Equal and fair access to safe, effective and responsive health and social care for our communities that
represent value - now and in the future
Our Strategy for Commissioning Better Health 2014-2019
Table of Contents
Page No.
Foreword
7
Introduction
10
Executive Summary
12
Section 1: How we operate
15
1.1:
Our organisational values
16
1.2:
CCG governance and management
16
1.3:
Managing performance and risks
19
Section 2: Where we are now
22
2.1:
Context
23
2.2:
Demography and changing need
23
2.3:
Health profile
30
Page 2 of 175
Page No.
2.4:
Joint Strategic Needs Assessment
32
2.5:
What local people tell us
35
2.6:
Workforce challenges
38
2.7:
Estates and premises
39
Section 3: Where we want to be
40
3.1:
National drivers for change
41
3.2:
Local drivers
44
3.3:
Our vision, aims and objectives
47
3.4:
Measuring success
50
¾ Improvement Goals
56
Page 3 of 175
Page No.
Section 4: How we will get there
57
4.1:
Our overall strategy
58
4.2:
Our transformational programmes
68
¾ Our plan on a page
71
¾ Our planned initiatives in 2014-16
73
¾ Primary Care
74
¾ Mental Health
81
¾ Urgent Care
86
¾ Elective Care
90
¾ Collaborative Commissioning
95
Page 4 of 175
Page No.
4.3:
Enablers
103
¾ Integration: A Modern Model of Integrated Care
104
¾ Better Care Fund
104
¾ Finance
107
¾ Workforce
107
¾ Research & innovation
110
¾ Information technology
110
¾ Estates and premises
111
¾ Stakeholder engagement
112
¾ The health economy
114
¾ Tackling health inequalities
118
¾ Improving quality
118
¾ Commissioning
120
Page 5 of 175
Page No.
Section 5: Sustainability
133
5.1:
Financial sustainability
133
5.2:
Environmental impact
137
5.3:
Sustainable transformational change
137
Glossary
139
Alternative Formats
146
Contact us
149
Appendices
Appendix 1: Organisational values and behaviours
150
Appendix 2: National drivers for change
156
Appendix 3: Improvement Targets
161
Appendix 4: NHS England and Public Health Commissioning
167
Page 6 of 175
Foreword
Clinical Commissioning Groups are the statutory bodies responsible for commissioning local health services for local communities.
The people we serve deserve to have a premium quality health service, where commissioners and providers work seamlessly
together to optimise the total resources available for the benefit of patients.
Working together, Chorley and South Ribble and Greater Preston Clinical Commissioning Groups have engaged with key
stakeholders in the wider local health economy and with local people to identify priorities for improving health and health care. This
has informed our strategy for the next 5-years and will influence our commissioning decisions during that period.
Last year was our first year of operation and through the leadership of local GPs we published our inaugural delivery plan. This set
out our blueprint for commissioning improved health care as a new organisation.
We want to create a radically new healthcare system which is patient centred, efficient and effective, combining improvements in
patient experiences, better health outcomes for patients from healthcare providers, and better use of wider NHS resources.
We set out to do things differently and have quickly developed strong and effective relationships with key stakeholders in the wider
health economy in order to deliver our plans.
We have made an excellent start in our first year of operation and our Annual Report for 2013/14 (add as a hyperlink) shows in
detail what we have achieved so far. Some highlights include:
¾ Implementation of a range of Primary Care Services including a Community DVT service in Chorley, a local Anti-coagulant
service, a Vascular Screening service, a diabetes local service and pulse screening
¾ All our GP practices have implemented a Primary Care Improvement Plan
¾ Completing a review of all Local Enhanced Services
¾ Introduced ‘direct to test’ pathways across a range of services and improved access to diagnostics for all GPs, resulting in a 3%
reduction in GP referrals
¾ Worked with our providers to achieve the 4-hour Accident & Emergency target and a 10% reduction in Accident & Emergency
attendances at both Royal Preston and Chorley Hospitals
¾ Commissioned a review of placements for complex and out of area cases, bringing patients closer to home
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¾
¾
¾
¾
¾
¾
¾
Improved the quality of prescribing and achieved savings of just under £1m
Achieving financial balance in 2013/14
Agreeing the Better Care Fund
Signing off contracts with all key providers
Establishment of an Ownership Council, Patient Voice Forum and Patient Participation Group
Establishment of a Programme Management Office to drive delivery of our key transformation programmes
Review of our Constitution and supporting governance structures
Our Operational Plan for 2014Ǧ2016 builds on the work we have undertaken over the last year. In addition to clinician and patient
feedback, we have also drawn upon key national guidance and local strategies to develop our plan for the next 5-years.
Our vision is that in the future patients will have far more personalised healthcare choices, better support to ‘navigate’ the system,
access to 24/7 care at the appropriate level and location, pro-active management of their conditions and greater support and
guidance to enable them to manage their self-care, and have care delivered as far as possible at home.
There will be ‘no decision about me, without me’ and GPs and their practices will be the patient advocate, supporting and coordinating individualised care for their patients. Local GPs are at the centre of this system and are leading the changes needed to
deliver our ambitions.
Our plans are rooted in our core values which are at the heart of everything we do. We will:
¾
¾
¾
¾
¾
¾
Be open and accountable to our patients, their carers and the local community
Be professional and honest
Work in partnership with others to achieve our goals
Listen and learn, and be willing to change based on what we hear
Respect and care for our staff, the people we work with and our local community
Protect and invest the public funds that are given to us in a well-managed way
We are at the start of an exciting 5-year journey during which we will work with key stakeholders to transform the way that health
services are provided in our area. This strategy identifies the drivers for change, sets out where we are now and where we want to
be and what we will do to realise our ambitions.
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We have set out in Section 1.2 (Managing performance and risks) how we will monitor our progress in realising our ambitions.
However, in order to make sure that our communities can see how we are doing, we will ensure that our progress is reported at 6month intervals via our website in a format that is accessible to the people in our communities.
Dr Gora Bangi
Chair, Chorley and
South Ribble CCG
Dr Ann Bowman
Chair, Greater Preston CCG
Jan Ledward
Joint Chief Officer
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Introduction
Following our Executive Summary, which provides a high level overview, this plan is set out in five sections as follows:
Section 1: How we operate
Section 2: Where we are now: this describes the health of our local communities now and what they tell us needs to be
different
Section 3: Where we want to be: this describes where we want to be by 2019. It provides an overview of the national drivers
and requirements as well as the things we want to see change locally. It describes what the system will look like in
2019, and the performance measures and targets we will use as proxies to measure success.
Section 4: How we will get there: this section sets out how we will get to where we want to be. It provides an overview of our
core transformational programmes that will deliver the changes we have described and includes information on the
resources, systems and processes we will use to achieve our vision of the future (enablers).
Section 5: Sustainability: this section sets out how we will ensure a sustainable health system for the future
Each section is colour coded to help the reader to navigate through the document. The diagram below shows the colours used
and the key components of each section.
Throughout the document there are also links to more detailed plans where you can get more information and there is a
glossary section at the end of this plan which explains some of the terminology used throughout the document. Details of how to
contact us are provided at the end of the document.
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Navigating through this document
This diagram shows the key sections of this plan and what is included in each section
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Executive Summary
Where we are now
Chorley and South Ribble and Greater Preston Clinical Commissioning Groups (our CCGs) commission health services for more
than 386,000 people. By the year 2019, our population is forecast to increase significantly as a result of house building under the
Preston, South Ribble and Lancashire City Deal and further house building in Chorley.
The health needs of these people vary in different areas, but overall, we have social disadvantage and an increasing population
size with a trend towards a more elderly population combined with a higher incidence and prevalence of the health problems
associated with this demographic, including high numbers of people with multiple co-morbidities.
Despite the growing demand for healthcare services, we only have a limited budget to meet the health needs of our communities
and within this budget, we need to ensure local patients get a range of health services including hospital care (A&E, planned
procedures), community services (such as physiotherapy, outpatient’s appointments) and mental health services amongst others.
The Government has been clear that there can be no further investment in healthcare services either at a national level or locally.
This means that the scale of the challenge that the NHS and public services face is vast.
Where we want to be
We want to bring together and co-ordinate services for people with multiple conditions and our residents also want better and
quicker access to seamless health and social care, in settings that are convenient.
Our aim is to move away from a reactive hospital based system to a preventative, anticipatory, whole person approach to care. The
services we commission will be integrated across the appropriate health and social care spectrum and redesigned with the patient
and their carers at the centre. As a consequence services will be easy to navigate, promote equity, accessibility and choice.
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How we will get there
We have set ourselves ambitious targets for the next 5-years, and these will be achieved through the re-design of services.
We are targeting our resources towards the delivery of a number of programmes of work focused on transforming Primary Care,
Urgent Care and Elective Care and a collaborative programme across Lancashire which seeks to transform services for both
adults and children and young people with mental health conditions.
Working with the key stakeholders and providers of health and social care we will re-balance the local health economy, so that we
can address the health needs of our communities whilst creating a more responsive system that meets their expectations in a
financially sustainable way.
What success will look like
By 2019, we will see:
¾ New systems of care coordination for all patients regardless of age or need
¾ A supportive community providing support to people in residential or nursing homes and to any vulnerable person, ensuring that
they remain in the community or neighbourhood in which they live
¾ Individuals able to access help and support to enable them to self-manage their needs
¾ Patients waiting less to get to health services and being more engaged in the choices of where, when and how to access their
care
¾ People feeling in control of their lives and their care, with the services they receive being seamlessly co-ordinated and planned
with them around their individual needs
¾ Quicker, easier and reliable access to primary care 365 days per year, twenty four hours a day and speedier contact for urgent
problems
¾ Easier access to a range of diagnostic services
¾ Routine clinics such as anti-coagulation, dermatology, paediatric care being provided either alongside GP services or in
locations outside the hospital environment
¾ A range of virtual hospital beds in the community, enabling patients to be managed within their own homes with support from a
multi-disciplinary team
¾ New technologies enabling the patient pathway to be planned so that specialist skills are integrated within it
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¾ The hospital estate refashioned and used in part for acute care and in part for the community needs of the locality it serves and
recognised as a community hub
Success will be measured through improved health outcomes and patient experiences of health and social care, and
ultimately in increased life expectancy for both existing and future generations.
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Section 1: How we operate
This section describes how we are organised to manage our business effectively. It includes the following information:
1.1:
Our organisational values: the values and behaviours that underpin everything we do
1.2:
CCG governance and management: our formal committee structures and how we are managed
1.3:
Managing performance and risks: how we manage the performance and risks to achieving our objectives
Page 15 of 175
1.1: Our organisational values
In the first year of our operation, we worked together with our staff to develop a set of core values that apply to everything we do.
We will:
¾
¾
¾
¾
¾
¾
Be open and accountable to our patients, their carers and the local community
Be professional and honest
Work in partnership with others to achieve our goals
Listen and learn, and be willing to change based on what we hear
Respect and care for our staff, the people we work with and our local community
Protect and invest the public funds that are given to us in a well-managed way
To underpin these values, we have worked with our staff to develop a description of the behaviours expected of Governing Body
members, senior managers and all staff. This will ensure that the standards of our work and our dealings with everyone who comes
into contact with our CCGs will know the standards to expect and will be treated with respect and dignity. Our values and the
behaviours associated with them are set out in Appendix 1.
1.2: CCG governance and management
We are two different Clinical Commissioning Groups with a shared vision for the future of healthcare for our respective areas. We
have separate governance to provide assurance for what we do but are supported by a single management team. The diagram
below shows the key components of our governing structures.
Page 16 of 175
Over the last two years, both organisations have restructured internally and brought together a new senior leadership team with a
strong track record of delivering strategic change. We have enhanced this further by investment in analytic, commissioning and
performance management capability. Each Governing Body consists of:
Page 17 of 175
Voting members:
¾
¾
¾
¾
¾
GP Chair
Chief Officer (shared across both CCGs)
5 GP Directors representing their local practices (five for each CCG)
Chief Financial Officer (shared across both CCGs)
Three lay members, one with a lead for audit and finance, one with a lead for public participation and one with a lead for
governance who is also Vice Chair of the Governing Body (three for each CCG)
¾ One specialist consultant and a nurse (shared across both CCGs)
Non-voting members
¾ A HealthWatch representative
¾ A representative from the LMC
¾ A consultant in Public Health (shared across both CCGs)
The Governing Bodies are supported by a formal committee structure as shown below. The diagram on the previous page shows
how this links to the whole system of governance.
Governing Body
Audit Committee
Clinical Policy
Committee
Remuneration
Committee
Patient Voice
Committee
Quality &
Performance
Committee
Page 18 of 175
Our work is further supported by an internal leadership structure and a wider health economy supporting infrastructure referred to in
Section 4.3 (The health economy).
The supporting internal leadership structure is made up of a combination of clinicians and non-clinical senior managers. Our Joint
Executive Committee (JEC) oversees and challenges performance of all our work programmes and our suite of key performance
measures to ensure that progress is being made. Our Quality & Performance Committee scrutinises and challenges the
performance dashboards and reports to the Governing Bodies which also consider performance reports. Our Joint Audit Committee
monitors and manages risks and also reports to the Governing Bodies.
In addition to these formal arrangements, each GP Member of the Governing Bodies has lead responsibility for a service area
aligned to the key priorities.
1.3: Managing performance and risks
Clinical leadership is essential to the development of continuous improvement and we have invested specifically to improve our
capacity and capability in this regard.
Performance management is led by the Head of Health Economics, who ensures that performance and systems management
functions work effectively with our contracting functions to maximise our ability to drive reform. We also have a Programme Office
Lead and a Performance Lead whose responsibilities are to monitor, track and co-ordinate the interventions and escalations
required to ensure that evidence from different parts of the system are triangulated and provide strong and robust performance
information and that performance improvement is achieved and maintained.
We collect and review data at a number of levels, to ensure that performance in key areas is on target and to provide us with the
opportunity to intervene in a timely way if targets are not being achieved. The range of performance measures we monitor are
categorised in tiers as shown in the diagram below and are reported via a suite of report cards. This ensures that different levels
and audiences within our organisation have the information they need to manage their part of the business.
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Tier 3
Report Card:
Strategic
Tier 2
Report Card:
Senior Management
Tier 1
Report Card:
Operational
We also have an outline logistics programme for monitoring the delivery of our key strategies. This has two components – project
management using the key milestones, and performance monitoring using the work stream KPIs.
Specific project managers are assigned to co-ordinate the implementation of our programmes as part of a wider systems
management function. Alongside this, we have derived a specific set of KPIs associated with the work streams and undertake
specific work to address areas of concern. For example, between the summer of 2013 and April 2014 we undertook a structured
programme with Lancashire Teaching Hospitals NHS Foundation Trust to improve their 18-week performance. This involved
systematic analysis of their present position, the co-ordination of multiple external consultancy projects to overcome internal
management capacity constraints, work with the national Intensive Support Team and a joint process of engagement with senior
clinicians within the Trust. This programme has been successful.
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The key lessons from our early successes are that the greater the involvement of clinicians, and the earlier in an improvement
programme they are involved, the greater the chances of success. Coupled with strong analysis and clear project management,
clinical engagement is the central to sustainable performance improvement.
Our Assurance Framework sets out how we identify and manage risks to achieving our objectives. We have a risk management
system that allows us to capture and monitor the management of all risks in a systematic way and this is used to provide regular
and exception reports to our Senior Management Team and our joint Audit Committee.
In 2013/14, we commissioned a comprehensive review of our risk management and assurance arrangements using our internal
auditors as an independent set of experts. This review concluded that our systems of internal control are effective, designed to
meet our objectives, and are being applied consistently.
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Section 2: Where we are now
This section describes the health of our local communities now and what local people tell us needs to be different. It includes the
following information:
2.1:
Context: our geography and population
2.2:
Demography and changing need: the size and shape of our local communities
2.3:
Health Profile: what data tells us about the health of our communities
2.4:
Joint Strategic Needs Assessment (JSNA): what the local JSNA tells us about the health and heath inequalities in our
communities
2.5:
What local people tell us: and what needs to be different in the future
2.6:
Workforce challenges: across the health economy
2.7:
Estates and premises: across the health economy
Page 22 of 175
2.1: Context
We are responsible for commissioning health care for two different areas for more
than 386,000 people, almost all of which are registered with a GP practice within our
area.
Our area has large variations in deprivation, from relatively deprived to relatively
affluent. The central urban areas of Preston and Chorley have areas were
deprivation is high and health needs significant, as opposed to rural areas in the
North of Preston and South Ribble which are relatively affluent and have a low
population density.
Our boundaries can be seen on the map shown to the right. We operate in a two-tier
local authority area, with Lancashire County Council having responsibility for the
development of the Health & Well Being Strategy but we also work locally with the
three district councils of Preston, Chorley and South Ribble.
2.2: Demography and changing need
NHS Greater Preston CCG comprises 33 GP practices serving more than 212,000
people. NHS Chorley and South Ribble CCG comprise 32 GP practices serving more
than 174,000 people.
By the year 2019, our population is forecast to increase significantly as a result of
house building under the Preston, South Ribble and Lancashire City Deal and further house building in Chorley. Over the period of
the plan the prediction is for at least 6,067 new homes to be constructed with average occupancy of 2.3 people per home. This will
put significant additional demand on health services in our area.
The chart below shows the proportion of the population within our area that live in the 20% most deprived areas in England.
Page 23 of 175
Percentageofpeoplelivingin20%mostdeprivedareasinEngland
SouthRibble
Chorley
Preston
England
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
This split is reflected in the life expectancy for these areas as shown below:
(Source: HSCIC 2012)
LifeExpectancyatBirthͲ Males
LifeExpectancyatBirthͲFemales
83.5
80.0
79.5
79.0
78.5
78.0
77.5
77.0
76.5
76.0
75.5
83.0
82.5
82.0
81.5
81.0
80.5
80.0
England
SouthRibble
Chorley
Preston
England
SouthRibble
Chorley
Preston
The trend in life expectancy shows that although women still live longer than men in Chorley and South Ribble and Greater
Preston, the gap is closing due to strong improvements in male life expectancy against relatively static female life expectancy.
Page 24 of 175
(Source: HSCIC 2012)
Our biggest challenges are in Greater Preston, where levels of deprivation are more than twice the national average and life
expectancy for both men and women is significantly lower. However there are big variations even across Greater Preston with the
highest levels of deprivation concentrated in fairly distinct geographical areas. This has a significant impact on how we target and
commission services.
How is demand changing?
We also expect our local population (in line with national trends) to live longer and this increase in life expectancy is forecast to
continue, impacting on population size particularly within the over 65 population. Over the period of the 5 year plan it is forecast to
increase 1.9% year on year, in comparison with a 0.5% growth year on year in the under 18 and a 0.1% growth in adults of a
working age.
The impact of this growth will be reflected with a population which will have proportionately more over 65’s than at present, as
shown in the chart below.
Page 25 of 175
Increasing need
As the population ages, then the demand on Health Services within the area will increase disproportionately. For example those
people over 65 make up 17% of the present population within the region, whilst the latest 12 month full period for non-elective
admissions to hospital shows that patients over 65 account for 38% of those admissions.
This illustrates the relative demand which an aging population will bring. The prevalence of conditions such as chronic obstructive
pulmonary disease, chronic heart failure and diabetes are relatively higher in this age group.
Page 26 of 175
A good example is the forecast of dementia prevalence within the region. As the population over 65 increases and life expectancy
increases, the prevalence of dementia will increase. The forecast shows that over the period of the plan, the population is expected
to increase by 3.2% whereas dementia is forecast to increase by 18% (see chart below).
We will need early intervention and prevention strategies if health and social care services are going to cope with the expected
increased demands from this changing population and we will need sustained influence on communities and clinicians around
choosing health services appropriately.
We know our current service model is overly dependent on acute hospital provision, particularly for the over 65 age group. The
national Right Care analysis shows that we spend approximately £25m on acute services which in other similar economies is
directed towards community and primary care services. This has the effect of reducing productivity and limiting the capacity of nonacute services to cope with increased service demand.
Page 27 of 175
The acute trust has estimated that they have 100 serviced beds in the hospital which should actually be in more appropriate
community settings. This is illustrated in all aspects of care delivery as shown in the charts below.
A&E Activity by Age Profile
Elective Care Activity by Age Profile
Outpatient Activity by age Profile
Overall we expect the growth in demand through demographic changes and the improvements in productivity in the acute sector to
be broadly similar and these two effects will negate each other as shown below:
Analysis shows the health economy is overly dependent upon Acute Hospital care and if it was performing at the level of our
comparator groups, we could reduce acute costs by c£20m. It is also overly dependent upon providing Urgent Care in hospital
settings and if it was performing at the level of our comparator groups, we could reduce acute costs by c£5m.
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Potential elective care savings if our CCGs performed at the average of Comparator Group
Genito urinary
1166
Trauma and injuries
1093
435
433
Musculo skeletal
3858
Gastro intestinal
562
Respiratory
1421
694
750
398
Circulation
958
Neurological
1528
790
142
Endocrine, nutritional
& metabolic
116
Cancer
904
0
1258
1000
2000
3000
4000
5000
6000
Potential savings (£000’s)
Similar 10 CCGs
Best of 5 similar 10 CCGs
Page 29 of 175
Potential urgent care savings if our CCGs performed at average of Comparator Group
Genito urinary
256
Trauma and injuries
Musculo skeletal
80
Gastro intestinal
Respiratory
618
Circulation
1506
398
Neurological
235
Endocrine, nutritional
& metabolic
179
222
Cancer
495
322
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Potential savings (£000’s)]
Similar 10 CCGs
Best of 5 similar 10 CCGs
Page 30 of 175
2.3: Health profile
Life expectancy for both men and women is lower in our area than the England average and there remain too many avoidable
deaths from four main disease categories: cancer, respiratory, heart disease and stroke.
