Draft Commissioning Intentions 2014/15 City and Hackney Clinical Commissioning Group.

Draft Commissioning Intentions 2014/15

City and Hackney Clinical Commissioning Group

Maternity Programme Board

Programme Board Objectives

• Ensure our maternity services are affordable, of high quality and improve patient experience

• Increase the numbers of women who book early• Improve the quality of the community midwifery• Early identification and provision co-ordinated care for

vulnerable and at risk women• Ensuring user views drive the service model and

improve quality

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Commissioning IntentionsEnsure our maternity services are affordable, of high quality and improve patient experience• On-going review and monitoring of Homerton staffing levels; • Roll out of friends and family.• On-going review and monitoring of the levels of care offered to pregnant women

Improving the care of socially vulnerable women: • Improving the services offered to vulnerable women• Agreeing the enhanced offer for vulnerable women• Roll out joint antenatal visits, midwifes and health visitors, for vulnerable women.

Review of community midwifery: • Improved patient experience; • Ensuring low risk births receive their care in the community rather than in a hospital setting; • Ensuring maternity services are provided in high quality, patient friendly compliant sites; • Improved access to community provision; • Improved communication between GPs and midwifes.

Review of antenatal classes• Review of the full spectrum of Parentcraft provision to see where improvements can be made• Input from the Maternity Services Liaison Committee parent reps• Review of settings and times of classes to increase accessibility• Training for midwifes

Urgent Care Programme Board

Commissioning IntentionsAccident and Emergency (A&E) performance

• Review of senior staff (decision makers) presence in A&E and compare against other London A&Es

Frequent attenders group

• To develop improved relationships with our practices, providing data and improved collaboration with other teams;

Improved winter planning

• Preparation and provision of additional funds to cope with recognised capacity challenges.

Observational Medical Unit (OMU) and associated pathways

• New pricing to be agreed to avoid duplication of costs;

• Increased utilisation and encourage direct referrals from GPs;

• Additional pathway development and implementation – Cellulitis is ready for implementation, Chest pain, Tonsillitis/Quinsy and sudden onset headache are under development.

Primary Urgent Care Centre (PUCC)

• Development of new service specification taking into account changing needs and the local environment.

Commissioning IntentionsOut of Hours (OOH)

•Embed new provider (City and Hackney Urgent Healthcare Social Enterprise (CHUHSE) into the system;

•Strategic marketing of service;

•Review likely implementation of additional sites to deliver base services closer to City and the rest of Hackney;

•Improved collaboration with local providers, delivering integration where possible.

Access in primary care

•Increase access and support for same day urgent appointments for practices;

•Development of the duty doctor responsibilities and activities;

•Increased interaction with Trust A&E and OMU regarding admission and discharge;

•Increased capacity for patient visits referred via community services;

•Extension of practice hours;

•To consider evening and weekend coverage;

•To consider individual and collaborative working for practice provision.

London Ambulance Service (LAS)

•Collaborative review and assessment of existing pathways and the current impact in order to agree necessary changes;

•Development of GP support to LAS paramedics in a car service. Pilot to be developed for January 2014 to provide support to emergency calls where GP intervention may help avoid conveyance to hospital and increased interaction with patients GP and community services.

Planned Care Programme Board

Programme Board ObjectivesCity and Hackney CCG aims to: • Improve the equality of healthcare for our registered patients• Ensure our health care system is affordable, of high quality and

improves patient experience• Work with our partners to reduce health inequalities and improve

outcomes

The Planned Care Board is responsible for commissioning services from hospitals that are arranged by your GP – for example outpatient appointments, planned operations as a day patient or inpatient. Our approach: • Agreed pathways for patients with GPs and hospital doctors working

together • Providing training to keep GPs informed• Hospital consultants providing support and advice • Services in the community

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Commissioning Intentions

Commissioning an integrated multidisciplinary community based pain management service • Educating and supporting patients to improve quality of life whilst continuing to live with

persistent pain. • Reduced uptake of interventional therapies (injections), promoting a psychosocial

approach • An increase in self-management strategies and tools• Increased peer support for service users with persistent pain

