Governing Body 23 June 2015
Paper 04, Appendix A
Delivering the vision
Five Year Strategy & Operational Plan
Year 2 Edition – Final Cut – GB Version – May 2015
Contents
Introduction


The vision

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
105
Operational plan on a page
Moving from 2014-15
The focus for 2015-17
Risks and mitigations
Supporting Information & References



95
The five year plan
QIPP and investment
Statement of financial position
Operational plan




75
Quality and safety
Medicines management
Contracting and performance
Innovation
Information management and technology
Governance
Organisational development
Sustainability: our five year financial plan



29
6 areas of transformation
What it will mean for services
Patient participation in their NHS
Urgent and proactive care
Mental health and learning disabilities
Planned care
Children, young people and maternity
Primary care
Taking care of the essentials


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


19
The case for change
Local health needs
The financial challenge
Services under pressure
Areas of transformation
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11
The vision
Commissioning principles
Outcomes in 2019
Why we need to change




6
Who we are
Our five year strategy
Annex 1 – System outcome trajectories to 2019
Annex 2 - Workplan for 2015-16
Annex 3 - Reference list
117
Foreword
The NHS is something we all cherish. Every day for the last 65 years it has cared for us when
we were unwell and has given us all the chance to live more healthy and fulfilling lives. It is
rightly seen as more than a public service; it is a part of our community. And that is why we
must protect it and safeguard it for future generations.
The demands on our NHS have never been greater. People are living longer and, whilst this
is good news, an ageing population presents a number of serious challenges for a health and
care system, primarily set up in 1948 to deal with one-off episodes and curable illness. We
already have one of the oldest populations in the country with over 25% of the population
over 65; by 2019 there will be 13% more people aged over 85 living locally. With age comes
frailty and illness. One quarter of our population has a long term condition such as diabetes,
dementia or lung disease. Old age should be celebrated, not dreaded, and we need an NHS
and social care system where care is just as important as treatment.
There are also wide inequalities between our communities; some local neighbourhoods have
a life expectancy over 10 years shorter than their neighbours just a few miles away. Too
often people living with mental health conditions do so behind closed doors without the
support and care they need. Around 80% of deaths from major disease, such as cancer, are
attributable to lifestyle risk factors such as smoking, excess alcohol or poor diet. If we want a
local NHS that is future-proof, we all need to look after ourselves, and those in our
communities, and use precious NHS resources wisely. We need to plan for change.
This is set against a backdrop of flat funding for the NHS. Budgets are not increasing to meet
the demand, and if services continue to be delivered in the same way, we will have a local
funding gap of £40m per year over the next five years. Public expectation is rising, and the
current system is already costly and uncoordinated.
Locally we do not want to contemplate reducing core services so we need to transform
them. Whilst we want to have first class hospitals, we need to concentrate on delivering
really good care in the community, reducing duplication and bureaucracy. We want to make
the system easy to navigate for patients, carers, and health professionals; this will give us
better care and will be more cost effective.
Our local NHS is great because of the hard work and dedication of the people that work in it.
Care, compassion, good communication and common sense are just as important as the
actual treatment. Our workforce are our future and we are committed to recruit, train and
motivate them to provide the very best, safe and effective care now and for the future. We
want to liberate them from red tape and organisational boundaries and allow them to focus
on patients.
Our local NHS needs to make some profound changes. If we fail to face up to them, the
pressure created, will put at risk the very thing we cherish most about the NHS – its unique
ability to deliver high quality care to all with dignity and compassion. This strategy will tell
you how we plan to transform services to meet these challenges over the next 5 years. We
want to make these changes in partnership with you, please tell us what you think.
Dr Katie Armstrong
Clinical Chief Officer
Andrew Williamson
Chair
I am in control of my health and my medical conditions are well managed
I feel safe and confident that I will be looked after well
I have access to a choice of high quality, responsive services 7 days a week
I feel part of my community
Transformation Plans and Interventions
The Essentials
Securing additional years of
life and improving health
related quality of life for
those with mental and
physical health conditions
Patient participation in their NHS truly putting
patients at the heart of service planning and delivery
and giving them greater control of their own care.
Reducing avoidable time in
hospital through better and
more integrated
community care
Urgent and proactive care ensuring more responsive
and integrated services for all patients, but
importantly for our large elderly population and a
growing number of people living with one or more
long-term condition such as diabetes, COPD and
dementia.
Quality and safety
we know that dignity,
compassion and respect are as
important to patients as
treating their condition
Increasing the proportion
of older people living
independently at home
following hospital
discharge
Mental health and learning disabilities continuing to
integrate services and provide more supportive
community services that ensures people can live full
and independent lives regardless of their condition
Improving the experience
of hospital care for people
with physical and mental
health conditions
Planned care commissioning better access, more
streamlined pathways and improved outcomes for
patients; specifically in those areas where we spend
more and get worse outcomes than other parts of
England.
Improving the experience
of general practice and
community care for people
with physical and mental
health conditions
Children, young people and maternity focusing on
giving children the best possible start in life through
excellent maternity care and children’s services,
especially for children with complex and chronic
conditions
Making significant progress
towards eliminating
avoidable hospital deaths
caused by problems in care
Primary care acknowledging the pivotal role of
primary care and developing a strategy to ensure it is
ready to meet the challenges of working at greater
scale through improving access, services and
collaborative working between practices in
partnership with NHS England.
Medicines management is
about making sure medicines
are used safely and effectively,
improving outcomes
Contracting and performance
we will use contracts to drive
performance, service
improvement and better
patient outcomes
Innovation we will ensure a
system-wide commitment to
the spread of best-practice
IM&T we will ensure clinical
information is always available
at the front-line empowering
clinicians and patients
Governance transparent and
fair decision making will be a
crucial part of delivering this
strategy
Organisational development
we will support our staff to be
the best they can be
Whole-System Working
Governance
System Outcomes
Critical success factors
In 2019 patients will tell us:
My wellbeing is as important as my physical health
The care I receive is built around me
I am supported when I become unwell
Values & Principles
System
Vision
 Transparency in the way we work, ensuring
sound and fair decision making;
 Working collaboratively with partners through

the Coastal Cabinet;
Engaging with the local Health and Wellbeing
Board, HASC and NHS England.
 Delivery of system objectives;
 All organisations within the health economy to
report a financial surplus in 2019;
 No provider under enhanced regulatory
scrutiny due to performance concerns;
 Shift care and resource from hospital based
care safely to community
 Patients at the centre of everything we do;
 Quality and value;
 Clinicians and managers working in
partnership;
 Whole system integration providing joined up
care
 Whole pathway approach to service
improvements
 Reducing inequalities, working in partnership
with Public Health
Introduction
1
6
Five year strategy
Introduction
7
Who we are
The NHS has changed. Beginning in April 2013, Clinical Commissioning
Groups (CCGs) led by local doctors and health professionals have
assumed responsibility for planning, buying and monitoring safe, highquality care and to make decisions about the use of local NHS
resources.
Our CCG serves a population of over 482,000; has an annual budget of around £600m is
made up of 54 member GP practices working together to form six localities.
Our great advantage is that local GPs are ideally
placed to know what care is most needed. We now
use their knowledge of individual patients and
the entire population, to shape the local NHS
putting patients first and foremost in
everything we do.
We work in partnership across our system
to improve outcomes for our population.
This includes NHS England (who
commission primary care and specialist
services); the local authority, West Sussex
County Council (with whom we jointly
commission a range of services including
mental health, learning disability and children’s
services), District and Borough Councils; health and
social care providers and the third sector.
There is one main acute provider, Western Sussex Hospitals NHS Foundation Trust, who run
two general hospitals and provides the majority of our hospital care. We have one
community service provider, Sussex Community NHS Trust, who also work across Brighton
and the north of West Sussex.
There is one ambulance provider, South East Coast Ambulance NHS Foundation Trust, who
work across Surrey, Sussex and Kent and one NHS mental health provider, Sussex
Partnership NHS Foundation Trust, who provide both inpatient and community mental
health services.
8
NHS Coastal West Sussex CCG | Delivering the vision
Our five year strategy
Our five year strategy describes how we will turn our vision for the
local NHS into a reality; how we will secure a safe, sustainable and
resilient NHS and better outcomes for local people.
‘Delivering the vision’ sets out a journey for health and care services in Coastal West Sussex
over the next five years and is built on the knowledge of local doctors and health
professionals and managers, ensuring genuine partnerships with local public services.
Importantly, this strategy builds on a growing engagement with (and between) the public
and clinicians, and it is this that will continue to drive and inform decisions about the local
NHS as we move from 2014 towards 2019 and our vision. The vision for 2019; together with
our principles, which define the way we will work and how we will be led; and the outcomes
we plan to see in 2019 are all detailed in Chapter 2.
The challenges faced by the local NHS are set out in Chapter 3 - Why we need to change.
Our role is to meet these challenges head on so that we can change and improve services for
local people.
Our six areas of transformation are set out in Chapter 4 (and below). In this chapter we talk
about how we will work with patients as partners in their own care and in decisions about
changes to services, and describe each priority in terms of the changes we will make to
services, what patients will experience in 2019 and how we will deliver.
6
areas of
transformation






Patient participation in their NHS
Urgent and proactive care
Mental health
Planned care
Children, young people and maternity
Primary care
Chapter 5 - Taking care of the essentials talks about how we will how we will continuously
improve the quality and safety of care; how we will make best use of medicines; how we will
drive change through improving our contractual arrangements and how we will improve the
way services use information. Together Chapters 4 and 5 constitute our CCGs Clinical
Strategy.
Our financial plan that underpins our five year strategy is set out in Chapter 6 Sustainability: our five year financial plan.
Finally, the Two year operational plan is detailed in Chapter 7 and sets the framework for
delivery in 2014-15 and 2015-16; it talks about where we are starting from and what we will
focus on in the first two years of our strategy. This is supported by more specific information
in Appendix 2 – Workplan for 2014-16.
Introduction
9
How we developed this strategy
This strategy is the product of an on-going and clinically-led engagement process that has
included local people, healthcare providers and public sector organisations. It builds on our
experience as commissioners as well as incorporating robust information and analysis
developed through the Joint Strategic Needs Assessment in partnership with Public Health.
We are also fully engaged with West Sussex Health & Wellbeing Board and as an active
member have helped set the overall framework for improving services (the West Sussex
Joint Health & Wellbeing Strategy, 2013) against which this strategy is set. The West Sussex
Health & Wellbeing Board has endorsed our overall vision, strategy and plans and the
journey they will take the local health and social care system on.
Our local providers share our vision and we have worked closely with them to ensure that
this strategy will secure clinical services and improvements for the long-term. We see this
document, ‘Delivering the vision’, as our system-wide strategy into which all provider plans
will reconcile.
We understand that many of the challenges faced locally are also being tackled in other
parts of the region, and are looking forward to working with NHS England and our partner
CCGs across Sussex in a wider ‘Unit of Planning’ to ensure our plans are complimentary and
deliver the highest-quality care for the people of Coastal West Sussex and Sussex.
10
NHS Coastal West Sussex CCG | Delivering the vision
The vision
2
12
NHS Coastal West Sussex CCG | Delivering the vision
The vision
Our vision for health and social care is built on the foundation that
patients are at the centre of all we do. In five years’ time we want to
deliver services and support patients and their carers so that any
individual can say:

My wellbeing is as important as my physical health

I feel safe and confident that I will be looked after well

I have access to a choice of high quality, responsive services seven days a week

I am in control of my health and my medical conditions are well managed

The care I receive is built around me

I am supported when I become unwell

I feel part of my community
The vision
13
Commissioning principles
Our way of working is part of what defines us. Having a clearly
developed set of commissioning principles focuses our energy into
delivering our vision.
Patients at the centre
Patients are at the centre of everything we do; every decision we make. Whether we are
talking about finance, HR or front-line services, patients are the focus of the discussion and
wherever possible they are involved themselves.
We are committed to listening to and acting on what really matters to local people; making
their priorities our priorities. For us this starts by ensuring that the care given to local people
is tailored around their needs, their goals and their lives. Too often, care is designed around
the service not the patient. Patients think about more than just getting well, they think
about getting well alongside being treated with dignity, respect and compassion. That’s why
we will always commission care that promotes these ideals and reduces confusion about
services; improves access and makes sure that patients are equal partners in decisions about
their care.
Every single day and in every single consultation local people
talk to their GP about their care and their experience and as a
CCG we can harness this insight through local doctors and
primary care teams in designing and changing the NHS.
We also know patients want to be involved in designing how
their local NHS works. One example of this is Let’s Talk, our
innovative response to ’A Call to Action’ (2013). Let’s Talk
isn’t a one off exercise – it is how patients and clinicians and
healthcare professionals can continuously engage and
communicate about the changes needed and the changes they want for the local NHS. Let’s
Talk involves a whole range of approaches from events through to online communications; it
reaches out into local communities to systematically gather insights and ideas, as well as
concerns about care and services that will directly inform commissioning and planning.
You can find out more about ‘Let’s Talk’ and how we will ensure real and meaningful patient
participation in Chapter 4.
14
NHS Coastal West Sussex CCG | Delivering the vision
Quality and value
Local patients deserve the highest quality care the NHS can give. This care must be safe,
effective and offer a good experience. We face a big financial challenge in our local NHS over
the next five years, we have committed that we will never talk about the cost of services
without talking about the quality of them; they are inextricably linked. Spending less time in
hospital, with fewer cancelled appointments and living a full and independent life supported
by local services is not only better for patients, it is less expensive for the NHS. In short,
transforming services, not cutting them, is how we will keep services safe and of high quality
and meet the financial challenges we face.
To deliver both quality and value we will always listen to what local people and clinicians tell
us about services (what we call ‘soft intelligence’), we will combine this with what the hard
data and information shows us, so we can pick up when things aren’t right and address
them.
We will also support and empower staff to offer great care; we know that happier staff give
better care which means a better experience for patients.
Clinicians and managers in partnership
Clinicians are a driving force for change because they know their services, their patients and
often know the solutions to the problems the NHS faces; being a GP membership
organisation puts these perspectives at the heart of our work. To realise this potential we
will provide excellent management support; from clear performance and programme
management systems to rigorous approaches to corporate management and business; it’s
this partnership that will make a difference for patients across Coastal West Sussex. Whilst
we are one of the largest CCGs in England, with 54 member practices, we are still a small
organisation so how we work with different people and partners is extremely important.
So far over 100 local GPs have played an active clinical leadership role and 100% of local GPs
are involved as active membership practices. Making sure that we harness the benefits of
being a membership organisation will remain a core CCG priority.
We are committed to clinical involvement coming from every part of the local NHS not just
membership practices. Therefore our service redesign work will always be multi-disciplinary
incorporating the skills and knowledge of a broad range of expert clinicians.
Whole-system
For us integration means that patients experience joined-up care, because most patients
aren’t worried about who provides or commissions their care so long as it is seamless, highquality and delivered with care and compassion. To make this a reality we must work
together, in collaboration with partners, breaking down the artificial barriers between
organisations. This is even more important locally given that proportionately, there are more
elderly and frail people in Coastal West Sussex than almost anywhere else in England. We
know that living with complex and multiple long-term conditions often requires complex
health and social care responses and can mean their experience of care is confusing and disjointed.
In our introduction we have already talked about how we worked as a system to develop
this strategy and the vision. This has set the precedent for a new way of working and for new
ways of behaving, rooted in collaboration, innovation and transparency. Our CCG will
provide system leadership in developing plans to transform services so we can allow local
providers to deliver these changes on the ground with our support. The Better Care Fund
will be part of this process but it won’t be the end as we work increasingly closely with our
The vision
15
partners in social care. We know that only together, as a whole-system, will the vision be
delivered.
Whole pathways
Patients don’t look at the healthcare as a set of services, organisations and teams; they see it
as a journey; their journey from diagnosis through treatment and to recovery. That is why
we commission in that same way, along pathways. Working in this way helps us to remove
duplication (by reducing hand-offs) between clinical teams making the patient’s journey as
seamless as possible; it is also much more efficient and cost-effective for the NHS to provide.
This also means that we can design services to improve access and support providers to
develop innovative approaches to how they run their services. This will be important to
ensure that the local NHS can continue to meet the rights set out in the NHS Constitution
(2012) and will mean that services work better together, so in partnership they can cope
with changes in demand and growing system pressures. We know that seven-day working
right across the system will be a key part of this.
Taking a whole pathway approach in everything we do also means that we can take a more
holistic view of a patient’s wellbeing and have the opportunity to put prevention at the heart
of service design, ensuring patients get lifestyle support and signposting to services at every
step of their journey. It also means that we can ensure physical health and mental health are
treated on an equal basis; delivering true parity of esteem for patients.
Reducing inequalities
Health inequalities are a very real problem in Coastal West Sussex; there are areas amongst
the most deprived in England and differences in life expectancy of ten years between
different communities. We talk more about where these inequalities are in Chapter 3 - Why
we need to change. We are committed to doing our part to reduce these inequalities over
the life of this strategy and will review specific local needs for every clinical
programme of change. This will improve our understanding of the issues local
people face in access to services and in the outcomes they experience.
Importantly it ensures that we can invest resources appropriately and
services are developed proportionately to the unique needs of different
areas according to principles set out by Sir Michael Marmot (2010).
Working in partnership with
West Sussex Public Health we
have already reviewed how we
are doing locally against the
high impact interventions set
out by the National Audit Office
(2010). Joint plans are in place
to enhance them and in our
Health & Wellbeing Strategy
have agreed some joint areas of
work where we will focus on
prevention in specific response
to
Commissioning
for
Prevention (2013). This type of
partnership approach will be
how we always work and will
be vital to our success in
reducing inequalities.
16
Tackling inequalities
in localities
Our practices, grouped into
localities, know their populations
well and therefore have an
important role to play in meeting
the unique and changing needs of
local communities.
For example,
partnership with
Public Health we
a campaign to
related ill health.
in Arun, in
the locality and
have worked on
reduce alcohol
NHS Coastal West Sussex CCG | Delivering the vision
The vision
17
Outcomes in 2018-19
In 2019 we expect people to be living not just longer, but healthier,
more independent lives. In this strategy we describe how we will
deliver better outcomes through changes to clinical services and
improvements in how patients experience care.
Below we have set out the national outcomes against which we can be held to account by
local people. Against each measure we have set a target for improvement over the life of
this strategy (we have included trajectories in full in the appendices) and have aligned these
against our six areas of transformation (Chapter 4) and our essentials (Chapter 5).
System outcome
Securing additional years of life for
people with treatable mental and
physical health conditions
In 2019
Transformation or Essential
 We will be top of our ONS
cluster
 Reduced variation between
our localities
Improving the health related
quality of life of people with one
or more long-term condition,
including mental health conditions
 Quality of life is good and as
Reducing the amount of time
people spend avoidably in hospital
through better and more
integrated care in the community,
outside of hospital
 15% reduction in the number
Increasing the proportion of older
people living independently at
home following discharge from
hospital
 Awaiting national measure
 More older people will live
Increasing the number of people
with mental and physical health
conditions having a positive
experience of hospital care
good as the best 25% of areas
in England
of people admitted to hospital
for conditions considered to
not require hospital care
independently at home
following a hospital stay
 Experience will be as good as
the best 25% of areas like ours





Urgent care
Proactive care
Mental health
Planned care
Children, young people and
maternity
 Proactive care
 Mental health
 Children, young people and
maternity
 Proactive care
 Urgent care
 Children, young people and
maternity








Proactive care
Primary care
Mental health
Quality and safety
Proactive care
Mental health
Planned care
Children, young people and
maternity
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
 Fewer people will tell us that
out of hospital care is not as
good as they expect
 Experience will be as good as
the best 25% of areas like ours
 Proactive care
 Urgent care
Making significant progress
towards eliminating avoidable
deaths in our hospitals caused by
problems in care
 Awaiting national measure
 There will be fewer avoidable




18
deaths in local hospitals that
are a result of problems in care
Proactive care
Primary care
Mental health
Quality and safety
NHS Coastal West Sussex CCG | Delivering the vision
Why we need
to change
3
20
NHS Coastal West Sussex CCG | Delivering the vision
The case for change
Our local NHS needs to make some profound changes. If we fail to face
up to them, the pressure that will be created will put at risk the very
thing we cherish most about the NHS – its unique ability to deliver high
quality care to all with dignity and compassion.
We are in no doubt that a new approach to organising and delivering NHS care is needed. To
continue to improve diagnoses, treatments and support to patients to live healthy lives we
must take a longer term view about the future of the NHS. We know that there are a whole
range of pressures we must address, many of which we explore in detail in this chapter, but
we have set out a summary below.