There is a considerable body of evidence to suggest that areas of high deprivation experience poor health outcomes. The mortality
statistics for the CCGs’ area show some significant differences.
Early deaths from heart disease and stroke are significantly higher in Preston than in either Chorley or South Ribble, as are early
deaths from cancer and smoking related deaths, all of which are above the England average for Preston.
Mortality Statistics
England
Preston
Chorley
South Ribble
201
4.3
60.9
108.9
255
5.3
82.1
126.9
205
5.2
67.3
106.9
195
2.7
56.6
94.3
Smoking related deaths1
Infant deaths2
Early deaths: heart disease and stroke3
Early deaths: cancer
(Source: Public Health England Health Care Profiles 2013)
The mortality statistics translate themselves into the National Outcomes Framework indicator for Potential Years of Life Lost from
Causes considered amenable to healthcare4 which shows:
¾
¾
Greater Preston CCG area above the national average (2,060) at 2,306
Chorley and South Ribble CCG area below at 1,949
1
Directly age standardised rate per 100,000 population aged 35 and over, 2009-2011
Rate per 1,000 live births, 2009-2011
3
Directly age standardised rate per 100,000 population aged under 75, 2009-2011
4
Directly age standardised rate per 100,000 population aged 35 and over, 2009-2011
2
Page 31 of 175
¾
¾
Greater Preston CCG also shows higher than average mortality against cardiovascular, respiratory, cancer and liver disease
Chorley and South Ribble CCG shows worse than average mortality for cancer and is significantly above for respiratory
disease
The data across a range of indicators shows relatively high levels of disease and poor health across the CCG area. The rates
appear higher in Preston than in Chorley and South Ribble. All three areas show higher rates of melanoma than the England
average which is consistent with the mortality rates for cancer.
Disease and Poor Health
Incidence of malignant melanoma5
Hospital stays for alcohol related harm6
Drug misuse6
People diagnosed with diabetes7
Hip fracture in 65s and over8
England
Preston
Chorley
South Ribble
14.5
15.9
20.0
17.6
1895
2875
2343
2141
8.6
10.9
5.6
5.7
5.8
6.3
6
5.6
457
567
602
494
(Source: Public Heal th England Health Care Profiles 2013)
5
Directly age standardised rate per 100,000 population
Estimated users of opiate and/or crack cocaine aged 15-64, crude rate per 1,000 population, 2010/11
Percentage of people on GP registers with a recorded diagnosis of diabetes 2011/12
8
Directly age and sex standardised rate for emergency admissions, per 100,000 population aged 65 and over, 2011/12
6
7
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2.4: Joint Strategic Needs Assessment (JSNA)
The data set for the Lancashire JSNA is available through the existing Lancashire Profile website and is updated on a continual
basis.
Lancashire's Health and Wellbeing Board includes representation from all six CCGs in the county. It has considered the intelligence
from the Lancashire JSNA and used this to set a small number of priorities for the county-wide Joint Health and Wellbeing Strategy.
The Chorley and South Ribble and Greater Preston CCG JSNA profile has been produced using intelligence from the Lancashire
JSNA and as such there is a direct “line of sight” between the needs reflected in the latter, through to the local JSNA to inform our
Commissioning Plan.
Information from the Joint Strategic Needs Assessment (add as a hyperlink to final plan) has informed the development of our
priorities and plans, including our work to develop 11 localities, each of which has a ‘locality pack’ to identify and address the
bespoke health needs of local areas. A summary of the key issues from this is shown below.
A summary of the key demographic and health issues for our area
Taking into consideration the demographics and changing health needs of our local communities identified in the health profile
above and the information on health inequalities taken from the latest JSNA, the key health challenges for our area have been
summarised below.
Population growth and age
As a university town, Greater Preston has a big student population and accordingly the population is relatively young compared to
the national profile especially in the age group 20-24 for both males and females. Conversely, the population in Chorley and South
Ribble is relatively aged compared to the national profile.
The population overall is expected to get relatively older and increase significantly in number over the next 10 years. This will give
our CCGs some significant challenges in providing services as people aged over 75 use healthcare proportionally more than the
rest of the population.
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Deprivation
Greater Preston has very diverse deprivation levels with 29.7% of the population in the most deprived quintile and 22.8% in the
least deprived quintile, and about 6,250 children living in poverty. Chorley and South Ribble are relatively affluent when compared
to the national average. The profile of deprivation shows that Chorley is becoming slightly more deprived and South Ribble slightly
less deprived. There are currently about 2,900 children living in poverty in Chorley and about 2,650 children living in poverty in
South Ribble.
Mortality
The health of people in Greater Preston is varied compared with the England average. Life expectancy for both men and women is
lower than the England average. It is 10.7 years lower for men and 6.7 years lower for women in the most deprived areas of
Preston than in the least deprived areas. The health of people in Chorley is varied compared with the England average. Life
expectancy for women is lower in Chorley than the England average. It is 8.7 years lower for men and 7.2 years lower for women in
the most deprived areas of Chorley than in the least deprived areas. The health of people in South Ribble is varied compared with
the England average. Life expectancy for men is higher in South Ribble than the England average. It is 8.9 years lower for men and
6.5 years lower for women in the most deprived areas of South Ribble than in the least deprived areas.
Disease prevalence
Over the last 10 years, all-cause mortality rates have fallen in Greater Preston, Chorley and South Ribble. The early death rate
from heart disease and stroke has fallen in Greater Preston and South Ribble and early deaths from cancer have also fallen in
South Ribble. However there are more smoking related deaths and early deaths from cancer in both Greater Preston and Chorley
against an improvement in the trend nationally. There have been falls in the rate of cervical and breast screening in Chorley and
South Ribble.
Hip fractures have increased significantly In Greater Preston in the previous 2 years to 602 per 100,000 population 65+ against an
England average of 452 per 100,000 and there are relatively low diagnosis rates in primary care for hypertension, chronic
obstructive pulmonary disease in all three areas. Infant deaths in Greater Preston are significantly higher than the national figure
and deteriorating and there are more new cases of tuberculosis. There are more over 18s with a diagnosis of diabetes in all three
areas.
There are high levels of malignant melanoma in Chorley and South Ribble compared to the national average and the situation has
deteriorated from the previous year.
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Alcohol, smoking and drug use
Over 18s alcohol related hospital admissions have increased significantly over the last 10 years in Greater Preston and South
Ribble and there are more alcohol specific hospital stays for under 18s in South Ribble. There is also more drug misuse in Greater
Preston than the national average.
Smoking prevalence is lower than both national and North West levels in both Chorley and South Ribble. However this is increasing
in South Ribble and falling in Chorley. Smoking in pregnancy is higher in all three areas.
Mental Health
There are more hospital stays for self-harm, and self-harm is significantly higher than the England average in Greater Preston,
Chorley and South Ribble, and continues to deteriorate. Mortality from suicide is increasing faster than the England average in all
three areas. There are also relatively low diagnosis rates in primary care for dementia in all three areas.
Obesity
There are fewer Healthy Eating adults in Chorley (27.8%) and South Ribble (26.5%) than the England average (28.7%), but there
are proportionately fewer obese people in Chorley and South Ribble than the England average. The level of obesity of children in
Year 11 in Greater Preston is reducing against an increasing national trend.
Teenage Pregnancy and sexually transmitted diseases
There is an increase in acute sexually transmitted diseases in Greater Preston and higher than average rates of teenage
pregnancies
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2.5: What local people tell us
The table below sets out some of the key themes which have emerged from our recent engagement with our communities. Our
responses are set out in Section 4. A more detailed report on the outcome of our engagement with patients can be found on our
website (link to be inserted)
“I know we’ve had a good old whinge, but they’re not doing a bad job.
At least they’re listening to what we have to say”
(Source: member of the public, 5 year plan engagement event, June 2014)
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Our Communities said
Future engagement efforts would benefit from a deeper penetration into patient communities
They want more opportunities to get involved with shaping services
The needs of different groups such as BME, disability, carers and other people with protected characteristics are not always
catered for
That services (primary care, hospital and community) need to improve communication with patients, especially when there are
changes to a service or new protocols
That waiting times to get an appointment with a GP, hospital or community service needs to improve.
That booking appointments can be problematic, especially multiple appointments or people with complex needs.
That they often do not know who to contact and would like to have a single point of contact.
Co-ordination of care for people with multiple Long Term Conditions needs to be improved.
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Our Communities said
There is an assumption anyone with a long term condition has support at home or in the community to help with their care or to
get to appointments.
That they would like more information to help them self –care, including signposting to additional support
That they felt that continuity of care was important. Frustrations arose when patients had to repeat medical histories.
“The NHS has done a fantastic job of adding years to life. I hope that
this five year plan will help add life to years. Long live the NHS!!”
(Source: member of the public, 5 year plan engagement event, June 2014)
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2.6: Workforce challenges
We have a legacy of under investment in the primary care workforce in comparison to other areas of Lancashire. The predicted
increase in our population poses an obvious challenge and a need to focus on modernising our workforce and the services we
provide across social and health care settings in order that we have sufficient skilled and experienced clinicians to meet the needs
of this growing population. The chart below shows the proportion of GPs in relation to other doctors in the health economy at
national level.
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The table below shows the reduction in numbers of primary care nurses over recent years.
Head count
Full-time equivalent
Practice nurses
Decreased by 2.8%
Decreased by 3.1%
Health visitors
Decreased by 3.4%
Decreased 4.6%
School nurses
Decreased by 8.1%
Decreased by 9.1%
Qualified nurses (excluding bank and
GP practices)
Increased by 0.4%
Increased by 0.7%
Within the wider health economy we also have significant challenges to the workforce across many specialities and disciplines. We
struggle to compete with Manchester and Liverpool to attract and retain as many of the best medical and nursing graduates to this
area as we’d like, despite the quality of training at our local acute provider ranking as one of the best available.
These are significant challenges for us and our partners and ones that we are jointly committed to addressing during the life of this
plan.
2.7: Estates and premises
Our analysis has shown that we are overly dependent upon hospital-based services, compared to similar CCGs and there has
been under investment in primary care. To allow us to move care outside of hospital and provide services to improve health and
well-being in the local community, we need to develop a strategy to improve our premises and community facilities. The expansion
of housing development in our area as part of the City Deal will put further pressure on our existing infrastructure and require a
change in the location of some services and the expansion of others.
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Section 3: Where we want to be
This section describes where we want to be by 2019 and how we will measure success. It includes the following information:
3.1:
National drivers for change: the national drivers and targets that have informed our plans
3.2:
Local drivers: the local drivers that have informed our plans
3.3:
Our vision, aims and objectives: our vision of the future and the aims and objectives that underpin it
3.4:
Measuring success: a description of how we want the health system to look in 2019, including the national and local
performance measures and targets we will use as proxies to measure our success
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3.1: National drivers for change
The diagram below provides an overview of some of the national requirements that are driving our plans for change. The National
Outcomes Framework has informed the development of our plans and our outcome ambitions and we have described the outcome
measures associated with these in the next section. Further details of other national drivers are set out in Appendix 3.
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The National Outcomes Framework
The NHS Outcomes Framework provides a means of measuring local performance against a set of fundamental outcomes that the
NHS should deliver. It sets out five domains for improvement as shown in the diagram below.
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These domains are underpinned by the following seven outcomes for patients, which we have taken into account in developing our
strategy for the next 5-years
Outcome 1:
Securing additional years of life for the people of England with treatable mental and physical health conditions - this means
improving life expectancy for all our population
Outcome 2:
Improving the health related quality of life of the 15 million+ people with one or more long-term condition, including mental health
conditions - this means helping local people with long-term conditions such as diabetes, COPD, CVD and mental health conditions
to manage their health so that they have a better quality of life
Outcome 3:
Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside
of hospital – this means ensuring that alternative care is available so that fewer people have to go into hospital
Outcome 4:
Increasing the proportion of older people living independently at home following discharge from hospital – this means ensuring that
alternative care is available to support older people so that they can leave hospital sooner
Outcome 5:
Increasing the number of people having a positive experience of hospital care – this means fewer general complaints and improved
patient satisfaction
Outcome 6:
Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in
general practice and in the community – this means improving the facilities and support available for people to receive care out of
hospital
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Outcome 7:
Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care - this means fewer
‘serious untoward incidents’, ‘never events’ and hospital infections
Our plans for how we will achieve these targets through delivery of our transformational programmes are set out in Section 4.2 and
our local targets associated with them are set out in Section 3.4.
3.2: Local Drivers
Financial pressures
The NHS is facing extraordinary pressures. However, despite the growing demand for healthcare services both CCGs have
managed in our first year within our allocated budget given to us by central Government.
We only have a limited budget to meet the majority of health needs for all local people. With this budget, we need to ensure local
patients get a vast range of health services including hospital care (A&E, planned procedures), community services (such as
physiotherapy, outpatient’s appointments) and mental health services amongst others.
The Government has been clear that there can be no further investment in healthcare services either at a national level or locally.
This means that the scale of the challenge that the NHS shares with local people is vast not least because locally our population is
forecasted to grow significantly over the life of this plan.
CQUINs
We use the Commissioning for Quality and Innovation (CQUIN) framework to support improvements in the quality of services and
the creation of new, improved patterns of care.
CQUIN incentivises our providers to deliver quality and innovation improvements over and above the standard requirements set out
in the NHS Standard Contract, whether this be incremental improvement or radical service redesign.
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The initiatives agreed with providers are both challenging but realistic, therefore there is an expectation that a high proportion will
be met by providers in-year. Our focus locally is on a small number of high impact goals, with each provider.
Lancashire Health & Well Being Strategy
We sit alongside a wide range of stakeholders from other locations within Lancashire on the Lancashire Health & Well Being Board
(including providers of health and social care and other clinical commissioning groups) and contributed to the development of a
vision for Lancashire that ‘every citizen in Lancashire will enjoy a long and healthy life.’ This vision for wider Lancashire is
underpinned by three high level goals as follows:
¾
¾
¾
Better health: Improving healthy life expectancy, and narrowing the health gap
Better care: Delivering measureable improvements in people’s experience of health and social care services
Better value: Reducing the cost of health and social care
These goals are underpinned by three aims as follows: Starting Well, Living Well and Ageing Well.
Our plans are aligned to achieving these aims and we have shown the connections to our transformational programmes in Section
4.2 below.
As Lancashire is a large and diverse county with significant variations in levels of deprivation evidenced by widely differing health
needs, we are also members of three local Health & Well Being Forums led by the three district councils in our area. This enables
us to tailor our interventions to a local level whilst still being sighted on the overarching vision for Lancashire. Plans are currently
underway to formalise these arrangements into local Health & Well Being Partnerships.
Addressing diversity and achieving equality
To ensure that we commission healthcare services to meet the needs of our diverse population, we are committed to involving local
people in the continuing development of commissioning activity, and also to ensuring our staff and providers meet statutory equality
duties. We are aiming to achieve our equality objectives over the life of this plan.
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Equality Objectives
¾ To improve the health outcomes for people with protected characteristics by improving access to services, patient engagement
and experiences of accessing the services we provide and commission
¾ To embed the equality agenda into the day to day practices to position the CCG as the local expert body commissioning health
service
¾ To improve on the Equality Delivery System submission year on year by promoting successful, efficient and effective
commissioning
¾ To engage and involve member practices regularly and appropriately to ensure equitable services are delivered across
Chorley, South Ribble and Greater Preston
¾ To improve the experience of all service users and use their experiences to inform, influence and develop services
¾ To involve the public, patients and stakeholders at the appropriate states of the commissioning cycle
¾ To explain our commissioning plans so that all members of our community can understand them
¾ To reassure patients and stakeholders about our plans through stakeholder engagement events and public information notices
that will be provided in different formats, such as posters, leaflets, electronic, media and easy read documents
¾ To be clear about our intentions; how we made decisions based on community engagement and plan to achieve them
¾ To manage the implications of difficult commissioning decisions by undertaking equality impact assessments / analysis which
will be supported by stakeholder engagement that challenges and ensures good practice
¾ To empower service users and make appropriate use of resources
¾ To utilise the unique selling point of a human rights based approach to manage the CCGs public reputation and brand
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3.3: Our vision, aims and objectives
Our key health and social care economy partners came together in March 2014 to explore how we could align our collective
ambition into a single vision for the health economy over the next five years.
The purpose of the workshop was to agree an aligned and jointly understood vision of healthcare in our area, supported by
identified programmes of transformation and an exploration of the enablers required to deliver large scale change.
There was a shared view among partners that the current known transformation programmes in the health economy were focused
on the right areas but much of it was equal to the approach of the ‘lots of lots’.
There was broad agreement that work should continue in partnership and it should focus on delivering a formalised and
overarching aim. Working together we want to develop a model of care that is “preventative, anticipatory, and focused on the
whole person”. Future services will be integrated across health and social care, and redesigned with the individual and their carers
at the centre. People will have better access to appropriate care and support and make choices about their care through simple
processes.
In order to deliver this we need a fundamental change to a more radical model that challenges traditional systems thinking and
critically has an ethos of ‘No Unnecessary Waiting, No Unnecessary Cost and No Compromise on Quality’ as key standards.
The new design will come from a change of commissioning philosophy and practice from one which is centred around more general
population-based services to one which is more individual, with personalised healthcare services as the norm.
Some emergent thinking arose from the exploration of what care would look like when the system has transformed. These included:
¾
¾
¾
¾
Care Coordination
Developing Supportive Communities
Care Closer to Home / integration
Primary Care Access
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Achieving the change in the delivery of healthcare in our area will enable us to improve patient health outcomes and patients’
experiences of the healthcare system within the limited resources available to us
We have used this thinking to develop our vision, strategic aims and objectives, which describe where we want to be (see diagram
below).
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In order to achieve our goals we have launched a series of initiatives to address the root causes of ill health in our population.
These initiatives will form the cornerstone of our investment over the next 5-years and have been designed to improve prevention,
increase the responsiveness and efficiency of services and bring forward a new and more personalised approach to care delivery.
In order to achieve our goals we have launched a series of initiatives to address the root causes of ill health in our population.
These initiatives will form the cornerstone of our investment over the next 5-years and have been designed to improve prevention,
increase the responsiveness and efficiency of services and bring forward a new and more personalised approach to care delivery.
Preventative
We will work with Public Health to proactively reach out to members of the population to reduce the prevalence of all
diseases. This focus upon prevention will reduce mortality, improve quality of life and improve financial efficiency through a
reduction in future healthcare requirement. Working with other key stakeholders across the wider health and social care
economy, our preventative strategy will address the determinants of health including poverty (and including fuel and food
poverty), housing, education, environment and social isolation, enable people to make healthy choices, provide
immunisation, early detection including screening and case finding and provide good healthcare to prevent further
development of the disease and its complications.
Responsive
Services will be delivered earlier in the disease cycle to maximise their effectiveness. We will target segments of our
population to make people more aware of symptoms that should cause concern, leading to earlier presentations to primary
care. Diagnostics will be carried out earlier and more expediently to reduce the overall wait to treatment. These changes will
improve outcomes and reduce mortality in the period of the plan.
Individualised
We will design a system that tracks risk and disease prevalence on an individual rather than collective level so that frontline
primary care clinicians are able to predict the probability that individuals will experience and we will design services to
address these individual needs. We believe that this work will uncover important differences in reported prevalence in some
of our deprived areas and where this is the case, a far improved service offering will be made available to individuals and
support the reduction in health inequalities.
Tailored
Services will be tailored to be more effective to local populations. In some cases, services will be delivered entirely
differently based upon locality, for example outreach spirometry testing.
We shall strive to deliver more from our existing resources and these efficiencies will be re-invested to improve outcomes
particularly in deprived areas. Efficiencies will be realised through pathway redesign, service reconfiguration and by moving
the focus from secondary to primary care.
Efficient
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3.4: Measuring success
By 2019 we will have moved away from a reactive hospital based system of unplanned care to a preventative, anticipatory, whole
person approach to care. The services we commission will be integrated across the appropriate health and social care spectrum
and redesigned with the patient and their carers at the centre. As a consequence they will be easy to navigate, promote equity,
accessibility and choice.
The way in which our patients will understand this is explained in more detail in the following table.
Care Coordination
In 2014 (now)
In 2019
In 2014 (today) age-related chronic and complex medical
conditions account for the increasing demand and
healthcare spend in the health economy. However, there
are no systems for integrated coordinated care, so
people living with multiple health and social care needs
often experience a highly fragmented service which is
creating sub-optimal care experiences, poorer than
expected outcomes and increasing costs. In addition,
patients and carers are finding the health and social care
system complex, confusing and difficult to navigate and
access whilst the health professionals are concerned
about inefficiency, poor patient experience, multiple
hand-offs and governance risks.
We will have in place new systems of care coordination
for all patients regardless of age or need. Dedicated care
coordinators will act as advocates for their patients
and/or carers. They will help them to navigate the system
and access appropriate health and/or social support to
meet their identified need at any given time. In this way,
care co-ordinators’ in the health economy will:
x Be responsible for undertaking a holistic
assessment of the patient, taking account of their
health and social care needs and those of their
wider family;
x Plan the care with the patient and their family to help
address these needs;
x Facilitate access to services and support to address
need from a menu of interventions; and
x Liaise with the multi-disciplinary team, ensuring the
individual received consistent evidence based care
at the point of need.
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Hospital At Home
Services
In 2014 (now)
In 2019
In 2014, there is a reliance on hospital beds with a
reasonable degree of alternative step down support in
the community. However, around 50% of people with
dementia, previously managing in their own homes, once
admitted to secondary care are frequently unable to
return home due to deterioration in their dementia.
There will be a range of virtual hospital beds in the
community, enabling patients to be managed within
their own homes with support of a multi-disciplinary
‘virtual’ team. Services will range from those providing
more maintenance therapies to those that manage very
sick patients at home, made possible by the new
advances in technology and Telehealth that facilitate
remote monitoring and timely responses where the
patients’ condition indicates a need.