Total Knee Replacement Pathway • Improved health gain for people who have a Total Knee Replacement procedure • A simplified pathway reducing number of ‘steps’ in the process• Shared Decision Making with patients from all clinicians involved in the new pathway

Ophthalmology• Working with Optometrists to provide more testing for glaucoma in the community and

to increase numbers of people referred for a cataract operation direct from the optometrist after being supported to make an informed decision about the procedure

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Commissioning Intentions Dressings care • Dressings care will be provided by the right person in the right place through

a coordinated service model.• Commissioning specialist dressings care for venous leg ulcers from

community nursing service and commissioning for post-operative and ‘other’ wound care from a community provider(s)

Diagnostics • Re-commissioning diagnostic tests directly accessed by GPs • Increasing direct access booking for Colonoscopy as part of the

implementation of Cancer Best Practice Pathways

Community Health Services• Review of current service specifications for ‘Locomotor’ (physiotherapy)

Foot Health, Dermatology GPSI and Community Gynaecology services

Cancer - Early diagnosis • Working with primary care to improve early detection and treatment of

cancer, supported by the Planned Care Board cancer lead in partnership with Macmillan.

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Children’s Services Programme Board


• Improve the equality of healthcare for our registered patients• Improving the health and wellbeing of vulnerable children and

families in the longer term• Improve working arrangements between practices and

community practitioners;• To improve the management of long term conditions including

asthma, diabetes & epilepsy• Ensuring child mental health is a higher priority and that

assessment of a child’s mental wellbeing becomes routine across primary care

• Ensure we are commissioning child friendly services• Safeguarding children and young people

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Commissioning IntentionsImproving the management of LTCs in children: • Standardised care plans for children with a long term condition• Annual reviews for all children with a long term condition• GP Practices following up children & families who frequently attend A&E. • Patient education programmes to help children and families manage their long term

condition

Early identification and enhanced support for vulnerable children and families: • Early identification of vulnerable children and families and enable practitioners to

recognise, assess, plan and provide for children as well as parents who need extra support in bringing up their children.

• To ensure more pro-active care to address inequalities for those families who may not seek help.

• GP Practices to follow up children & families who frequently attend A&E.

Improving children’s mental wellbeing• Every family which completes a treatment with CAMHS/First Steps to be offered a follow up

appointment in primary care within 3 months of discharge• Every child who presents with self-harm/OD at A&E to be proactively followed up

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Delivering child friendly services

• GP Practices will be required to develop policies that ensure their services are accessible and child friendly following a Department of Health Framework.

• Developing child friendly leaflets

• Ensure practices have knowledge of the range children’s services available locally and how to refer

• Ensure the service provision, environment and atmosphere are young people friendly

Implementing the changes in special education needs (SEN) code of practice:

• Rolling out personal budgets for children with complex health needs;

• Working with the Local Authority and Education to roll out joint education, health and care plans for children with special educational needs and disabilities.

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Long Term Conditions Programme Board


• Improve the equality of healthcare for our registered patients

• Ensure our health care system is affordable, of high quality and improves patient experience

• Work with our partners to reduce health inequalities and improve outcomes

• Develop integrated out of hospital services to mitigate the increasing cost of hospital based unscheduled care

• Reduce the early death rates from cardiovascular and respiratory disease


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Invest in an expanded integrated care programme

• GPs proactively identifying people who would benefit from care planning, based on their risk of being admitted to hospital

• Multi-disciplinary care planning, including comprehensive geriatric assessment, regular review of care plans and help for patients from “care coordinators” to manage their care plans

• Pro-active home visiting for housebound patients who have a care plan

Additional investment in primary care to better identify and manage cardiovascular and respiratory disease, and other leading causes of illness and death in City and Hackney

• Building on work to date which has meant that C&H GPs now deliver some of the highest standards of care in London

• Extra focus on chronic kidney disease

• Making better use of existing data and systems to identify new cases

• Extra support for patient on diagnosis with extra long nurse appointments

Invest in a new fast track service to diagnose and treat people with atrial fibrillation

• Atrial fibrillation is a leading cause of stroke

Primary Care Quality Board

Programme Board Objectives– shared with LTC board







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Educational support to practices to deliver our plans for long term conditions