An aging population; the frail and elderly population account for the majority of
healthcare expenditure and we already have one of the oldest populations in
England, which is set to grow significantly by 2019. We have a model of care that is
not set up to deal with the significant increase in demand.

Complex long-term conditions; as people live longer they often live with more longterm conditions including dementia, diabetes and heart failure. This will mean the
NHS must focus more on supporting people to live well with long-term conditions
rather than just waiting for people to become ill.

Increasing patient expectations; rightly patients expect the very best every time
they need NHS services. They expect the most up-to-date treatments, access to the
right information and to be involved in decision about their care. To deliver this the
NHS must change the way it is organised to increase access 7 days a week and adopt
more innovative ideas to ensure the NHS offers convenience as well as excellent
outcomes.

Services under pressure; we know local services offer good outcomes to most
people, but services continue to face rising demand; seeing more people in less
time. This is putting pressure on staff who want to offer great care to every patient,
but who are finding it increasingly difficult to do so.

Increasing costs of providing care; we now provide more extensive and
sophisticated treatments that have made a major contribution to curing diseases
and improving outcomes. But it comes at a price; new treatments are often more
expensive than the treatments they replace. To continue to adopt these new
technologies we must ensure they offer best value and meet local needs and seek
greater efficiency in every part of the NHS.

Constrained resources; public sector finances continue face significant pressure.
Whilst the NHS has its funding ring-fenced, the increased costs of care and
increasing demand means that there will be a local funding gap of £201m over the
next five years. This will require the NHS to work in a different way if it is to meet
this challenge.
Why we need to change
21
Local health needs
Over the last 30 years, life expectancy has improved significantly and
the number of deaths from conditions like heart disease has fallen.
People are able to live longer and healthier lives. Locally, the
population is relatively healthy and affluent and has health outcomes
above the England average in most areas.
However, this hides the underlying diversity of our local area. Working with Public Health,
and by undertaking a Joint Health Needs Assessment we know that within Coastal West
Sussex we have one of the oldest populations in England and there are some of the most
deprived urban and rural areas in England and some large and growing ethnic minority
communities. Social isolation and wide health inequalities are a very real problem – for
example, average life expectancy is 10 years longer in Arundel than in Worthing.
An elderly population
Over 25% of the local population is aged over 65 (compared to the England average of
around 17%) and by 2019 there will be 13% more people aged over 85 living in Coastal West
Sussex. There will also be an 8% increase in the young population which together with an
increasingly elderly population will squeeze the proportion of working age people living
locally. This is consistent across our patch apart from Worthing (Cissbury) who will see the
proportion of elderly people fall and a growth in working age people.
Local population change between 2011 (bars) and 2019 (lines)
Females
22
Males
NHS Coastal West Sussex CCG | Delivering the vision
With age comes disease
As people live longer many live with a number of long-term conditions such as Chronic
Obstructive Pulmonary Disease (COPD), Diabetes and Dementia. For example, by 2026 there
will be around 3,200 more people living with Dementia in Coastal West Sussex, and many
patients with common long-term conditions such as Hypertension, and Asthma remain
undiagnosed which can lead to poorer outcomes. We know that half of GP appointments,
and two-thirds of outpatient appointments and A&E visits are for people with long-term
conditions.
Disease prevalence
Expected prevelance
Observed (QOF) prevelance
We also know that the burden of disease and disability is not spread evenly across the
population it varies from locality to locality, from town to town.
Residents with a condition or disability limiting day-to-day activities
Rate per
100 population
6.4 - 9.8
9.8 - 12.0
12.0 – 14.3
14.3 – 17.0
17.0 – 22.2
Why we need to change
23
Adur in particular has a high rate of people living with a disability or long-term condition. We
also know that whilst Chanctonbury has one of our oldest populations, it has low
percentages of people taking up the invitation to be screened for both breast and bowel
Cancer. In Cissbury, Chichester and Regis there are high rates of emergency admissions for
COPD; in Cissbury the rate of admission for COPD is 20% higher than the local average; and
Arun has nearly a third more readmissions for patients with Stroke than anywhere else in
Coastal West Sussex.
Our analysis also shows us that many of those people living with health conditions and
disabilities that limit day-to-day activities also live in those areas that are the most deprived.
This tells us that whilst we should ensure equity of provision across the whole of Coastal
West Sussex, energy and resources should be targeted proportionately to where need is
greatest.
Complex health inequalities
Coastal West Sussex has a diverse and varied landscape with large rural areas; large urban
towns and everything in between. Whilst this offers a range of cultural and leisure
opportunities, and an excellent quality of life for many local people, it also contributes to
some of the health inequalities that we see and experience. For example life expectancy in
Worthing (Cissbury), Littlehampton (Arun) and Bognor (Regis) is ten years shorter than in
Pulborough (Chichester) or Arundel (Regis). Specifically, we know that there are some links
between the high rates of Cardiovascular Disease, depression and severe mental illness and
a higher than expected premature mortality in Cissbury.
Life expectancy at birth
Life expectancy
in years
82.4 - 85.5
81.3 - 82.4
80.1 - 81.3
78.2 - 80.1
72.8 - 78.2
Some of this can be explained by the important differences that exist between the six
Coastal West Sussex localities; many of which are rooted in lifestyles factors such as
smoking, alcohol and obesity.
In Adur, fewer people eat a healthy diet (5-a-day) compared to the rest of Coastal West
Sussex and there is a higher percentage of obesity among adults, Arun also has a high rate of
people that smoke. Chanctonbury has increasing alcohol consumption among the middle
aged population; in Cissbury there are high rates of smoking, and alcohol related admission
to hospital both play a part in the high proportion of people with Cardiovascular Disease and
respiratory conditions we see in this locality; and in Regis there are high rates of smoking
and obesity among adults.
24
NHS Coastal West Sussex CCG | Delivering the vision
Inequalities are also driven by deprivation. Coastal West Sussex has some of the least
deprived areas in the country, however we also have some of the most deprived.
Deprivation
Deprivation
National Rank
Most Deprived 10%
Least Deprived 10%
Arun and Cissbury have the highest rates of people claiming Jobseekers allowance in Coastal
West Sussex and high rates of children living in poverty. Whilst there are fewer deprived
areas in Chichester, the number is increasing. There are also important communities of
ethnic minorities in Regis; specifically a growing eastern European population and a higher
than average number of Asian families living in and around Bognor town who will have
different health seeking behaviours that can have an impact on their health outcomes.
Social isolation is also a particular problem given our ageing population; high levels of
deprivation in our coastal towns and the rural nature of many of our communities.
Specifically, Chichester has a large proportion of residents over 65 living alone. This can lead
to an increased risk from falls and poorer access to amenities and care because we know
families and carers are crucial in maintaining a person’s independence and wellbeing
especially when they live alone. This will require a particular focus for both health and social
care.
Residents over 65 and living alone
% 65+ population in
lone person
household
1.5% - 12.6%
12.6% - 15.9%
15.9% - 22.9%
22.9% - 27.5%
27.5% - 36.6%
Why we need to change
25
The financial challenge
We have talked about the rising demand for health services, but this is
set against a backdrop of financial pressure. Budgets are not increasing
to meet demand and if services continue to be delivered in the same
way, we will have a significant funding gap.
Whilst the wider economy begins to show signs of recovery, public services must continue to
be more efficient and work with fewer ‘real terms’ resources. Even with small increases in
NHS funding, the demand for services will outstrip those by up to £30bn by 2020 across
England (NHS England (d), 2013).
We have estimated that the local health economy (both commissioners and providers) share
of this will be £201m over the next five years or over £40m each year.
This is in part due to the
increased
costs
of
providing care and the
use of new technologies.
The NHS can now treat
conditions that previously
went undiagnosed or
were simply untreatable.
This is of course a good
thing, however many of
these innovations are
more
expensive
to
provide
than
the
technologies they replace. So we must ensure we invest in those technologies and drugs
which represent the best value for the best outcome. This rigorous approach to evaluating
the treatments the NHS will provide must also be extended to the whole way in which care
is delivered and organised.
It is also recognised that the NHS in Coastal West Sussex is under-funded for the needs of its
population and has inherited a challenging financial position. We do not want to
contemplate reducing core services so we need to transform them.
We must also recognise that spending on social care is not ring-fenced like it is in healthcare.
Changes in social care funding can have an effect on health services we will therefore need
to consider how we work together with our Local Authority to use our collective resources
effectively to support patients and deliver better outcomes.
Further details of our financial approach can be found in Chapter 6 – Sustainability: our five
year financial plan.
26
NHS Coastal West Sussex CCG | Delivering the vision
Services under pressure
The NHS has continued to meet rising demand for services; greater
expectation from patients and significant financial pressure. Locally,
services are performing well with most outcomes above the England
average; but these are often provided in silo’s creating duplication and
confusion.
Performance and outcomes
Services continue to perform well and meet most national clinical standards and deliver
good outcomes for most people. For example, the number of years of life lost (a measure
used to test overall population health) is
lower than in other areas like Coastal West
Sussex; as is under 75 mortality from
How outcomes compare
cardiovascular disease.
However, in recent years it has been more
challenging to meet all of the rights set out
in the NHS Constitution (2012) most notably
the 18 week ‘Referral to Treatment’ time,
particularly in some high volume specialities
such as musculo-skeletal (MSK).
Accident & Emergency (A&E) departments
and emergency services have continued to
meet growing demand but have come
under increasing pressure to meet response
times, due to the increasing number of
elderly patients, who require more complex
care both in hospital and in their own
homes.
Local clinicians have also told us that they
are caring for significantly more patients
living with dementia than ever before, and
we know this is only going to increase in the
future.
Why we need to change
Better than the areas like ours

Under 75 mortality from
cardiovascular and respiratory
diseases

Quality of life for people with
long-term conditions

Number of years of life lost
Worse than the areas like ours

People feeling supported to
manage their long-term
condition

Under 75 mortality from cancer

Patient experience of GP
services

Patient reported outcomes for
hip and knee replacements
27
What patients tell us
Patients are the best judge of the quality of services, and rightly have ever-increasing
expectations about the quality of care the NHS should provide as well as about how, where
and when services should be accessed. Listening to patients is a key part of how we work as
we have already talked about in our commissioning principles.
This engagement has already started and we are hearing from patients and their clinicians
that services can be confusing and disjointed. Patients have to tell their story to a range of
professionals as information often isn’t shared, making clinical decisions more complicated.
Much of this is due to the way the NHS has evolved over the years as it has adapted to meet
the changing and growing needs of local people. This means that whilst local services are
built on the dedication and commitment of staff who continue to deliver real results for
patients, services have developed organically and often without the overall co-ordination
that delivers seamless care.
Workforce
NHS staff spend their lives caring for others, giving everything to support and treat people
when they need it most. However, we recognise that some staff are being stretched;
treating more patients, with more complex needs, in less time. This shows us that we need
to continually consider how to ensure our workforce matches local need and demand.
Some staff are simply in short supply, GPs, care staff, some hospital specialities and nurses
are well documented examples. With our working age population being squeezed, we will
need to work with local providers and the education system to shape new roles and
encourage more people to follow fulfilling and rewarding careers in the NHS. We will need
to think differently about how we are going to ensure that our future workforce has the
right numbers, skills, values and behaviours to meet our patient’s needs.
We also know that staff satisfaction is directly linked to quality of patient care. The
following factors contribute to staff satisfaction and are measured in the annual National
Staff Survey. Results locally are comparable nationally and in the main staff were satisfied in
their ability to offer good patient care; with support from colleagues and freedom to act but
there are opportunities to improve.
Innovation and new technology
The introduction of new technologies, medicines and procedures has also changed the way
we can diagnose and treat patients in recent years which changes the way staff work. Whilst
these are good for patients, they can increase the costs of providing care. To ensure that we
can make the most of these improvements we must change the way we work to make the
savings which can then be reinvested into new and emerging technologies.
28
NHS Coastal West Sussex CCG | Delivering the vision
Areas of
transformation
4
30
NHS Coastal West Sussex CCG | Delivering the vision
6 areas of transformation
We believe that focusing on transforming key local services which
meet the greatest number of local needs gives us the greatest chance
to deliver our vision now and into the future.
In this section we describe the six areas where we will transform the local NHS. All are fully
aligned to the NHS Outcomes Framework (2013), the West Sussex Health & Wellbeing
Strategy (2013) and national priorities including improving the standard of care following the
Francis Inquiry (2013) and developing a more 7-day services as set out by Sir Bruce Keogh
(2013). These transformations are recognised by our partners and reflect a whole-system
commitment to change and improve services towards the vision.

Patient participation in their NHS; how we will truly put patients at the heart of
both service planning and delivery but also in greater control of their own care.

Urgent and proactive care; describes how we will ensure more responsive and
integrated urgent and emergency care services for all patients, but importantly for
our large elderly population and a growing number of people living with one or
more long-term condition such as diabetes, COPD or Dementia.

Mental health; how we will continue to integrate services and provide more
supportive community services that ensure people can live full and independent
lives regardless of their condition.

Planned care; how we commission better access, more streamlined pathways and
improved outcomes for patients needing elective care and treatment; specifically in
those areas where we spend more and get worse outcomes than other parts of
England.

Children, young people and maternity; how we will give children the best possible
start in life through excellent maternity care and children’s services, especially for
children with complex and chronic conditions.

Primary care; we set out the pivotal role of primary care in delivering our vision and
how we plan to develop a strategy to ensure it is ready to meet the challenges of
working at greater scale through improving access, services and collaborative
working between practices in partnership with NHS England.
Areas of transformation
31
Changing local services
Using our vision as our guide, we have defined what the NHS will look
like in Coastal West Sussex in 2019. It is against this blueprint that the
six areas of transformation will align.
In this Chapter we describe the changes we plan to make across all settings; for all patients.
Together they will deliver our vision for patients, drive better outcomes and create a model
of care that will:










Shift care and resources from the hospital setting into the community
Integrate care around patients
Ensure we have thriving and sustainable providers
Secure high quality responsive and effective clinical services
Decrease inappropriate use of clinical services and decrease variation
Increase access and decrease duplication
Deliver seven day a week access to health and social services
Improve services so they are easy to navigate for patients and professionals
 Easier to do the right thing
 Right care, right place, right time
Ensure the local NHS is a great place to work
Ensure Coastal West Sussex is a great place to be a patient
Inequalities, Wellbeing & Prevention
Tackling the determinants of health at their source
Collaborative
Primary Care
Local doctors working together
within communities
Proactive Care
Integrated and enhanced community health &
social care teams
Smaller Acute Footprint
Reduced capacity and increased
specialism in acute hospitals
+
+
Integrated Care Services
Integrating elective care pathways around key specialities
32
NHS Coastal West Sussex CCG | Delivering the vision
Patient participation
in their NHS
Areas of transformation
33
We are committed to putting patients at the heart of everything we
do, with an equal commitment to working with patients and the public
as partners.
Listening to and acting on what really matters to local people starts by ensuring that the care
given to local people is tailored around their goals and their lives. This means that patients
must be seen as active and equal partners in decisions about their care and treatment. It
also means that patients should be involved in decisions about how we change services and
should be able to offer feedback on the quality of services they receive to help the NHS
continually improve services. We promise to do all three and are working hard to put these
at the heart of commissioning approach and decision making process.
Fundamental to this will be adhering to the principles laid down in ‘Transforming
Participation in Health and Care’ (NHS England (e), 2013) and supporting the NHS
Constitution's pledge that 'The NHS belongs to the people’.
Putting patients in control of their care
Throughout ‘Delivering the vision’ we talk about how more patients must be empowered to
take control of their health and decisions about their care. It is vital to everything we do
because we know that around 80% of deaths from major diseases, such as cancer, are
attributable to lifestyle risk factors such as smoking, excess alcohol or poor diet. If we want
to protect our NHS for the future we all need to look after ourselves and we are committed
to helping people to do that.
Patients living with long-term conditions such as Diabetes are too often just the recipients of
care, but we see them as co-providers; they are often experts in their own health and
wellbeing. To bring this belief to life we will need to commission services that systematically
ensure patients get the training and support they need to manage their conditions every
day; to stay well and reduce the risk of needing hospital care. In the rest of this chapter this
message is loud and clear and is at the heart of how we will transform services over the next
five years.
Patient feedback is also vital in monitoring and planning services so we have worked with
providers to implement the Friends & Families Test as well as in developing and using
Patient Reported Outcome Measures (PROMs) in more services. As we go forward this
approach, where we act on feedback from patients and make tangible improvements in
services and help patients to choose which services they use, will be a key part of how we do
business.
34
NHS Coastal West Sussex CCG | Delivering the vision
Public involvement in commissioning
We know that meaningful patient and public engagement cannot be the responsibility of
one person or one team, but must come through a cultural shift throughout every part of
our organisation; from the GPs in local practices to our commissioning teams.
So in 2013 we reviewed our patient and public engagement approach and identified some
key actions to establish better patient and public involvement. We have already delivered
several key recommendations such as a Patient Reference Panel which reports to the
Governing Body via one of the two lay people for patient and public engagement, along with
patient and public representation on each of our Locality Boards. But we have more do in
the coming months and years; including:




establishing an enhanced patient and public e-panel that is recruited to reflect the
demographics of our area
enabling the development of Patient Participation Groups (PPGs) at all of the GP
practices (currently 37 of the 54 practices (66%) have active PPGs)
establishing a consultation database and software to improve engagement
ensuring our staff receive engagement training, advice and guidance
Importantly we have already set up ‘Let’s Talk’ our mechanism for continuously engaging
with the public about the local NHS. This on-going programme will include workshops for
patients, public and partners and public roadshows. This programme will ensure local people
are fully engaged in our work at every step of the commissioning cycle. Patients have already
given us some key messages which have informed this strategy. These are illustrated below.
“Treat the
person, not the
condition”
“We want a 7 day
NHS – we want
better access”
“You need to help
patients to find the right
information about
services”
“We are worried
about the
privatisation of the
NHS”
“We want to be
partners in our
own care”
Areas of transformation
35
Equality and diversity
We understand and are committed to ensuring equality of access and non-discrimination,
irrespective of age, gender, disability (including learning disability), gender reassignment,
marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender)
or sexual orientation. In carrying out our functions, we will have due regard to the different
needs of protected equality groups, in line with the Equality Act 2010.
Equality issues will always influence how we reach our decisions, how we act as an
employer, how we develop, evaluate and review policy, and how we commission and
procure from others.
To help ensure we achieve this, we have an equality and diversity strategy in place. Within
this is an action plan devised using the Equality Delivery System. The plan covers the period
2013 to 2017 and contains 16 primary objectives which are reviewed annually.
36
NHS Coastal West Sussex CCG | Delivering the vision
Urgent and proactive care
Services for people who are suddenly unwell or experience an
emergency, including services for people who are vulnerable or elderly
or live with long-term conditions like Diabetes or heart failure
Areas of transformation
37
Why change?
Just like many parts of England, local urgent and emergency care services are facing ever
increasing demand and changing patterns of disease. In 2012-13 there were over 125,000
attendances at our two local A&E departments; nearly 46,000 emergency admissions and
over 80,000 calls to 999 ambulance services in Coastal West Sussex; all increasing (on
average) 3% each year in recent years.
We know that some of this is related to our large and growing elderly population who often
live with multiple long-term conditions including Diabetes, Chronic Obstructive Pulmonary
Disease (COPD), heart failure or Dementia and require more complex care. However, some
of the increase in demand can also be attributed to hospitals simply being the default setting
for urgent and emergency care, firstly, due to how responsive and effective their services
are, and secondly, because navigating and accessing alternative services closer to home can
be complicated and confusing, and even more so for the people who don’t speak English as
a first language or those from hard to reach groups.
Despite this we know most urgent care needs are not life threatening, for example, national
research has shown that around 40% of patients are discharged from A&E with no treatment
at all (Keogh, 2013) and locally more people are admitted to hospital for illnesses that don’t
usually require hospital care compared to other areas (NHS England (a), 2013).
In 2019
On the following pages we have set out ambitious plans to transform urgent and emergency
care, so that in 2019 we have a high-quality and sustainable system where patients will tell
us:
38