The new acute hospital at home service provides a real
alternative for people with conditions such as dementia,
reducing the stress and distress associated with
hospital admission, improving health outcomes and
reducing the number of older people admitted to long
term care.
Primary Care
Access
In 2014, access to primary care is one of the most
fundamental barriers to effective care. There remain 65
GP surgeries, throughout the health economy with very
few state of the art, modern clinical and surgical spaces.
That means there has become an over reliance on
expensive hospital based care.
We will have a health economy in which there is
significantly reduced demand on secondary care, more
care will be provided closer to home and it will be more
responsive. Access to primary care will be a far more
convenient routine as access to GP services has
improved along with the speed of contact for urgent
problems. Patients recognise that there is reliable and
easy access to primary care 365 days per year, twenty
four hours a day.
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Care Closer to
Home
In 2014 (now)
In 2019
In 2014 (today), the whole health and care community
have a tacit recognition of the need to move health and
social care out of institutions such as hospital, and into
community settings because demand on acute hospital
services is becoming unsustainable. In addition, patients
do not benefit from the widest range of choices and are
often inconvenienced by what choice does exist.
New technologies have enabled the patient pathway to
be planned so that specialist skills are integrated within
it.
The hospital estate has been refashioned and is used in
part for acute care and in part for the community needs
of the locality it serves and is recognised as a
community hub.
Individuals are supported within the community as a
way of not just reducing the demands and impact of an
ageing population on hospital services but also as a key
way to improve patient choice, convenience and
experience.
Many hyper-acute and general acute services will
continue to be provided in hospital settings but there will
be significantly more outpatient clinics in community
settings and a very large proportion of sub-acute care
will be provided within the community.
There will be a range of one stop diagnostic clinics in a
variety of locations so that X-ray, CT and MRI scans are
more easily accessed.
Routine clinics such as anti-coagulation, dermatology,
paediatric and so on will be provided either alongside
GP services or in new locations outside the hospital
environment.
Patients will wait less, take less time to get to health
services and be more engaged in the choices of where,
when and how to access their care.
Furthermore, the health economy is has become very
costly because of the way in which it provides care for an
ageing population within the acute sector.
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Developing
Supportive
Communities
In 2014 (now)
In 2019
In 2014 (today) social isolation is prevalent within our
communities and this has an evidenced detrimental
impact on health outcomes for our population in turn
leading to escalating costs for the health and social
economy. Patients are often discharged into nursing and
care homes for prolonged periods and work needs to
continue on the preferred place of discharge. In addition,
whilst engagement work is on-going, more can be done
to reflect the views of service users and carers in
commissioning discussion and there is an opportunity to
work in a more collaborative manner with the 3rd sector in
terms of understanding social needs and also to develop
service provision to reduce some of the community gaps.
Again, patients often find the health and social care
system complex and confusing and do not understand
how multiple organisations can work together to provide
support and assistance.
The health economy will be a supportive community
providing support to people in residential or nursing
homes and to any vulnerable person, ensuring that they
remain in a community or neighbourhood and are not
seen as external to it. Patients will understand this
because they will be able to identify designated care
homes where facilities offer social support to the wider
community by providing day care, meals and/or
management and will be invaluable in creating
dementia friendly neighbourhoods and offering short
term respite services.
A range of Community Partnerships linked to
neighbourhoods will be in place and focused on
improving the lives of local people because individuals
and organisations are working together to build
stronger, safer and better communities. These
community partnerships are empowered to deliver more
effective, better tailored services to the people who
most need them. For example, health organisations are
working with local employers to offer health checks or
one stop shops to help prevent people from becoming ill
and needing their crisis input.
Community hubs will provide holistic health and
wellbeing services for people. These will be managed
by community resources, utilising the expertise of
previous and current service users to co-produce
interventions for people with minor to severe health and
social care problems.
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In 2014 (now)
Developing
Supportive
Communities
(continued)
In 2019
Individuals will be able to access help and support to
enable them to Self-Manage their needs. Access to
information by patients and health and care
professionals will be timely and in a variety of formats,
so that it facilitates independence, self-management,
and supports people to navigate the system according
to their level of need at any given time. New
technologies are providing a range of new opportunities
to help people self-manage their condition, for example,
there will be much greater use of mobile phone apps,
telecare and telehealth and to support the selfmanagement of long term conditions.
Individuals will have far more responsibility for their own
health and care needs and health and social care
professionals will ‘Make Every Contact Count’ because
they will using every contact with an individual to
maintain or improve their mental and physical health
and wellbeing wherever possible, whatever their
specialty or the purpose of the contact. Patients will take
greater control of their own health and focus on
improving health and wellbeing by recognising they
have a need and will either use community partners to
or individually sign post themselves to the right care
agency, support programme or support themselves
directly, through online and mobile apps if and where
appropriate.
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In 2014 (now)
In 2019
Integrated Care
In 2014, there remains a real lack of joined-up care,
which has been described as a huge frustration for
patients, service users and carers. The health economy
recognises that the provision of integrated care is the
most important contribution that health and social care
services could do to improve quality and safety.
People will feel in control of their lives and their care,
with the services they receive being seamlessly coordinated and planned with them around their individual
needs. This will start to be recognised early in the life of
this plan, as changes are made to integrate care.
Addressing
diversity and
achieving equality
In 2014 we will have an equality champion in each team
ensuring that equality and diversity is embedded in all
our functions.
Chorley and South Ribble CCG and Greater Preston
CCG aspire to be a leader amongst all clinical
commissioning groups across England.
We will improve our Equality Delivery Submission for
both CCGs.
In developing a highly motivated and culturally diverse
workforce, we aim to learn from our communities and
collaborative working with our partners to commission
services that provide equitable services for the majority
of people within our community
We will have engaged with people who represent all nine
protected characteristics.
This will be reported as ‘Achieving’ for the Equality
Delivery System indicators.
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Improvement goals
We will measure the impact of our improvement activities against the five domains and seven outcome measures of the NHS
Outcomes Framework and other national requirements and have selected 15 key improvement targets linked to our key
transformational programmes of work which form the basis of our strategic performance report card.
To set ambitious targets, we have compared our current performance against that of other CCGs in England and have set targets
on the basis of:
¾ Achieving performance that is equal to or above the national average where our performance is currently below national average
¾ Achieving performance that is equal to or above the next appropriate quartile where our performance is already equal to or above
the national average
All our improvement targets are shown in the tables set out in Appendix 2.
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Section 4: How we will get there
This section sets out how we will get where we want to be. It includes the following information:
4.1:
Our overall strategy: the overarching principles we will apply to deliver our vision
4.2:
Our transformational programmes: an overview of our priorities, how we will meet national requirements and the four
programmes of work we will deliver to make change happen
4.3:
Enablers: the resources, systems and processes we will use to achieve our vision
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4.1 Our overall strategy
Our data tells us that too many people are dying too soon, that care is not organised in the optimum settings, that inefficiency and
waste remains, and we know that we have finite resources which will be exhausted without change. We also have social
disadvantage and an increasing population size with a trend towards a more elderly population. Working with key partners across
the wider health economy we want to address the challenges identified in section 2 and the wider determinants of health, with a
focus on prevention, including reduction on tobacco use and alcohol consumption, whilst at the same time prioritising reducing
deaths from conditions that are amenable to health care and changing how and where health care is provided so that patients’
experiences of the system is improved.
The NHS and social care organisations in our local health economy are in agreement with the drivers for change and our ambitions
are clear. We have a desire to join forces to explore how we can collectively provide the best possible healthcare, for the best value
for money and to agree how services need to change to achieve this.
We want to improve the quality, safety and affordability of health services provided to the residents living in the Greater Preston,
South Ribble and Chorley areas. We want to coordinate services so that easier access to specialist advice is available and fewer
hospital stays are needed. We want to combine expertise across our hospitals to make sure that in an emergency, people have
access to a specialist opinion 24 hours a day, seven days a week.
We want to bring care closer to people’s home wherever possible and to provide more opportunities for people to have tests,
treatments and appointments carried out in a local or community setting, such as in GP practices, rather than having to travel to a
hospital.
We want to develop more specialist centres of excellence at our main hospital – Lancashire Teaching Hospital– in line with national
best practice and will work with NHS England to explore opportunities for achieving this.
We want to be bigger, better, safer together and there is a high degree of alignment between commissioner and provider
aspirations and a common sense of agreement to unify the system, through the use of:
¾ Registered lists to organise care with primary care as the gateway to better health
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¾ Integrated neighbourhood teams (to include social care) in order to better manage long term conditions organised around new
GP Networks
¾ Where appropriate consultant opinion to be alongside GPs with greater nurse, Allied Health Professionals and social care input
¾ Technology to enable better care delivery and continued choice with better access for longer
¾ Teaching hospitals with smaller healthcare campus / satellite
¾ Exemplar mental health services with patients getting parity of esteem
Whilst our ambitious plans are focused on preventing and reducing the effects that cancers, heart disease, stroke, respiratory
disease, muscular skeletal (MSK) and poor mental health have on our community, we also want to change our relationship with
patients and our population through new channels of communication and the commissioning of far more personalised services.
We have developed an overarching framework to help us better explain strategy and vision for our health economy and this is set
out below.
Personalised
Advanced
Care
Environment
We will establish a new relationship with our population where they are at the fulcrum for lifestyle healthcare
choices and shaping health services. For example, the GP practice-based register will be the core to ensuring
individuals’ well-being.
We will ensure that our patients have access to the most effective leading-edge technologies.
We will re-commission services to provide integrated health and social care and in so doing incentivise providers
to respond with innovative models of provision.
We will not be bound by particular buildings in the future. Health and social care will be delivered closer to home to
meet particular needs, expectations and lifestyles of patients and citizens.
Our analysis clearly demonstrates that marginal service pathway change will not have the desired impact on effecting improved
outcomes - if we retain our present structure, the impact of our programmes will be significantly beneficial for our population but it
will have a marginal impact on the overall pattern of investment.
Whilst retaining a focus on our core strategies, we see integrated care as a real enabler for large scale change. Integration will
have a much greater impact on the profile of our contracts and the next twelve months will be critical in establishing the foundations
for this as a cornerstone to deliver our plans.
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Overall, we are planning an additional investment of £36 million to support the introduction of initiatives in each of our main health
need areas. This funding has been made available by NHS England non-recurrently over the next 5-years to invest in
transformational change. These initiatives are expected to improve health outcomes and alleviate pressure from growing patient
numbers on Lancashire Teaching Hospital. These investments have been prioritised according to their anticipated impact and their
value for money to deliver the outcomes outlined above.
There are clear challenges to delivering high quality care for our patients, including:
¾ Population changes that are increasing demands on health care services and the resources available which are not increasing
at the same rate. As the population ages and the number of people with chronic diseases rises, the way we currently use our
hospitals is becoming unsustainable
¾ Improving our ‘out of hospital’ services will improve patient care and cost less. Better care, closer to home is the only way to
maintain quality of care in the face of increasing demand and limited resources
¾ Access to care and quality are variable across the CCG. Improving primary and community services in Greater Preston and
Chorley & South Ribble will require new and innovative ways of coordinating services, more investment and greater
accountability
In order to realise our vision for the future of health and care across Greater Preston and Chorley & South Ribble over the life of
this plan, it is vital that the building blocks are laid through our work over the next two years.
The Joint Strategic Needs Assessment (JSNA) provided us with crucial insights to our local population, providing Local Needs
Profiles for our CCG, its localities and GP practices. We have used this information along with clinician and patient feedback (see
Section 2 above) to inform our thinking and develop care pathways and services to improve health outcomes and experiences for
our patients.
We have also taken into consideration other local factors such as areas of spend. The areas we are spending significantly more
than comparator CCGs include circulation, cancer services, respiratory and MSK.
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In particular, our ‘Commissioning for Value’ (CfV) pack identifies the best opportunities to increase value and clinical outcomes for
patients and our JSNA also highlight these as areas where people on average experience worse health outcomes than compared
to England.
The principal challenges and risks to achieving our vision
We have ambitious plans to transform health services for our communities and we have set ambitious targets to improve the health
outcomes and patients’ experiences of health and social care. We have significant challenges to address, not least of which is to
reduce the health inequalities that exist in our communities, within financial constraints and a changing political landscape, and we
recognise that the scale of our ambitions carries risks that we will need to manage as we deliver our plans.
The key risks we have identified are those relating to potential reductions in funding, the challenges in attracting and retaining the
best clinical workforce across the health economy to deliver our plans and addressing the challenges of the existing estates and
premises within our local health economy. Managing these issues is critical to the successful delivery of all our plans and will
feature as key risks in our strategic risk register.
Delivery of our plans will transform services but existing models of healthcare must remain in place until new models are fully
embedded and effective. This is itself a key risk as we attempt to navigate and effectively ‘bridge’ existing and new models of health
and social care over the next few years.
Addressing diversity and achieving equality
We have developed a work plan to show how we are going to meet the equality and diversity objectives set out in Section 3 and
some of our actions are set out in the following table.
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For our community
Objectives
How we will get there
Better health
outcomes
We will:
x do equality analysis when we commission healthcare services
x work with provider services to improve the transition of patients from one service to another
x continue to work with providers to improve the safety of our patients
Improved patient
access and
experience
We will:
x engage with patients to identify the barriers for people who feel their health needs are not being met
x work with providers to ensure that all potential patients can access their services
x monitor patient surveys to identify our patient’s experiences and any areas of concern they may have
x work with providers to improve patient experiences
x improve our customer care services to capture the barriers for people to ensure the needs of our
communities are met
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For our employees
Objectives
How we will get there
A representative
and supported
workforce
We will:
¾ promote fair recruitment and selection and share the importance of a diverse workforce with our
employees
¾ do an equal pay audit to identify our workforce baseline
¾ ensure that all our staff can access training and development and undertake an annual personal
development review that incorporates the need for any reasonable adjustments due to having a disability
¾ promote our values and provide staff with a variety of opportunities to raise concerns about abuse,
harassment, bullying or violence in the workplace
Inclusive
leadership
We will:
¾ identify equality champions in all teams across the CCGs to support the equality agenda
¾ hold quarterly meetings with our equality champions and report the outcomes to the Quality and
Performance Committee and Governing Body meetings.
¾ Ensure that all papers that have an impact on patients or staff and go before the Governing Body have a
robust equality analysis
“Buying health services is our business. Inclusion is at the heart of what we do”
(Source: Chorley and South Ribble CCG and Greater Preston CCG, 2014)
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How we will report equality and diversity
Equality
Champions
Equality and
Diversity Lead
GP Directors for
Equality and
Diversity
Quality and
Performance
Committee
Governing Body
Our responses to the things local people told us
In Section 2, we summarised the key things local people told us was important to them. The table below summarise how
we will address these issues.
Future Engagement to penetrate deeper into communities
Our engagement arrangements are tailored to the particular audiences we are seeking to reach, targeted and designed around
specific service transformation and improvement projects, and also around specific demographics to ensure we listen to the
voices of seldom heard groups, and people in protected characteristic groups
Practice-level Patient Participation Groups (PPGs) provide feedback to GP practice ‘peer groups’ to help drive healthcare
planning, and we also have an established Ownership Council made up of around 440 people. We have also established a
Patient Advisory Group, to help provide advice and reference on our engagement plans and external publications. We use a
range of different tools to enable us to reach out more effectively to local people. We use local media, websites and social media
channels as well as more traditional methods, such as events, focus groups, surveys and field research. We directly target
communities and patients, and also engage through our active, local community, voluntary and faith sector.
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More involvement in shaping services
We are developing a Standard Operating Procedure to ensure that patient voice is embedded throughout the commissioning
cycle. We are already involving patients and members of the public in service re-design workshops. Our engagement
arrangements are tailored to the particular audiences we are seeking to reach, targeted and designed around specific service
transformation and improvement projects, and also around specific demographics to ensure we listen to the voices of seldom
heard groups, and people in protected characteristic groups
Catering for people with protected characteristics
We undertake comprehensive Equality Impact Assessments every time we make changes to or develop new services. We will
also monitor this through our contracts
Improving communication
We will work with our GPs, other providers, patients and members of the public to improve communication at all levels. Practicelevel Patient Participation Groups (PPGs) provide feedback to GP practice ‘peer groups’ to help drive healthcare planning, and we
also have an established Ownership Council made up of around 440 people.
Improving waiting times
All our programmes of work seek to address waiting times alongside other key changes.
Address issues with booking of appointments
We are working with the Referral Management Centre to improve the booking process
Single points of contact
We will address this through our Transformation Programmes
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Improve coordination of care for people with long-term conditions
We will address this through the roll out of Integrated Neighbourhood teams
Providing support for people with long-term conditions
A major part of our plans is to develop the capacity to provide more support at home or in the community. We will work more
closely with our patients and carers to better understand their needs and are developing Integrated Neighbourhood Teams
improve co-ordination of support
More information on self-care and signposting to additional support
Self-Care is one of the strands of the Transformation Programme. We will work with patients, partners and providers to improve
information and signposting
We will also work more closely with the Voluntary, Faith and Community Sectors to enable this.
A Directory of Services will be developed and shared with professionals
Continuity of care: not having to repeat information to different clinicians
We are investing in new IT technologies to join up patient records
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4.2: Our Transformational Programmes
Our priorities for improvement have been identified and agreed taking into account of the health needs of our local population and
the outcome of our engagement activities with our GP practices, local communities and the local health economy.
There are common themes across the priorities that we will address within our work programmes. These include:
¾ A more systematic and proactive approach to the management of chronic disease – this will improve health outcomes, reduce
inappropriate use of hospitals and have significant impact on health inequalities in our areas
¾ The empowerment of patients – patients are arguably the greatest untapped resource within the NHS
¾ A population based approach to commissioning – a key challenge for commissioners is to direct resources to the patients with
the greatest need and redress the “inverse care law” – hence move the focus from patients that present most frequently in their
practice to the wider population they service geographically
¾ More integrated/joined up models of care – from development of networks to improved co-ordination, joint working with other
health and social care providers, to wrapping services around groups of practices, virtual integration, pooled budgets and where
appropriate organisational integration
¾ Improving core primary care by driving change through the use of data sharing for benchmarking and peer review (supported by
mechanisms/frameworks to enable sharing)
¾ Improving primary care infrastructure to support change required to deliver the agenda
Our plans over the next 5-years are aimed at reviewing, reshaping, redesigning and where appropriate re-commissioning services
in the following areas:
¾
¾
¾
¾
¾
¾
¾
Urgent Care
Orthopaedics - MSK and Physiotherapy
Mental health: with a focus on Dementia & improving access to psychological therapies (IAPT)
Children: with a focus on admission avoidance
Healthy Lifestyles with a focus on Smoking, Alcohol, Obesity & Drugs
Cancers
Referral Management
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All our work in these areas will be aimed at integrating care, reducing unnecessary and unplanned admissions to hospital and
reducing elective interventions when alternative care and treatment options with better health outcomes for patients are available.
Developing Integrated Neighbourhood Teams is a priority and will lay the foundations for sustaining the improvements we are
seeking to achieve.
We have developed four transformational work programmes (listed below) which are already underway and on which we will focus
our attention and resources in the first two years.
¾ Primary Care: this will include referral management, healthy lifestyles and inappropriate admissions avoidance and elements of
End of Life care)
¾ Mental Health and Learning Disabilities: this is a collaborative programme with other commissioners and will include dementia
and IAPT)
¾ Urgent Care: this will include re-design of pathways for End of Life care)
¾ Elective Care: this will include MSK and physiotherapy and cancer treatments)
We are also engaged in collaborative commissioning activity to implement the mental health in-patient bed reconfiguration, develop
a Lancashire-wide hospital and out of hospital strategy, review stroke services and re-procure the contract for community
equipment. These strategic work programmes are being delivered under a programme led by the Midlands and Lancashire
Commissioning Support Unit and further information is provided later in this section.
In line with the NHS Mandate and linked to these priorities all our work will:
¾
¾
¾
¾
¾
Improve standards of care and not just treatment, especially for older people and those at the end of life
Support economic growth, including supporting people with health conditions to remain in or find work
Diagnose, treat and care for people with dementia
Prevent premature deaths from the biggest killers
Support people with multiple long-term physical and mental health conditions, particularly by embracing technology and
delivering services that value mental and physical health equally.
Each programme of work will also address the six nationally defined characteristics of a high quality and sustainable health system
(see Appendix 3).
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With an aging population, End of Life is also a key priority for us and we are working with key stakeholders in the local health
economy to develop an End of Life Strategy to meet the needs of people requiring End of Life Care in Greater Preston and Chorley
South Ribble CCG.
The vision for end of life care is that the patient and their family/carer receive the care and support that meets their identified needs
and preferences through the delivery of high quality, timely, effective individualised services.
Ensuring respect and dignity is preserved both during and after the patient’s life. Our emerging strategy aims to:
¾
¾
¾
¾
Support people to be cared for and die in their preferred place of care
Improve patient and family experience
Ensure all providers are skilled and competent in delivering high quality End of Life care
Encourage and support people to start thinking and planning for end of life at the earliest opportunity and whilst they are well
able to contribute to decisions affecting their future care
¾ Reduce inappropriate transfers of care from all settings
The following diagram sets out our ‘plan on a page’ and shows how our work will be phased over the life of the plan.
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Our planned initiatives in 2014-16
The diagram below shows how each of our four programmes link to the overall vision and systems of governance. An overview of
each of these is set out in the following sections.
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Primary Care
The Case for Change
The CCGs recognise that primary care is the bedrock of an effective healthcare system for its population. Strong and effective
primary care is acknowledged to be a critical aspect of a high-performing health care system. This is predicated on the basis that
high quality primary care improves health outcomes and helps contain health care costs.