• Education and training re cardiovascular disease, respiratory disease, diabetes, hypertension, chronic kidney disease, all specifically tailored to meet the needs of GP, practices nurses, health care assistants and other members of the practice team

• Training in care planning to support integrated care with protected learning time to share good practice across City and Hackney

Helping practices improve quality through intra-practice working

• Enable practices to find the time to work together to share what works well, e.g., appointment systems, or to provide services for patients from neighbouring practices in order to improve equity of access to additional services

Additional support for those practices who need it the most

• Practices who have been identified by NHS England (who commission general practice) as outliers on measures of performance, e.g., GP Outcome Standards – practical support to these practices on reviewing systems and procedures

Mental Health Programme Board

Mental Health NeedChildren/adolescents • 1 in 10 children & young

people aged 5 - 16 have a diagnosable mental health disorder - around 3 in every class

• Only 25% access effective care

• Between 1 in every 12 and 1 in 15 children & young people deliberately self-harm – admissions have increased by 68% in 10 years

Adults• 1 in 6 at any time• 50% of all women & 25% of

all men are affected by depression at some time in their life

• 0.4% adults have a psychotic illness

• 5.4% of men & 3.4% of women have a diagnosable personality disorder

• Suicide is the greatest cause of male deaths < 35 years

• People with schizophrenia are likely to die 15-25 years earlier than others

• 30-50% of people with mental health problems are not acknowledged as having a mental health problem at consultation with GP

Seniors• 1 in 6 over 65 have

depression due to social isolation or physical ill- health

• Dementia effects 5% over 65s, 10-20% over 80

• 30% of over 65s in acute trust beds have dementia

In physical care services• Up to 50% of people in

outpatient clinics have medically unexplained symptoms

• 25% of all people with long term physical conditions have depression & die earlier

• Alcohol-related injury is approx. 24% of A&E presentations

• Stroke patients have anxiety rates of 30-49% up to 12 years post stroke

Rhiannon

Rhiannon

do you mean GPs do not recognise MH issues in 50% or that 50% of consults have a MH component?

Children and young people Adults

Children with parents who have mental health• 4-5 fold increase in onset of mental disorder

Children with parents who have substance use problemsChildren experiencing personal abuse or witnessing parental domestic violence

• 2 fold increase of all mental disorder (child abuse)‘Looked after’ children’

• 5 fold increased risk of mental disorderChildren with learning disabilities

• 6.5 fold increased risk of mental illnessChildren excluded from schoolTeen parentsYoung offenders

• 18 fold increased risk of suicide for men (15-17yrs)Young lesbian, gay, bisexual & transgender peopleYoung Black & minority ethnic groupsChildren in families living in socioeconomic disadvantage

• 3 fold increased risk of mental health problems (children from lowest quintile of household income)

Black & minority ethnic groups (7.9% of UK pop) Rates of schizophrenia:

• 5.6 times higher in the black Caribbean group• 4.7 times higher in black African group • 2.4 times higher in Asian groups

Homeless people• 11.3 fold increased risk in psychosis• 5.5 fold increase alcohol dependence

Unemployment• 2.7 fold increase in Common Mental Disorder

In debt• 3 fold increase in Common Mental Disorder

Adults with a history of violence or abuseAdults with alcohol or substance misuseOffenders & ex-offenders

• 20 fold increase in psychosis among prisonersLesbian, gay, bisexual & transgender adultsTravelers, asylum seekers and refugeesPeople with a history of being looked after/adoptedPeople with intellectual disabilities

• 3 fold increased risk in schizophreniaIsolated older people

Groups at risk

Our Target GroupsTarget Groups Headline InterventionsChildren and young people - Improved waiting times, access to psychological therapies, DNA and user choice

- Improved training for school nursing to identify early prodromal signs

- Every child aged 14 upwards thought to meet the EIP criteria will be assessed within 2 days

- All children and families social workers, residential staff and foster carers will receive basic mental health training to be repeated every 2 years

People new to services - Rapid assessment interface and discharge working within A&E and inpatient settings