I am supported to be healthy and well

I have access to all services seven days a week and get to the right service first time

I have a single point of contact for advice

The health and social care professionals that support me have a single point of
access for all the services I need

My care is planned, people work together to understand me and my carer, put me in
control, and co-ordinate and deliver services that achieve my best outcomes

I am looked after in my own home whenever possible

If I need hospital care it is rapid, responsive and high quality and I am able to return
home as soon as possible

I am supported to get back on my feet and if I need services and equipment they are
rapid, responsive and high quality

Everyone who cares for me has access to the information they need

I am part of my community and supported by it
NHS Coastal West Sussex CCG | Delivering the vision
Areas of transformation
39
A new model of care
We recognise that Urgent Care, Proactive Care and Long Term Conditions are all intrinsically
linked, and this is especially important when we plan services for our elderly population and
those with complex needs. In planning these services we have looked at the entire pathway
of care, ensuring we are not pushing pressure from one area to another but are improving
the whole system, ensuring care is wrapped around a patient, rather than a patient having
to fit into our care model.
Over the next five years, we will continue to develop our Proactive Care services in order to
identify sections of the population who have more complex needs, proactively supporting
them to be in control and live well with their medical condition. We will improve our Urgent
Care services so that when people do become unwell, they can rapidly access appropriate
advice and care to enable a swift recovery. In this way we will provide high quality
integrated care using a holistic and multidisciplinary approach, putting patients at the centre
of everything we do, in order to improve outcomes for our population.
Proactively Caring for the Frail Elderly and those with Complex Needs
Coastal West Sussex has one of the largest elderly populations in the country and this is
something to celebrate, however we recognise that they have more complex health and
social care needs which we need to focus on when planning integrated services that work
for them. This is what we call Proactive Care.
Our patients and the carers tell us they want to be in control, feel safe, but stay in their own
homes whenever possible. To support them to do this, we will proactively identify and care
for those with complex needs at every stage of their pathway, with integrated health and
social care multidisciplinary teams, Proactive Care Teams, at the heart of the service.
40
NHS Coastal West Sussex CCG | Delivering the vision
Our community multidisciplinary Proactive Care teams will work with patients and their
carers to plan, coordinate and deliver their care.
They will support the patient:

To stay well

To plan for when they become unwell, so they know when and how to get help

Through planned admissions (such as hip replacements) and unplanned admissions
(such as a bad chest infection)

To optimise their recovery
We have already begun to roll out these teams and will continue to evolve and develop
them, working with the team
members. Each team is based
Core Proactive Care team members:
around
a
population
of
 GP champions
approximately
30-60k.
We
recognise that the needs of our
 Practice nurses
population vary across the area and
therefore we have given each team
 Community nurses and matrons
the flexibility to develop and
 Therapists
respond to their local population
whilst adhering to the same core
 Mental Health workers
principles.
The multidisciplinary
(MDT) team will be THE community
 Social Care workers
service. It is instead of not as well as
 Generic care assistants
current provision.
The teams will ‘risk assess’ our
population in order to identify
those at greatest risk of becoming
unwell.

Care coordinators or Case managers

Administrators

Managerial support
The teams will ensure each patient
is allocated a key worker within the MDT who will coordinate their care. This key worker will
ensure a single comprehensive and holistic assessment is carried out which looks at the
whole person, exploring their health and social care needs. A care plan will be drawn up
setting out all the needs of the individual, and how each will be addressed. We know that
this group of patients will, at times, become unwell so we will plan for those times - we call
this contingency planning The care plan will be shared with all staff including the ambulance
service so the whole system acts as one, offering the individualised care that person needs.
The team members are all generalists and will be supported by specialist services including a
consultant geriatric service which will provide key leadership in the system, provide training
and education, and also support hospital colleagues during any planned or unplanned
admission.
Many of these patients have more than one Long Term Condition such as Diabetes, Chronic
Obstructive Pulmonary Disease, heart failure, and Dementia. Each Long Term Condition
Areas of transformation
41
requires high quality care which will predominantly be delivered by the generalists within
the MDT. We will therefore have specific evidence based, best practice clinical pathways
and guidelines for each individual Long Term Condition, as well as ensuring specialists are
available to support the generalist clinicians. We will provide End Of Life Care in a similar
way, with holistic patient centred care planning and coordination, integrated with other
services.
A case study from 2019
Peggy and John, both in their 90s, live in
Arundel. Peggy has diabetes and was in poor
health when her GP referred her to the local
Proactive Care team.
Peggy and John have worked in farming
throughout their lives and are used to an
independent. Recently, as a result of ill health
and lack of mobility they were finding it more
and more difficult to maintain and clean their
home and look after their health.
For the past three months a multidisciplinary
team of therapists, nurses, social workers and
physiotherapists have co-ordinated daily visits
to see Peggy and John developing and
delivering a personalised care plan that was
shared across all local services.
A Community Matron took a lead role in
providing their care ensuring Peggy’s diabetes
was controlled and leg ulcer was treated. The
couple were supported to stay together at
home, rather than be cared for in a nursing
home. The Proactive Care team also arranged
cleaners and meal deliveries to visit regularly.
We will utilise information technology
to enable access to patient records,
keeping all parts of the health and
social care system fully informed. We
will also use assistive technology to
enable the delivery of services,
reducing visits people need to make to
doctors surgeries and hospitals.
Where Proactive Care patients reside in
a nursing or care homes, the MDT will
support the care home staff including
providing training and education so
they feel better able to care for them.
We will ensure whole system working,
removing traditional organisational
barriers, and communicating care plans
and contingency plans to all partners
including the ambulance service.
By proactively caring for these patients
we will be better able to keep them
well, improve their quality of life and
reduce the risk of deterioration and
admission to hospital.
Urgent and Emergency Care Services
Local evidence shows that in our area significant numbers of patients are still receiving care
in hospitals that could and should be delivered in the community. These findings are in line
with national data (Keogh, 2013), which reinforces the need to shift care away from the
hospital setting and in to the community.
Supporting our population to choose the right care, in the right place, first time
Unnecessary A&E attendances are placing the system under significant pressure and we are
concerned that this may risk poor outcomes for patients experiencing genuine emergencies.
We therefore intend to redesign this ‘front door’ to Urgent Care to allow us to direct
patients to the most appropriate service, first time.
42
NHS Coastal West Sussex CCG | Delivering the vision
Our population is diverse with
pockets of deprivation, large
immigrant groups who may not
speak English as a first language, and
a large frail elderly population who
have limited mobility, hearing and
sight impairment.
Through a
programme of education and
support, we will strive to reach all
our population in order that they
understand how and when to access
appropriate Urgent Care services.
It is vital that everyone can easily
and simply access information about
the full range of services available at
their time of need and we
appreciate that over recent years
our Urgent Care system has become
increasingly complex, confusing and
difficult to navigate.
We will
promote to our population the
value of using the single point of
advice NHS 111 service so they
know there is one number to call to
access all the advice and support
they need.
A case study from 2019
Mrs Jones, an 80 year old lady and main carer
for her husband who has dementia, awoke
confused one morning. Their neighbour rang
their GP who subsequently visited and was
concerned by her level of confusion. The GP
contacted One Call One Team (OCOT) who
arranged Patient Transport to the Ambulatory
Care Area at the local hospital and a support
from the Dementia Crisis Service for her
husband. On arrival at hospital a flag on her
patient record indicated the presence of an
Advanced Care Plan stating her wishes to be
nursed at home wherever possible.
The assessing doctor reviewed her GP record,
noted that she had fallen the previous week
and requested a CT scan. Following a normal
scan she was reviewed by the Consultant who
felt her confusion was attributable to an
exacerbation of her COPD.
Mrs Jones
returned home that afternoon with the
support of the RAIT Team. The couple were
referred to the Proactive Care Team for ongoing
support
to
prevent
further
exacerbations.
Wherever possible, NHS 111 will encourage individuals to self-care and give advice on where
to seek further help in the community such as pharmacies. When it is necessary to see a
healthcare professional, support will be given to ensure they get the right care, in the right
place, first time. A rapid assessment will be provided by an appropriate clinician (which may
be a doctor, a specialist nurse, or a paramedic practitioner) and treatment will be provided
promptly.
Community services including primary care are struggling to provide same day appointments
resulting in many people finding it easiest to attend A&E when they need prompt advice and
care. We will work with these services to improve their accessibility and alleviate the
unnecessary pressure on A&E and we will explain the importance of this to our population.
We will ensure primary care is flexible and responsive and can be accessed the same day
when clinically necessary, and that the Out of Hours GP service is fully integrated with the in
hours teams, accessing a single health record to give continuity of care wherever possible.
When people self-present to A&E, we will triage their medical needs and redirect them to
other services if more appropriate. We will work in partnership with our population so they
understand the value of receiving care in the community, rather than being admitted to
hospital.
Areas of transformation
43
One Call One Team
One Call One Team is the
admission avoidance service in
Coastal West Sussex. They
provide a 24/7 service, 365
days a year, and are the single
point of access for all hospital
and community urgent care
services.
We have already
made a good start in setting up
this system, but we need to
build on this to ensure every
patient receives the same high
quality service.
When needed, healthcare
professionals will call the single
point of access to additional
services, One Call, in order to
access all One Team services,
including the Rapid Assessment
and Intervention Team; GP in
A&E; Paramedic Practitioner;
Community Geriatrics Service
and Dementia Crisis Team and
to access community beds
across CWS. Where necessary,
One
Call
can
organise
conference calling so the health
professional
can
receive
immediate telephone advice
from a medical or geriatric
consultant. One Call can also
book a rapid comprehensive
community geriatric review,
reducing the need for hospital
admission for our frail elderly
population.
When an unwell patient is
suitable for care in their own
home (including care homes),
One Call will arrange for short
term comprehensive care by the multidisciplinary community health and social care team,
One Team, safely keeping people in the community whenever possible.
44
NHS Coastal West Sussex CCG | Delivering the vision
Integrated Urgent and Emergency Care within our hospitals
We will ensure our A&Es are appropriately designated as Emergency Care or Major
Emergency Care Centres and are part of a high performing network. We will continue to
introduce Ambulatory Care Pathways which will streamline the care for certain conditions
such as DVT and exacerbations of heart failure. These pathways will enable hospital medical
teams to rapidly assess patients with these conditions and discharge them home with a
treatment plan that can be safely provided by the Community teams with hospital support.
We will support our hospitals to provide high quality, evidence based care. During any
hospital admissions, we will strive to ensure complex patients are cared for by an integrated
multidisciplinary team on an appropriate ward, with medical, surgical and geriatric teams
working in a joined up way during elective and emergency admissions. This will ensure the
patient is treated holistically and Long Term Conditions are not unduly destabilised.
Facilitating discharge
Proactive discharge planning involving hospital and community teams, especially for those
with complex health and social care needs, will ensure people are returned to their homes
as quickly as possible with all the rehabilitation and reablement support in place to help
them return to their previous state of wellbeing or better. This discharge planning should
begin at admission in order to be most effective.
Our first priority is to get these essentials working well, but we will then move more care
into the community through ‘discharging to assess’. This will involve hospital specialists and
GPs working together to mutually support each other and enable the patient to get home
more quickly by completing investigations and management planning in the community.
Beds in the community setting (care homes, nursing homes and community hospitals) will
support those who require a little longer to recover but do not need intensive specialist
hospital care. Short term care packages and easy access to equipment services will allow an
earlier return to their own home. Geriatric follow-up and community support teams will
underpin our discharge service.
Working as a joined up health and social care system
We will ensure we commission across the entire pathway in partnership with West Sussex
County Council, committing to working towards a single integrated rehabilitation and reablement service.
To enable this Urgent Care, Proactive Care and Long Term Conditions vision to be realised,
we will develop an integrated IM&T system to allow information from all health and social
care services to be pulled together into a single place, allowing appropriate access to
comprehensive patient information to allow informed decision making and care planning.
This will also allow effective identification of patients who are already under the Proactive
Care teams so their key worker can be informed and involved in discharge planning, and in
identifying individuals who may be appropriate for accelerated discharge to a community
setting.
Areas of transformation
45
Importantly, we believe we need seven day working across the whole system, both in
hospital and in the community to ensure the highest quality of care is always provided. It is
a top priority to plan how this can be achieved.
Stroke services
There is Sussex-wide agreement that stroke services need to improve. We will be working in
partnership with local CCGs and to undertake a thorough review and develop a clear
strategy for reducing the variation in standards of stroke care and deliver a best-practice
model of care.
How we will deliver change
We currently have lead provider arrangements for One Call One Team and for Proactive
Care which are both underpinned by a Memorandum of Understanding. Both
commissioners and providers have committed to work together to deliver these new
models of care and in 2014-15 we will work with them to design contracts that:

Provide clear incentives for integrated working

Share risk more equitably across our system

And are focused on delivering better outcomes to our population
This will involve a lead provider for the proactive care pathway and for urgent and
emergency care. The programme of work to develop these arrangements will be
underpinned by a Chief Executive level board and we will aim to have these new
arrangements in place by April 2015.
Joint commissioning with West Sussex County Council will be vital, as will our part in an
effective Health and Wellbeing Board. Our plans see a fundamental shift of care from
hospital into the community and into patients’ own homes. This needs to be a safe and
well-planned transition and resource must follow the patient for this to happen. We will
make effective use of the Better Care Fund to ensure that we accelerate transformation
and make best use of pooled budgets.
Working across Sussex, in partnership with other CCGs, we will develop more local
commissioning arrangements for Ambulance services. Coordinated by Horsham & Mid
Sussex CCG, we will work toward securing locally responsive and more integrated
emergency services which work seamlessly with our vision for urgent and proactive care.
We will also work across boundaries to drive improvements in stroke services; we know
locally performance can be improved but working at scale across a larger population will
provide even greater opportunities for high quality and responsive care for patients who
have suffered a stroke.
We will carefully plan the workforce and infrastructure implications for our
transformational changes and work with providers to reduce hospital capacity and retrain
staff for a role in the community. This is large scale change and will require us to work with
our partners to ensure that good organisational development supports our workforce in
changing behaviours and attitudes. We believe that our staff are the jewel in our crown
and if we support them to embed sustainable change we know that we will improve
patient experience and deliver our vision.
We will work with West Sussex County Council on their journey to become a
commissioning organisation, supporting the joint provision of adult social care and
46
NHS Coastal West Sussex CCG | Delivering the vision
community services. We will jointly tender for a new rehabilitation service and work with
them to drive up standards in the domiciliary and care home sector.
Working with our membership to support and develop primary care to be at the heart of
urgent and proactive community care. In 2014-15 we will ensure that we spend the £5 per
head for practices set out in Everyone Counts in support of our plans for Proactive Care and
to enable strong clinical leadership for multi-disciplinary teams.
As in 2013-14 we will use the marginal rate rule monies and all such contract levers to
support reinvestment in rapid access and intervention and a reduction in avoidable
readmissions.
Over the following pages we have set out our roadmap for the next 5 years. It shows the
key milestones in each year and the outcomes that will be improved by 2018-19. We have
also set out an output and outcomes map which highlights the measures we will monitor
ourselves against each year and trajectories for key indicators of our success.
Areas of transformation
47
48
NHS Coastal West Sussex CCG | Delivering the vision
Call One Team to provide a single
point of access for professionals
and rapid assessment and
intervention
 Commissioned and delivered One
DGHs and one Minor Injuries Unit
 Two A&E departments in two
reviewed and models in
development
 Long-term condition pathways
launched
 Proactive Care MDT pioneer sites
The journey so far
discharge processes and
seven-day working
 Whole system focus on
conditions pathways and
House of Care model
 Make progress with Long-term
out to all MDTs
 Risk stratification tools rolled
MDTs live
 All 13 Proactive Care Hubs and
2014-15
whole system approach to sevenday working
 Larger care homes aligned to
meeting 7/7 clinical standards
 First wave of services begin
model of emergency care and
Out of Hours
 Developing a new integrated
capitated pathway and contract
for Reactive Care including One
Call One Team and Ambulatory
Care
 Designing outcome based
launched
 New End of Life Care pathway
condition pathways launched for
diabetes and COPD
 New system-wide long-term
integration delivered
 Model for community provider
supported by BCF
 Expanding Proactive Care
2015-16
standards
 All services meeting 7/7 clinical
A&E and emergency care is
launched
 The new integrated model of
implemented and services
operational
 New contract arrangements
solutions into Proactive Care
MDTs and Hubs
 Early adoption of telehealth
2016-17
2017-18
A&E and emergency care is fully
operational and includes Out of
Hours Primary Care
 The new integrated model of
common practice for all patients
with diabetes and COPD
 Annual medication reviews are
improvements in Proactive Care
MDTs
 On-going review and
Urgent and Proactive Care Roadmap to 2019
towards eliminating
avoidable deaths in our
hospitals caused by problems
in care
 Making significant progress
people with mental and
physical health conditions
having a positive experience
of care outside hospital, in
general practice and in the
community
 Increasing the number of
people with mental and
physical health conditions
having a positive experience
of hospital care
 Increasing the number of
older people living
independently at home
following discharge from
hospital
 Increasing the proportion of
people spend avoidably in
hospital through better and
more integrated care in the
community, outside of
hospital
 Reducing the amount of time
quality of life of people with
one or more long-term
condition, including mental
health conditions
 Improving the health related
life for people with treatable
mental and physical health
conditions
 Securing additional years of
Outcomes
improved by
2018-19
Areas of transformation
49
£8.641m
A&E 4-hour target met
A&E attendances
Emergency admissions
100% of designated services meeting 7/7
clinical standards
Reduction in permanent admissions of older
people to residential and nursing homes
75% of high and medium risk stratified
patients on Proactive Care MDT caseloads
% Reduction in admissions to care homes in a
crisis
2017-18
£6,938m
£9,150m
Efficiency savings
5,810m
Improving quality of life for people with one or more long-term condition
A&E 4-hour target met
65% of high and medium risk stratified
patients on Proactive Care MDT caseloads
100% of patients on Proactive Care MDT
caseload with a care plan, care
coordinator and on IBIS
Ambulance handover times met all
national standards
95% Proactive Care patients feel involved in
developing their care plan
85% Proactive Care patients feel involved in
developing their care plan
100% of the population risk stratified
% Reduction in care cost per patient per
month on Proactive Care MDT caseload
2016-17
2015-16
2014-15
Urgent and Proactive Care Outputs and Outcome map to 2019
£6,120m
2018-19
50
NHS Coastal West Sussex CCG | Delivering the vision
Mental health and learning
disabilities
Care and support for people living with conditions such as anxiety,
Dementia and learning disabilities
Areas of transformation
51
Why change?
Approximately 1 in 4 people has a mental health problem at any given time and it is
estimated that one third of all GP consultations relate to mental health problems. About 5%
of our population will have a severe mental illness like Schizophrenia. There are also around
9,000 people with some form of learning disability, with around 2,000 living with a severe or
moderate learning disability. Addressing the needs of people with mental illness and
learning disabilities will be at the heart of our work to reduce inequalities. Our research tells
us that those people in our community who are most deprived are more likely to be affected
by mental illness; are more likely to experience particular conditions such as anxiety and
depression; and are more likely to experience poor physical health.
The link between mental health and the physical health is critical. Whilst we have been
working hard to improve our mental health services and the support provided to local
people, we know that there is evidence which suggests much poorer outcomes for people
with co-existing mental health and physical health care problems. For example, we know
that around 30% of people with a long term condition are also known to have a mental
health problem and that there is a 20 year gap in life expectancy for people with a serious
mental illness. We also know that people with learning disabilities are also more likely to be
admitted to hospital in an emergency than electively; significantly higher than the England
average.
This is why we are absolutely committed to moving towards parity of esteem, making sure
that we are just as focused on improving mental as physical health and that patients with
don’t experience inequalities, either because of the mental health condition or learning
disability itself or because they then don’t get the best care for their physical health
problems.
In 2019
In partnership with West Sussex County Council and Crawley and Horsham and Mid Sussex
CCGs we have developed a strategy for improving mental health services. Our strategy
recognises the significant challenges currently around the consistency, quality and reach of
mental health provision identified in consultation with local people and sets a new direction
focused on localised commissioning for prevention and community services and a new
model for care which means that by 2019 local people will be able to say:
52

