

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clinical board members and the practice manager leads from the steering group to plan the dissemination and spread of good practice within the practice cluster groups .Support will also be offered from O/D colleagues around the possible impact the information will have, the reaction from individual GP’s and how this might be managed.

• The aim of the matrix is to reduce variability within general practices promote and spread good practice through peer challenge and support.

• Application submitted for a SHA bursary of £42k to underpin Innovation Health & Wealth implementation within primary care A number of general practices have become aware of a number of electronic solutions to the effective telephone triage of patients who wish to access their GPs on an ongoing basis. The solution will facilitate the practices ability to reduce the levels of patients who currently appear not to be able to access services in a timely manner and as a direct consequence result in an emergency attendance at a local hospital. It is advocated by the providers of the solution that emergency attendances at a secondary care provider could be reduced by as much as 20% and that £ms may be saved as a direct result.

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In order to test this hypothesis NKCCG proposes to incentivise 5 practices to be able to run a pilot of the active use of one of these systems and either prove or disprove the theory.