- Wider skills and competencies for community based staff to recognise the signs of psychosis in order to enable swifter referrals

- Every patient to have a recovery plan and introduction to benefits and employment support

People with short term problems - Reduce waiting times from referral to assessment and treatment

- Expand the range of interventions available through IAPT to include IPT and brief interventions

People with ongoing problems - Review of Community Mental Health Teams and the role of EIT, AOT etc

- Improved inpatient standards including medication reviews, and a Patients Charter which reflects a minimum set of standards

- Improved access to MH support across LTC pathways and within acute carePeople with dementia - Improved screening and coding

- Improved support for patients and carers in the community

People with complex needs - Alcohol and substance misuse screening

- Improved referral pathways for eating disorders

- Integrated psychological therapies improving access at the right time for complex presentations (including Child Tavi?)

Our plans to improve performance

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Initiative What will be different/what will be the impact

By end of March 2015

Each practice to have access to an SMI management bursary to fund additional training and upskilling of staff.

- Increased levels of patients receiving care closer to home- Parity of esteem

Integration of voluntary sector reporting systems to support stepped care for common mental health problems

- Increased access points to MH services

Inclusion of Cluster 18 (mild/moderate dementia) patients in SMI LES

- Additional annual health checks for this cohort of patients- Reduced secondary care service costs

Development of Single Point of Entry for Psychological Therapies - Improved care pathways across psychological therapies with - Reduced DNA and drop out..- Increase in need being meet moving from 15% to 17% for common MH- Increase in concurrent employment support services

Develop a primary care oriented CAMHS Tier 1 approach which supports identification and case management within Primary Care (Hackney Healthcheck)

- A targeted mental health approach which identifies problems early and supports good emotional health within schools

Finalise a CAMHS development curriculum which will actively address concepts of recovery and community involvement within it, identifying people currently missing services

- A map local mental health services available to under 18s- A combined CAMHS and First Steps referral form- A family model of CAMHS provision within primary care offering a service to children and families not engaging with CAMHS services

Identify who is being missed completely (ie no depression or anxiety diagnosis) - working with public health to look closely at suicide figures, self harm, people on long term sick notes, MUS and repeat analgesics and anxiolytics etc.

- Increased numbers of patients receiving psychological support to help manage pain and medically unexplained symptoms- Provide a service for those patients repeatedly presenting in crisis but not then engaging

Develop a depression & anxiety element to the SMI LES which will actively address concepts of recovery and community involvement within it, identifying people currently missing services.

- Improved voluntary sector interfacing with IAPT and primary care based services for common mental health, increasing the options of support for SMI LES patients.

Revised Outcomes Framework across CAMHS services to an integrated model with sessional reporting

- All providers delivering high quality care to the same standards across statutory and non-statutory

Our plans to address user concerns

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By end of March 2015

Discharge Counselling for medication - 100% of patients to receive discharge counselling improving compliance and reducing readmission

Social marketing of emotional wellbeing resources - Improved self-care amongst MH patients with a refocus on community and personal assets

Recovery planning - All patients to hold a user-defined recovery plan- 100% of patients to be given or offered a printed copy of their care plan

Advocacy - All patients to receive an easy to read version of the Care Review process to include information on advocacy.

Alcohol - 100% of patients to be asked about their alcohol intake and brief interventions/treatment initiated where relevant

Carers - All carers to receive an assessment and signposting to support

Crisis - Timely access to crisis which uses inpatient resources effectively and at the right time

User voice - Pan borough User Advisory Group to influence and inform commissioning decisions.

Employment support - Employment support services coterminus across service provision. This will involve coordinated work with Job Centre Plus.