I know where I can get information about condition and where I can go to get
support in my community

I have access to a range of effective local psychological and social support services
which will support my recovery and maintain my well-being

I have access to a range of effective local and personalised health and social care
support which keeps me safe, is available when I need it and helps to maximise my
independence

I am able to get really good physical healthcare alongside the care and support I
have for my mental health problems

I get good support for my mental health problems when I am in hospital, whether
that admission is for my mental health problems or for my physical health problems
NHS Coastal West Sussex CCG | Delivering the vision
A new model of care
In consultation with local people and our stakeholders we have developed a four tier model
for the delivery of care and support to people with mental health conditions. This model is
designed to shift the focus of provision to make more help available earlier, preventing
problems from developing and escalating, and thereby reducing pressure on our more
specialised services.
Level 1
Level 2
Level 3
Level 4
Universal
Targeted
Specialist
Highly Specialist
Need
Need
Preventing MH
conditions
Advice &
information
Maintain
independence for
people living with LD
and MH conditions
Early intervention
Low key specialist
support
Need
Need
Support for recovery
when needs are
more serious and
enduring
Support for recovery
when needs are so
serious that hospital
is required
Ongoing & multi
professional support
When MH problem is
less common and
needs specialist
support
Support
Support
Support
Non specialist health
and community
support including
housing
Campaigning to
lessen stigmaqw
Specialist social &
psychological
recovery focused
early intervention
and prevention
Psychological
therapies
Primary care led MH
support
Link to substance
misuse services
Areas of transformation
Integrated
assessment, care &
treatment
Dual diagnosis
support & substance
misuse services
Medical &
psychological
treatment
Support
Inpatient Services
Highly Specialist
Community Services
Support planning &
brokerage
Recovery support
53
How we will deliver change?
To support integrated services we will need to develop more integrated commissioning.
Whilst this has been a long tradition in mental health and learning disabilities in terms of
joint commissioning structures and pooled budgets with West Sussex County Council, we
need to do more. The Better Care
Fund provides the opportunity to do
A case study from 2019
this through specific support over
the next two years and we expect
Mr Jones is 32, he is a father of 2 but has
mental health and support for the
recently separated from his wife and lost his job.
mental health needs of those with
He is facing homelessness. He makes an
long term conditions to be a
appointment with his GP complaining of very
priority. The fund will allow CCGs
low mood, irritability, uncontrollable anger and
and West Sussex County Council to
suicidal thoughts.
extend the pooling resources to
accelerate transformation, enhance
The GP who understands how to assess him and
the commissioning of prevention
his level of risk, shows compassion, is empathic
and wellness services, support the
and instils hope. The GP understands the tiered
greater contribution of mental
care approach and recognises the severity of his
health in urgent care pathways,
condition, so rings the urgent care co-ordinator
drive activity and resources into the
at the local Assessment and Treatment Centre to
community; and move the system
discuss the case. As there is no immediate risk an
toward 7-day working.
appointment is made for the next day.
We will also continue to work with
its commissioning and provider
partners to ensure that a fair tariff
system is established to support
better outcomes for mental health
services. We will also continue to
provide
the
co-ordinating
commissioner function for Sussex
Partnership NHS Foundation Trust
on behalf of local CCGs. Whilst a
national tariff is not in place for
2014-15 we will continue to support
the introduction of Payment by
Results in mental health. payment
by results will:




Mr Jones sees a mental health practitioner with
expertise in severe depression; from this point
forward he does not have to repeat his story as
the same person becomes his lead practitioner
and also plans his care. After some individual
sessions his mood improves but he is diagnosed
as having emotionally unstable personality
disorder and is offered a CBT-based course
focussing
on emotion
and
behaviour
management strategies. He continues to meet
with a member of the community team who
helps him write a crisis plan which he shares
with the GP, A&E, One Call and the ambulance
service.
Improve clarity for service users and carers about what they can expect from
services and the outcomes they can achieve
Facilitate an understanding of clinical processes between commissioners and
providers and between clinicians and service managers
Incentivise both commissioners and providers to deliver effective, efficient and
equitable models of treatment and care
Distribute the burden of financial risk fairly between commissioners and providers.
We will also need to focus on supporting providers to develop the infrastructure that will
drive transformation and integration; more effectively sharing information and, wherever
beneficial and possible, co-locate services and teams. Provider focus on workforce
development programmes will also be crucial in supporting improvement and
transformational change.
54
NHS Coastal West Sussex CCG | Delivering the vision
Areas of transformation
55
commissioned
 Acute LD Liaison nurses
available for all people living
with LD
 Annual Health Checks made
Health Provider Forum to
encourage innovation and good
practice sharing
 Continue to support a Mental
health awareness training for
staff working in universal
services.
 Continue to support mental
monitor local in-patient beds to
meet needs
 Continue to contract and
The journey so far
Board to support
development and
implementation of local plans
 Develop local Programme
websites are accurate and
up-to-date
 Ensure WSCC and NHS
waiting times (where
applicable)
 Develop plans to address
improve quality and
consistency of GP input at
tier 2 and interface with tier
3.
 Develop local plans to
commission local services at
tiers 1, 2 and 3.
 Develop local budgets to
2014-15
provision of life-long functional
mental health services
 Develop a pooled budget for
outcome and quality measures
and indicators within all
contracts
 Ensure that there are clear
grants scheme to encourage
innovation (First grants to be
awarded in 2015-16)
 Introduce an annual small
payment mechanisms
 Introduce activity based
2015-16
framework for future relevance
 Review 5 year strategic
2017-18
supported by an improved
contract
 LD residential services
for people living with LD
for people living with LD
 More assistive Telecare available
LD day services
 1700 health checks undertaken  Improvements in place for WSCC
inpatient services review
 Implement outcome of the
2016-17
Mental Health and Learning Disabilities Roadmap to 2019
towards eliminating avoidable
deaths in our hospitals caused
by problems in care
 Making significant progress
people with mental and
physical health conditions
having a positive experience of
hospital care
 Increasing the number of
older people living
independently at home
following discharge from
hospital
 Increasing the proportion of
quality of life of people with
one or more long-term
condition, including mental
health conditions
 Improving the health related
for people with treatable
mental and physical health
conditions
 Securing additional years of life
Outcomes
improved by
2018-19
56
NHS Coastal West Sussex CCG | Delivering the vision
Planned care
Pre-arranged care for people who have conditions such as Cancer,
Arthritis or hearing problems, often for patients referred by their GP
Clinical strategy
57
Why change?
The NHS now provides more treatments for more people in more locations than ever before.
Every year, local people attend nearly 400,000 outpatient appointments and receive nearly
90,000 planned treatments and procedures. In most cases, patients are seen more quickly
than in the past, and waiting lists are shorter for many common diagnostics and treatments.
While this should be celebrated, there is still unwarranted variation in access, clinical care
and outcomes. For example, patient reported outcomes from hip and knee replacements
are not as good they are in other areas (NHS England (b), 2013). There are also times when
patients move around the system unnecessarily having unnecessary appointments and
duplicated investigations. These inefficiencies create unnecessary pressure in the system,
which in some cases and for some conditions, means the demand for services and treatment
is greater than the system can currently manage.
There are also too few occasions where patients are a genuine active partner in their own
care and too often are simply the recipients of care. Evidence shows that techniques like
Shared Decision Making and empowering people to self-manage can lead to better
outcomes and patient experience.
Locally, Cancer is the most common cause of premature death for people under 75 and we
have more premature deaths than in similar areas (NHS England (b), 2013). For example,
the outcomes for our patients with Colorectal Cancer are worse than the England average.
We must do more to drive earlier diagnosis, treatment and prevention to improve patient
outcomes. We also know that circulatory diseases are the next most common cause of
premature death locally which can be linked to our higher than average levels of obesity in
some communities as well as the low rates of people quitting smoking. We must educate
our population and support them to make healthy lifestyle decisions in order to address this.
In 2019
On this and the following pages we have set out ambitious plans to transform planned care,
so that in 2019 we have a high-quality and sustainable system where patients will tell us:
58

I am supported to look after myself and I will have the information and advice to
make informed decisions about the best care for me

I receive the right care, first time and will not be passed from pillar to post

I will have access to a choice of high quality, timely services (within 18 weeks)

My treatment will be evidence based and delivered by professionals with
appropriate skills in the most appropriate setting

If I need specialist care most of it will be delivered at my first appointment in one
stop

If I require follow up it will be timely and convenient and utilise modern methods of
communication

All professionals involved in my care will be well informed about me and will
communicate effectively with each other. They will keep me informed.
NHS Coastal West Sussex CCG | Five year strategy
A new model of care
We are committed to achieving high quality personalised care for our population, ensuring
every person receives the right treatment in the right place at the right time. In order to
achieve this we must drive innovation and integration across primary care, community care
and secondary care, ensuring that
all our services work together to
A case study from 2019
deliver excellent clinical outcomes.
Mrs Jones is a 68 year old retired teacher who
This will reduce inefficiencies in the
has suffers with stiffness and pain in her right
system, remove unnecessary
knee as a result of osteoarthritis.
duplication, and so ease pressure
on our services so they will no
Her GP refers her to the MSK Integrated Care
Service, a community based multidisciplinary
longer be ‘busy being busy’ but can
team made up of physiotherapists, nurses,
in turn take the time to consider
doctors and support staff who are specialists in
and develop further improvements.
orthopaedics, rheumatology and chronic pain.
Demand management
We will do everything we can to
support management of demand in
the system, building vital links
between primary care, community
services and secondary care,
ensuring they mutually support one
another to ensure patients receive
excellent quality care.
We will drive up the quality of care
provided across the area and
reduce variation in outcomes,
ensuring our services continue to
meet the needs of our population in
terms of quality of care, equity of
provision, accessibility, patient
experience and clinical outcomes.
Mrs Jones is seen 5 weeks later in a local
community clinic. During this appointment, she
is asked about her symptoms and how these are
impacting on her life, and what her goals are for
treatment.
All the treatment options are
explained to her and she agrees a personalised
care plan in partnership with her specialist. Mrs
Jones is given a patient-held care record which
sets out all this information which she can refer
to, and show to others as she wishes.
They agree the next step for her is to have a
knee replacement and she is able to choose the
date for her surgery there and then. In
preparation for surgery, before she leaves the
clinic, she has an x-ray and blood tests, and she
sees the physiotherapist who explains a series of
exercises to do before the operation, and after.
Mrs Jones feels in control of her own care and
knows that if she has any problems or questions
she can call the Patient Support Line and her
care coordinator will call her back quickly.
We will educate and encourage
patients to self-care, empowering
them to take a key role in keeping themselves healthy and sharing the decisions in planning
their treatment. We will also support and encourage the voluntary sector, acknowledging
the vital role they play in supporting our population.
We must achieve a balance between demand and supply if we are to meet the challenges of
caring for our population over the next five years. We will continue to drive down
inappropriate demand within planned care by ensuring primary care manage patient needs
as far as they are able, and refer patients only when clinically necessary, supporting them
with evidenced based guidelines, training and education as well as improving real-time
communication. Where clinical referral thresholds are appropriate, they will be developed
in collaboration with specialists in order to remove unnecessary demand. Triage of referrals
Areas of transformation
59
will be developed to ensure there are no inappropriate referrals clogging the system, and we
will promote the use of proformas for cancer referrals to support GPs in deciding when to
refer.
In this way, we will shift the focus of care away from hospital services, into integrated
primary and community care, supporting our population to self-care as far as possible.
Self Care
Primary and
Community
Care
Hospital
Services
We will drive forward system wide changes which will enable improvements in patient care,
such as the use of e-Referrals, in order to increase access and choice for patients and reduce
the number of wasted appointments due to non-attenders.
Working with providers to streamline pathways and drive efficiencies
We must support our hospitals to drive up efficiency, working with them but ensuring they
take the lead on the necessary changes. We have already identified some clinical areas
which require improvement, including dermatology, cardiology, neurology, cancer care and
ophthalmology services, and we will continue to review our services over the next 5 years to
seek out further need. We will also continue to monitor new guidelines from national
clinical bodies such as NICE to ensure we provide best practice care at all times.
Providers may need to work on a larger scale to become more efficient, and we will support
them to achieve this, for example supporting them to rationalise specialist low volume
services (such as vascular surgery and paediatric surgery) to fewer centres of excellence in
order to achieve productivity savings whilst driving up clinical outcomes.
Once referred, we will work with our providers to minimise the number of outpatient
appointments required by each patient by developing one-stop assessment, diagnostic and
treatment clinics. This will improve patient experience, shorten waiting times facilitating
achievement of 18 week Referral to treat targets, and realise savings. We will also support
the shift of elective surgery from inpatient operations to a day case setting wherever
clinically appropriate, again improving patient experience and outcomes and driving up
efficiency.
We will, however, not only focus on our acute hospital provider. Our principles are aligned
across the whole system and we will support all our providers to make the changes needed.
We will support all our providers in primary community and secondary care to achieve
compliance with all ten of the Seven Day Service Clinical Standards by 2016-17.
60
NHS Coastal West Sussex CCG | Five year strategy
Large scale service redesign
MSK
We are currently undergoing a total redesign of our musculoskeletal (MSK) services and we
will be completing this project over the next twelve months.
We began the project in 2012 by reviewing our MSK services which consist of Orthopaedic,
Rheumatology, Chronic Pain, Musculoskeletal Assessment Triage and Treatment service
(MATT) and our outpatient Physiotherapy services. We looked at their outcomes and we
met with many frontline clinicians and patients in order to fully understand the issues with
the current system and the needs of our population going forward.
Our patients told us that whilst the care they receive from each service was good, they
found the system to be disjointed and slow, with lots of duplication, and at times the
outcomes didn’t meet their expectations. Our data confirmed there were more steps on the
patient’s journey than necessary and this was driving down efficiency in terms of time,
capacity and cost, and we were struggling to attain our 18 Week referral to treatment (RTT)
targets. It was clear we needed to achieve large scale change, bringing all these services
together into a single integrated team – the MSK Integrated Care Service.
Our new MSK Integrated Care Service (ICS) will use several simple common sense principles
to eradicate these issues. The integrated services will be more effectively coordinated and a
single prime provider will be accountable for the entire MSK patient journey, rather than
individual services taking responsibility only for their own service. This will achieve
improved quality and coordination of care, better clinical outcomes, improved patient
involvement and satisfaction, all at a reduced cost.
How will the new service feel different for patients?
Building on the outcomes that patients told us they want, we plan to bring together all
musculoskeletal services for patients into a single integrated service, introducing:





Genuine shared decision making that really explores patients’ needs and
expectations to ensure they can make informed decisions about their options for
treatment
Clinicians and patients working together to define problems, set priorities, establish
goals, create treatment plans in this way set achievable goals and patients will be
supported to meet them
A range of support for patients to empower them to manage their own MSK
condition wherever possible, patients with a long term condition will have a named
clinician to coordinate their care and respond to queries through a helpline
Multi-disciplinary team working with free flow of patients between teams so a
patient can be booked into the clinic of any clinician in the service they need to see
without the need to ‘refer’
Patients and their clinicians will work collaboratively to develop a personalised
patient care plan that will contain all letters, notes and results
Areas of transformation
61
How will the new service feel different for clinicians?




Regular updates for GPs giving them all information they need to support the
patient in primary care whilst they are on their MSK pathway
Prompt imaging, where possible available as a ‘one stop’ clinic to reduce wait times
and the number of appointments to which a patient needs to travel
The transfer of patients from one part of the integrated service to another will be
simple and GPs will no longer have to ‘refer’ patients already in the MSK system
Multidisciplinary working with several clinicians from various specialities working
together, will allow the patient to see the right person each time, utilizing the skill
mix of doctors, nurses and support staff appropriately, and will enable clinicians to
learn from each other.
We are seeking a prime provider for the entire MSK service, who will be responsible for the
entire MSK pathway and the single MSK budget via a competitive procurement process. This
process should be complete by October 2014 and the new service will launch January 1st
2015.
We believe that in the case of MSK services, this system redesign was the only way of
achieving the large scale change required.
How we will deliver change
We developed our Planned Care clinical strategy and determined our locally our priorities
and approach to ensuring choice by listening to formal and informal feedback from local
clinicians and the public, benchmarking our services and using best practice and evidence.
We will continue to robustly monitor the quality and performance of our all services and
work with our providers to improve services were necessary.
We are committed to managing demand in the system and working with our providers to
drive up efficiency. Where possible, we will refine existing services via collaboration and
contract variation. When we redesigned the whole system of care for MSK, the scale of
service change meant that procurement was necessary to allow us to move to a new model
of care with a contract based on outcomes. We recognise that this is a massive undertaking
in terms of time, cost, and the stress on the system. We do not envisage needing to take on
further massive redesign within the next five years and intend to instead focus on managing
and improving our existing services wherever possible.
To improve outcomes for our population we will always consider options such as whether to
use procurement, pilot or a contract variation to commission future clinical services,
ensuring the process we follow is fair and transparent and will not restrict patient choice,
but will remain consistent with the patient’s best interest and the reputation of the NHS,
and in line with the NHS constitution.
Our commissioning responses can be broadly grouped into 3 levels of intervention based on
the level of change required:


62
Improve utilisation of services via new clinical pathways
Refine existing services in collaboration and through a contract variation
NHS Coastal West Sussex CCG | Five year strategy