In recent years, there has been renewed interest locally in the nature of primary care service delivery, and in particular what needs
to be done from primary care to scale up to meet the challenges of increasing demand from older and frail patients living with
complex and multiple chronic diseases, and other vulnerable groups such as those with mental health problems, and families living
in poverty. Primary care provides the following:
¾
¾
¾
¾
¾
¾
Prevention and Screening
Assessment of undifferentiated symptoms
Triage and onward referral
Care co-ordination for people with long term conditions
Treatment of episodic illness
Provision of palliative care
The NHS policy over the last decade has focused largely on improvements in hospital care and development of payment, quality
and performance systems linked to this. The financial constraints on public services have revealed the vulnerability of a large
hospital-focused approach due to high cost infrastructure.
Delivering care upstream and community based services, particularly for frail patients and those with long term conditions is an
essential part of meeting this challenge.
Closer integration of health and social care has been a pervasive and recurrent theme of public policy with primary care at the
centre of transformation.
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The recently published national framework document, ‘Integrated Care and Support’ and the associated call for ‘pioneers’ clearly
signal the Government’s commitment to integrated care and the willingness of national organisations to work together to ensure
that the policy and regulatory levers are joined up.
General practice locally and across the country is under significant strain, facing pressures from a range of supply, demand and
health service factors. These include:
¾ An expected increase in population as a result of investment in the area from the New City Deal
¾ The rising prevalence of chronic disease due to an ageing population focusing attention on unhealthy lifestyle behaviours
(prevention)
¾ Poor communication between professionals involved in care of the patient often results in fragmentation of care, low quality
patient experience and sub-optimal outcomes
Other factors that are creating a need for a change in primary care include development of technology and innovative drug
treatments, which will enable more community and home-based care together with rising expectations from patients about access
to care, and the range of services that should be available to them
Developments in the primary care workforce also create new opportunities for example through extension of nursing roles in the
management of long-term conditions and minor injury.
Unwarranted variation in primary care is also a significant issue and is at the heart of the conflict inherent in the NHS reforms.
Current payment mechanisms do not incentivise innovation and change in behaviour, which lead to improved outcomes
Transforming Primary Care will also make a significant contribution to each of the three goals of ‘Starting Well’, ‘Living Well’ and
‘Ageing Well’ contained in the Lancashire Health & Well Being Strategy.
Our Vision for the future of Primary Care
We want to see accessible and equitable, high quality sustainable primary care services for the people of Greater Preston and
Chorley & South Ribble. Working with our local health economy partners, future primary care provision will:
¾ Be accessible to all people regardless of who they are, where they live, or what health and social problems they may have
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¾ Provide improved quality including patient experiences of services, reduction in health inequalities, improved outcomes, coordinated care across provider boundaries and fewer hospital admissions
¾ Provide integrated services within primary care, offering continuity of care consisting of multi-disciplinary teams of health and
social care professionals and the integrated health and well-being team
¾ Use clinical pathways for consistent and effective care, with referral processes for specialist consultations
¾ Use connected information and data systems including electronic patient records to optimise clinical activity and
information/data facilitating quicker and more effective decision making
¾ Provide sustainable primary care providers who are able to take on clinical work being taken out of the acute sector working
in localities / federations
¾ Be supported by Primary Care workforce plans which include career pathways for practice staff, clinical and non-clinical
development opportunities and the recruitment of appropriately skilled staff for potentially new roles within primary care
¾ Provide suitable facilities and infrastructure including digital healthcare, to provide a range of access options.
How we will achieve our vision
We are working with our local health economy partners to re-design primary care services so that they are accessible, provide an
improved patient experience, are integrated and effective making best use of shared data and infrastructure across the wider
system and above all are sustainable in the long term.
To achieve this we will encourage a functional approach to changes in a primary care delivery model (as opposed to an
organisational/premises approach), giving due consideration to the distribution of required key skills and abilities across the
available and potential workforce, consider the population scale needed to support local delivery of specialist and diagnostic
services, and involve Patient Participation Groups and provide regular communications with our population during any proposed
and actual changes to delivery.
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Achieving our vision for primary care centres around building an effective and sustainable model of care, wrapped around general
practice in localities of about 20,000. To deliver this model, we will work alongside NHS England in implementing the Primary Care
Strategy, and in particular in developing general practice at the heart of wider systems of more integrated out-of-hospital care to
facilitate:
¾
¾
¾
¾
¾
Improved care for vulnerable older people
Seven day working
Reduced avoidable admissions
Continuity of care
Improved overall quality and productivity of services
We will redesign the Primary Community Services Model to deliver a person-centred, population oriented, accessible, joined up
high quality service with improved outcomes for patients and commission a Primary Care Plus contract in line with ‘Improving
General Practice – A Call for Action’ (August 2013 and February 2014).
This does not mean closing smaller practices but provides opportunities for groups of practices to come together to share
resources. Some practices have already come together locally to share resources for the training of front line staff, providing cover
and sharing nursing staff to provide a more flexible and sustainable workforce.
Over the next 12 months we will develop a Primary Care Plus approach which will also provide opportunities for groups of practices
coming together ideally around a defined geographical area with community, social care and specialist input where appropriate
wrapped around it, providing personalised centred outcome based care for that locality.
Based on the patient profile across our area, our Primary Care Plus specification will be for a targeted population of over 75s and a
range of extended services including shared care and treatments under proposed markers which will improve the existing
infrastructure in Primary Care.
This will be above and beyond the care provided under the national contracts. We have taken into account the following key
changes to the National Contract 2014/15:
¾ From April 2014, all elderly patients will be assigned a named GP to co-ordinate their care, while practices will draw up detailed
care plans for the most vulnerable/high risk patients
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¾ For most practices this will not change responsibilities as most already have a name GP allocated to every patient, which
provides personalised and continuing healthcare
¾ The development of the Directed Enhanced Service (DES) for unplanned hospital admissions and proactive management of
vulnerable people
The CCG will support practices in transforming the care of patients aged 75 or older and reducing avoidable admissions by
commissioning additional services which practices, individually or collectively (i.e. as a locality group or in federation with others)
have identified will further support the accountable GP in improving the quality of care for older people. We will also work to ensure
individual practices have as much influence as they need over the commissioning of associated community services – e.g.
community nursing, district nursing and end of life care.
The national strategic framework for commissioning general practice will be core to these plans and we will work with the NHS Area
Team to develop proactive and holistic local services alongside preventative and wellbeing services. This includes maximising the
contribution of community pharmacy services to preventative approaches.
What success will look like
Successful delivery of our programme will result in:
¾ Improved access to primary care
¾ Improved overall patient experience of primary care
¾ Improved health outcomes for patients
¾ Improved quality of clinical patient centred care in General Practice with emphasis on multi-disciplinary approaches to the care
and management of the patient
¾ Reduction in the inappropriate use of expensive secondary care resources
¾ Multi-disciplinary teams in place to manage patient care
¾ Community assets routinely used in the provision of primary care services
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We will develop a suite of key performance measures with targets for improvement over the next 5-years as proxies for measuring
the success of our work in achieving our vision for primary care.
Our Primary Care Plan on the Page below provides an overview of our work programme. Further details can be found in our 2-year
Operational Plan for 2014-16 (add as hyperlink)
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Mental Health
The Case for Change
Poor mental health (which includes learning disabilities and dementia) is the largest cause of disability in the UK. It also has close
associations with other problems such as poor physical health and issues in other areas such as relationships, education and work
prospects.
The report, ‘Whole-Person Care: From Rhetoric to Reality’ highlights the significant inequalities that exist between physical and
mental health care, including preventable premature deaths, lower treatment rates for mental health conditions and an
underfunding of mental healthcare relative to the scale and impact of mental health problems.
In all areas of Lancashire the prevalence of depression in adults is significantly higher than the England average, though variations
do exist. Whilst in Preston the reported prevalence of mental ill health is significantly higher than the England average, Chorley and
South Ribble’s is lower than the England norm. We also have low rates of diagnosis of dementia leading to a lack of support being
made available to patients and their families and carers.
“Without sounding selfish, it’s me that needs help. She doesn’t know
what’s going on. I am the one who is at breaking point!”
(Source: carer, 5 year plan engagement event, June 2014)
The Government has included a specific objective for the NHS to “put mental health on a par with physical health, and to close the
health gap between people with mental health problems and the population as a whole” and achieving parity of esteem between
physical and mental health is a key priority for us as a CCG. We want the services we commission to reflect the importance of
mental health in the planning and delivery of care, giving it parity of prioritisation with physical health conditions.
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Our Vision for Mental Health
We don’t just need to enhance our mental health services - we need to change how people think about mental health and ensure
that patients with mental health conditions and learning disabilities have equal and fair access to other health services. Our vision is
for local people who need mental health care and support to have simple and easy access to mental health services to assist them
in their mental wellbeing.
We want to ensure that mental health is taken into account when considering overall wellbeing, and to reduce the stigma
associated with mental health issues, which acts as a barrier to people seeking help.
“They need to do more to combat stigma. They all think we are stupid
– and that’s the staff as well as everyone else”
(Source: member of the public, 5 year plan engagement event, June 2014)
We want a range of services to be available to meet peoples’ needs and for there to be renewed confidence in local services. A
focus on patient recovery and satisfaction will be tangible in local services with equal regard for mental health as for physical
health. This means:
¾
¾
¾
¾
¾
¾
Equal access to the most effective and safest care and treatment
Equal efforts to improve the quality of care
The allocation of time, effort and resources on a basis commensurate with need
Equal status within healthcare education and practice
Equally high aspirations for service users
Equal status in the measurement of health outcomes
Our work will include improving the services and outcomes for and quality of life people with dementia, including their families and
carers.
Improving Mental Health Services will also make a significant contribution to each of the three goals of ‘Starting Well’, ‘Living Well’
and ‘Ageing Well’ contained in the Lancashire Health & Well Being Strategy.
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How we will achieve our vision
To achieve our vision for mental health, we are working collaboratively with other CCGs in Lancashire and providers to enable
better access to mental health services and to reduce waiting times for treatment and support. Our Lancashire wide work
programme will provide new inpatient services and will reconfigure and remodel the existing provision. The key strands of work are
summarised below:
Single Point of Access: We will develop a consultant led single point of access for patients offering mental health triage and
assessment to enable clients to be directed to the most appropriate service to meet their needs in a timely manner.
Equitable distribution of resources: We will work with others to support the commissioning of services which tackle the
association between physical and mental disorders linking in with the development of our integrated neighbourhood teams.
We will develop existing networks of people with learning disabilities to comment on and shape the health services they receive
in their localities.
We will raise awareness, professional knowledge and understanding to ensure people with dementia are properly diagnosed
and to develop a range of services for people with dementia, their families and carers which fully meet their needs.
What success will look like
Improving Access to Psychological Therapies (IAPT): We will provide good access to these invaluable therapies that help patients
manage their conditions and improve their quality of life. We have a local ambition by the end of March 2015 to increase access so
that at least 15% of those with anxiety or depression have access to a clinically proven talking therapy services, and that those
services will achieve 50% recovery rates.
Improving diagnosis and support for people with Dementia: We are committed to making considerable progress towards diagnosis,
treatment and care of people with dementia by 2015. We recognise that key to this is a diagnosis as this can unlock access to
support services. We have a local ambition for two thirds of people with dementia to have received a formal diagnosis and be
accessing care and support by end March 2015.
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Patients, carers and professionals will have the right information needed to provide the right care at the right time (e.g. medical care
in hospital and social care at home).
Services will be available as and when needed by people without undue difficulty in transferring between agencies and settings.
People will know where and to whom to turn for assistance in managing their conditions.
We will develop a suite of key performance measures with targets for improvement over the next 5-years as proxies for measuring
the success of our work in achieving our vision for mental health.
Our Mental Health Plan on a Page below provides an overview of our work programme. Further details can be found in our 2-year
Operational Plan for 2014-16 (add as hyperlink)
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Urgent Care
The Case for Change
It has been clear for a while that there is a pressing need to improve the quality and cost-effectiveness of urgent care provision
across the local health economy.
Several factors have led to demand for services increasing over recent years. These include increasing life expectancy and the
associated rise in the number of people living with chronic long term conditions, the advancement of medical technology and an
increase in the range of diagnostic services available to patients and clinicians
.
A recent audit of non-elective admissions for three ambulatory care sensitive (ASC) conditions (diabetes, COPD, Heart Failure),
undertaken by member practices, has identified the potential to avoid 15% of non-elective admissions through better use of and
access to existing services (acute, community and primary care), the development of patient and clinician education and training,
access to emergency medication and redesigning services.
Transforming Urgent Care will also make a significant contribution to each of the three goals of ‘Starting Well’, ‘Living Well’ and
‘Ageing Well’ contained in the Lancashire Health & Well Being Strategy.
Our Vision for Urgent Care
The delivery of high quality and accessible urgent care services is an important priority for our health economy. As commissioners
we aim to ensure that urgent care services in the future are delivered in a seamless integrated way to best meet the needs of our
local population.
Successful delivery of our Transformational Urgent Care programme will support the delivery of our vision. We want local people
who need access to urgent care receiving care which is fit for purpose in a timely fashion. The system will need to achieve a
balance between patient experience, quality outcomes, access and cost. To achieve this we will develop a simplified, proactive,
robust system for patients that will promote health and well-being, and redirect current levels of urgent care into planned or
managed care within the managed health and social care system 24/7.
The changes we will make will ensure that we continue to meet the needs of a growing population with increasing health and social
care needs. Whatever the urgent or emergency need is and in whichever location, we will ensure that our local population has
access to the best care from the right person in the right place at the right time.
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We will use our limited resources better to provide safe, sustainable and high quality care in an integrated way, delivering the best
possible outcome for individuals.
How we will achieve our vision
Our programme is focused on reviewing, improving and redesigning urgent care services to ensure they are responsive and
appropriate to meet patient’s needs, are easy to navigate and able, where appropriate, to be delivered in patients communities.
We will re-design and or / develop ‘step up / step down’ pathways so that people do not end up in hospital or stay longer in hospital
than they need to because there is no alternative support available to help them.
Our integrated neighbourhood teams will provide support in community settings and / or support people to self-manage their
conditions, and ensure that services are enabled and accessible 24/7 through better use of premises, a flexible workforce and
technology.
“Why can’t we have treatment at a local hospital?”
(Source: member of the public, 5 year plan engagement event, June 2014)
What success will look like
Our plans for Urgent Care are structured around four core programmes of work, and a description of what success will look like for
each of these is shown below.
Ambulatory Care
¾
¾
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Fully integrated clinical pathways incorporating primary, secondary and social care
Prevention of disease through primary prevention activities
Identified cohorts of patients managed safely and effectively across primary / secondary care interfaces
Better quality, cost effective treatments provided closer to home
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System Wide Capacity Planning
¾ Patient needs are met by high quality services across the system, regardless of the time of day, day of the week or time of year
¾ Capacity and resource within health services across the whole system is optimised in order to meet patient demand at the best
possible quality and cost
¾ Reduced peaks in demand for services
¾ Reduced waiting times in Accident & Emergency at all times of the day, week, month and year
Re-design of Accident & Emergency ‘front door’
¾
¾
¾
¾
Improvements in the system’s ability to address urgent care needs
Improved streamlining of patients to the most appropriate pathways
Fewer inappropriate attendances at Accident & Emergency
A seamless service for patients that is simple to access and more responsive to patient needs offering a better experience and
higher standards of patient care
¾ Resources targeted on areas of greatest need
Better Care, Better Value
¾
¾
¾
¾
¾
¾
Integrated health and social care teams
Improved flow of patients into tier 2 care
Improved access to appropriate services
Single point of access for referring patients to integrated neighbourhood teams
A quicker and simpler patient assessment process
Technologies routinely used within the home to enable people to manage their own care packages
We will develop a suite of key performance measures with targets for improvement over the next 5-years as proxies for measuring
the success of our work in achieving our vision for urgent care.
An overview of our programme to achieve these ambitions is shown in the diagram below. Further details can be found in our 2year Operational Plan for 2014-16 (add as hyperlink)
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Elective Care
The Case for Change
Across our CCGs we spend over £110 million a year on planned care (elective inpatients, day cases and outpatient care).
Commissioning for value packs indicate a higher than expected elective admission rate for MSK conditions within our CCGs, and
the last Programme Budgeting Report (2011/12) confirmed that our CCGs spent more per head on MSK than CCGs in our
comparator groups.
We also know there is inequality of access to elective care across the CCGs’ footprints. A review of relative access rates across
practices has identified the need to work with practices to address variances in levels of access experienced.
We have high mortality rates and relatively low survival rates for cancers across the CCGs. Review of the Commissioning for Value
packs has identified that work needs to be undertaken in relation to years of life lost.
Demand for healthcare services is driven by demographic change, improving technology, unmet need and the failure to detect and
manage disease.
Access targets and patient choice issues also continue to drive demand as does the rise in patient expectations and constitutional
access rights such as delivery of 18 weeks referral to treatment and waiting times for cancer treatment pathways and the
sustainable delivery of national performance and quality standards, improved choice and care closer to home.
One of the challenges is to deliver local services within maximum waiting times whilst improving patient experience of their care
pathway. This can involve challenging current practice to ensure that pathways reflect current national good practice, using
evidence based guidelines and optimising the opportunity for transformational change.
We have low uptake of cancer screening programmes – in particular breast cancer screening - and we need to rebalance the
health economy by bringing more services out of the acute setting to be delivered in the community whilst ensuring that the patient
receives high quality care at the right time in the most convenient location to them.
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Comparative data suggests that the CCG makes a much higher than expected use of outpatient hospital services. If this care were
provided more efficiently in the community, up to £25m would be available to be spent on other services.
Transforming Elective Care will also make a significant contribution to each of the three goals of ‘Starting Well’, ‘Living Well’ and
‘Ageing Well’ contained in the Lancashire Health & Well Being Strategy.
Our Vision for Elective Care
Our vision is to commission high quality services closer to home. This will improve patient access, improve early detection, and
improve people’s experience of healthcare.
The Elective Care programme of work aims to manage current and future demands on elective care, which currently accounts for
£154m (63%) of the combined CCGs financial allocation.
Our aim is to ensure that regardless of location, patients can access the same services, safe in the knowledge that they will receive
high quality care regardless of their location.
How we will achieve our vision
The CCGs have a duty to ensure that they use resources in the most efficient and innovative ways. The most effective manner of
achieving this is to optimise demand management programmes and reduce variation in elective care. The programme will therefore
focus on the transformation of pathways and management of care in high volume specialties. The elective care programme will also
include schemes to address the poor uptake of cancer screening programmes across the CCG footprints and development of
services in relation to end of life care.
We are adopting a systematic approach to developing and commissioning new pathways for elective care to support the
development of evidence based, high value care pathways that:
¾ Promote self-management, supported by care management plans that ensure the patient knows where and when to access
support, rather than routinely seeing all patients as follow-ups
¾ Reduce unnecessary secondary care use and maximise what can be managed in primary care
¾ Improve access to diagnostics services and agree pre-clinic work ups that ensure when a patient sees a specialist for the first
time they are able to get maximum benefit from that appointment
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¾ Reduce unwarranted variation in intervention rates
¾ Support patients to review the treatment options available to them and make an informed decision which best suits their needs
and expectations (Shared Decision Making)
¾ Apply Enhanced Recovery Programme principles to elective procedures to reduce length of hospital stays
¾ Move interventions to the most effective care setting i.e. Inpatient Procedures to Day Case and Day Case to Outpatient
Procedures
We are also working to establish a community based Intravenous (IV) therapy service which will move simple antibiotic therapy
closer to home for patients requiring this treatment on a daily basis and we hope it will serve as a building block for future services
such as home based chemotherapy.
The elective care programme includes work to improve cancer screening uptake and to reduce cancer associated mortality rates.
This particular challenge has to be addressed in collaboration with Public Health to develop a strategy that improves preventative
healthcare across the CCG footrpints and links to work of the primary care workstream around improved access and focus on the
needs of the most vulnerable.
We will prioritise high quality care in primary and community settings so that we can treat an increasing number of our patients in
community facilities. This will mean fewer unnecessary hospital appointments for our patients, shorter waiting times, and
appointments closer to home at locations and times that they find more convenient. Our patients will be able to see consultants or
General Practitioners with a Specialty Interest (GPwSI) working in specialist clinics in the community for conditions such as
Dermatology, Neurology and Gynaecology.
Our Referral Management Service will be further developed to play a central role in managing referrals from primary care to ensure
referrals are directed to the most appropriate clinician, and patients are offered choice and equity of access.
We will explore working collaboratively with the national Choose and Book Team to become an early adopter for the new Enhanced
Booking System to help us implement new ways of delivering our referral management service whilst improving the ownership and
transparency for the patient and primary care colleagues alike. This innovative work will bridge the gap to ambulatory care where
referrals can potentially be linked directly through to the Integrated Care Teams, which will include specialist community and social
care providers.
Our plans for the coming years include the implementation of a redesigned:
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¾ MSK service and Physiotherapy service
¾ A range of community services including Neurology, ENT, Gynaecology, Dermatology, Community IV, community oxygen
service and tier two Urology service all of which will be operational within the next two years
¾ A programme for enhanced recovery with seven-day access to diagnostics
¾ Procurement of a Community Equipment Service across Lancashire (as part of our collaborative commissioning work described
below)
¾ Review of current stroke service provision across Lancashire (as part of our collaborative commissioning work described below)
¾ Encouraging a one stop approach to healthcare consultations, where clinicians are empowered to ‘see, treat and discharge’ if
clinically appropriate and safe to do so
¾ A health economy programme around improving awareness, screening and early detection of cancer and improving diagnosis
and early referral of cancer in primary care and support the survivorship pathway
What will success look like
Our approach to improving access to elective services will in the long term reduce demand for urgent and non-elective care as
patients are treated earlier and more proactively for a range of conditions. The delivery of this programme of work will:
¾
¾
¾
¾
Enhance community-based capacity to support self-care and self-management
Enhance community-based capacity to deliver a move from the acute setting into the community
Improve quality, outcomes and provide better value for money
Encourage innovation and the use of technology in health care and self-management
Patients will feel more in control of their healthcare than ever before, with the ability to work collaboratively with clinicians in both
primary and secondary care to make informed and evidence based decisions about their care.