Prescribing Programme Board

Introduction

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• Medicines are the most frequent intervention and cost the NHS over £12 Billion in

2011

• If used appropriately, medicines can make significant impact on reducing morbidity,

mortality and demand on other health resource

• Research has shown that at least 6% of emergency admissions are due to adverse

drug reactions and that up to 50% of prescribed medicines are not taken as intended

• City & Hackney CCG will spend approximately £27M on medicines in 13/14 - this

medicines expenditure is likely to grow annually

• Effective management medicines activities will enable City &Hackney CCG to:

– secure efficiency and value for money through cost effective prescribing choices

– improve patient outcomes

– ensure quality of medicines used in commissioned services

Our plans to improve clinical outcomes

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By end of March 2015 By end of March 2016

Adherence and improvements in Clinical Outcomes

• Medication review of prioritised patients in key clinical areas

• Cardiovascular • Respiratory• Mental Health • Improved use of medicines to

prevent morbidity and hospital admissions in the prioritised areas

• Subject to level of funding make available to each C&H practice, medication review for all prioritised clinical areas

• Improve adherence & clinical outcomes of patients with cardiovascular, respiratory and mental health

• Reduce medication waste

Adherence - Increase patient engagement http://www.nice.org.uk/CG76

• Identify through patient groups – gaps in medication reviews/ use reviews

• Improved provision of information for patients on appropriate ordering of repeat prescriptions

• Increased access to medication related counselling for patients Improving patients awareness and uptake of medication review / Medicines use review schemes

• Improvements in patients’ knowledge about the medicines that they take

http://www.nice.org.uk/CG76

Our plans to address members concerns

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At the June 2013 – CCG Prescribing Forum, practices identified areas of concern - clinical areas to be addressed as follows:

By end of March 2015 By end of March 2016

Prioritising clinical outcomes over cost savings Reviewing how we align cost effectiveness of prescribing with clinical outcomes

Measuring the impact of medicines related interventions on morbidity and hospitalisations

Clarification about recommendations from the Pain Clinic Pain guidelines – development and practice implementation

Measuring impact of Pain pathway and prescribing guideline on prescribing and hospital services

Review of combined drug inhaler use Respiratory Medication reviewsImproved implementation of NICE/BTS guidelines on Asthma and COPD

Continuation of Pharmacist support at individual Practice level

Each practice to be offered support from dedicated Pharmacists (pending funding) to support quality improvement of prescribing

Each practice to be offered support from dedicated Pharmacists (pending funding) to support quality improvement of prescribing

An overview of the relationship between our future plans and our strategic objectives

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Area Strategic Objective Activity Future plans

Medicines Optimisation Strategy



Patients supported with medicines takingSafe use of medicines in all settings

• Respiratory pharmacist to extend medication review pilot which has ↑ QoL, adherence to therapy, ↓ unnecessary prescribing

• Medication reviews in care homes • Use of "NHS Informatics" tool to relate outcomes/ prevalence data to prescribing,

use of ScriptSwitch • Continued use of sessional pharmacists to identify opportunities for medicines to

be optimised within practices

Effective Formulary, prompt implementation of NICE guidance


NHS constitution and NICE funding direction are met

• Continued management of the eBNF following launch in 2013. This joint project between CHCCG and HUHT will support DoH requirements for Innovation, Health and Wealth.

• Future NEL wide formulary to improve quality and cost planning

Effective local decision making arrangements



Robust process for entry of new medicines, safe/effective systems in place for considering individual funding requests

• Continued collaboration with NEL Medicines Management Network, impact of new drugs being identified

• Strengthened management of Individual Funding Request process

Cost effective use of medicines and budget management


Expenditure data, future strategic plans, management of payment by results excluded drugs

• Sessional pharmacists will continue to deliver QIPP plan and generated savings to enable CCG to stay within prescribing allocation and reduced inappropriate prescribing

• Budget updates and forecasts provided regularly, improved processes in the management of HCD to reduce variation for C&H patients

Continued development of relationship with community pharmacy


Effective methods of communication established with community pharmacy

• Future plans to train community pharmacists to provide CVD and respiratory interventions and motivational interviewing for patients on long term medication

Advice available for safe handling of medicines provided or commissioned by CCG


Ensuring access to medicines out of hours, development use and monitoring of patient group directions (PGDs), medications governance and policy

• Development of audits to encourage reflection on current practice and to support implementation of procedures where deviations from safe and effective practice had been identified

• Monitoring of Serious Incidents and effective use of PGDs

Draft Commissioning Intentions 2014/15 City and Hackney Clinical Commissioning Group.

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