Design a new service and procure via the appropriate route
Improving system relationships
We recognise it is vital to form strong trusting relationships with our providers and partners
if we are to achieve improved outcomes for our patients and the 20% productivity
requirements in planned care. We will support our providers to deliver the innovative
efficiency improvements required to achieve both our QIPP plans and their own required
savings.
We will work to develop contracts that incentivise providers to do the right thing, focussing
on outcomes rather than activity, and we welcome the opportunity of the new pricing
strategy as set out by NHS England and Monitor to support improved outcomes, and in
particular more integrated services for patients.
We intend to develop our Planned Care services in this way in order to keep the system as
stable as we can, whilst increasing efficiency and encouraging our providers to work at scale,
driving up outcomes for our patients and ensuring a sustainable system for the future.
Areas of transformation
63
64
NHS Coastal West Sussex CCG | Five year strategy
Gynaecology continence and
Neurology headache
 Pathway refinement for
MSK including Triage Plus and
surgical thresholds to improve
quality and streamline the
pathway
 Commissioned improvements in
range of specialities to support
primary care and other refers
 Published clinical guidelines in a
and delivered service
improvements in Dermatology
support the launch of the
NHS new e-referral system at
the end of 2014
 Develop infrastructure to
Upper Gastrointestinal
services
 Direct to test pathways for
support GP education and
early diagnosis
 Focus on Cancer that will
model for Neurology
 Scope an integrated service
to GPs to inform shared
decision making and
improved referral processes
 New support tools provided
 Delivered a new AQP contracts
 New Weight Management
procurement underway with
new outcome based contract
delivered in Q4
 MSK Service redesign and
2014-15
services launches under AQP
contract
The journey so far
paperless NHS
 Support the move to a
phlebotomy services
 Review community
Providers to ensure greater
integration of services and
seamless pathways
 Continue to work with all
and pathways in place
 New integrated MSK services
Cardiology pathways including
direct access echocardiograms
 Begin roll out of redesigned
2015-16
place under new contract
 Revised Dermatology services in
2017-18
Providers to improve patient
experience and outcomes using
innovation, tele-health and
telemedicine for planned care
 Continue to work with AHSN and
Providers to ensure greater
integration of services and
seamless pathways
 Continue to work with all
service model for Urology
Providers to ensure greater
integration of services and
seamless pathways
 Continue to work with all
pathways fully operational
 Scope and develop an integrated  Improved Urology services and
pathways designed and rolled
out
 Improvements in Cancer
another AQP window of
opportunity for Dermatology,
Tier 3 Weight Management
 Review services and open
2016-17
Planned Care Roadmap to 2019
towards eliminating avoidable
deaths in our hospitals caused
by problems in care
 Making significant progress
people with mental and
physical health conditions
having a positive experience of
hospital care
 Increasing the number of
for people with treatable
mental and physical health
conditions
 Securing additional years of life
Outcomes
improved by
2018-19
Children, young people
and maternity
Services that support families through pregnancy and children up to 18
years old including hospital and community care
Areas of transformation
65
Why change?
The start of life is a crucial time for children. Having a positive start; good care and support
from the NHS and the right support to parents can often lead to positive outcomes in many
aspects of a child’s later life. However, too often children’s physical and mental health is
separated by the way services are set up. This can mean the services supporting children and
their families are not as joined-up as they could be and their whole experience of care is
more complicated.
For example, a recent assessment of the mental health and well-being needs of children and
young people in the area has highlighted specific areas of improvement across social care,
education and health including support for children presenting with behavioural difficulties,
and parents have specifically told us that access points must be simpler and services more
integrated around them.
There is also some inequity of services across Coastal West Sussex which means that
children can sometimes get a different level of support depending on where they live. Whilst
targeting support to the most vulnerable communities is right, and we know we have some
areas where children are living in poverty; we must invest proportionally for the benefit of
all children living in Coastal West Sussex.
Although most local services offer really good care and support, for example maternity care
performs well against most benchmarks although we know improvements can be made in
some areas such as increasing choices about birth options for expectant mothers; we do
know more children are admitted to hospital in an emergency for conditions such as Asthma
and Diabetes in Coastal West Sussex when compared to other areas (NHS England (b), 2013).
There is likely to be a whole range of reasons which lead to this outcome for local children
and these must be addressed to ensure more children and their families are supported
earlier to stay well and develop into healthy young adults.
In 2019
On this and the following pages we have set out our plans to transform maternity and
children’s services, so that in 2019 we have a high-quality and sustainable system where
patients and their families tell us:
66

I have a choice of where to give birth that meets both my clinical and emotional
needs

I know where to get advice, support and treatment for my child when they suddenly
become unwell

Our child’s needs are looked at together, not separately by different people in
different places

As parents we are supported to give our child the best start in life and especially
through difficult times

I know our child’s care is designed around our whole family’s needs

I can contact one person who coordinates care for our child, they always keep us
informed
NHS Coastal West Sussex CCG | Five year strategy
A new model of care
Together with West Sussex County Council, the CCG will ensure that services around
children are more joined-up, so that the NHS, schools and social care working with families
can ensure every child gets the best start in life. There are several ways in which we will
improve services over the next five years, we see these changes in three main areas;
maternity care; children’s urgent and acute care and children’s community services,
including services for children with complex needs.
Maternity care
The care and support a family receives before, during and after a child’s birth is so important
to get right. As a first step we will ensure expectant mothers have a choice of place of
delivery. This will include a choice of homebirth; a midwife-led unit or a consultant-led unit,
(choices will only be offered when clinically appropriate). We will also ensure that all
consultant-led units will have a co-located midwife-led unit to enhance the choices and
options available.
To deliver a greater range of choices
of delivery safely we will ensure that
all women have an assessment to
establish health and social care needs
and risks within the first 12 weeks of
pregnancy, we will also commission
1:1 care from a midwife when women
are in established labour regardless of
the care setting. We know that whilst
this time is usually one of the happy
times in people lives, others need
more support for example, if they are
experiencing post-natal depression or
have suffered a miscarriage. That is
why we will ensure improved access
to psychological support in these
situations.
A case study from 2019
Kyle is 3. When his mum collects him child
from the play group at the end of a long day's
work the playgroup leader mentions that Kyle
has started to become unwell during the
afternoon but is still alert. However, Kyle
does not want to eat and the mother notices
he feels very hot and has a mild pink rash on
both face and trunk.
She thinks of heading going straight to
hospital 3 miles away but instead, at 6.45pm,
she calls 111 who assess the combination of
rash and fever and passes her call
immediately onto a GP who speaks to the
mother at 6.55pm. The GP is able to offer an
appointment with a doctor for 7.30pm at a
local practice just 2 miles away.
Children’s urgent and acute care
Kyle is assessed and a call is made to the local
Admission to hospital can be
Hospital where the GP is put straight through
traumatic for a child and their family,
to an Advanced Paediatric Nurse Practitioner
and we know that we can do more to
who is working with the Duty Consultant.
support families to remain at home
They decide that Kyle is safe to remain at
when their child becomes suddenly
home and the written Fever Advice is given to
unwell. At the heart of the changes
the mother to help manage Kyle safely at
we will make is developing the
home.
capacity and capability of primary
care and community services in assessing and managing the acutely unwell child. We are
already starting to pilot an acute NHS at Home children’s community nursing team and have
developed improved guidelines for professionals to use when assessing a child with common
conditions, such as fever and bronchiolitis.
GPs will also be able to rapidly access to senior paediatrician advice when assessing a child in
primary care and will begin to more consistently offer improved access for children. All this
work is underpinned by providing more support to parents to recognise the signs and
symptoms of childhood illness and to have signposts to the right support and professionals
first time.
Areas of transformation
67
We know that there will always be times when hospital care is the safest option for a child.
So we will also commission consistent pathways in children’s short-stay and assessment
units, as well as ensuring workforce standards are always met so that hospital care is always
safe and high quality.
Children’s community services
We will ensure Children and Young People’s Emotional Health and Wellbeing Services and
Child Development Services work in a more integrated way as clinical teams across Coastal
West Sussex.
This vision will break down organisation boundaries and simplify access, including common
assessment processes for those who will benefit, ensuring every child starts on the correct
care pathway to ensure the best outcomes, whether they have learning, behavioural or
communication needs.
There will be new protocols to ensure a smooth and supported transition into adult services
when the time comes. We know in the past that a child’s experience of this transition has
not been as good as it might have been and will closely across agencies to ensure we
address this. Joint education, health and care plans will also replace Statements for Special
Educational Needs children ensuring that families are put in greater control of the plan and
budget for their child.
Children’s community nursing teams will also facilitate access from hospital care for those
children with complex needs who can be cared for at home and will work closely with
schools and other children’s services.
In addition, to support this we will work in partnership with Public Health to ensure more
prevention and early intervention by continuing to progress the Health Visitor
Implementation Plan (2011). There is significant evidence that improving early interventions
to children and families can reduce the need for higher cost interventions later.
How we will deliver change
Whilst our vision for more integrated and joined-up children’s and maternity services is at its
heart simple, change of this kind will take time and ill rely on us using different approaches
to commissioning and partnership working.
For acute and maternity care we will use regional standards to ensure workforce and staffing
ratios are consistently safe. We will be clear that local hospitals must meet the ‘Facing the
Future’ standards as set out by the Royal College of Paediatrics & Child Health (2010)
including staffing and appropriate cover for peak times of demand.
Developing an acute NHS at Home children’s community nursing team will be piloted using
investment from readmissions but we will look to a longer term and sustainable solution as
we gather evidence of the teams impact.
To drive integration of children’s community services we will be considering the most
appropriate contractual agreements, clarify services and agree better performance
information. Irrespective of the model adopted it will seek to secure these services for the
longer-term and provide the flexibility for services to innovate, and will sit outside of core
service contracts. For example, at an operational level within emotional well-being and
CAMHS services, we will be commissioning more integration between different NHS,
voluntary and other independent providers.
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NHS Coastal West Sussex CCG | Five year strategy
Areas of transformation
69
out of “special measures”, and
are now deemed “adequate”
following recent Ofsted review
 Children’s services are coming
improving primary and
community based health
services already developed
 Strategies and business cases for
The journey so far
pathways and Community
Nursing services piloted
 Children’s Urgent Care
Children’s Community
Nursing model
 Phase 1 of NHS at Home /
Speech and language therapy
model
 Implementation of new
specification and immediate
changes to CAMHS and
emotional wellbeing services
 Develop final model,
2014-15
CHC families extended
 Personal Health Budgets for
specifications and service
models
 Implementation of new
Programme investment
 Evaluation of Healthy Child
emotional wellbeing tier 2
launched
 Improved CAMHS and
2015-16
Children’s special education
needs through the integrated
planning process and local offer
of services.
 Much earlier support for
2017-18
referrers of children with mental
health and wellbeing services
 Improved experience of CYP and
Children’s Community Nursing
number of parents who have a
PHB for services they and their
family use , according to patient
and family choice
 Begin Phase 2 of NHS at Home /  Significant increase in the
pathways between child
development, emotional wellbeing professionals, social
workers, schools and CAMHS
clinicians
 Greater integration on joint
2016-17
Children, Young People and Maternity Roadmap to 2019
people spend avoidably in
hospital through better and
more integrated care in the
community, outside of hospital
 Reducing the amount of time
quality of life of people with
one or more long-term
condition, including mental
health conditions
 Improving the health related
for people with treatable
mental and physical health
conditions
 Securing additional years of life
Outcomes
improved by
2018-19
70
NHS Coastal West Sussex CCG | Five year strategy
Primary care
Care and services provided by GPs and local practices and in
communities
Areas of transformation
71
Local GPs have been the front-line of the NHS for over 60 years and are the part of the
system that communities know best. In fact, most contacts with the NHS on a daily basis
take place in primary care. We believe that primary care underpins all our clinical strategies
as they are fundamental to delivering high quality urgent, proactive and planned care, as
well as mental health and maternity care to all our population, adults and children. They are
the key to managing referral demand and initiating care pathways in the community and
secondary care as needed. With the breadth and depth of clinical knowledge and
responsibility of GPs widening every year, we must support them to innovate and adapt in
order to ensure they can maintain this role into the future.
Planning for the future
Over the next five years we expect primary care’s share of workload to increase, covering
greater proportions of clinical pathways. We must therefore support them to address how
they will achieve that challenge,
working at scale, closely integrated
A case study from 2019
with community teams with strong
Mrs Jones had been feeling unwell with a
links with secondary care. There is
worsening cough and needing to use her
growing evidence (and many
asthma inhalers more. She called her GP
examples) that practices may be able
surgery and was able to get an appointment
to work more efficiently and flexibly
to see an Advanced Nurse Practitioner that
at scale. This does not necessarily
same evening on her way home from work.
mean the loss of sovereignty of
Mrs Jones was diagnosed with an infective
exacerbation of asthma and was treated
individual smaller practices, but
accordingly.
rather that practices may find more
and more areas where they can
The nurse booked a follow up appointment
collaborate to provide better care for
with Mrs Jones to review her inhaler use once
the local population. Examples might
she was well again, so she would be able to
manage her own condition effectively.
be extended access and the
management of long term conditions.
Before leaving the surgery, Mrs Jones also
We will facilitate the development of
booked an appointment for a routine smear,
such collaboration.
at the Saturday morning Local Women’s
Health Clinic. When she was offered an
There
are
growing
concerns
appointment
between
9-12am
she
nationally regarding the decline in
commented to the receptionist that this was a
overall number of GPs in the
really convenient time for her to attend whilst
workforce, and the increasing
her son is at football club.
average age of GPs. We are seeing
The receptionist also reminded Mrs Jones
the same issues locally and have
that she was welcome to attend in future for
already
begun
to
facilitate
any women's health issues including
discussions around the future of
emergency contraception and sexual health
primary care provision and how we
advice, as local practices were now working
can introduce innovation and
together to offer better access to local
changes to manage the ever-growing
people.
workload and achieve sustainability.
We will continue to fully support
primary care to make changes so the role of a GP and primary care nurse are once again
tempting to newly qualified healthcare professionals.
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NHS Coastal West Sussex CCG | Five year strategy
Developing a strategy
We believe our membership practices are best placed to come up with the solutions for the
future, so we intend to work with them in 2014-15 in order to develop a strategy for primary
care from the bottom up. They are struggling under the weight of current demand so we will
provide resource and support but most importantly give them the time to plan their own
solutions for the future.
NHS England holds the main GMS/PMS contracts with primary care practices however as we
are a membership organisation we believe we well placed to work with local practices. So
we will work in partnership with NHS England to develop this strategy and with the LMC who
represent GPs as providers.
As with our other strategies we will start with the patient, working to understand what they
want and need first and foremost; we will look at access both in and out of hours to ensure
we have appropriate responsive 7 day a week primary care. We will also focus on how we
support the primary care workforce, to ensure that it is a good and attractive place to work.
We will learn from best practice both nationally and internationally, exploring the use of
new technology as well as more traditional methods such as the telephone.
In order to achieve the vision of a sustainable and accessible primary care service, we will
need to ensure all the necessary infrastructure is in place, including appropriate buildings
and premises. This can only be achieved by working closely with Surrey and Sussex Area
Team, NHS Property services, and our partners in local authorities at district and county
level. Greater IM&T integration is essential in order to ensure appropriate information is
readily available to all services in order to facilitate high quality care planning and provision.
The only area of service directly commissioned by the CCG is Locally Commissioned services
(formerly known as “Enhanced services”). We will continue to ensure that LCSs are used to
ensure high quality, safe, convenient, and clinically effective services for patients outside the
hospital setting. We are mindful of the potential conflict of interest for GP commissioners
who may also be providers of these services, and will ensure transparency in their
development and procurement.
We understand the challenges facing our primary care workforce, and are committed to
supporting them to adopt innovation and integration to overcome these issues and continue
to provide NHS services in the heart of our communities.
Areas of transformation
73
74
NHS Coastal West Sussex CCG | Five year strategy
Areas of transformation
75
Taking care of
the essentials
5
76
NHS Coastal West Sussex CCG | Five year strategy
Taking care of the essentials
77
What are the essentials?
There are some things which will support every part of our clinical
strategy and every part of our vision for better outcomes, we call
these the essentials.
Whilst we will focus our energy into
transforming key service areas like urgent
and emergency care or mental health, we
know we will only truly secure better
outcomes for local people if we also take
care of the quality and safety of all
services; ensure patients have the right
support to take their medicines; maintain
effective contracts with providers and use
technology to enable more integrated
care.
In this chapter we have set out how we
will do this; how we will take care of the
essentials.
78
 Quality and safety
 Medicines management
 Contracting and performance
 Innovation
 Information management
and technology
 Governance
 Organisational development
NHS Coastal West Sussex CCG | Delivering the vision
Quality and safety
The quality and safety of care is the foundation on which health
services are built. Locally we know that dignity, compassion and
respect are as important to patients as diagnosing and treating
condition.
Quality and safety are at the heart of our strategy and our plans. We have used the Francis
Report (2013) and the Government’s response (2013) to consolidate our local work
programme. We have also continued to develop actions that ensure lessons learned from
national incidents and the recommendations from the Berwick (2013), Winterbourne View
(2013) reports and the Francis Inquiry (2013), are embedded in the culture of our
organisation as well as those from whom we commission services.
Integral to the success of these measures is the continued development of working
relationships with the Care Quality Commission (CQC), Healthwatch, Monitor, the Trust
Development Agency and NHS England, allowing the triangulation of soft intelligence,
quantitative, and qualitative information on local health and social services. Such
triangulation will enable decisive and timely actions to be taken so as to ensure that patients
are seen in a safe environment and protected from avoidable harm.
Working in Partnership
‘Delivering the vision’ will continue to build on these foundations, so as to further reduce
avoidable harm and improve patient experience. We will do this by working collaboratively
with providers, partner commissioners and NHS England. We will continue to use national
tools to report and measure harm; and will benchmark our provider organisations against
organisations with similar profiles. Locally we will continue to work with CCGs in Sussex to
scrutinise all serious incidents so as to ensure that lessons learnt are not only embedded in
the practice of the organisation concerned , but also where appropriate shared across the
local health economy. In order to continue the development of the quality assurance
process, we recognise the need to strengthen the proactive elements of the process whilst
retaining the ability to react to local challenges and/or changes in national guidance in a
timely manner.
Learning from Experience
We will continue to contribute to the development of ourselves as a learning organisation in
which everyone understands and values their contribution to the shared vision of high
quality sustainable health care for all. We believe that the embodiment of the 6Cs (care,
compassion, courage, communication, competence and commitment) in everything that we
do will help us to achieve our shared vision.
We will support and promote the NHS England annual Proud to Care awards which recognise
excellent practice in all of the 6C categories and patient feedback across all NHS healthcare
providers.
Taking care of the essentials
79
Our promise to patients
Ensuring that people have the right care at the right time in the right place is core to our
current quality assurance process. In continuing our to drive toward this part of our vision
for 2019 we express our plans by making promises to patients. They are based on what we
have learnt from national inquiries into the quality of care and local feedback on patient
experience.
We promise to do everything we can to:

Prevent problems: through improving and maintaining a culture of patient safety,
openness and candour, listening to patients, learning from complaints and ensuring
and demonstrating safe staffing

Detect problems quickly: to support CQC inspections to look more closely at
records, improvement of fundamental and enhanced quality standards and of taking
a more collaborative approach to working together

Use Quality Surveillance groups: to encourage staff speaking out safely and
promote the role of Boards in providing clear strong governance

Take action promptly: in response to clear and meaningful information and making
use of clear risk based interventions

Ensure robust accountability: through clear levels of accountability and holding to
account, high professional standards and professional regulation application of “fit
and proper persons” test for Board level appointments and use of internal scrutiny
and challenge