We will develop a suite of key performance measures with targets for improvement over the next 5-years as proxies for measuring
the success of our work in achieving our vision for elective care.
An overview of our programme to achieve these ambitions is shown in the diagram below. Further details can be found in our 2year Operational Plan for 2014-16 (add as hyperlink)
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Collaborative Commissioning
We are working in partnership with other CCGs in Lancashire and key stakeholders to deliver a programme of work governed
through the CCG Network. An overview of these work programmes is provided in the diagram below.
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The programme is split into Strategic Work Programmes (programmes of at least 12 months duration) and Operational Work
Projects (projects of less than 12 months in duration).
Strategic Work Programmes
Mental Health Reconfiguration
Our vision for Mental Health and Dementia services across the Lancashire health economy is to ensure appropriate access and
treatment for people with mental health problems and ensure they have timely and effective help at the right place and the right
time.
The Lancashire CCGs are undertaking a significant mental health acute reconfiguration in partnership with Lancashire Care
Foundation Trust (LCFT). The new service model aims to treat people with mental health problems in specialist community mental
health teams and reduce the requirement from mental health inpatient capacity.
The CCGs are in the third year of a 5-year programme of transition and so far have achieved £9million of savings of a total
£15million due by 2017. The transformation programme will then undergo a period of evaluation to ensure all outcomes have been
met.
The programme began in 2006 with an extensive consultation process on inpatient mental health facilities. This resulted in the 15
existing in-patient units being reduced to four more appropriate, modern facilities.
Although good progress has been made, there are still challenges and the main priorities going forward are:
¾ Single Point of Access (SPoA) to ensure that access to mental health services is managed through a single point. This is
currently not functioning well. Over 50% of admissions into the acute mental inpatient services present through Accident and
Emergency (A&E) and are unassigned
¾ Unscheduled Mental Health Care Pathway. There is a requirement to redesign a number of current teams to introduce one
single pathway to ensure better quality outcomes for patients whilst reducing duplication
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Dementia Reconfiguration
In early 2013 the Mental Health Reconfiguration Programme moved on to look at dementia, and conducted another public
consultation focused on moving the majority of dementia care closer to home or into the community. The vision for dementia care
across Lancashire is defined as:
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¾
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¾
Good quality early diagnosis, intervention and on-going support within dementia friendly communities
Living well with dementia in care homes and the community and reduction in the use of antipsychotic medication
Improved quality of care in general hospitals
Improved quality of care in specialist hospitals
Dementia in-patient services will now be consolidated onto one site (The Harbour, Blackpool) which is a brand new in-patient
facility, due to open in March 2015.
Although good progress has been made, there are still challenges and our main priority currently is in Dementia Specialist
Community Services. We plan to review the overall implementation of IST and NHL function in all areas, aligning with integrated
neighbourhood team developments and ensuring all gaps are addressed in 2014/15 through specific transition plans.
Learning Disability Programme
Following the recommendations made by the Winterbourne Report, we have identified the need to redesign our Learning Disability
Service to ensure that patient needs are met and improved outcomes are delivered.
To achieve the Report recommendations, we will put in place systems for ensuring the quality of service provision. We will do this
by:
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Revisiting our service specifications and implementing new, seamless service models
Establishing the means of monitoring performance and standards
Agreeing processes to provide links and smooth transition for patients between services
Developing and monitoring an improvement plan
The Learning Disability programme is focused on three main work streams as follows:
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Enhanced Support Services
We are currently undertaking a review of the enhanced support services through current and future state mapping techniques. We
will be supporting the establishment of a multi-agency steering group for the project allowing us to develop and implement a new
referral process and pathway.
Our main outcomes for this work stream will be:
¾
¾
¾
¾
Development of a Learning Disabilities provider framework
Development of assessment & treatment services at Calderstones
Undertaking engagement with service users, carers and families
Supporting the development of a revised provider business model and organisational form
Child and Adolescent Mental Health Service (CAMHS)
Lancashire CAMHS is in the process of restructuring and integrating with Lancashire County Council, to provide a comprehensive
and consistent service across the county that meets nationally set quality standards. This involves a refresh of the strategy, a
review of current services leading to new service specifications and models and the oversight, monitoring and delivery of 8 work
streams.
Our aim with this programme is to increase access and provide 24/7 services, to agree an integrated CAMHS/ psychology service,
implement and monitor a local and national reporting system and provide developmentally appropriate services for young people
over the age of 16.
Children with Special Educational Needs and Disabilities (SEND)
Inequitable service provision for children with special educational needs and disabilities (SEND) across Lancashire has been
identified by Ofsted and the CQC and our group of CCGs have committed to address this. We are therefore conducting a review of
services, which will include the checking of compliance with national standards, and will make recommendations for areas of
potential service improvement.
In addition to the review, we will be looking to implement a single service specification for Tier 2 and 3 services and to develop and
deliver support for care pathways in and out of services.
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Diagnostics/ Pathology
As new tests come in, and with an aging population with multiple conditions, there is a need to rationalise, determine where
efficiency and cost savings can be made, and have agreement around use of tests, technology and good practice.
The Diagnostics & Pathology programmes look to reconfigure pathology services including the laboratory-testing element of the
cervical cytology-screening programme and pathology diagnostic services in the community, by developing a service specification
for the pathology services that reflects current best practice.
As part of this programme we will develop standardised activity reporting and payment for Direct Access Pathology Services,
benchmark practice utilisation of services and undertake review of service provision in support of wider Lancashire strategy. The
expected outcomes of the programme are:
¾
¾
¾
¾
¾
Common list of tests across all Lancashire providers with consistency in naming and units of measurement
Updated specification for DA pathology
Report on level of variation in use of diagnostic tests across Lancashire
Agreement with providers on the process to address any variation
Agreement with providers of Lancashire-wide disease specific testing algorithms
Operational Work Projects
Community Equipment Re-Procurement
The CCGs within Lancashire have identified opportunities to consolidate purchasing power for Community Equipment Services
across the area achieving greater value for money, improved procurement pathways and quality of service.
This programme will develop, mobilise and monitor a consolidation plan to bring the current service provision from three providers
down to one provider. This will include the specification development, financial analysis and procurement/ framework establishment
for the service.
Overall we expect to provide a singly high quality service based on a Lancashire wide service specification and contract that
ensures value for money through the buying power of a single provider. This will deliver improvements across the whole service,
giving us an increased ability to re-use and re-purpose high cost equipment as well as develop streamlined pathways for equipment
provision.
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Stroke/ TIA/ Vascular
This programme has been identified as initially less than 12 months in duration on the basis that it is currently subject to a scoping
exercise, which will be reported in June 2014. It is anticipated that the stroke review will offer a real opportunity to be
transformational around 7-day working and potentially drive major reconfiguration.
The implementation of an Abdominal Aortic Aneurysm screening programme is cited as a ‘must do’ in the NHS Operating
Framework, focusing attention on the establishment of specialist interventional centres. We intend to establish three specialist
vascular interventional centres covering the region, linked by a vascular network. This will in turn, identify pathways and
commissioning issues and priorities for individual CCGs.
Our stroke/ TIA review will identify a best practice service model, assess our current service provision against this and recommend
further service improvement or transformation opportunities to achieve a high quality stroke service for the population of
Lancashire.
Healthier Lancashire
The commissioners of health services across Lancashire are keen to undertake the development of a “Health & Care” strategy
across the county that will build upon the work undertaken by the Lancashire Improving Outcomes Board and more recently, the
Lancashire Transition Group.
We recognise the need to bring together the shared ambitions of both commissioners and providers from both health and social
care together with the voluntary sector and other agencies.
We recognise the need to prioritise the strategies across the county based upon our current knowledge but do not undervalue or
underestimate the need for local ownership and implementation.
The strategy (‘Healthier Lancashire’) will be brought together by the Lancashire Leadership Forum but will be shaped and
implemented by those organisations allied to it, including the Health and Wellbeing Boards of Lancashire.
The Healthier Lancashire Strategy is being developed to improve outcomes for the people of Lancashire, and consists of 7 main
projects, as outlined below:
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In Hospital Care
Out of Hospital
Care
Neighbourhood
Pilots
The Big
Conversation
Digital Health
Single Version of
the Truth:
Collaborative
Leadership
This project is a clinically led assessment of opportunities to improve patient outcomes through provider
collaboration for the provision of specialist and hard to recruit to services. The three main drivers are
improved outcomes, clinical sustainability and financial sustainability.
This project seeks to improve outcomes for patients who no longer require an acute hospital bed but who
would benefit from further treatment or therapy delivered in a non-acute setting. The project will seek to
provide health and social care support that cannot be provided in a person’s own home. It will address the
long standing problem of hospitals (physical and mental health) being unable to discharge patients who
require further rehabilitation, therapy or intermediate care in a timely fashion due to lack of suitable
alternatives.
All CCGs are developing a neighbourhood and locality approach for multi-disciplinary teams and multi
agencies to work within community.
This will aim to engage the public around why Lancashire’s health and care delivery needs to be transformed,
to support the development of the strategy by engaging with public and stakeholders and to ensure that
thoughts, ideas and concerns are part of decision-making and the strategy development process from day 1.
This is about designing a new digital plan for Lancashire, which will harness digital technology to promote
wellness and self-care, improve access and efficiency, offer new ways of accessing and delivering care.
This will involve creating a public document that sets out the position for health and social care in Lancashire
for the period 2014 – 2020. It will include information on money, workforce, health outcomes, service
sustainability and estates, and provide background information.
This is about finding a collaborative team approach to address this strategy and work together across
organisations and streamlining our efforts.
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4.3: Enablers
The key enablers across the local health economy that are driving our plans are shown in the diagram below.
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We will make use of a combination of resources, systems and processes to make these changes happen and these are described
in the remainder of this section.
Integration: A Modern Model of Integrated Care
A coordinated, care system with services wrapped around the patient using integrated care services and support accessed and coordinated by Primary Care teams is the foundation stone for our strategic vision, and across both our CCGs and LCC are already
engaged in a programme of Urgent Care transformation as set out in our plan aimed at developing integrated community health
and care services. As a system we aim to use the Better Care Fund as an opportunity to further strengthen this work and deliver at
greater pace and scale.
We are, however, confident that the investment and joint working in place builds on our success to date and will make a significant
impact in addressing what we see as the key challenges / barriers to delivering modern integrated care .
The commissioners, hospital and community providers have come together to start to develop a new model of integrated care that
will help to create the foundations for sustainable delivery against the efficiency challenge faced by the NHS. Collectively all believe
this is essential to meet the needs of the ageing population, transform the way that care is provided for people with long-term
conditions and enable people with complex needs to live healthy, fulfilling, independent lives.
Better Care Fund
The Better Care Fund will provide £3.8 billion to local services to give elderly and vulnerable an improved health and social system.
Local areas will work together across health and social care to develop plans for how they will use their portion of the fund to join up
health and care services around the needs of patients, so that people can stay at home more and be in hospital less.
The national conditions set out the things that each plan must consider, such as 7-day services and steps to improve data sharing,
but there will also be as much flexibility as possible in the model of care locally that areas develop to meet the needs of people in
each area of England.
Our Better Care Fund Plan outlines in more detail our plans for the integration of care. Locally our CCGs, Lancashire County
Council, our providers and other key stakeholders have identified the following vision for integrated care:
People will stay healthier at home for longer by doing more to prevent ill health, by supporting people to manage their
own health and well-being and by providing more services in people’s homes and in the community
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We want people to feel in control of their lives and their care, with the services they receive being co-ordinated and planned with
them around their individual needs.
The CCGs, Lancashire County Council and our providers and partners will build upon our existing work to integrate services
around people’s needs, but recognise that to do this we need to transform the way we work together across health and social care.
Our key aspirations for integrated care across our CCGS are to deliver:
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¾
¾
¾
¾
¾
¾
¾
¾
More care in people’s homes and in their local neighbourhoods
Person-centred care, organised in collaboration with the individual and their carers
Better experience of care for people and their carers
Population-based care that is proactive and preventative, rather than reactive and episodic
Better value care and support at home, with less reliance on care homes and hospital care
Less duplication and ‘hand-offs’ and a more efficient system overall
Improvements to key outcomes for people’s health and wellbeing
Stronger, more resilient communities
Greater Preston and Chorley & South Ribble as a great place to live and work
The CCG and Lancashire County Council are committed to using joint resources to achieve the shared vision. The way that
services are currently commissioned and organised does not always achieve these aims, and there are differential incentives that
work against our vision of services working together to support better health and more independence.
We will use our resources differently to remove organisational impediments to the provision of person-centred care and financially
incentivising prevention, earlier intervention, recovery and reablement with our providers. Our plans will lead to less reliance on
care in hospital or care homes, and more care in people’s home or delivered in community based settings. We will work with our
partners via our established Clinical Senate to enable this movement of resources to happen.
The main schemes and changes under the Better Care Fund that will deliver this are as follows:
In 2014/15: The CCG will implement a step up / step down model across the health economy and support the development of
Integrated Neighbourhood Teams. This will support development of the following:
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¾ Discharge support and move towards 7 day access
¾ Specific investment in step up / step down
¾ Investment made in infrastructure costs for developing integrated neighbourhood services
In 2015/16: Following evaluation of our work in 2014/15 (above), the services described above will be rolled forward into the
2015/16 Better Care Fund. In addition, as the funding pooled under the Better Care Fund increases to £25 million the following
services will be covered by the fund:
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¾
¾
¾
¾
¾
¾
¾
¾
Admissions avoidance service
Discharge support and enhanced 7 day access across primary care and integrated community health and social care services
Home care quality improvement, capacity and capability to support integrated care
Self-management: expert patient programme for people with long term conditions and building a community asset approach to
keeping well
Telecare expansion
Voluntary and community sector prevention, particularly aimed at addressing issues around social isolation in older people
End of life care / Hospice at Home
Protecting social services - maintaining access and eligibility levels in the face of central government funding reductions
Joint Carers Strategy
The CCG and its partners anticipate the impact of the Better Care Fund investment over the next two years to be seen by:
¾ Increases in the numbers of people benefitting from the community multi-disciplinary team approach, and enhanced activity
levels in the Better Care Fund funded services such as home ward, admissions avoidance and reablement
¾ Reductions in the rate of avoidable emergency admissions to hospital
¾ Moving the balance of care away from care homes, including reduced admissions
¾ Impact of reablement in reducing the care needs of clients using the service
¾ Reduced numbers of patients whose transfers of care are delayed
¾ A reduction in length of stay in hospital and emergency bed days for older people
Specific targets in relation to these are included within the performance tables in the previous section.
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A key underlying aim of our Better Care Fund Plan and the Urgent Care programme, is for integrated care to help achieve financial
sustainability for the whole health and social care system, as well as to improve general population health and to improve key
health and life outcomes. The success of this will be evaluated with reference to the financial position of all commissioners and
providers.
We have developed our plans jointly with Lancashire County Council, fully engaging with providers and patients throughout the
process and have developed our commissioning intentions with the same partners, working to ensure a close alignment between
those areas of transformation they will lead together through the Better Care Fund and those which will be led primarily by us.
Finance
Under the ‘City Deal’, the population in our part of Lancashire is expected to grow rapidly over the next 10 years and we recognise
that we must work with other commissioners and providers to deliver services to meet this expansion.
Our plans assume the funding to provide health services for these people will lag behind the actual population increases and we
have assumed no adjustment to our allocation over the 5 year planning horizon. We have assumed that NHS England will
commission the additional GP primary care services (although we are currently working with NHS England to develop an approach
to the co-commissioning of primary care) alongside the work we will be doing with the Local Authority through the Better Care Fund
to increase service capacity.
The outlook over the course of this and the next Parliament is unchanged. Funding constraints will continue, while demand
continues to rise. The challenge of growing demand within constraints of ‘flat’ real funding growth remains the same. The NHS
England ‘Call to Action’ forecasts a financial gap nationally of £30bn by 2020/21.
We have prepared a five-year financial outlook to support the strategic and two-year operating plans. The starting position is the
financial plan must facilitate improving outcomes and maintaining quality, with a demonstrable improvement in outcomes for local
people. The financial plan is explicit in dealing with the financial gap and related risk and mitigation strategies.
Workforce
The workforce is a key enabler to achieving our ambitions. It is already a significant challenge for us and national, regional and
local priorities and the implementation of new models of care will have further significant impact on the workforce of our providers.
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Changing the settings of care (centralising specialist services, localising routine medical services, integrating care between primary
and secondary care) will require significant planning.
As we move towards new models of care we will need to understand the training requirements to support these models, and this is
particularly relevant for those groups who will play a more central part in delivering the new models of care, such as non-medical
professions and community services. We will also need to establish new roles to support the new models of care, such as GPs with
a special interest in emergency medicine, end-of-life care or gynaecology.
Increasingly, there will need to be a movement of more staff from the hospital to the community to support out-of-hospital models of
care. There will be a need to support staff making this transition as well as more developed career structures for community
consultants in both elective and emergency care. In order to secure the delivery of the new models of care, better use of workforce
incentives, including individual-level incentives linked to outcomes, need to be explored and strengthened. To address these
challenges, we will:
¾
¾
¾
¾
¾
¾
Create integrated multi-disciplinary teams across primary, secondary and social sectors
Re-skill staff to enable them to deliver the new models of care effectively
Enable the community to play an oversight role and enforce consistent, high quality delivery of care
Manage talent and ensure robust processes are in place for hiring, replacing, and retaining necessary skills
Provide strong support for on-the-job training and development
Develop the use of action learning
We want to encourage people to positively choose Greater Preston, Chorley and South Ribble as a place to work and to be able to
offer interesting and imaginative opportunities for staff and the support needed to retain skills and capability locally.
We are therefore also exploring with the existing clinical workforce the role they could play in the future by moving their roles into an
‘in and out of hospital’ job plan. We are considering ‘portfolio’ job plans / descriptions across acute, community, primary and social
care settings to produce a suite of portfolio job plans / job descriptions across health and social care settings, alternative
employment contracts for joint appointments, opportunities for joint working and employment across sectors.
We will identify opportunities and flexibilities to support the design and development of new innovative career structures and the
use of information technology across organisations to support flexible training and working.
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This work will make a significant contribution towards a range of key issues and challenges that are common across our health
economy. Specifically it will help to:
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¾
¾
¾
¾
¾
¾
Improve recruitment and retention of clinicians across the health and social care economy
Integrate service provision across the health economy
Create a flexible workforce for the future
Address clinical workforce gaps
Improve relationships between acute, community and primary care settings
Improve care pathways
Improve staff and patient satisfaction
Existing Training and Development Arrangements
Health Education North West (HENW) is responsible for the education, training and continuing personal development (CPD) of
every member of NHS staff, and recruiting for values in the North West. It has provided funding for us to roll out our plans to identify
opportunities and flexibilities to support the design and development of new innovative career structures and the use of information
technology across organisations to support flexible training and working across sectors referred to above.
With a budget of around £715 million per annum they contract with Higher Education Institutions (HEIs) to train the new and
develop the existing medical, general practice, non-medical and wider workforce utilising intelligence, strategy, planning,
commissioning and transformation to support delivery of their vision, business plan and priorities through their mandate with the
Department of Health (DoH).
Their annual workforce planning process identifies 5-year workforce supply and demand forecasts across NHS commissioned
health services and wider, and highlights gaps which may prove a risk to delivery of commissioned services by Local Area Teams
(LATs) and Clinical Commissioning Groups (CCGs).
The intelligence gathered from providers and service commissioners informs the education and training commissioning process
and workforce solutions to be developed to ensure that the availability of a competent and compassionate workforce is not a barrier
to providing the services needed for our patients now and in the future.
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Research and innovation
Innovation and the adoption of best practice are vital in transforming health care. The CCGs are working together with partners in
several key ways to ensure that it keeps a focus on innovating and adopting best practice.
We are members of the Academic Health Science Network (AHSN) for Cumbria, Cheshire, Lancashire and Merseyside and will
play a key role in making it a success as patients will benefit from the research, knowledge and role the AHSN can play in
improving health locally.
Medicines management input to the CCGs is provided by Commissioning Support Unit. The offer includes production of a horizon
scanning document to support a systematic process to track NICE Technology Assessments and an Innovation Scorecard has
been developed.
A Lancashire wide Medicines Management Board has been created that includes primary care, community care and secondary
care. A key aim for them is to produce a Lancashire formulary to ensure that we have consistency across the county and improve
prescribing practice through the use of a formulary.
Telehealth and telecare will be considered as part of the CCGs’ long term conditions programme. Investment in this area will be
reinforced by the need for providers to meet the pre-qualifiers for two particular CQUIN areas: digital first and 3 million lives. Both of
these initiatives are highlighted in Innovation, Health and Wealth as areas in which service delivery can be transformed. We expect
our providers will be able to meet these pre-qualification requirements.
There is, however, some evidence emerging that telehealth and telecare may have limited effectiveness, and should be considered
as supplementary to other primary care delivery methods. We will closely monitor the evidence of effectiveness of tele-based
services, and flex its plans to ensure it commissions them at an appropriate level.
Information technology (IT)
IT is a key enabler to achieving our vision - an effective way to connect communities, commissioners and providers and to
streamline and speed up processes within patient pathways, including access to patient records. IT will also play a significant part
in the successful delivery of our Integrated Neighbourhood Teams and our patient engagement strategy makes use of IT in
communicating and engaging with local communities.
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We are therefore are working to develop an IT strategy to encompass core GP IT and also the wider IT needs of the local health
economy to support the increase of shared records across the economy and care providers’ patients with access to their records.