Ensure staff are trained and well-motivated: through staff engagement, education
and training, support workers training and development encouragement of
leadership culture, compassionate care and value based recruitment
How will we deliver?
Our promises are backed up by clear actions, described below.
Patient Experience
We will build on the current quality assurance process so as to provide assurance of the
quality of services commissioned on behalf of our population. For example patient
experience is already a key performance indicator for all services we commission, and is the
subject of monthly scrutiny as part of the quality assurance process applied to all our
commissioned services.
We will also continue to triangulate patient experience results with complaints and PALS
information and have sought additional assurance of the quality of complaints management
by requiring scrutiny of a selection of complaints across all CCG localities and the Provider’s
response; these complaints will represent a random sample to show a range of
ward/departments/services across all localities for review of themes of complaints and
quality of response each quarter. We have developed a local system called Quality
Information Feedback (QIF) whereby local clinicians, who everyday discuss patients
experience of care can quickly and easily raise concerns about the quality of services and
liaise directly with our Quality team.
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NHS Coastal West Sussex CCG | Delivering the vision
We will, with both our NHS and independent providers, review and implement national
guidance on safe staffing levels. This will allow us, and patients/carers, to easily understand
the staffing required for each service. In advance of the publication of the government’s
response to the Francis Inquiry, we required those NHS providers for whom services were
commissioned to provide a quarterly report outlining: The details of funded staff posts
(trained and untrained, including specialist posts), identifiable by inpatient units and
community teams at locality level; including staff numbers currently in post compared with
the funded establishment; identification of any ward/departments of concern to the
organisation and a brief outline of mitigating actions in place and/or planned.
We will continue to work with providers to implement the national Friends and Family Test.
In addition we will continue to review implementation across divisions and/or wards so as to
ensure representative data is submitted. Where areas have a consistent negative response,
we will work with providers to understand the challenges and actions in place to improve
patient experience in those areas in a timely fashion.
Staff Experience
We recognise the importance of staff satisfaction and the impact that this has on patient
experience. We will continue to scrutinise the national staff satisfaction survey results all
providers from whom we commission services and as necessary will require remedial action
plans and will benchmark our provider organisations against organisations with similar
profiles. We will work with providers to support the implement the national staff Friends
and Family test.
Staff satisfaction levels, strategies to provide continuous professional development as well
as compliance with mandatory training for all staff groups form part of the on-going
discussions with providers each month.
Many of our providers have put in place comprehensive programmes designed to increase
staff satisfaction, and therefore improve patient experience, and we will facilitate the
sharing of good practice across the local health and social care economy.
Our quality assurance process allows us to review progress of the integration of the 6Cs
(care, compassion communication, competence, courage, commitment) in plans and care
delivery. We will continue to work with providers in order to ensure that these elements are
truly embedded in the organisation and across all staff groups.
Patient Safety
We will actively participate in the patient safety collaborative led by NHS England and in
addition will work closely with them to develop patient safety champions in each member
practice so as to increase the reporting of patient safety incidents in primary care.
We will continue to triangulate patient safety information from national and local databases
with the other quantitative and qualitative data that we scrutinise monthly as part of our
quality assurance process so as to identify (and where appropriate) address recurring
themes.
We also recognise the need to consider patient safety across the health and social care
spectrum and will work in partnership with West Sussex County Council and key
stakeholders to align patient safety initiatives to improve safety as a whole.
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81
Safeguarding Adults & Children
The vision for safeguarding adults and children across West Sussex is to maintain safe and
effective safeguarding services and to strengthen arrangements for safeguarding adults and
children across West Sussex, working collaboratively with partner agencies.
We will continue to build on the work started in 2013-14, (outlined in detail in Appendix 2
the workplan), so as to ensure that safeguarding adults and children is an integral feature of
all commissioning decisions, as well as in the on-going assurance processes of commissioned
services.
We will, in partnership with West Sussex Adult Safeguarding Board, implement the locally
agreed comprehensive action plan in response to the Department of Health report on
Winterbourne View (2013). This will ensure that our residents with learning disabilities have
access to high quality services close to their families and extended support network.
We will continue to work collaboratively with our multi-agency partners. We will continue to
support and take an active role in the West Sussex Adult Safeguarding Board (WSASB) and
West Sussex Children Safeguarding Board (WSCSB).
We will continue to fully engage in the collaborative delivery of the 2013-15 WSASB business
plan and the five strategic priorities within that, as well as the long term WASB strategy.
Similarly we are fully engaged in the collaborative delivery of long term strategy of the West
Sussex Children’s Safeguarding Board.
The NHS Constitution
At NHS Coastal West Sussex CCG we work hard alongside our partners to uphold the patient
rights set out in the NHS Constitution. As we move toward 2019 we will continue to maintain
and where we can, improve our performance against these rights so that patients always
have access to treatments and care in a timely way; experience excellent standards of care
and are more involved in decisions about their care (NHS Constitution, 2012).
Where these rights are not met we will work with patients and providers to ensure that we
learn the reasons why and put in place plans to continually improve in the future.
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NHS Coastal West Sussex CCG | Delivering the vision
Medicines management
Medicines are the most commonly used intervention in the NHS.
Medicines optimisation is about making sure medicines are used safely
and effectively, improving outcomes and reducing the risk of harm.
A need to optimise medicines use
We know from studies that between 30% and 50% of medicines are not used or taken as
they were intended by those who prescribed them. This can lead to patients not seeing the
benefits of their treatment and in some cases their condition can deteriorate as a result.
There can be lots of reasons for this, some are because the NHS doesn’t always explain how
and why medicines should be taken or support patients to participate in decisions about
their own care.
We know that as we all live longer, we often have to rely on more medicines to help us stay
well and independent. This means that in the future medicines and especially medicines for
people living with long-term conditions will become even more important, prescribed in
greater volumes to even more people. Therefore it will be vital that we make sure every
single patient is supported to take them correctly and fewer medicines are wasted.
Medicines are also evolving and developing as innovative uses for existing drugs are found
and new drugs are available to the NHS. This means that the cost of medicines rises quickly
as does demand. To manage this, and give access to the right medicines for those who need
them, we will have to improve how the whole of the NHS works together to use medicines
effectively. Right now the systems are not always in place to help us do this, meaning that
sometimes patients are prescribed medicines which are less effective than others or for the
wrong kind of condition, leading to unwarranted variations in how people are treated.
We have evidence from Commissioning for Value (NHS England (b), 2013) and other national
and local benchmarking tools, together with knowledge of current systems, that
improvements could be made in some areas of the way medicines are used, for example in
diabetes; circulation problems; gastrointestinal; trauma and injuries; genito-urinary. We also
know that addressing medication errors; managing antimicrobial medicines; ensuring we
reduce waste; and improving how we take local decisions about what medicines are best for
our patients; and transfers of care will improve support and outcomes for patients.
We want to offer value that is the best within the Local Health Economies in our ONS cluster
in respect of FHS Prescribing, but need to do further analysis to understand root causes,
population need, local behaviour and costs and trends. We therefore plan in depth analysis
and further work with partner organisations in the first half of 2014-15 to understand
opportunities, threats, strengths and weaknesses of use of medicines in our area.
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83
Looking to 2019
Patients taking medicines will feel supported and empowered to manage their own
conditions. When someone is prescribed a medicine, they will feel able to ask questions of
the healthcare professionals such as ‘What am I taking this medicine for’, ‘Who should I talk
to if I want further help and support with taking this medicine?’. Patients will routinely
receive medication reviews, and regularly use modern technology to help them get more
from their medicines such as My Medication Passport, apps for mobile devices to remind
when the medicine dose is due, and access to patient-friendly information about their
medicines. The prescriber, pharmacists and other members of the healthcare team will work
in partnership with patients and across care settings to support frail patients, patients with
complex or multiple conditions, and their carers to understand the medicines that they have
been prescribed, look for ways for patients to get, take or use medicines that fit in with daily
life, look for any problems, and find solutions to those problems, and review medicines
regularly together with patients and carers.
Prescribers
and
other
healthcare
professionals will feel supported to
understand the patient’s experience with
their medicines, have access to evidence
based choice of medicines, undertake regular
service reviews to improve quality and value
of medicines use, will have medicines
optimisation as a routine element in patient
care and will have improved systems and
increased knowledge and awareness to
ensure medicines use is as safe as possible.
Medicines will be embedded into patient
care pathways so that the NHS works
seamlessly around the patient without
duplication.
This will mean that; more patients will be
empowered to self-care and be in control of
their medicines use, in partnership with their
healthcare professional; patients will be at
less risk of harm from taking the wrong dose
or medicine and they get the maximum
benefit from their treatment; and we will use
our resources more effectively as there will
be fewer wasted medicines.
A case study from 2019
Derek has Diabetes and takes lots
of medicines to manage this longterm condition. When Derek was
rushed in to hospital for an
emergency operation he showed
the doctors his My Medication
Passport on his mobile. Because of
this the doctors then knew straight
away how to manage his blood
sugars during the operation.
He recovered quickly from the
wound he had, helped by
successful optimisation of his
diabetes treatment. He was able to
go home, knowing that all the
information about the medication
he had received in hospital would
be communicated to the people
who needed to know. Including his
GP, diabetes nurse and of course
his pharmacist Emma.
How will we get there?
The right medicines can be used to reduce health inequalities, improve outcomes and
support patients to live full and independent lives. To achieve this we will need to ensure
that expert advice and improved communication of medicines (e.g. at discharge, from outpatients, from community services) is always available to prescribers so they can best
support their patients. Investment in better quality and wider use of medicines can
decrease other clinical care costs, reducing referral and admission costs and improving
outcomes. In addition, increased uptake of latest innovations and technologies as
recommended by National Institute for Health and Care Excellence has benefits across
health and social care and for national economics, as well as fair access to medicines for
patients, requiring flexibility between NHS budgets. We will improve shared working with
secondary care to achieve joint goals - shared responsibility for prescribing costs, and the
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NHS Coastal West Sussex CCG | Delivering the vision
patient being treated in the right place by the right person at the right time (with the right
budget). We will improve awareness of individual clinician responsibility for optimum use of
limited, fixed resources - each clinician recognising he has an individual commissioning
responsibility each time he writes a prescription.
We will continue to collaborate with all organisations in the local NHS, to improve joint
working across the interface, improve systems for and patient experience in medicines use,
to minimise medicines waste, to avoid duplications of services and effort, to drive local
decision making on medicines and to share clear information about what medicines are
available, and when they should be used. This collaboration and partnership working will
benefit not only the individual patient but also the whole population.
We will also work with partner organisations to deliver service and patient care
improvements through specific focused project workstreams including:

Targeted initiatives to improve quality, safety and efficiency of GP prescribing

Antimicrobial stewardship in primary care

System management of high cost medicines

Continued development of a Coastal West Sussex formulary

Anticoagulation monitoring services review

Training for healthcare professionals and support for patients in inhaler technique

Right Place Medicines – ensuring medicines are prescribed in the right part of the
system to ensure optimum efficiency, safety, value and best experience for patients.
We will also continue to provide advice and underpinning support to other commissioning
teams to ensure medicines optimisation and management principles are embedded
throughout commissioned services and patient care pathways, including a focus on planned
care, out of hours services, Diabetes and other long term conditions, community pharmacy
services, proactive care pharmacists. This will be achieved through improved collaborative
team working within the CCG and in partnership with secondary care, with an integrated
approach keeping the patient at the heart of collaboration.
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85
Contracting and
performance
Our contracts embody the standards of care we have commissioned for
patients and we will use them to secure greater local control over
decision making; drive performance, deliver service improvements and
better patient outcomes.
The rules and guidance as set out by NHS England in ‘Better Procurement, Better Value,
Better Care’ (2013), Monitor and Public Health England, encompass the ethos of being a
responsible commissioner. We are committed to these principles in our commissioning role.
Payment of all NHS funded services must be equitable, fair, transparent, consistent and nondiscriminatory. For the first time, the NHS Standard Contract has been published as an
eContract, making contracting easier, and reflects the requirements as set out in Everyone
Counts: Planning for Patients (NHS England (c), 2013).
This NHS Standard Contract is the key enabler for commissioners to secure improvements in
the quality of services for patients and deliver service transformation. It provides us with
the mechanism to hold our providers to account for the quality and cost effectiveness of the
services they provide and to drive service innovation and transformation whilst ensuring
providers deliver the pledges and obligations set out in the NHS Constitution (2012).
In line with our transformation plans, the NHS standard contract provides the flexibility to
commission innovatively, using a range of service models and incentives. Our Muskoskeletal
model is a good example of where commissioners will use the contract to deliver innovation
and transformation whilst ensuring the contract is tailored to the type of provider and the
services being commissioned.
There are four main components which we will include in our contracts:

Service Specification: This sets out the outcomes and standards required from the
services

Quality Requirements: This is associated information which enables us to measure
quality, performance and progress against key outcomes and apply sanctions if
agreed standards are not being met

Incentive Schemes: This includes but is not limited to CQUIN and allows us to drive,
recognise and reward quality improvement

Contract Management Processes: This is to safeguard against any deterioration in
quality and performance.
CQuIN presents an opportunity for commissioners to secure local quality improvements over
and above the norm by agreeing priorities with our providers. It is set at a level of 2.5 per
cent of the value of all services commissioned through the NHS Standard Contract. We will
only make CQuIN payments when our providers deliver a level of quality that is over and
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NHS Coastal West Sussex CCG | Delivering the vision
above the NHS Standard Contract. This allows us the freedom to secure greater and locallyfocused quality from our providers.
We will use the NHS Standard Contract for all commissioned services as it also provides us
with a number of levers with which we can hold our providers to account for delivering high
quality services and, where necessary, address situations where the provider is not
delivering the service to the standards we have set. We call this monitoring provider
performance.
We will work with providers and through our Commissioning Support Unit (CSU) ensuring
they submit accurate and timely data sets that comply with published information standards
in order to improve knowledge and data for the services commissioned. This will enable
better future commissioning plans and outcomes for our population. We acknowledge our
obligations to use sanctions within the NHS Standard Contract if we are not satisfied over
the completeness and quality of a provider’s data on the Secondary Uses Service (SUS), and
we will enforce the standard terms, including the financial consequences for underperformance, or failure to provide data on which to assess performance.
We will also enforce other obligations within the NHS Standard Contract where providers
are not allowed to be reimbursed for care below national standards, such as admissions
within 30 days of discharge following an elective admission.
We will ensure our providers meet requirements set out in the NHS Standard Contract for
letters following outpatient appointments. These letters must contain standard information,
such as the rights under the NHS Constitution (2012) to treatment within a maximum
waiting time, and what patients can do if they are concerned that they are, or will be,
waiting longer than 18 weeks.
All providers will also be expected to ensure proportionate public engagement takes place
on any operational changes to services. As commissioners we will continually engage the
public on changes but providers when making operational changes will be expected in the
spirit of putting patients at the centre of their care and supported by the standard contract
to do the same.
Through these contractual and commissioning levers, we will ensure our population receive
the highest possible quality of care.
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87
Innovation
For over 65 years the NHS has adapted the way it delivers care to meet
rising demand, new technologies and higher public expectations often
because of the creativity and hard work of staff. Now there needs to be
a system-wide commitment to innovation and spread of the best and
most transformative ideas, products and practice.
‘Innovation Health and Wealth’ (Department of Health, 2011) set out a clear agenda for
delivering this step change in the way the NHS views and supports innovation at every level.
We take our duty to innovate seriously and have begun to develop the way we work to
make innovation part of everyday business.
We have already committed to using part of any reward we receive for achievement of the
Quality Premium to create a local innovation fund. This fund will be open for small to
medium sized bids from local NHS, care and third sector organisations where they are
aiming to develop new and exciting ways of working and improving patient care.
Research plays a key role in developing clinical practice and we will support local clinicians to
undertake their own research where aligned to and supported by local academic institutes
and providers. For example we have supported a local physiotherapist who is researching if
extensive shoulder physiotherapy can reduce the need for replacement surgery by
authorising and funding additional appointments for those patients who are taking part in
the study.
The Academic Health Science Networks (AHSN) are important in driving research and
innovation at scale and we have identified some areas, aligned to our clinical strategies,
where we will actively promote and encourage providers to work with and through the local
AHSN. We are proud that local trusts have been proactive in their work with the AHSN so far
and have made progress on the Digital First and Telehealth agendas and we will enhance our
involvement in the coming months and years.
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NHS Coastal West Sussex CCG | Delivering the vision
Information management
and technology (IM&T)
Accessing the right clinical information can greatly improve decision
making about a patient’s care. Whilst we live in world full of new and
exciting ways to share and access data and information, the NHS has
not kept up with the technology we all take for granted; it hasn’t yet
harnessed it to drive better outcomes for patients.
We will address this by ensuring clinical information is available at the front-line by
implementing a range of technologies that empower both patients and their clinicians.
Sharing data to improve front-line care
Organisational boundaries have often stood in the way of sharing information critical to a
patient’s care. Patients tell us that they don’t want to repeat their story at every
appointment; they want to know that their records are shared safely and efficiently to
everyone that is caring for them.
We have set out to make this vision a reality so that:






Information will be built around the individual
Subject to patient consent, information will move seamlessly between organisations
and care professionals
Information will be up-to-date and relevant to support effective clinical decision
making and the safe handover of care
Providers of care will have an easy to use, single point of access to a full view of
individual health and social care records
Using information that is already available from local care records will help to avoid
duplication and unnecessary interventions, treatment or dispensing that does not
benefit the patient
Integration will avoid creating further isolated pockets of information.
Traditionally clinical and social care information has been held within organisational
boundaries and is a mix of paper and electronic records. Often service providers,
particularly in urgent and emergency care settings, do not have to hand the information they
need to make informed care decisions and this causes delays and requires additional effort
to find out information, a barrier to effective working.
We will therefore undertake an ambitious IT integration project to build a real time read
only record viewer, to be delivered in 2014-15 with data sources from both health, and for
the first time, social care. Access will inform our Proactive Care teams and our One Call One
Team service. Access will also help A&E and out-of-hours clinicians understand any
significant medical history, and what support provision was already in place in the
community. For patients it will help to avoid repetition of tests or additional prescribing that
they do not benefit from. In some cases timely access to this information could help avoid a
hospital admission.
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89
Key to the success of the IT integration project is the ability to search for a patient’s clinical
record across various care systems and then join the result for display to the clinician. We
are using the NHS number as our primary key for this system and therefore are encouraging
all providers, including our social service colleagues, to use the NHS number as the primary
patient identifier.
We consider the GP clinical record to typically be the most complete source of clinical
information about an individual. Providing 24/7 access to this data for the purposes of direct
patient care is fundamental to our plan. Subject to patient consent we will make this data
available to the front line clinician so that care can be better tailored to the needs of the
individual, to improve quality and outcomes. We already have around 60% of patient data
available via the Summary Care Record and plan to continue our upload project aiming for as
close to 100% as possible. We are similarly pursuing our GP2GP electronic record transfer
programme to facilitate the ease of patient transfer between practices.
Harnessing care.data
We are aware of the opportunities that care.data will bring to support the planning of high
quality care and better outcomes. Working with NHS England, we will support the
achievement of standards set out in ‘Everyone Counts’. In line with the guidance recently
received from the National Director for Patients & Information, we will shortly begin work
on a data strategy that develops and maximises these opportunities.
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NHS Coastal West Sussex CCG | Delivering the vision
Governance
We know that transparency in the way we work as well as ensuring
sound and fair decision making will be a crucial part of delivering this
strategy and our vision. We must create an environment that reflects
this both inside our CCG and across our whole system.
Decision-making and member practices
CCGs are different from any previous NHS commissioning organisation. Whilst a statutory
NHS body, CCGs are built on the GP practices that together make up their membership. Our
members ensure that we are led and governed in an open and transparent way which
enables us to serve our patients and population effectively.
To facilitate this, each of our six localities has an elected representative, a Locality Director,
who has responsibility for decision making alongside executive managers within the
organisation, promoting our principle that clinicians and managers work in partnership.
We have also appointed lay and clinical members to hold the CCG to account for fulfilling its
statutory duties; ensuring the voice of patients, carers and the local community are
represented in our work and which also support us to deliver our vision.
Corporate governance
Good governance requires clear accountability and transparency. We strive to ensure we
are truly accountable to our local population with appropriate arrangements in place to
discharge our functions effectively and efficiently in accordance with the best practice
principles of good governance and transparency.
A rigorous and strategic approach is taken to managing good governance within Coastal
West Sussex to give visibility across the organisation of critical business requirements and to
comply with statutory requirements. We recognise this approach continues to present us
with opportunities to strengthen our internal processes and enhance our business practices.
The continued refinement of our Business Assurance Framework is essential to supporting
corporate governance, establishing clear business domains, principal objectives and
performance indicators across the organisation; providing a robust governance framework
and processes to underpin commissioning and corporate activities. This assurance is also
essential to communicate progress towards achieving our vision to our colleagues, members
and the public.
The public are also constituted as part of our overall governance structure through our
Public Refernce Panel and on the assurance meeting of our Governing Body, placing patients
at the centre of how we work and commission.
To drive this governance model, we have established a programme management approach
to delivery that is based on best management practices and is aligned is the NHS Change
Model. This includes the design and implementation of bespoke information and reporting
systems and commissioning documentation that ensures consistency and transparency in all
of our work.
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91
To realise the full potential of this approach we will continue to invest in our staff through
in-house training of a tailored programme management model as well as support staff to
gain industry recognised qualifications where most appropriate. We will continue to develop
this way of working and refine our approach in the coming years and use it to ensure we
support delivery within our providers.
CCG Governance
Wider system governance
We also work as part of a commissioning landscape that includes a number of other
partners. This includes West Sussex County Council and NHS England. We have strong and
robust arrangements with West Sussex County Council with whom we jointly commission a
mental health, learning disabilities and children’s services and work closely with the West
Sussex Health & Wellbeing Board to set local the overall priorities for commissioners. In
partnership with NHS England we also support improvements in primary care and work with
them to secure high quality specialist services for our population.
However, West Sussex County Council and NHS England have a further role that ensures we
are accountable for our work and the outcomes we deliver for local people. Firstly the West
Sussex County Council Health & Adult Social Care Select Committee (HASC) work on behalf
of local people to assure our plans and changes to services, specifically to ensure they are in
the public interest and have followed due process in reaching decisions. NHS England also
holds CCGs to account, through on-going assurance of their finances as well as the quality of
care that is being delivered locally.
In Coastal West Sussex we have also developed an additional mechanism that drives
engagement between all local partners including local providers in the transformation of
services. We call this the Coastal Cabinet and it is where all senior leaders discuss service
developments and set the overall system strategy and objectives. This forum has been
crucial in developing this strategy over the past two years and will continue to be crucial as
we set about delivering the improvements we have described in ‘Delivering the vision’.
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NHS Coastal West Sussex CCG | Delivering the vision
Wider system governance
Working in partnership with other CCGs
Our neighbouring CCGs are also key partners in commissioning improvements in services
both locally and across a wider area. In Sussex we have worked together to establish the
Sussex Clinical Commissioning Executive Committee (SCCEC) and coordinating commissioner
arrangements for key providers, as well as continue to provide funding to ‘Sussex
Collaborative Delivery Team’ who work on behalf of all CCGs where issues need to be
tackled across CCG boundaries.
Sussex CCGs
Coordinating commissioners
Brighton & Sussex University Hospitals NHS Trust
East Sussex Healthcare NHS Trust
Maidstone & Tunbridge Wells NHS Trust
Queen Victoria Hospital NHS Foundation Trust
Surrey & Sussex Hospitals NHS Trust
Sussex Community NHS Trust
Sussex Partnership NHS Foundation Trust
South East Coast Ambulance NHS Foundation Trust
Western Sussex Hospitals NHS Foundation Trust
Taking care of the essentials
Brighton & Hove CCG
Eastbourne, Hailsham & Seaford CCG
High Weald, Lewes & Havens CCG
Horsham & Mid Sussex CCG
Crawley CCG
Horsham & Mid Sussex CCG
Coastal West Sussex CCG
Horsham & Mid Sussex CCG
Coastal West Sussex CCG
93
Organisational development
Our staff are our greatest asset. We will support them to develop and
be the best they can be, because we know the patients will benefit if
we do.
Our vision for health and social care is built on the foundation that patients are at the centre
of all we do. Everything we do should be judged from the patient perspective and our
decisions informed by real outcomes. Our organisational development plan will make this a
reality.
Organisational Development (OD) is the process through which the CCG develops its internal
capacity and capability to ensure the delivery of our strategic objectives. The right OD means
the CCG can build an effective and efficient organisation with the right people and the right
capabilities.
Over the next five years we will work on three priority areas which will drive our
development, these are:
Leading the system and promoting engagement
We must continue to demonstrate leadership with our partners across the whole-system to
ensure we can be effective commissioners and lead the changes to services our context
requires us to. Our work also continues to ensure member practices and localities are
empowered to take a leading role in that commissioning process. To build on this strong
foundation it is vital that we:




Ensure mechanisms are in place to encourage and support system wide working
Develop the ways in which we interact and engage our membership
Develop and embed our clinical leadership structure
Continually review our support team structure and our decision making committees
Developing and embedding the processes that enable delivery
Effective systems and processes are crucial in ensuring active participation in decision
making and efficient information sharing. We believe we have a model that works; that
supports locality and practice engagement; and allows us to have clear sight of how our
work is changing local services and improving patient outcomes. That is why we will:




94
Ensure that patient engagement is at the centre of how we work in all
commissioning processes
Embed and develop the use of our Commissioning & Delivery Process
Review our Business Assurance Framework
Introduce an organisational improvement programme
NHS Coastal West Sussex CCG | Delivering the vision
Supporting our staff
Our staff are our greatest asset. So we know that supporting them to do their best is crucial
to getting great outcomes for patients. We want to be a highly credible, respected
organisation that people want to work for, where they know we are able to nurture their
talent and passion for the NHS. To do this we will:



Ensure we identify, and review the knowledge and skills required to achieve our
strategic objectives
Put in place a robust development programme to meet individual and team needs,
that adapts to meet the changing needs of the organisation
Manage our talent and ensure we can always fill our business critical posts
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95
Sustainability: our
five year financial
plan
6
Sustainability
97
The five year plan
The financial climate and subsequently the national economy continue
to be extremely challenging. This means that public sector spending
continues to be under pressure, and although the NHS has been
promised no real term reduction in its funding, other factors such as
inflation mean, the NHS has to make real savings.
For 2015-16 the CCG will receive a recurrent growth in its allocation of 6.0% which includes a
recurrent £3.3m allocation for Seasonal Resilience. In addition the CCG will receive an
additional non-recurrent allocation in 2015/16 to cover the cost pressures caused by the
implementation of the “Enhanced Tariff Option” with its main NHS Service Providers. As part
of the Treasury’s Comprehensive Spending Review (CSR) the NHS has been promised no
‘real’ reduction in resources in the medium term, but does suggest there will be lower levels
of growth in future years, especially as the CCG gets closer to its weighted capitation target.
However, this could be adjusted for a number of factors including the changes in the NHS
landscape and a change to the allocation formula.
The five year financial plan
Table 1 below shows the five year summary financial plan for income and expenditure.
Table 1
(figures £m)
2013-14
2014-15
2015-16
2016-17
2017-18
2018-19
Income
594.8
616.6
657.2
668.5
685
701.8
Expenditure
599.8
615.6
650.5
661.8
678.1
694.8
Surplus/Deficit
-5.0
1.0
6.7
6.7
6.9
7.0
Surplus %
-0.80%
0.20%
1.02%
1.00%
1.00%
1.00%
Financial plan headlines




98
£1m planned surplus has been achieved in 2014-15 following on from a £5m
inherited underlying deficit recognised in the previous year
Realistic QIPP achieved, contributing to 2014-15 outturn position and the planned
£6.5m surplus in 2015-16
In setting the allocation for 2015-16 NHS England has recognised that Coastal West
Sussex is among the CCGs with funding more than 5% under target allocation and
has further increased the allocation for 2015-16. CWS CCG has received an increase
in funding of 6% compared to an average for CCGs of 3%.
The increased allocation over the planning period will enable;
o Repayment of prior year debt
NHS Coastal West Sussex CCG | Delivering the vision



o Making good underlying deficit
o Transfer of NHS funds to social care
o Reserving of funds for specific non-recurrent purposes (Better Care Fund)
o Supporting shorter waiting times for patients (RTT)
System wide achievement of cash releasing efficiency savings and QIPP will enable
o management of growth in demand
o new investments
o creation of general reserve
o achievement of modest surplus in 2014-15, and the achievement of the
national planning requirements of a 1% surplus in future years
o ability to manage other pressures
o progression towards full business rules during planning period
 QIPP aligned with six areas of transformation and is focussed on
major transformation in urgent and proactive care and planned care
o Improved efficiency within other priority areas while holding or increasing
proportionate levels of total investment
 Mental Health services
 Community Based services
National allocation increases and other financial assumptions beyond 2015-16 do
not assume further progress towards target allocations at this stage
Achievement of transformational QIPP in 2014-15 and 2015-16 places Coastal West
Sussex in stronger position to shift the balance of investment in line with clinical
strategy over the full five year period
o increased spend in community based services and proactive care
o maintaining or marginally increasing investment in mental health services
o recognising increased need for continuing healthcare services
o continued investment and efficiency in primary care prescribing maintaining
or marginally increasing proportionate levels of funding
o Reduced proportion of investment in acute and reactive services as a result
of improved proactive care, and offset by advances and availability of
planned acute care
Sustainability
99
Below in Table 2 we have provided details of the assumptions used in the planning process
and Table 3 highlights the planning and statutory duties, and key indicators that will help us
deliver our financial responsibilities, called the business rules.
Table 2
2014-15
2015-16
2016-17
2017-18
2018-19
Allocation Increase
3.68%
6.02%
2.52%
2.50%
2.49%
Tariff Inflation
2.4%
1.9%
2.4%
2.5%
2.8%
Cost Releasing
Efficiency Savings
-4.00%
-3.50%
-3.80%
-3.80%
-3.80%
Tariff Net
-1.60%
-1.60%
-1.60%
-1.50%
-1.20%
Prescribing Inflation
1.90%
1.80%
1.70%
1.70%
2.00%
Prescribing Growth
5.00%
5.00%
5.00%
5.00%
5.00%
Demographic Growth
1.60%
1.60%
1.60%
1.60%
1.60%
Headroom
0.00%
1.00%
1.00%
1.00%
2.00%
Non Demographic
Growth
1.00%
1.00%
1.00%
1.00%
1.00%
Table 3
2014-15
2015-16
2016-17
2017-18
2018-19
Deliver 1.00% Surplus
£1m Surplus
0.20%
£2.4m
0.40%
£6.7m
Surplus
1.02%
£3.3m
0.50%
£6.7m
Surplus
1.00%
6.7m
1.00%
£6.9m
Surplus
1.00%
6.9m
1.00%
£7.0m
Surplus
1.00%
7.0m
1.00%
Breakeven
Breakeven
Breakeven
Breakeven
Breakeven
QIPP
£19.0m
£17.3m
£18.9m
£14.9m
£15.6m
Running Costs
£11.9m
£10.7m
£10.7m
£10.7m
£10.7m
Target (per head)
£24.73
£22.07
£21.88
£21.70
£21.53
Actual spend (per
head)
£23.91
£21.29
£21.29
£21.29
£21.29
1.50%
1.00%
1.00%
1.00%
1.00%
0.00%
1.00%
1.00%
1.00%
2.00%
Minimum 0.50%
General Reserve
Cash Planning
Non Recurrent
Headroom
100
NHS Coastal West Sussex CCG | Delivering the vision
Based on the assumptions presented above, Table 4 (A and B) below outlines the resources
available for the next five years.
Table 4A
(figures £m)
2014-15
2015-16
2016-17
2017-18
2018-19
Recurrent Resource
Allocation
582.0
612.9
654.4
670.1
686.1
Growth
21.4
31.2
15.7
16.0
16.3
Transfer of Specialised
Commissioning
-2.4
Seasonal Resilience
3.3
Better Care Fund
8.9
Enhanced Tariff
Funding
2.0
Running Costs
11.9
-1.1
Recurrent Allocation
612.9
657.2
670.1
686.1
702.4
Non Recurrent
Surplus/Deficit
1.0
6.7
6.7
6.9
7.0
Non Recurrent
Allocation
5.1
1.0
6.5
6.7
6.9
2014-15
2015-16
2016-17
2017-18
2018-19
7.2
7.2
3.2
3.2
3.2
620.1
663.8
673.3
689.3
705.6
Table 4B
(figures £m)
Social Care Funding
Total Income
The above highlights the level of investment available to us over the next five years;
however it is important to take a balanced approach to this in view of the resulting impact
on the level of QIPP requirement. However, this is a strategic decision in light of the
challenges the health community faces.
As part of our overall strategy, we recognise there needs to be fundamental changes to
pathways of care to ensure a sustainable health economy moving forward. The financial plan
above, through its levels of investment and QIPP, reflects that strategic investment is
needed to deliver changes to patient pathways along with an approach to drive out current
inefficiencies in the system and deliver greater productivity.
Sustainability
101
QIPP and investment
We have highlighted the significant challenge we face around the
delivery of QIPP to meet its financial plan. However, as also highlighted
above, QIPP is seen as one of the necessary levers to ensure real
change within the health system is delivered to ensure future financial
stability.
The figure presented in Table 8 are indicative values based on proportion of the CCG
allocation and/or known QIPP plans; agreed annual QIPP plans are presented in Chapter 7.
Table 8
(figures £,000)
2014-15
2015-16
2016-17
2017-18
2018-19
18,973
17,294
18,875
14,870
15,570
3%
3%
3%
3%
3%
Total QIPP
102
NHS Coastal West Sussex CCG | Delivering the vision
Financial Risks and Mitigations
Risk
Mitigation



Serious financial
difficulties throughout
the local health and
care system leads to
an adverse impact on
commissioning plans
and budgets





Achievement of QIPP
and other activity/
financial variances






Potential Adverse
Allocation Changes
Sustainability

System wide focus on shared objectives
QIPP focused on transformation and aligned with clinical
strategy
Continued strengthening of CCG programme office
approach to in year delivery of QIPP
Development of strong business relationships
Appropriate balance of integration and innovation
through competition
Development of authentic risk sharing arrangements
between organisations, recognising the need for
transitional funding where costs need to be reduced
Development of co-commissioning on wider planning
footprint, including commissioners of specialised
services
Pooling of budgets supported by governance
arrangements to achieve integration of services in line
with clinical strategy and across health and local
government
QIPP focussed on major transformational programmes
Level of QIPP and CRES within achievable levels
Programme Office approach further developed by CCG
to manage in year delivery including activity/ financial
variances
Availability of modest general reserve
External review and strengthening of plans using expert
actuarial advice and benchmarking
Continuing to develop and build local risk sharing
arrangements within West Sussex using pooled funds
Developing co-commissioning relationship with
commissioners of specialist services to jointly manage
potential allocation/ funding challenges that impact on
local health system
103
Investment
Successful delivery of QIPP and management of overall finance budgets will free up reserves
allowing choices to be made in line with our clinical strategy. While increased levels of
funding support costs of inflation and some increased demand relating to growing and
ageing population, most of the investment is supported by savings released from existing
services over the five year period.



Increased Funding
Cash Releasing Efficiency Savings
QIPP (including Prescribing CRES)
£101m
£87m
£86m
Planned reductions in running costs of £1.2m will free up resources for health services. The
successful delivery of CRES/QIPP enables these funds to be created:

Better Care Fund
£31.2m
Creating headroom allows stranded costs resulting from major transformation programmes
to be supported. Creating a balance for investment enables:



104
Increased spending on innovation and technology
Resilience to manage slippage in savings programmes
Further investment in priority programme areas in line with our clinical strategy.
NHS Coastal West Sussex CCG | Delivering the vision
Operational plan
7
Sustainability
105
The Coastal
Context
Our Population
We have the second
oldest population in
England, and we
recognise that with
age comes greater
prevalence of disease.
We also have
significant health
inequalities between
some communities
and areas of high
deprivation and social
isolation.
Performance
In 2013-14, to date,
demand for service
has been rising in
many areas notably in
urgent and emergency
care.
Delivery
We have continued to
make significant
progress in a range of
areas, including
Proactive Care, Mental
Health and Planned
Care laying solid
foundations which will
enable us to continue
to drive change in
2015-16.
Our Financial
Challenge
To build a safe,
sustainable and
resilient system we
release efficiencies of
nearly £50m through
2014-15 and 2015-16,
to recover our deficit
and deliver financial
balance.
Areas of transformation in 2015-17
Urgent & Proactive Care
Commission safe and responsive urgent and emergency care
services by:



underpinning delivery of One Call One Team and Proactive
Care with robust contract arrangements to share risks and
offer incentives
focussing on discharge planning and designing new
approaches to patient flow
ensuring 5 of the 7 day service clinical standards are in place
Planned Care
Empower patients to make more informed choices about their care
and treatment through:


more Shared Decision Making and more support to enable
more self-management
streamlining pathways, improving referral management and
supporting our GPs to manage planned care needs effectively
Mental Health & Learning Disabilities
Implementing the Functional Mental Health, Dementia, Learning
Disabilities and Autism Joint Commissioning Strategies focusing on:


developing and sustaining accessible, responsive and high
quality services
care delivered around the individual needs of people
requiring support.
Children, Young People & Maternity
We will integrate services around children and their families by:



Proactive Care
Drive the on-going development of Proactive Care
so it is more integrated with social care and other
NHS services including primary and secondary care
Front door of urgent care
Develop a new model for the front door of urgent
care integrated with other urgent care services
and a commissioning model to underpin a
transformed system
Demand Management
Implement operational changes to key specialties
to effectively manage demand and improve quality
MSK
Deliver an integrated MSK care through an
outcome-based model
Mental Health Support
Improving crisis care, dementia care and
implementing a tiered model of support
Adults with Learning Disabilities
Re-commissioning the supported Living & Personal
Support Framework Agreement
Children’s Urgent Care
Pilot and develop Children’s Community Nursing
and NHS at Home to support children on the
urgent care pathway
Key Outputs









commissioning a new model of community care
ensuring parents know where and how to access to support
and advice about urgent and emergency care for children
Primary Care
We must support practices to meet the challenges of:

Key Projects
working at scale and developing integrated services with
community teams
building strong links to secondary care.
Integrated Community Services
Commissioning integrated services (including
CAMHS) for children with complex emotional,
behavioral and communication needs
Primary Care Development Strategy
Working with partners and practices to create a
strategy to secure the future of primary care
enabling new models of care set out in the 5 Year
Forward View

Co-commissioning
Exploiting the opportunities of co-commissioning
to develop primary care services

Total QIPP impact
Other areas include Medicines management, Continuing Healthcare contributing a combined value of £6.116m in 2015-16.