“Every specialist you go to asks what medicines you are on.
It’s so frustrating – surely they should know”
(Source: Patient Engagement for 5-year plan June 2014)
Estates and premises
We have identified the challenges we are facing in relation to estates and premises in Section 2 above. However we cannot deliver
our ambitious plans without this key enabler.
To achieve our vision, we need local practice premises which are welcoming, with a broad range of clinical staff and facilities
available to meet the needs of the local population. This will require significant investment in existing estates and premises.
In the longer term we wish to provide access to a broader range of diagnostic and therapeutic services in purpose built buildings
which are easily accessible and which serve as a focus for a range of community activities, not necessarily just a space for the
provision of health services. Patients should be able to experience a more ‘seamless’ service where the primary, secondary,
voluntary sector and social care are more integrated, offering a wider range of services at a single point of contact. The services
provided will support the aim of avoiding unnecessary admissions to, or attendance at, hospital or facilitate earlier discharge from
hospital.
We will work with our other partner organisations to map our current estate infrastructure and develop a long term strategy for
‘transforming our care environment’.
We have already invested in the development of two new Urgent Care Centres at Chorley and South Ribble Hospital and at Royal
Preston Hospital, which will provide state of the art facilities for patients and clinicians and treat patients in the most appropriate
setting, speeding up access to treatment and freeing up valuable A&E resources for those most in need of this service.
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“If I had someone I could ring up who knew what I was talking about, I
probably wouldn’t need to go to A&E!”
(Source: member of the public, engagement event, June 2014)
Stakeholder Engagement
We are committed to meeting the needs of our local communities, and to responding to their views and concerns, and also those of
their GPs. Our plans have been developed to address the issues identified in the previous section alongside priorities identified in
our engagement work with key stakeholders.
Our engagement arrangements have been tailored to the particular audiences we are seeking to reach, targeted and designed
around specific service transformation and improvement projects, and also around specific demographics to ensure we listen to the
voices of seldom heard groups, and people in protected characteristic groups (see diagram below).
Practicelevel
Localitylevel
Practicememberpeergroups,locality
engagementevents,ongoingfeedback
Corporatelevel
PatientVoiceCommittee,PublicAdvisoryGroup,
OwnershipCouncil,ongoingfeedback
Commissioningactivity
Patientparticipationgroups,patientengagement
toolkitsandsupport,ongoingfeedback
Bespoke
Consultations,thematic
engagement,events,surveys
andpolls,supportfor
servicechangeand
improvements,engagement
withseldomheardgroups
(protectedcharacteristics)
ADD
image or
Lancashirehealthandsocialcare economy
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All of our engagement is designed to learn from patients. Public engagement is embedded across our organisation at all levels and
is reported to the Governing Body at its public meetings.
Practice-level Patient Participation Groups (PPGs) provide feedback to GP practice”peer groupsெ to help drive healthcare planning,
and we also have an established Ownership Council made up of around 440 people. This Council is a network that allows residents
who live and work in the area to receive news and updates through newsletters and bulletins, and get involved with health and
wellbeing events, surveys and focus groups.
We have also established a Patient Advisory Group, to help provide advice and reference on our engagement plans and external
publications, and a Patient Voice Committee, which as a formal sub-committee of the CCG Governing Bodies will seek assurance
that patient views are embedded into strategies, plans and processes.
The diagram below sets out our patient voice flows:
Involvement Network
(Ownership Council /
wider involvement
network)
Patient Advisory
Group (Core group of
patients and members
of the public –
reference group)
Patient Voice
Committee
(Formal assurance and
scrutiny on behalf of the
Governing Bodies)
NHS Greater Preston
CCG Governing Body
NHS Chorley and
South Ribble CCG
Governing Body
We use a range of different tools to enable us to reach out more effectively to local people. We use local media, websites and
social media channels as well as more traditional methods, such as events, focus groups, surveys and field research. We directly
target communities and patients, and also engage through our active, local community, voluntary and faith sector.
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How we have listened to inform the development of our 5-year plan
Who?
The local population
Local Community Groups
Member practices
Health and social care
economy
How?
We have recently undertaken large scale engagement which has involved: tele-interviews, face to
face interviews, focus groups, online surveys, questionnaires and public facing events such as the
local health Mela. We will be refreshing the CCGs’ Ownership Programme in an effort to get more
people involved in the work of the CCGs.
We will also use the data we collect via our customer care service more effectively.
When we re-design our services, we ensure that we have patient representatives at our service redesign workshops and have patient representatives at our procurement panels.
We have well established networks with the voluntary, community and faith sectors, and regularly
attend BME and faith forums, Health and Well Being Partnerships and Third Sector Lancashire
events
Through workshops, membership councils, peer groups, practice manager meetings and through
the development of Patient Participation Groups
Through a stakeholder ‘visioning event’ (see Section 3.3)
The health economy
The challenges we are facing as described in Section 2 cannot be addressed by any organisation standing alone and we are
committed to working collectively to bring about the changes we want to see.
Locally the health economy in which we operate faces exactly the same challenges. The ability to work more closely in partnership
or as a “health economy” is therefore more necessary than ever before.
Much thought has been taking place across Lancashire as a whole system about how it may work together to tackle the issues
facing both health and social care.
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This work has been progressing with all 8 CCGs, the NHS Local Area Team, the major acute and community health care providers,
social care commissioners, local authorities and the core democratically elected members in the newly reformed health system.
The work has seen the establishment of the Lancashire Leadership Forum, supported by the Transformational Executive Group,
which will oversee the development of a consistent health and care improvement framework for the county through three core
pieces of work across the entirety of Lancashire: in-hospital strategy; out of hospital care strategy; and neighbourhood care pilot
programmes. These arrangements are shown in the diagram below.
3Health&WellbeingBoards
LancashireLeadershipForum
Transformational
ExecutiveGroup
DesignWork
streams
LancashireCCG
Network
Localhealtheconomy
workingarrangements
(Seebelow)
Collaboration
Arrangements
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In support of this work, the local health economy for Chorley, South Ribble and Greater Preston has started to formalise is own
internal arrangements to provide a framework for aligning commissioner and provider plans and intentions to eliminate duplication
and connectivity of plans to around a collective ambition.
To help us to do this, we have established a Clinical Senate, which has been used thus far as a vehicle to engage in regular
dialogue. It has enabled commissioners and providers to talk on an equal footing to find areas of common agreement. With the
emergence of a new narrative for the NHS nationally, it will serve as a solid foundation upon which to further build.
The Clinical Senate is underpinned by three working groups focused on urgent care, elective care and primary care, which have to
date focused on managing operational-type issues across the health economy.
This infrastructure has served well to establish and cement relationships in the health economy and is now evolving into
arrangements that are less dependent on structure and more dependent upon overseeing a common strategic direction, as shown
below.
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Tackling health inequalities
Achieving success in addressing health inequalities in our area requires all stakeholders within the health economy to play a part.
Within Public Health, a series of health equity audits are being undertaken for programmes to identify groups and areas with lower
coverage of services and poor health outcomes. This will assist the Public Health Teams from the Local Area Team and Lancashire
County Council to develop action plans to address health inequalities. The Public Health Teams also requires Acute and
Community sector service providers to assess inequalities in their services and to develop action plans and improve access and
coverage for vulnerable and deprived groups.
The CCG is addressing the health inequalities identified in the JSNA through the roll out of its Integrated Neighbourhood Teams
(see below) across Chorley, South Ribble and Greater Preston. These teams are being developed with the joint aims of improving
the health and wellbeing of local patients and their carers, improving professional experience and to achieve greater efficiencies
though collaborative working in a challenging financial climate.
Each ‘locality’ has its own ‘locality pack’ derived from the JSNA which sets out the health needs of the people in the area, to enable
services to be tailored to meet specific needs.
Improving quality
The drive to secure positive health outcomes for local people and continuously improve the quality of services is at the heart of the
work of our CCGs. It requires focused leadership by the CCG’s Governing Bodies, together with relentless individual and collective
commitment across the CCG’s membership and staff.
Securing and improving quality cannot be achieved by the CCGs in isolation. We recognise that our patients’ journeys cut across
primary, secondary and specialist health and social care and those services are commissioned and delivered by multiple
organisations and professions both within and outside the NHS.
Our partners in the wider health economy are committed to working with us to continually improve quality, and we support and
collaborate with provider organisations to improve the quality of services provided, whilst holding them to account for the standards
of services they deliver.
The various failures at mid-Staffordshire NHS Foundation Trust, University Hospitals, Morecombe Bay NHS Trust, the independent
hospital ‘Winterbourne View’ and the review into 14 hospital Trusts in England, highlight the risks to patients if we do not have
robust systems and processes in place to assure quality and to identify and act when quality falls short of expectations. These
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examples act as a reminder that when failures in expected standards occur, the consequences are directly felt by patients, service
users, their carers and families.
We are committed to supporting the recommendations highlighted by the Francis Report, the Keogh Review, the Cavendish
Review and the Berwick Report (Department of Health 2013).
In addition, ‘Compassion in Practice’ (Department of Health 2012) sets out the requirement for all organisations to promote the 6C’s
of care, compassion, competence, communication, courage and commitment and we support and monitor the implementation of
the 6C’s within all the services we commission.
Systematically and continuously improving the quality of services across settings of care represents a significant challenge for the
CCGs and partner agencies. As financial resources are constrained, we need to improve quality and outcomes through innovation
in service design, efficiency, and a continued focus on prevention of ill-health alongside treatment and care.
The measures of quality are not static. We know that we need to improve year on year to have a positive effect on health outcomes
and patient experience. We are eager to make realistic and measurable progress against nationally and locally agreed standards.
This is likely to require some difficult and courageous decisions by the CCG in the years ahead.
To this end, we have worked with key stakeholders to develop a Quality Strategy (insert as a hyperlink) that describes our
responsibilities, approach, governance and systems to enable and promote quality across the local health economy. Quality is,
above all else, about people and our strategy supports how we will commission services that are safe and effective.
We want health care in our area to be the ‘best in class’ whilst commissioning for greater effectiveness and efficiency, and have
created the capacity within our CCGs to lead and sustain this. We have a specialist quality and clinical effectiveness team
dedicated to the pursuit of quality, and robust governance arrangements in place to ensure that pursuit of quality becomes
embedded in everything that we do and everything that we commission.
The strategic objective of the Quality and Clinical Effectiveness Team is to improve quality through more effective, safer services
which deliver a better patient experience. The team’s key aims are:
¾ To ensure that commissioned services are safe, evidence based, personal and effective
¾ To promote the continuous improvement in the safety and quality of commissioned services
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¾ To ensure the right quality mechanisms are in place so that standards of patient safety and quality are understood, met and
effectively delivered
¾ To provide assurance that patients safety and quality outcomes and benefits are being realised, and to recommend action if the
safety and quality of commissioned services is compromised at any stage
¾ To monitor outcomes for local populations and ensure systems are in place to address areas for improvement
¾ To create a research and innovation culture that supports continuous improvement in the safety and quality of commissioned
services
¾ To ensure that commissioned services are safe, evidence based, personal and effective
¾ To ensure a robust mechanism is in place to approve and monitor the implementation of clinical commissioning policies
To underpin our work, we have developed a series of ‘Quality Dashboards’ for each of our main providers, and which consist of a
wide range of performance measures acting as proxies for quality. These include waiting times, mixed sex accommodation
breaches, cancelled operations, hospital infections, never events and patient experience to name a few. Providers populate these
dashboards at regular intervals to help us to monitor and manage the quality and effectiveness of the services we commission from
them, and thus to ensure that improvements are not solely focused on activity levels and the speed and efficiency of services.
A priority for 2014/15 is to integrate the management of quality with our arrangements for managing other elements of performance
and to do this we will refine these dashboards to produce a suite of performance report cards for different audiences within the
system.
We are also reviewing the way in which we manage complaints across the whole system to ensure that we capture and triangulate
softer intelligence and anecdotal evidence from these and from patients collected through our patient engagement work.
Commissioning
A range of different organisations have responsibility for commissioning different elements of health services in our area and an
overview of this is shown in the table below. However, we work collaboratively through the local health economy networks and our
Clinical Senate to ensure that the commissioning plans are aligned for the benefit of our local communities. Further details in
relation to the commissioning responsibilities of NHS England can be found in Appendix 3.
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Our CCGs commission
Urgent and emergency care:
¾ NHS 111
¾ Accident & Emergency
¾ Ambulance services
¾ Out-of-hours primary medical services
Acute hospital care:
¾ Diagnostic tests
¾ Surgical, medical, women’s and
children’s services for both elective
and emergency care
¾ Maternity services
NHS continuing healthcare:
¾ Packages of care arranged for
individuals who are not in hospital, but
have complex on-going healthcare
needs
Education & advice:
¾ Promotion of opportunistic testing and
treatment
¾ Advice as part of other healthcare
contacts
¾ Self Help for Long Term Conditions
such as COPD, Diabetes etc.
Community health services:
¾ Rehabilitation services
¾ DVT and anti-coagulation services
¾ Physiotherapy
¾ Speech and language therapy
¾ Continence services
NHS England commission
Specialist Commissioning including:
¾ Renal (kidney services)
¾ Mental health care in secure settings
¾ Neonatal intensive care services
¾ Cancer services
¾ Burns care
¾ Medical genetics
¾ Specialised services for children
¾ Cardiac surgery
¾ Trauma and head
Primary Care:
¾ General Practitioners
¾ Pharmacy Services
¾ Ophthalmology
¾ Dental Services
Public Health:
¾ Screening
¾ Immunisations & vaccinations
¾ Health visitors
Health & Justice Commissioning
¾ General prison healthcare including
police custody suites and immigration
centres
¾ Substance misuse services for prison
inmates
¾ Healthcare for secure children’s homes
Lancashire County Council commission
Adult Services:
¾ Domiciliary care
¾ Residential care
Public Health:
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
Health checks
Exercise referral
Weight management
Physical activity
Nutrition and generic healthy
lifestyles
Social prescribing
Health Champions
Sexual health services
Teenage pregnancy services
Substance misuse, drugs and
alcohol services
Tobacco control and smoking
cessation
School nursing
Infant feeding
Health services for armed forces & veterans
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Our CCGs commission
Community health services (continued):
¾ Wheelchair services
¾ Occupational Therapy
¾ Home oxygen services)
Other community-based services:
¾ Enhanced services provided by GP
practices e.g. minor surgery, minor
injuries
¾ Community-based eye care services
¾ Counselling for bereavement and
domestic abuse
¾ Cancer care
¾ Carers support
Mental Health and Learning Disabilities:
¾ Mental health services (including
psychological therapies)
¾ Treatment services for children,
including child and adolescent mental
health services (CAMHS)
¾ Children’s healthcare services (mental
and physical health)
¾ Services for people with learning
disabilities
¾ Eating disorders
NHS England Commission
Lancashire County Council commission
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CCG Commissioning
Commissioning principles
Our CCGs have a responsibility to commission a range of healthcare interventions. The CCG defines those through a suite of
polices which are kept under continual review. That suite of policies includes a statement of the principles on which the more
specific policies are based. Those principles are:
¾ Appropriateness: This principle considers the purpose of the intervention, ensuring that CCG commissioned services will
address health issues
¾ Effectiveness: This principle considers whether the proposed intervention is likely to achieve its purpose, and to doing so
without disproportionate side effects or other clinical dis-benefits
¾ Cost effectiveness: This principle considers whether the proposed intervention is a priority for the use of scarce resources
¾ Ethics: This principle considers a range of issues including equity, discrimination and fairness, and the effect of the service on
the whole population
The principles to guide our commissioning
¾ Registered list to organise care with primary care as the gateway to better health
¾ Integrated neighbourhood teams to include social care and mental health in order to better manage long term conditions that is
organised around new GP Networks
¾ Where appropriate consultant opinion to be alongside GPs with greater nurse, allied health professionals and social care input
¾ Excellent use of technology to enable better care delivery and continued choice with better access for longer
¾ Teaching hospital with smaller healthcare campus/satellite
¾ Exemplar mental health services with patients getting parity of esteem
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¾ Underpinned by an ethos of no compromise on quality, waiting or standards
Providers
The healthcare providers from which the CCG directly commissions can be categorised as those providing:
¾ Primary Care: This includes a range of services commissioned from GPs which are not provided from their core contracts e.g.
anticoagulation services, treatment rooms/ minor injuries, vasectomy procedures, near patient testing
¾ Secondary Acute Care: This includes accident and emergency services, urgent and critical care, elective inpatient and
outpatient services and maternity services
¾ Community Care: This includes District Nursing, Community Matrons, Phlebotomy, Speech & Language Therapy,
Occupational Therapy, Adult Learning Disability Team, Podiatry and Rheumatology
¾ Mental Health Care: This includes Primary Care Mental Health Teams, Child & Adolescent Mental Health Services, Community
Rehabilitation Teams, Adult Mental Health Inpatient Care
¾ Ambulance services: This includes paramedic emergency services and routine patient transport services
¾ Nursing Home Care: This includes NHS Continuing Health Care (CHC) and Funded Nursing Care (FNC)
¾ Services provided by the independent and third sectors: This includes hospice services, cancer care, carers’ support,
bereavement counselling, service for older adults and bereavement counseling
All services, irrespective of the type of provider, or the type of service, are commissioned using the NHS Standard Contract as the
contractual vehicle. This ensures that all providers, where appropriate, meet consistent performance standards and conditions and
are subject to the same performance management regime.
Secondary Acute Care
Currently 84% (£201m) of secondary care activity is undertaken by Lancashire Teaching Hospitals NHS Foundation Trust (LTH).
Greater Preston CCG is the coordinating commissioner for the LTH contract, which it manages on behalf of the other associate
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CCGs, and Lancashire County Council (LCC). LTH is one of the largest trusts in the country, providing district general hospital
services to the population of Preston, Chorley and South Ribble, and specialist care to 1.5m people across Lancashire and South
Cumbria.
LTH provides care from three facilities at Chorley and South Ribble Hospital, Royal Preston Hospital and the Specialist Mobility and
Rehabilitation Centre at Preston Business Centre.
LTH is also a regional specialist centre (commissioned by NHS England) for cancer (including radiotherapy, drug therapies and
cancer surgery), disablement services such as artificial limbs and wheelchairs, major trauma, neurosurgery and neurology (brain
surgery and nervous system diseases), plastic surgery and burns and renal (kidney diseases).
In addition, the CCGs also commission a significant level of non-urgent activity from the independent sector, primarily from Ramsay
Healthcare Operations UK Ltd (Ramsay). Greater Preston CCG is the coordinating commissioner for the Ramsay contract that it
manages on behalf of the other associate CCGs. Ramsay provides services locally from two main facilities at Fulwood Hospital and
Euxton Hall Hospital.
The level of activity undertaken by Ramsay grew substantially during 2013/14 as a result of patients exercising their choice of
provider.
We also commission secondary acute services from several other NHS Trusts adjacent to our locality. The full range of acute
sector providers and contract values is shown in the chart below.
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SecondaryAcuteCareContractValues2014/15
£5.2m
£15.9m
£3m £2.4m £5.1m
£2.2m
£5.9m
LancsTeaching
Ramsay
Blackpool
Wrightington
CentralManchester
£201.4m
EastLancs
OtherContracted
NonContracted
Community and Mental Health Care
The main provider of Community & Mental Health Care services is Lancashire Care NHS Foundation Trust (LCFT). LCFT was
established in April 2002 and was authorised as a Foundation Trust on 1st December 2007.
LCFT provides health and wellbeing services for a population of around 1.5 million people.
The Trust specialises in inpatient and community mental health services. It also provides community based health services
including community nursing, health visiting and a range of therapy services including podiatry and speech & language therapy.
Wellbeing services provided include smoking cessation and healthy lifestyle services (commissioned by Public Health).
LCFT covers the whole of the county and employs around 7,000 members of staff across more than 400 sites.
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Chorley & South Ribble CCG is the coordinating commissioner for the LCFT Community contract on behalf of other associate
CCGs and Lancashire County Council. Blackburn with Darwen CCG is the coordinating commissioner for the LCFT Mental Health
Contract. LCFT manages its services under 4 networks as follows:
¾
¾
¾
¾
Adult Community Services
Adult Mental Health Services
Children & Families Services
Specialist Services
In addition, the CCGs also commission a range of private organisations to provide intensive and locked mental health rehabilitation
services. These services are currently contracted using the Lancashire wide Independent Sector Mental Health Framework
Agreement.
Ambulance Services
Paramedic Emergency Service (PES)
The lead commissioner (NHS Blackpool CCG) has produced commissioning intentions for the Paramedic Emergency Service on
behalf of the 33 CCGs in the North West. The Blackpool Ambulance Commissioning Team (BACT) utilised the agreed governance
framework within the Memorandum of Understanding between them and the NW CCGs to produce commissioning intentions for
2014/15 and high-level strategic intentions for 2014 to 2019. Consultation and engagement was carried out with each group within
this governance framework, and our CCGs attended a planning workshop held in December 2013 and contributed to this process,
as well as attending the Lancashire Ambulance Commissioning Group, working with the BACT and contributing to the final
document.
The PES commissioning intentions document recognises the need for whole system transformation in order to move towards the
healthcare system described by both the House of Commons Health Committee ‘Urgent and Emergency Services’ report (July
2013), and the Keogh ‘Urgent and Emergency Care Review’ (November 2013). Both reports describe PES as having a changed
role within an enhanced system of urgent care; a role where conveyance to hospital will be one of a range of clinical options open
to ambulance services and allow PES to become “mobile urgent treatment centres” (Keogh, 2013).
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One of these key required changes is to achieve a reduction in conveyance to hospital and the PES contract for 2014/15 has been
designed to encourage this by incentivising this through CQUIN. This will allow the provider, North West Ambulance Service
(NWAS), to build on the progress they have already made with commissioners over recent years; developing and implementing
initiatives such as the Urgent Care Desk, Paramedic Pathfinder, Referral Schemes into Primary Care, Targeting Frequent Callers,
and increasing the percentages of patients that are treated by ‘See and Treat’ and ‘Hear and Treat’. All of these schemes support
the achievement of ‘Safe Care Closer to Home’, which is a strategic goal of NWAS, as well as supporting our CCG plans for
integration.
In Chorley, South Ribble and Greater Preston a GP visiting scheme is currently being piloted. This scheme allows NWAS
paramedics to refer patients, who meet specific criteria, to a GP service rather than conveying them to A&E. The GP service
guarantees that the patient will be seen by the service within a maximum of two hours. This avoids A&E attendances, potential
hospital admissions and frees up paramedic capacity.
The governance framework includes an ‘Ambulance Strategic Partnership Board’ (SPB), and each county area has a
representative. In Lancashire our ambulance commissioning lead feeds back from the SPB to our Lancashire Ambulance
Commissioning Group, where our CCGs have representation. The SPB maintains the strategic oversight of all county area
reconfigurations, both at county and CCG level, acting as ‘Change Management Board’ and seeking assurance that county and
local change translate into a North West level. A workshop has been arranged for June 2014, to begin this work. Our CCGs will
continue to ensure local plans align with the SPB via the Lancashire Area Commissioning Group.
A key element of the governance framework is the ‘Clinical Development Group’ (currently being refreshed to include NHS 111 to
progress urgent care system transformation) and Lancashire has clinical and managerial representation on this group. These
representatives link back to the Unscheduled Care Board of which NWAS is also a member.
Patient Transport Services (PTS)
Five PTS contracts are in place across the North West, which were awarded following a procurement exercise. Each is a threeyear contract, which began on 1 April 2013. There is one provider for each of the county areas. The provider for Lancashire is
North West Ambulance Service (NWAS).
The current service specification contains increased operating hours, and higher quality standards than the previous one. The
service is provided for eligible patients. Planning for the next tender will begin during 2014/15, which will include reviewing the
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current service specification against new and emerging policy and guidance, such as 24/7 working. We will engage in this process
via the Lancashire Ambulance Commissioning Group, and the wider governance as described above.
In addition, Lancashire Teaching Hospitals NHS Foundation Trust also provides patient transport services for eligible patients who
need conveyance outside of the core operating hours offered by the current NWAS contract.
Nursing Home Care
The CCGs commission nursing home care from a wide range of private providers. These services are currently contracted using
the North West Framework Agreement for Nursing Home Services.
Services Provided by the Independent & Third Sector
The CCGs currently commission services from a number of independent and Third Sector providers across a wide range of
services for all ages of the population across all pathways. This ensures that a full breadth of services is available for local
communities. Current providers include Age Concern, Alzheimer’s Society, St Catherine’s Hospice, Marie Curie, and Cruse
Bereavement Service. As we move away from a reliance on in hospital care towards more community and home based care, we
will become increasingly reliant upon third sector organisations and therefore plan to support the sector to develop the capacity and
skills to enter the market (see Section 4.3: Market Management)
Linking the population conversation with the contract
We are entering a phase of commissioning development where there will be an ever greater need to increase the responsiveness
of our services. This applies not only to the need to inculcate a culture of personalisation within the services we contract for – which
we will begin to do by promoting patient reported outcome measures, incentivising the enhanced personalisation of services and
establishing a proactive population health outreach function – but also to the design of the contract requirements themselves.
The key challenge is to create a framework within which the new conversation with our population about service change can take
place in a way that is not tokenistic. In order to meet this challenge, we have to be able to meet two criteria.
The first criterion is that the nature of our discussion with the population should be genuinely deliberative and ask questions that are
both strategically significant and genuinely ‘open’ in the sense that the answers from the process will affect what we do next.
The second criterion is that we need to be able to show the process by which the outcomes from such a conversation can be
incorporated into our planning and delivery – or explain why certain aspirations are not possible.
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We are planning to develop an annual business cycle that divides the planning year into two phases – a ‘deliberative phase’ and a
‘contracting phase’ as shown in the diagram below.
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This will link in with other work we are undertaking to ensure our contracting positions are developed much earlier in the year,
enabling more clinical engagement with both commissioners and providers and more time to establish new requirements e.g. for
quality indicators.
The ‘deliberative phase’ would focus our efforts on stakeholder engagement into the period from January to September within the
cycle. This would in turn break down into three quarters of work.
We intend this process to have two effects over time – to both change the nature of our service design by placing a very high
premium on the extent to which it is embedded in the wishes of our population, and also to make the nature of our relationship with
our stakeholders more meaningful by engaging in appropriate discussions at the right time to maximise the opportunities for joint
working and explaining how best our plans can be influenced.
Collaborative Commissioning
In order to provide a focus for an agreed collaborative approach to the commissioning of the designated group of services, a
Collaborative Arrangements Group has been established for the Lancashire CCG Network. The key objectives of the Collaborative
Arrangements Group are:
¾ To oversee the collaborative commissioning programme agreed annually by CCG Boards
¾ To hold to account the delivery of the collaborative commissioning programme by the Commissioning Support Unit and other
delivery programmes and to provide a formal reporting mechanism into the CCG Network for the CSU for this programme
¾ To ensure the annual planning cycle for collaborative arrangements (including contribution to QIPP), takes place and proposals
are presented to CCG Boards for approval in a timely way
¾ To provide a forum for discussion of any emerging collaborative area
¾ To make recommendations to the CCG Network when a decision is required for any of the collaborative programmes
The key work programmes for this group in its first year of operation include the following:
¾
¾
¾
¾
Review of Stroke Services
Reconfiguration of Mental Health Beds
Transforming Community Equipment Services
Lancashire Strategy for Hospital Care
Page 131 of 175
Further details of these programmes can be found in Section 4.2 above.
Market Management
As Commissioners, we have a key role to play in shaping the market through dialogue and procurement to stimulate providers to
produce innovative solutions and to create an environment where these can be sustained. We want to actively encourage a strong
provider market, based on a diverse supply from all sectors, encouraging entry by new participants and growth from under
developed sources of supply, including social enterprise and the third sector.
We already have a good understanding of the structure and key players in the market, the current market offerings of services, the
drivers for the market, the scope for innovation and for expanding the market, current capacity and capability in the market and the
demands currently being placed on the relevant supply markets, and the barriers to entry into the market.
We want to focus attention on developing the capacity of the third sector as key partners and providers in delivering our vision. The
sector can be a major provider, bringing a distinctive approach to service delivery, based on specialist knowledge, experience and
skills which often come from the close relationship that the sector has with service users. However we recognise that there are
barriers (both perceived and real) faced by third sector organisations in their relationships with us as commissioners and in their
search for an effective role in the planning, commissioning and delivery of services.
We have therefore prioritised working with the third sector to help them to overcome these barriers, so that we have a wider source
of providers in our new model of health care in the future. We will do this by working with voluntary organisations and community
groups to develop capacity and by deploying effective procurement mechanisms to stimulate and manage the market. This will
include minimising the administrative burden on providers and using standardised procurement processes based on best practice.
We will also ensure that purchasing and contracting arrangements are proportionate to the scale and complexity of the services we
are commissioning so that third sector providers are not at a disadvantage.
“Third sector needs more recognition and support. Especially now
we’ve brought together health and social care”
(Source: member of the public, engagement event, June 2014)
Page 132 of 175
Section 5: Sustainability
This section sets out how we will ensure a sustainable health system for the future. It includes the following information:
5.1:
Financial sustainability: how we will manage our finances to sustain the changes that we are going to make
5.2:
Environmental impact: our contribution towards nationally set environmental targets
5.3:
Sustainable transformational change: how we will ensure that our work is future proofed
Page 133 of 175
5.1: Financial sustainability
The CCGs are committed to delivering a financially sustainable health economy as one of our main strategic themes. This means
providing financial leadership across the local health community ensuring that our resources are used efficiently and effectively and
that we focus our commissioning resources to ensuring high quality services, in the right place, delivered at the right time and
responsive to local needs, within available resources.
Delivery of our plans will progressively rebalance our current service delivery model from acute settings into more appropriate
community and primary care settings. This cannot be achieved overnight as we recognise it will require significant changes in both
our workforce and infrastructure. The restructuring of our health economy will be done through our transformation programmes led
by our Clinical Senate which will fundamentally change the way in which services are delivered over the next 5 years (see Section
4.2).
At the same time, in line with the national focus on improving service productivity, we aim to reduce elective care by 20% and
emergency admissions by 15% over the plan period based on our current population profile. However, we also know our current
demographic profile is changing rapidly. We have an ageing population and we expect an influx of working age adults and their
families arising from the expansion of our area of Lancashire under the ‘City Deal’. The chart below shows how we anticipate
delivery of our plans to impact on the acute sector.
Page 134 of 175
Page 135 of 175
Realising our plans will move spending away from acute care into primary, community and integrated care and the charts below
shows our estimate of how this will look.
Page 136 of 175
5.2: Environmental impact
Sustainability has become increasingly important as the impact of peoples' lifestyles and business choices are changing the world
in which we live. We acknowledge this responsibility to our patients, local communities and the environment by working hard to
minimise our footprint.
As a part of the NHS, it is our duty to contribute towards the national goal set in 2009 to reduce the carbon footprint of the NHS by
10% (from a 2007 baseline) by 2015. It is our aim to meet this target by reducing our carbon emissions 10% by 2015 using 2007 as
the baseline year.
As new organisations we do not have sufficient baseline data to show comparable change in our carbon footprint. However this is a
priority for us in 2014/15, so that we can quantify our plans to reduce carbon emissions and to improve our environmental
sustainability.
To help us do this, we are developing a Sustainable Development Management Plan (SDMP) and in 2014/15 will relocate our
operations to more modern, fit for purpose and energy efficient premises.
5.3: Sustainable transformational change
The significant transformational change, which is reflected in the ambition of this 5-year plan is intended to bring about sustainable
change to ensure that health outcomes and the experiences of patients continue to improve within a climate of tight financial
constraints.
To achieve this, we have used a number of practices aimed at ensuring buy in to changes we make. These include:
¾ Making use of local clinical knowledge and experience which demonstrates confidence in the ability of local clinicians to
influence and reduce the rates of emergency admissions and A&E attendances through a series of initiatives and interventions
targeted in these areas
Page 137 of 175
¾ Using existing analysis and benchmarking to identify scope to change settings of care within planned care as well as reducing
the scale of planned care in line with best practice norms, particularly within MSK services. There is also scope to address the
level of demand for unplanned care based on analysis that shows areas of significant over commissioning
¾ Assessment of best practice case studies, which has identified a range of best practice initiatives targeted at both specific
patient groups and broader care settings that improve the quality of patient care as well as reducing levels of demand for and
activity within acute care settings
¾ Use of ‘Anytown Lite’ (which is a modelling tool) shows significant scope for improvement through High Impact Interventions
such as Case Management / Co-ordinated care and reductions in variability within primary care. These suggested interventions
are congruent with CCG plans to develop primary care at scale and work within the Better Care Fund framework to improve the
scale and intensity of home based services. This would be particularly focused on the over 65s, which is the age group that
significantly impacts on resources.
As we bring together our detailed plans for the five-year period we will ensure that there is a clear understanding of how plans
within Health and Social Care work together, particularly making sure those initiatives through the Better Care Fund are not double
counted elsewhere.
Page 138 of 175
Glossary of Terms
Advancing Quality
Alliance (AQuA)
Is a membership body which aims to improve the quality of healthcare http://www.advancingqualityalliance.nhs.uk/
Ambulatory care
Is a patient focused service where some conditions may be treated without the need for an overnight stay in hospital.
Better care fund
(BCF)
Will provide £3.8 billion to local services to five elderly and vulnerable an improved health and social system
Care providers
The main care providers in this area are Lancashire Teaching Hospitals (Chorley and South Ribble Hospital and
Preston Royal Hospital); Lancashire Care Foundation Trust and Ramsay Health Care at Euxton Hall, Fulwood Hall
and Renacres Hospital.
Care Quality
Commission (CQC)
The Care Quality Commission checks if health care services are meeting the national standards.
Clinical senate
Is a source of independent, strategic advice and guidance commissioners and other stakeholders to assist them to
make the best decisions about healthcare for the population they represent
Commission
Is the process of planning, agreeing and monitoring services. Services range from a health-needs assessment for a
population, through the clinically based design of patient pathways, to service specification and contract negotiation
or procurement, with continuous quality assessment.
Commissioning for
quality and
innovation (CQUIN)
The CQUIN payment framework enables commissioners to reward excellence, by linking a proportion of English
healthcare providers' income to the achievement of local quality improvement goals. - See more at:
http://www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html#sthash.oF3NCkN4.dpuf
Page 139 of 175
Commissioning
intentions
Provides a basis for robust engagement between NHS England’s area teams and providers of specialised services,
and are intended to drive improved outcomes for patients, and transform the design and delivery of care, within the
resources available.
Comparable CCGs
NHS England promotes a CCG outcome tool that enables CCGs to view maps, charts and tables of other CCGs to
assess how outcomes for their CCG compare with other comparable CCGs. These are CCGs with similar
characteristics, such as population, demographics, disease prevalence’s, etc.
Elective care
Is care that is provided at a planned or prearranged time rather than in response to an emergency
End of life care
Is what you can expect from health providers at the end of your life, including palliative care to control pain and other
symptoms and to offer psychological, social and spiritual support.
Equality Delivery
System (EDS)
Helps local NHS organisations to focus on their local populations to review and improve their performance for people
with characteristics protected (Equality Act 2010)
Family and Friends
Test (FFT)
Enables healthcare services to report if patients and carers would recommend their services to their friends and
family members
Francis report
The Francis report provided a detailed analysis of what contributed to serious failures in care at Mid Staffordshire
NHS Foundation Trust.
Health champions
Health Champions are people who, with training and support, voluntarily bring their ability to relate to people and their
own life experience to transform health and well-being in their communities.
Health economy
The health economy focuses on efficiency, effectiveness, value, and behaviour in the management of health and
healthcare.
Page 140 of 175
Health inequalities
Health inequality is the differences in the quality of health and health care across different populations, such as the
"presence of disease, health outcomes, or access to health care" across different age groups, people with disabilities,
gender (including gender reassignment, cultures (race and religion), sexual orientation and socioeconomic groups.
Healthcare
associated infections
Healthcare-associated infections are infections that are acquired in a hospital or other health care setting, such as a
hospice or care home, or as a result of a health care intervention or procedure.
Incident response
plans
Is an organised approach to addressing and managing the aftermath of a security breach (also known as an incident)
Joint strategic needs
assessment (JSNA)
Joint strategic needs assessments (JSNAs) analyse the health needs of populations to inform and guide
commissioning of health, well-being and social care services within local authority areas.
Lancashire CCG
network
The Network supports the effective commissioning of NHS services that serves a larger geographical area and acts
as a forum in which CCG representatives can support CCG development for full commissioning responsibility,
develop in their roles as leaders and develop best practice in terms of Lancashire’s NHS service development.
Lancashire health
and wellbeing
strategy
The strategy has a vision to ensure every citizen in Lancashire enjoys a healthy life. They aim to do this by working
together to deliver real improvements to the health and wellbeing of Lancashire’s citizens and communities by
implementing three goals of ‘better health’, ‘better care’ and ‘better value’.
Long term conditions
Long-term or chronic conditions are illnesses that cannot be cured and that people live with for a long time, such as
diabetes, heart disease, dementia and asthma.
Never Events
Never Events are serious, largely preventable patient safety incidents that should not occur if the available
preventative measures have been implemented.
New referral gateway
Is guidance that provides a definition of what needs to be undertaken to enable a patient to access a service to
receive appropriate health care.
Page 141 of 175
NHS atlas of variation
in healthcare
Supports CCGs to make local decisions that will increase the value which a population receives from the resources
spent on their healthcare.
NHS comparators
Is an analytical service for commissioners and providers. It helps improve the quality of care delivered by
benchmarking and comparing activity and costs on a local, regional and national level.
NHS England
The new body, which has until now been known as the NHS Commissioning Board, will have overall responsibility for
the £95 billion NHS commissioning budget from 1 April 2013. The main aim of NHS England is to improve the health
outcomes for people in England. It will set the overall direction and priorities for the NHS as a whole.
NHS England Local
Area Team
NHS Local Area Teams have a core function of CCG development and assurance; emergency planning, resilience
and response; quality and safety, partnerships, configuration ad system oversight.
NHS Leadership
Academy
Is a Centre of Excellence and beacon of best practice on leadership development, owned by the NHS and working for
all those involved in NHS funded care
NHS North of
England CCG
ranking positions
The North of England publishes data that enables CCGs to monitor their performance based on how they meeting
their targets and compare their results with other CCGs.
NHS operating and
outcomes
frameworks
The framework contains measures to help the health and care system to focus on measuring outcomes. It provides a
national level overview of NHS performance, effective expenditure of public money and drives up quality by
encouraging a change in culture and behaviour.
Operational delivery
plan
The CCG plan reflects and builds upon our three – five year integrated plan and sets out the work we are undertaking
in collaboration with our partners in neighbouring CCGs and local and District Councils.
Ownership Council
Enables members of the public who live or work in the area to give your views on local health services in the area.
Page 142 of 175
Peer groups
A group of people of approximately the same age, status, and interests.
Primary care
Is health care that is provided in the community for people making an initial approach to a medical practitioner or
clinic for advice or treatment
Principal risks and
uncertainties
The risks and uncertainties that could potentially affect the CCG in the delivery of its objectives, unless appropriate
measures are taken to manage and control them.
Provider compliance
reports
Reports that are produced by the CCG to inform the CCG Board and other key stakeholders how well the hospital
trusts and community services are doing compared to what is expected of them.
Public Health
England (PHE)
Works with national and local government, industry, and the NHS, to protect and improve the nation's health and
support healthier choices. PHE is addressing inequalities by focusing on removing barriers to good health.
Quality accounts
A report about the quality of services by an NHS healthcare provider. Quality accounts are an important way for local
NHS services to report on quality and show improvements in the services they deliver to local communities and
stakeholders.
Quality and
performance
dashboards
A way of measuring, monitoring, and managing the performance of provider services on how they are meeting the
quality elements of their contracts.
Quality plan
Plans developed by practices to support quality improvements and improved outcomes for patients
Quality schedule
The NHS Standard Contract is mandated by NHS England for use by commissioners for all contracts for healthcare
services other than primary care. The quality section in the contract is known as the quality schedule
Quality strategy
The quality strategy informs the public and other stakeholders about the plans for improving the quality of care that
patients receive from the local provider services
Page 143 of 175
Quality surveillance
groups
Quality surveillance groups act as a virtual team across a local health location to bring together organisations and use
their information and intelligence to safeguard the quality of care that people receive.
Quality visits
Quality visits are visits undertaken by key members of the CCG to check the quality of care within the provider
environment by walking around the services doing observation checks and talking to staff
Quintile 1
The first quartile represents the lowest fifth of the data between 1% and 20%
Robust winter plans
Plans made by NHS trusts to enable them to react to any emergency situations in the winter months, such as
extreme cold weather, flu epidemic, etc.
Secondary care
Unplanned emergency care or surgery, or planned specialist medical care or surgery. If you go to hospital for planned
medical care or surgery, this will usually be because your GP, or another primary care health professional, has
referred you to a specialist. We are a secondary care provider.
Sir Bruce Keogh’s
methodology
Is a three stage process: 1. to gather and analyse the full range of information and data available within the NHS, 2.a
rapid response review, and 3. risk summit.
Social prescribing
Social Prescribing Service helps people with long term health conditions to access a wide variety of services and
activities provided by voluntary organisations and community groups
Step down
When a person is discharged from hospital to a rehabilitation unit to receive help and support to enable them to return
home.
Step up
When a person is admitted to a place of care from home because they have health problems that require short term
nursing help and support.
Page 144 of 175
The Berwick review
The Berwick Report was commissioned by the government to research the failings of Mid-Staffordshire and make
recommendations for the NHS, specifically around patient safety.
Urgent care
Fast access to health advice, emergency contraception and minor injuries such as cuts, sprains and small fractures
Urgent care services
Accident and emergency departments, major trauma services, ambulance services, minor injuries units, walk in
centres and NHS 111 services
Winterbourne
individuals
Winterbourne individuals are children, young people and adults with learning disability or autism who also have
mental health conditions or behave in ways that are often described as challenging.
Page 145 of 175
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Contact us
If you would like to get in touch with NHS Chorley and South Ribble CCG, or NHS Greater Preston CCG, you can contact us in the
following ways.
Contact the CCGs by post
Chorley and South Ribble CCG or Greater Preston CCG
Chorley House
Lancashire Business Park
Centurion Way
Leyland
Lancashire
PR26 6TT
Contact the CCGs by phone
01772 214 200
Contact the CCGs by email
Chorley and South Ribble CCG
[email protected]
Greater Preston CCG
[email protected]
Page 149 of 175
Appendix 1
OUR ORGANISATIONAL VALUES & BEHAVIOURS
Page 150 of 175
We demonstrate these values by showing
Page 151 of 175
You will see those who work for us demonstrating the following behaviours
because we believe these underpin our Values
Page 152 of 175
Page 153 of 175
Page 154 of 175
Page 155 of 175
Appendix 2
National Drivers for Change
NHS Mandate
The Government’s Mandate to the NHS Commissioning Board sets out the objective to ensure that Clinical Commissioning Groups
work with local authorities to ensure that vulnerable people, particularly those with learning disabilities and autism, receive safe,
appropriate, high quality care. Services should be local and people should remain in their communities, with a substantial reduction
in reliance on inpatient care for these groups of people.
We have taken this into account in developing our strategy for the next 5-years. Within our plans to transform health and care
services, we will improve the quality of the care offered to people of all ages with learning disabilities or autism and address the
areas identified in the Winterbourne View national reports. During 2014/15 we will develop joint commissioning arrangements to
ensure we always commission safe and appropriate care for vulnerable children and adults and our assurance framework will
provide us with evidence that this standard is consistently being met.
As we look to improve the health services for our local communities, we also recognise the importance of ensuring parity of esteem
for mental health, not only in the services that are commissioned specifically for the treatment of mental health but also by ensuring
fair access to other health services for those with learning disabilities and mental health conditions (see Section 4.3: Our
Transformational Programmes, for information about how we will do this).
In order to ensure parity of esteem for mental health we aim to address the 25 areas identified in ‘Closing the Gap: priorities for
essential change in mental health’, (DoH, January 2014), using national and local data to inform commissioning decisions for
patients with mental health conditions.
Call to Action
The ‘Call to Action’ is a national programme of sustained engagement with NHS users, staff and the public to give a voice to all who
care about the future of our National Health Service. It is intended to complement the work we have already started to develop a
new health system that delivers high quality, sustainable health and care over the next 5 years.
Page 156 of 175
The Call to Action will also shape the national vision, identifying what NHS England should do to drive service change and the
programme of engagement will provide a long-term approach to achieve goals at both levels.
Responding to this, we are committed to working collaboratively across the wider health economy to develop a system that
embraces:
¾
¾
¾
¾
¾
¾
Citizen inclusion and empowerment
Wider primary care, provided at scale
A modern model of integrated care
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
We have set out in Section 4.2 how we will achieve this.
Everyone Counts
NHS England has published a framework requiring commissioners (working with providers and partners in local government) to
develop strong, robust and ambitious five year plans to secure the continuity of sustainable high quality care for all, now and for
future generations. Our plan is developed in response to this and shows how we will address seven-day a week working for routine
NHS services, greater transparency and choice for patients, greater patient participation, better data to support the drive to improve
services and higher standards and safer care.
A high quality and sustainable health system
Our Transformational Programmes set out in Section 4.2 will address the following six nationally defined characteristics of a high
quality and sustainable health system.
Characteristic 1
Ensuring that citizens will be fully included in all aspects of service design and change, and that patients will be fully empowered in
their own care
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Characteristic 2
Wider primary care, provided at scale
Characteristic 3
Modern model of integrated care
Characteristic 4
Access to the highest quality urgent and emergency care
Characteristic 5
A step change in the productivity of elective care
Characteristic 6
Specialised services concentrated in centres of excellence
The Public Health Outcomes Framework
Also known as: "Healthy lives, healthy people: Improving outcomes and supporting transparency" this sets out a vision for public
health, desired outcomes and the indicators that will help us understand how well public health is being improved and protected.
The framework concentrates on two high-level outcomes to be achieved across the public health system, and groups further
indicators into four ‘domains’ that cover the full spectrum of public health. The outcomes reflect a focus not only on how long people
live, but on how well they live at all stages of life. The two high level outcomes are:
¾ Increased healthy life expectancy
¾ Reduced differences in life expectancy and healthy life expectancy between communities
The four domains are:
¾
¾
¾
¾
Improving the wider determinants of health
Health improvement
Health protection
Healthcare public health and preventing premature mortality
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Adult Social Care Outcomes Framework (ASCOF)
The Adult Social Care Outcomes Framework has a clear focus on promoting people’s quality of life and their experience of social
care, and on care and support that is both personalised and preventative. It is a key tool to track progress locally and nationally
towards the transformation of care and support.
The NHS Constitution
The NHS Constitution establishes the principles and values of the NHS in England. It sets out rights to which patients, public and
staff are entitled, and the pledges which the NHS is committed to achieve, together with the responsibilities which the public,
patients and staff owe to one another to ensure that the NHS operates fairly and effectively.
The Secretary of State for Health, all NHS bodies, private and voluntary sector providers supplying NHS services, and local
authorities in the exercise of their public health functions are required by law to take account of this Constitution in their decisions
and actions.
In particular, the Constitution makes a set of commitments to patients and the public. These include how patients access health
services, the quality of care they should receive, the treatments and programmes available to them, their right to confidentiality and
information and their right to complain if things go wrong.
We have taken these commitments into account in developing our strategy and plans for the next 5-years and are committed to
ensuring the delivery of the NHS Constitution for our local communities. We will factor it into our commissioning plans and will work
collaboratively with our partners to ensure that all parts of the NHS within the local health economy deliver the NHS Constitution
rights and pledges for patients.
Personal Health Budgets
The Government pledged to roll out Personal Health Budgets to patients in receipt of Continuing Healthcare (CHC) funding who
ask for one, from April 2014 and to all those in receipt of CHC from October 2014.
We have taken this into account in developing our 5-year strategy and are planning to refine the Personal Health Budget process
so that it becomes an integral part of the CHC assessment process and therefore an ‘opt out’ rather than an ‘opt in’ for patients at
the point of eligibility as a default position.
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We are committed to the national development programme and have identified a small cohort of individuals who have asked for
personal health budgets and whom we believe will benefit from one. We have started working with these individuals and their
families and the outcomes will be monitored locally and via the national Personal Outcomes Evaluation Tool (POET). Our progress
against implementation is being monitored against the National Markers of Progress.
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Appendix 3
Improvement Targets: National Outcomes Framework
NHS Greater Preston CCG and NHS Chorley and South Ribble CCG Combined Outcome Ambitions
Ambition
Area
Metric
Proposed
Attainment in
18/19
% Improvement in
Target from
Baseline in 2013/14
1
Securing additional years of life for the people of England with treatable
mental and physical health conditions
1966.0
8.3%
2
Improving the health related quality of life of the 15 million+ people with
one or more long-term condition, including mental health conditions
74.81
3.6%
3
Reducing the amount of time people spend avoidably in hospital through
better and more integrated care in the community, outside of hospital
2076.3
7.8%
4
Increasing the proportion of older people living independently at home This level of ambition has been set at
following discharge from hospital
Health and Wellbeing Board level on the
Proportion of older people (65 and over)
who were still at home 91 days after
discharge from hospital into reablement /
rehabilitation services
5
Increasing the number of people having a positive experience of hospital
care
117.1
13.9%
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Ambition
Area
Metric
Proposed
Attainment in
18/19
% Improvement in
Target from
Baseline in 2013/14
4.00
24.2%
6
Increasing the number of people with mental and physical health
conditions having a positive experience of care outside hospital, in
general practice and in the community
7
Making significant progress towards eliminating avoidable deaths in our The definition of this measure is under
hospitals caused by problems in care
development.
Proxy measures include
levels of MRSA (zero tolerance) and
C.Difficile (threshold of 52 in 2014/15)
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Improvement Targets: Local Targets
Measure
Baseline
(2013-14)
Targets
2014-15
2015-16
2016-17
2017-18
2018-19
Improving access to psychological therapies –
proportion of people entering treatment
2.60%
3.75%
Not yet set
Not yet set
Not yet set
Improving access to psychological therapies –
recovery rates
36.90%
50%
Not yet set
Not yet set
Not yet set
Reduction in non-elective COPD admissions
1,081
950
Not yet set
Not yet set
Not yet set
Improving the rate at which dementia is diagnosed
51.2%
67%
Not yet set
Not yet set
Not yet set
Page 163 of 175
Targets agreed
Targets to be approved
Measure
Target
2014-15
Baseline
Target
2015-16
Target
2016-15
Target
2017-18
Target
2018-19
Link to Transformational
Programmes
Link to national targets
Quality
Reduction in the number of attendances at Accident &
Emergency*
118,227
115,862
113,545
110,139
105,733
98,483
Overarching indicator on the
Urgent Care Transformation
Programme
Everyone counts 2014-15
Activity Measure EC. 7-8
42,274
42,274
41,640
41,015
40,400
39,794
Overarching indicator on the
Urgent Care Transformation
Programme
Better Care Fund Measure
Reduction in the number of hospital admissions*
5.4 days
Not Set
Not Set
Not Set
Not Set
Not Set
There are a number of
indicators measuring length of
stay across the Urgent Care
Transformation Project
Circa 10%
-9% on base
Not Set
Not Set
Not Set
Not Set
Overarching indicator on the
Urgent Care Transformation
Programme
61
56
51
45
40
36
2
0
0
0
0
0
GP - 36.9%
CSR- 38.9%
12/13
GP-50.2% CSR49.3%
52%
53%
54%
55%
<100
<100
<100
<100
<100
Reduction in the lengths of hospital stays**
Reduction in the number of hospital re-admissions
Reduction in the number of serious untoward incidents
Reduction in the number of never events
Increase in the % of people at end of their lives that die in
their preferred place
Reduction in mortality rate (HSMR)
95.1
Everyone counts 2014-15
technical definition. EC. 7-8
Overarching indicator on the
Urgent Care Transformation
Programme
* Data for 8 Lancs CCGs into Lancashire Teaching Hospitals
** Data for Emergency Admissions 8 Lancs CCG Lancashire Teaching Hospitals
*** At Lancashire Teaching Hospitals
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Targets agreed
Targets to be approved
Measure
Target
2014-15
Baseline
Target
2015-16
Target
2016-15
Target
2017-18
Target
2018-19
Link to Transformational
Programmes
Link to national targets
Patient Experience
Improvement in patient reported outcome measures
71.4
Reduction in the number of complaints
Increase in staff satisfaction
Reduction in the % of people reporting poor experience of
general practice and out of hours services
57
Not Set
5.0
Increase in patient satisfaction***
Increase in the % of friends and families that would
recommend the service
65
73.5
73.7
73.9
74.1
74.3
Not Set
Not Set
Not Set
Not Set
Not Set
Not Set
Not Set
Not Set
Not Set
Not Set
4.8
4.6
4.4
4.2
4.0
85%
85%
85%
85%
85%
70
75
80
85
90
Everyone Counts Planning for
Patients 2014/15 - 19
Everyone Counts Planning for
Patients 2014/15 - 19
* Data for 8 Lancs CCGs into Lancashire Teaching Hospitals
** Data for Emergency Admissions 8 Lancs CCG Lancashire Teaching Hospitals
*** At Lancashire Teaching Hospitals
Page 165 of 175
Measure
Baseline
Target
2014-15
Target
2015-16
Target
2016-15
Target
2017-18
Target
2018-19
Link to Transformational
Programmes
TBC
TBC
TBC
TBC
TBC
TBC
All
Link to national targets
Finance
Indicator to be developed to measure level of spend v
improved outcome
Page 166 of 175
Appendix 4
NHS England and Public Health Commissioning
Specialist Commissioning
Specialised services are those services which are provided from relatively few specialist centres. They are commissioned nationally
through 10 of NHS England’s 27 area teams. They account for around £11.8 billion of annual spending, or around 10 per cent of
the overall NHS budget.
We are working with NHS England to ensure patients requiring specialist care are treated by the most appropriate provider,
recognising that there is a need to change the provider landscape in order to deliver services designed around patients and carers,
and ensure our specialist centres are used to treat the most sick.
National thinking around hospital based care has been influenced through high profile reviews such as the Keogh review of MidStaffs, and the Berwick and Cavendish Reviews.
In his review of hospital services Sir Bruce Keogh recommended that serious or life threatening care should be delivered from
centres of excellence, with the best expertise and facilities to maximise chances of survival and recovery. This has led to national
recommendations moving towards commissioning of serious, life-threatening emergency care and rare services from centralised
locations to ensure clinical and cost efficiencies are maximised.
Engagement and local knowledge will inform local strategy development ensuring that specialised services will:
¾
¾
¾
¾
¾
Be commissioned to deliver quality, better outcomes and value
Have a qualified workforce to enable better equity of outcome and access and offer sustainable quality against standards
Provide value for money
Be based on integration of care Networks
Take account of interdependencies and care bundling
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The vision for specialist commissioning is to consolidate and develop sustainable services based in fewer centres to create
networks of excellence, aligned to research and innovation.
Within Lancashire, NHS England Area Team’s Specialised Commissioning Team is undertaking consultation to establish their five
year plan which is due to be published in the autumn.
Within the priorities being consulted on there is focus on the following:
Mental Health
¾ Developing a North West CAMHS tier 4 system review and potential procurements
¾ Reviewing Secure Mental Health provision
Cancer and Blood
¾ Compliance with Improving Outcomes Guidance standards and any procurements as a result
¾ HIV commissioning arrangements
Trauma and Head
¾ Adult neuro-rehabilitation services whole care pathway model, better capacity management
¾ Major trauma centres - alignment with specification and co-location (time/distance for required services), viability of multi-centre
model
Internal Medicine
¾
¾
¾
¾
¾
¾
Cystic fibrosis capacity
Cardiac services - specialised services review, surgery and devices
Vascular services - compliance with standards and reconfiguration and any procurements as a result
Respiratory services
Acute kidney injury
Inherited metabolic disorders
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Women and Children
¾ Neonatal services
¾ Paediatric neuro rehabilitation
Primary Care Direct Commissioning
There is an increasing recognition that primary care will have to change to meet the needs of the population and the challenges
described in this document. Both nationally and locally, general practice and wider primary care services are experiencing
increasingly unsustainable pressures.
Through the development of the Healthier Lancashire Strategy, part of which includes the Out of Hospital Strategy, NHS England
(NHSE) will support these transformational changes in primary care. Across Lancashire they have a set of objectives for Primary
Care, aimed at improving access, satisfaction, quality and outcomes across medical, pharmacy, dental and eye care services.
The health economy has agreed locally to a number of key themes to achieve transformational change include the need for new
models of service delivery, which includes general practice working at scale in neighbourhood teams integrated with wider primary
care and social care services.
The vision is for ‘A sustainable model of primary care which delivers consistent high quality outcomes for patients’
We will work together towards 7 day primary care services at scale by working in neighbourhoods and integrating with social care
services. This will be achieved through support of the Better Care Fund, GP contract changes, local improvement schemes and our
neighbourhood approach.
The Local Area Team is aiming to provide integrated out of hospital services to deliver consistently better outcomes for our patients
across the region, by reducing unwarranted variation in the quality and provision of services. To do this we will work collaboratively
and cohesively with local communities, partners and colleagues, ensuring our strategy is based on patient and public insight to
reflect the 6 characteristics of high quality care set out in “GP – A Call to Action”.
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Health & Justice Direct Commissioning
Prison health care across the North West has previously been commissioned in different ways and this is reflected in current
patterns of provision, which can, in some parts of the area appear fragmented.
The vision is to establish an integrated system with a single prime provider responsible for the provision of all health care within
prisons and perhaps across clusters.
Commissioning these services across a larger area and as part of a national organisation provides opportunities to take advantage
of new economies of scale to work with providers and explore potential new models such as, for example, secondary care in-reach,
mobile diagnostics or different models of ‘inpatient’ provision.
In the North West we are working together with partners to achieve excellence in Health & Justice outcomes for the North West to:
¾ Ensure that specifications for commissioned services are in line with national guidance (e.g. NHS Outcomes Framework, Public
Health Outcomes Framework, Securing Excellence)
¾ Support local and strategic partnership arrangements
¾ Ensure all commissioning is guided by robust health needs assessment
In particular the expected outcomes of implementing the single operating framework and commissioning intentions for each of the
areas within the remit of the NHS Area Team will see the following changes:
General Prison Healthcare
¾
¾
¾
¾
Quality of offender healthcare services improved and equivalent to those in the community
All prison health contracts compliant with NHS standard contracts
Comparable standards of quality and care across all the prisons within the Area Team boundaries
Prisoner’s health and (social care) needs being met
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Secondary Care
¾ The need for appropriate escort and bed watches reduced by the implementation of alternative access to services e.g.
Telemedicine and prison based clinics
¾ Activity and spend on secondary care reduced and replaced with care closer to home
Substance Misuse
¾
¾
¾
¾
Effective offender health substance misuse strategy in place and being delivered
Quality of offender substance misuse services improved
Substance misuse contracts compliant with NHS standard contracts
Comparable standards of quality and care across all prisons
Secure Children’s Homes (3 across the North West, Merseyside and Manchester)
¾
¾
¾
¾
¾
Transfer of NHS commissioned healthcare completed
Commissioned high quality NHS comparable services within secure children’s homes
Improved commissioning capability
Improved high quality clinical governance
Improved care pathways
Immigration Removal Centres (1 based at Manchester airport)
¾ Comparable standards of quality and care as in the rest of the NHS
Sexual Assault Services (1 in Manchester, 1 in Lancashire and 2 in Merseyside (Adult and Paediatric)
¾ Transfer of SARC commissioning to NHS offender health commissioning as a part of the transfer of police health
commissioning, in partnership with key agencies and based on NHS standard service specification and contract
¾ Improved health and reduced inequalities in health care
Liaison & Diversion
¾ Achieve national roll out across all Area Team police custody suites and courts against a national service specification and NHS
standard contract
¾ Continuity of care across pathways and back into the community
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¾ Offender health needs known and provided for by appropriate treatment services
¾ Offenders diverted from the Criminal Justice System when appropriate
¾ Effective planning which is aligned to an investment strategy
Police Custody Suites (4 Police Force Areas)
¾ Transfer of the commissioning of health care in police custody to NHS via Offender health commissioning
¾ NHS commissioned police custody healthcare
¾ Improved care pathways, through improved access to wider clinical expertise and integration with wider community based
services
¾ Strengthened clinical governance arrangements
¾ Equity of access to healthcare and a reduction in health inequality
Armed Forces & Veteran Health Direct Commissioning
NHS England, as part of its portfolio of directly commissioned services, is now responsible for the commissioning of some health
services for those individuals who are under the care of Defence Medical Services (DMS) GPs. This includes serving members of
the Armed Forces, their families, veterans and reservists. Services are commissioned through a single operating model, providing a
national approach to strategic planning and oversight.
NHS treatment for those Armed Forces personnel and families returning from overseas will be commissioned by the Armed Forces
Area Team in which the provider of the care that they receive is located. In Lancashire there are 2 MoD Medical Centres (at
Preston Fulwood Barracks and at Weeton Barracks).
NHS England’s objective is to ensure that the commissioning of services is organised in such a way as to provide the best possible
patient outcomes and avoid any geographical or organisational variation that may have existed previously, whilst maintaining
essential stakeholder relationships.
The model will support commissioners and providers of services to:
¾ Improve patient access
¾ Encourage transparency and choice
¾ Ensure patient involvement and participation
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¾ Identify better data to drive improved outcomes and better commissioning
¾ Deliver higher standards and safer care
Services to be commissioned include:
¾ All community and secondary acute and mental healthcare for families registered with a Defence Medical Services (DMS) GP,
in line with the principles of a common commissioning policy for NHS England
¾ All non-combat related community and secondary healthcare for Serving Personnel, Mobilised Reservists and Families
registered with Defence Medical Services (DMS) GPs. In line with the principles of no disadvantage and a common
commissioning policy for NHS England, with the exception of services normally commissioned by or provided by DMS including:
- In Patient Mental Health – normally commissioned by DMS from South Staffordshire and Shropshire Foundation Trust
- Community Mental Health – normally commissioned and provided by DMS
- Community rehabilitation
¾ Services commissioned in line with the requirements of the armed forces covenant:
- Prosthetics
- IVF for those with infertility as a result of injuries on military operations
- Mental Health
There are a number of changes expected over the next few years which will impact on the needs of the Armed forces. These
include:
¾ The withdrawal of Armed Forces personnel from Afghanistan
¾ Rebasing of service personnel returning from British Forces Germany
¾ Plans for the increased use of Reservists
Based on these changes, the key priorities for commissioning are:
¾ Working in Partnership
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¾
¾
¾
¾
¾
¾
Information, Activity & Finance
Contracting
CQUINs
QIPP
Service Redesign: Alcohol, Domestic Violence, Discharge / Transition Management
Service Review: Wisdom Teeth Extraction, Rheumatology, Dermatology, Termination of Pregnancies, CHC, Choose & Book
Public Health Commissioning
The changing demographic of the population currently experienced is set to continue in the coming years. More people are living
longer and will have a greater call on health services and the consequences of poor lifestyle choices will have an impact on the
services commissioned.
Public Health Commissioning in Lancashire is undertaken by two separate organisations. NHS England (via the NHS Lancashire
Area Team) currently commissions screening, immunisations and vaccinations and health visitors and Lancashire County Council’s
Public Health Team commissions health checks, exercise referral, weight management, physical activity, nutrition and generic
healthy lifestyles, social prescribing, Health Champions, other public mental health services, sexual health services including
contraception, chlamydia and HIV testing, GUM, teenage pregnancy services, substance misuse, drugs and alcohol services,
tobacco control and smoking cessation, school nursing, infant feeding, HomeStart, other children and families services for children
and young people aged 0-19 years.
Using the available data sources, the geographical and topic specific JSNAs and local health profiles, the Public Health Teams
understands the health inequalities and inequities across Lancashire and have taken into account the findings from the Marmot
Review that stressed the importance of giving children the best start in life to reduce health inequalities and associated mortality
and morbidity and life expectancy.
There is evidence to suggest that preventative health services have lower coverage and uptake amongst the more deprived and
vulnerable population groups.
For Public Health programmes that are currently achieving the section 7a baseline, the priority for the Public Health Teams’ 5-year
plans will be to reduce variation, both locally across Lancashire but also between the Lancashire position and the best performing
Public Health Teams in the country.
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For Public Health programmes that are currently achieving the minimum / acceptable standard, improving outcomes, coverage and
uptake will be a priority for Lancashire’s Public Health Teams.
The public health commissioned services, in many areas, is dependent on the services delivered by partners. It is recognised that
for any transformational change to take place, public health primary and secondary prevention interventions must be in place,
awareness raising about the programmes and encouraging the uptake of these services and applying the principles of ‘Every
Contact Counts’ to take advantage of the opportunities to provide a public health intervention. All of this will be driven by the work of
the Health and Well Being Boards.
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