QIPP
Impact
The Essentials
2015-16
Patient Participation
in their NHS
Let’s Talk, will help us
engage with our
communities continuously
and meaningfully
Reduced emergency
admissions in line with the
Better Care Fund
85% Proactive Care patients
feel involved in developing
their care plan
£7.485m
Compliance with 4-Hour target
in local A&E departments
RTT compliance achieved for
admitted, non-admitted and
incomplete pathways
80% of all GP referrals are
made via e-Referral
2015-16
£1.820m
New MSK service launched
Compliance with waiting time
standards by April 2016
Dementia diagnosis rates reach
67%
Fewer children admitted to
hospital for common
conditions that can be treated
in the community
New CAMHS and SALT services
in place and improving
outcomes
A locally owned and
understood strategy for
developing Primary Care with a
clear implementation plan and
timeline
2015-16
£1.873m
Financial
efficiencies part
of urgent care
and mental
health
Supporting all
other areas of
transformation
Improved patient experience of
GP services
2015-16
£17.294m
Quality and safety
we will focus on driving
more robust assurance
processes and using a wide
range of information and
feedback on the
performance and safety of
local services
Medicines management we
will continue to support
prescribers to make the
best use of medicines as
well as focussing on a range
of high impact actions such
as improving governance of
high-costs drugs
Contracting and
performance we will use
contracts to drive
performance, and deliver a
new integrated information
system to enhance our
commissioning
IM&T we will deliver a
health and social care
information reader to frontline teams to improve
patient care
Governance we will
complete a review of our
governance to ensure
transparent and robust
decision making
Organisational
development We have put
in place a comprehensive
plan to support and enable
staff to improve services for
patients
Moving from 2014-15
Working with our partners we have achieved a lot in recent years and
in 2014-15; we believe that we can carry this momentum into 2015-16
and continue delivering successfully against our vision.
Together with our provider partners we have had to manage rising demand in almost all
service areas; this has meant we have had to either accelerate or in some case realign our
plans for change; however, we have still managed to continue our strong track record of
delivering improved services for patients.
Over 4000 patients will be on local Proactive Care Team caseloads by the end of March
2015, up from around 1000 in April 2014. Each patient has their own care coordinator and
personal care plan developed by a community multi-disciplinary team of nurses, doctors,
social workers and other health professionals. We are already seeing that these patients
are conveyed and admitted to hospital less often as a result.
Whilst we have seen significant pressure in meeting the standards for referral to treatment
times, together with our providers we responded effectively opening additional capacity
and mobilising alternative pathways in key high demand specialities such as
ophthalmology.
In functional Mental Health services, the introduction of a GP referral line and a 5-day
priority referral pathway has closed the gap between the 4-hour urgent pathway and 4week routine pathway. It has also enabled GPs to quickly access advice and guidance from
specialist clinicians, supporting them to effectively manage patients in primary care.
Already in the first 6 months around 300 patients have been referred this way ensuring
they are supported appropriately. We have had really positive feedback from both GPs and
patients, so work is underway to expand this process to other agencies and 24 hours a day.
We are also working hard to protect vulnerable people in our communities by financially
supporting both local Adult and Children’s Safeguarding Boards. With our support the Local
Authority are ahead of schedule (and the national timetable) with the implementation of
the Adult Safeguarding Board which have a statutory requirement to provide assurance
that arrangements are in place across all parts of the health and social care system to
protect adults from abuse and neglect.
The Summary Care Record (SCR) is also being put to excellent use improving patient care by
allowing hospital pharmacists to accurately check the current medication of patients
admitted to hospital. SCR use has reduced calls between the pharmacy team at Worthing
and St Richards Hospitals and local GP Practices by almost 90%; releasing nearly 150 staff
hours per week so staff can focus on patient care rather than transferring records.
Not only are patients getting an improved experience and outcomes but we are delivering
better value. We are forecasting to achieve (QIPP) efficiency savings of over £13.5m.
In this chapter we have set out the mechanism for delivering the second year of our
strategy; our operational plan. Further detail on the work and milestones during 2015-17
can be found in Annex 2.
Operational plan
107
The focus for 2015-17
Our focus for 2015-17 will be to ensure that we work together with
our partners to accelerate change in key service areas through
commissioning and contracting arrangements which drive
transformation.
Delivering transformation
Our strategy has set out 6 areas of transformation. Here we describe the priorities for
transforming services in these 6 areas in 2015-16 and into 2016-17. This is supported by
further detailed work plan and milestone information in Annex 2.
Priorities for transformation
in 2015-17
Patient Participation in their NHS
We will develop our culture of
engagement to ensure that:


patients feel supported to manage
and make decisions about their
care as well
local people are a part of our work
7as we develop and improve
services
Urgent & Proactive Care
Commission safe and responsive urgent
and emergency care services by:



underpinning delivery of One Call
One Team and Proactive Care with
robust contract arrangements to
share risks and offer incentives
focusing on discharge planning and
designing new approaches to
patient flow
ensuring 5 of the 7 day service
clinical standards are in place
Planned Care
Empower patients to make more
informed choices about their care and
treatment through:


108
more Shared Decision Making and
more support to enable more selfmanagement
streamlining pathways, improving
referral management and
supporting our GPs to manage
planned care needs effectively
Key Projects
Let’s Talk
Will provide a firm foundation onto
which we can meaningfully and
continuously engage with patients,
starting with a number of workshops
throughout 2014-15.
PPE training
We will also implement a patient
engagement toolkit and training
programme for all staff to continue to
develop our culture of engagement.
Proactive Care
Drive the on-going development of
Proactive Care so it is more integrated
with social care and other NHS
services including primary and
secondary care
Front door of urgent care
Develop a new model for the front
door of urgent care integrated with
other urgent care services and a
commissioning model to underpin a
transformed system
Demand Management
Implement operational changes to key
specialties to effectively manage
demand and improve quality
MSK
Deliver an integrated MSK care
through an outcome-based model
Key Outputs
 5000
more local
people involved in
our work as members
of our Citizen E-panel
 Every
area of
transformation has a
communications and
engagement plan
 Reduced
emergency
admissions in line
with the Better Care
Fund
 85%
Proactive Care
patients feel involved
in developing their
care plan
 Compliance
with 4Hour target in local
A&E departments
 RTT
compliance
achieved for
admitted, nonadmitted and
incomplete pathways
 80%
of all GP referrals
are made via eReferral
 New
MSK service
launched
NHS Coastal West Sussex CCG | Delivering the vision
Mental Health & Learning Disabilities
Begin implementing the new Functional
Mental Health, Dementia, Learning
Disabilities and Autism Joint
Commissioning Strategies focusing on:


developing and sustaining
accessible, responsive and high
quality services
care delivered around the
individual needs of people
requiring support.
Children, Young People & Maternity
We will integrate services around
children and their families by:


commissioning a new model of
community care
ensuring parents know where and
how to access to support and
advice about urgent and
emergency care for children
Primary Care
We must support practices to meet the
challenges of:


working at scale and developing
integrated services with
community teams
building strong links to secondary
care.
Operational plan
Mental Health Support
Increase level of support and
psychological therapies in long term
condition pathways, acute & proactive
care
Adults with Learning Disabilities
Re-commissioning the supported
Living & Personal Support Framework
Agreement
 Compliance
with
waiting time
standards by April
2016
 Dementia
diagnosis
rates reach 65%
Children’s Urgent Care
Pilot and develop Children’s
Community Nursing and NHS at Home
to support children on the urgent care
pathway
 Fewer
children
admitted to hospital
Integrated Community Services
Commissioning integrated services
(including CAMHS) for children with
complex emotional, behavioral and
communication needs
 New
CAMHS and SALT
services
Primary Care Development Strategy
Working with partners and practices
to create a strategy to secure the
future of primary care enabling new
models of care set out in the 5 Year
Forward View
Co-commissioning
Exploiting the opportunities of cocommissioning to develop primary
care services
for common
conditions that can be
treated in the
community
 Aunderstood
locally owned and
strategy
for developing
Primary Care with a
clear implementation
plan and timeline
 Improved
patient
experience of GP
services
109
Delivery timeline
Through 2015-16 and 2016-17 we will need to make significant progress toward our vision. On the following page we have set out some of the key milestones
across the two years related to the six areas of transformation and our essentials.
Area of
transformation
Patient
Participation
Urgent and
proactive care
Programme/Project
2015-16
Q2
Let’s Talk
Q3
PPE Training rolled out
Proactive Care MDTs
Front door of urgent care
Revised Specification in Lead
Provider contract
Redesign process
begins
Stroke
Options development
7-Day working
SDIP in place for developing 7-day services
Dementia Support Workers
Demand Management
Children, young
people and
maternity
Primary care
CAMHS
Primary Care Strategy
Co-Commissioning
New model proposed to stakeholders
Final Sussex model proposed
Implementation begins
Review of enhanced service
MAS pathway redesign begins
MAS redesign complete
Service changes begin
New ophthalmology pathways
launched
Headache clinics starts
New e-referral system launched
Plans presented to WSCC and CCGs
Design
complete
Practices have named CCNs
Service aligned to urgent care pathways
All eligible families offered PHBs
First changes begin implementation
Arrangements in place
Begin implementing Orchid View recommendations
Medicines Management
PQRS scheme in place
IM&T
IT Strategy published
Organisational Development
Strategic Event
Quarterly Net QIPP Plan
Agreed clinical standards operational
Set-up
T&F groups
Enhanced service in place
Quality & Safety
Essentials
Q3
Review of Proactive Care and MCP model
Plans in place for
each priority
Children’s Community Nursing
Personal Health Budgets
Q2
3 Projects using consultation software
MSK
Delivering the NHS Constitution
Q1
Let’s Talk Events
PPE development
Memory Assessment Service
Planned Care
Q4
Let’s Talk Events
Crisis Care Concordat
Mental health
and LD
2016-17
Q1
£3,711,926
Annual CDI review begins
All high cost drugs authorised through new system
Electronic HR implemented
Electronic Prescription Service
deployed to practices
Staff Survey live
£3,962,621
£4,584,634
£5,034,915
~
Q4
Commissioning strategy
Ensuring delivery of patient rights and pledges in the NHS Constitution
We recognise the challenges our system has faced in meeting both the A&E 4-hour and 18
weeks standards in 2014-15 and are committed to ensuring we see a clear improvement in
2015-16. We have worked with our providers to ensure there are plans in place to meet
the rights set out for patients and have ensured resources are available to providers in
contracts to do so (including an 18-weeks recovery plan). We will monitor performance
closely against the standards to ensure patients are receiving the treatment they need
within the times they have the right to expect.
We continue to work with providers to improve and make changes to services and will
request all CIPs are shared with us so that we can offer assurance that they do not
negatively impact patient care or the workforce.
Working in partnership and the Better Care Fund
In Chapter 5 we set out the overall approach to partnership working between the Sussex
CCGs and in 2015-16 we will continue to invest in our time and energy into working
collaboratively. We already work effectively in partnership with our neighbours in Crawley
and Horsham & Mid Sussex CCGs and West Sussex County Council to jointly commission
over £250m of services including Continuing Healthcare; Mental Health and Learning
Disabilities services; services to support Carers; and children’s community services.
Together we have also agreed an ambitious set of plans that will drive integration across
health and social care transforming services across West Sussex through the Better Care
Fund (BCF). BCF projects are a core component of our work, fully integrated with our
commissioning activities. As such the benefits are represented within our QIPP plan in this
chapter and more detailed project information is within our work plan in Annex 2 and in
the full West Sussex Better Care Fund Plan.
In 2015-16, across Sussex we will focus our collective efforts through the Sussex
Collaborative Delivery Team in the following areas (this list is not exhaustive):






Realising the benefits from NHS111 and considering re-procurement
Improving and aligning of services for the Armed Forces in Sussex working with
Local Authority partner
Developing and improving Stroke services alongside the Strategic Clinical Network
Developing a Sussex-wide workforce plan
Reviewing rehabilitation services
Developing a Renal service model, specification, standards and reviewing services
to identify opportunities for improvement
We also continue to be the coordinating commissioner for Sussex Partnership NHS
Foundation Trust and chair quarterly strategy and performance with all CCGs and the trust.
Our CCG also takes a lead role in the wider NHS. For example our Chief Clinical Officer is the
Sussex CCGs representative in the Clinical Senate, as well as being the Surrey and Sussex
CCGs representative in the NHS Commissioning Assembly and participating in Strategic
Clinical Network meetings and reviews. We have made good progress developing
partnerships with Hampshire CCGs and will continue to share ideas, learning and support
shared commissioning agendas to ensure excellent services for those patients living on our
westerly boarders through 2015-16.
Operational plan
111
Quality Premium
We were awarded nearly £300,000 for our performance in 2013-14. We were able to use
this money to invest £50,000 in a local innovation fund. £25,000 of this went to voluntary
and community sector organisations throughout existing grant process and the remaining
£25,000 supported innovative working in Localities.
The remaining Quality Premium award enabled the CCG to fund projects that supported
local health services experiencing severe pressures, above and beyond the resource
available through the seasonal resilience funding. This included opening local GP practices
at the weekend and out of hours to help reduce pressure on A&E departments; increasing
capacity in local Rapid Assessment and Intervention Teams to support more people in the
community with urgent care needs; increasing capacity in a ‘sitting service’ to help people
on discharge from hospital; and increasing Consultant presence at local hospitals in
evenings and on weekends to improve clinical decision making.
We have made also good progress in delivering our planned actions which contribute
toward our local Quality Premium priority for 2014-15;

NHS Outcomes Framework 3.1ii
Patient reported outcome measures for elective procedures – knee replacement
Our performance in this and the other Quality Premium measures and subsequent award
will be assessed upon publication of the annual NHS Outcomes Framework information
(ordinarily around September) and the NHS England assessment process.
As we continue planning for 2015-16 we have selected the measures to be used in our
CCGs Quality Premium. Using available information and working with stakeholders we have
selected the following as local priorities for 2015-16;

NHS Outcomes Framework 2.10
Access to psychological therapy services by people from BME groups

NHS Outcomes Framework 3.1ii
Patient reported outcome measures for elective procedures – knee replacement
A full breakdown of all selected Quality Premium measures for our CCG is included in
Annex 3.
112
NHS Coastal West Sussex CCG | Delivering the vision
Financial planning
Our CCG is planning to fully meet the NHS business rules and policy requirements including
contributions to the Better Care Fund, investing in Mental Health services, maintaining the
requisite surplus and levels of non-recurrent investment; whilst planning for a challenging
but realistic level of efficiency (or QIPP), details of which are set out overleaf.
We benefited from the decision of NHS England to target additional funding at below target
CCGs. As a direct consequence our CCGs growth is 6% (nearly double our previous planning
assumption) and totalling £36m. This has enabled the CCG to do five things:

We will deliver a 1% surplus of £6.5m, compliant with business rules

We will create a non-recurrent reserve of 1% or £6.5m, this will enable us to invest
non-recurrently in winter resilience with local providers in 2015-16 and to meet our
Continuing Health Care Risk Pool contributions

We will create a 1% contingency reserve to meet as yet unknown pressures

We will invest 6% more in Mental Health services compared to 2014-15 outturn

We can plan for a realistic but challenging level of efficiency (QIPP) at around 3%, this
equates to approximately £19m.
Quality, Innovation, Productivity, Prevention (QIPP)
Below we have set out our QIPP (and BCF denoted in blue text) schemes for 2015-16 in
financial terms. The financial values represent our expected plan.
(All figures £,000)
2015-16
Urgent and proactive care
Proactive Care MDTs
One Call One Team
Ambulatory Care
Heart Failure
7-day working
Community Services contract
Ambulance Services contract
3,783
720
340
210
144
1,661
627
Mental health and learning disabilities
Mental health contracts
Learning disabilities contracts
1,581
292
Planned Care
Demand management
Cancer
1,781
38
Medicines Management
Medicines optimisation in primary care
Medicines optimisation in care homes
PbRE and High Cost Drugs
2,665
87
105
Other
Continuing Health Care (including Children’s CHC)
Locally Commissioned Services
Audit programme
Other programme services
Running Costs
Total identified QIPP
QIPP as % (of total budget)
Operational plan
1,046
134
250
629
1,201
£17,294m
2.7%
113
Critical success factors
Sustaining progress for 2015-16 and 2016-17 will be based on many of the key features of
our local system established in previous years, as well as realising and addressing the
critical success factors that will underpin delivery of our vision by 2019. We see these
critical success factors as:






114
Continued system-wide working and governance; a move away from transactional
approaches, and underpinned by the development of contracts which embed the
co-dependency of partners
Working collaboratively with other CCGs on key areas of work such as Stroke,
Ambulance services and the designation of emergency centres through the unit of
planning and Sussex Collaborative Delivery Team
Maintaining a shared vision for the system and establishing a clear plan which
manages the impact for all organisations in a sustainable fashion
Supporting a team of people at the CCG who have the right values and level of
competency to allow us to be effective system leaders
A vibrant patient and public engagement programme which underpins
transformation
Effective performance and programme management which drives our QIPP and
enables system wide delivery of commitments to the NHS Constitution.
NHS Coastal West Sussex CCG | Delivering the vision
Risks and mitigations
We recognise the risks inherent in our plans and those with could
impact our ability to deliver. We have set out clear and robust
mitigations to ensure we continue to our strong track record of
delivery.
Risk
Our plans fail to
deliver the clinical
transformation
necessary to underpin
sustainability
Transformation might
adversely affect the
quality of services
Mitigation









Lack of public support
for transformation
programmes



Workforce capacity
and capability is
unable to be meet
demands of
transformed services



Transformation plans
do not deliver
sufficient savings for
system-wide
sustainability
Performance of
services and
compliance with NHS
Constitution
deteriorates
Operational plan








Clinical leadership embedded in programmes & projects
Adoption of consistent programme and project
management approaches
Robust Programme Management Office
Clear system governance
Underpinning organisational development
Quality management to underpin all of our plans, service
specifications & contracts
Review provider CIPs to assure for quality & safety
impact
Continue to monitor both hard (through performance
data) and soft intelligence (through QIF)
Clear plans for transition with existing providers
Patient and public engagement at every stage of
development
Effective Let’s Talk campaign
Effective collaborative workforce planning with
providers across Sussex and engagement with Local
Health Education and Training Board(s)
Modelling workforce changes with providers as part of
project development
Monitoring workforce changes in partnership with
providers and CSU
Contracts with up front financial agreements and risk
share arrangements
Exploring new outcome based contracts for urgent and
proactive care with risk share
QIPP aligned with transformation goals across the
system
Better Care Fund providing support for transformation
Robust Programme Management Office approach
Contracts secure compliance with NHS Constitution
Detailed monitoring in place with weekly performance
reporting
System ownership of performance through System
Resilience Operational Group
Application of penalties but with reinvestment to
support improvement
115

Ineffective Cocommissioning with
NHS England, West
Sussex County Council
and partner CCGs





Providers unable to
collaborate effectively


Large scale
procurements
undermine provider
and system wide
sustainability
Disengaged clinical
community
Insufficient capacity or
capability in the CCG
support team
Assurance from NHS
England
116



















Strengthen relationships with clear executive
responsibility
Effective participation in Health and Wellbeing Board
Effective participation in Joint Commissioning Forums
Work in partnership with NHS England and Primary Care
Actively engage Sussex Clinical Commissioning Executive
Committee
Focus on relationship management with clear executive
responsibility
Facilitated Coastal Cabinet underpinned by clear lines of
accountability and governance arrangements beneath
Contracts to contain clear requirement for whole system
working
Clear service specifications for procurement exercises
which set parameters for stability of mandatory services
Robust and effective procurement process
Effective co-commissioning
Clear transition plans required from existing and new
providers
Clinical leadership programme
Promote continued and open dialogue
Establish coherent Primary Care Development Strategy
Strengthen relationships with LMC with clear executive
responsibility
Clear, consistent and timely communications
Clear individual and team priorities and work plans
Adoption of consistent programme and project
management approaches
Implement Organisational Development Strategy
Fully established teams
Effective Commissioning Support Unit
Consistent delivery
Clear and consistent reporting
Robust Programme Management Office
Clear and credible plans
Consolidate and enhance relationship supported by lead
executive arrangements
NHS Coastal West Sussex CCG | Delivering the vision
Supporting
Information
& References
Annex 1 – System outcome trajectories to 2019
Outcome 1. Securing additional years of life for the people of England with
treatable mental and physical health conditions
Trajectory
Blue = Actual
Red = Plan
Measure
NHS CCG OIS 1a i & ii
Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare
(Adults, children and young people)
Numerator
Denominator
Total years of life lost from amenable
causes
Total number of registered patients at the
CCG-level
Baseline year
Improvement is when
2012
The rate gets lower
Units
nd
The CCG started in the 2 best quintile for this measure and consistently performed
between the 2nd best and best quintiles since 2009. The trajectory is based on getting to
the middle of top quintile by 2018-19.
Rationale for
improvement
trajectory
th
Within the ONS cluster, the CCG was 4 out of the 14 other CCGs in the baseline year
(achieving 1841). North Norfolk was the top performer and achieved a rate of 1785.3 in
2012.
The England average in the baseline year was 2001; the CCG was above (better than) this
level.
th
2013-14
change
The CCG remains 4 out of 14 in the ONS cluster and the rate has reduced in line with the
trajectory into 2013.
The England average is now 2027; the CCG remains below (better than) this level.
118
NHS Coastal West Sussex CCG | Delivering the vision
Outcome 2. Improving the health related quality of life of people with one
or more long-term condition, including mental health conditions
Trajectory
Blue = Actual
Red = Plan
Measure
Units
NHS CCG OIS 2
Health-related quality of life for people with long-term conditions
Numerator
Denominator
Sum of the weighted EQ-5D (a standardised
instrument for use as a measure of health
outcome) values for all responses from
people identified as having a long term
condition
The weighted count of all responses from
people identified as having a long term
condition
Baseline year
Improvement is when
2012-13
The rate gets higher
rd
Rationale for
improvemen
t trajectory
nd
th
The CCG started in the 3 quintile for this measure and has moved between 2 and 4
nd
quintiles in recent years. The trajectory is based on improving the position back to the 2
quintile by 2018-19.
nd
Within the ONS cluster, the CCG was the 2 best performer in the baseline year (achieving
73.9). North Norfolk CCG was the top performer and achieved a rate of 74.4 for 2012-13.
The England average in the baseline year was 73.1; the CCG was above (better than) this level.
2013-14
change
The rate has increased into 2013-14 and is above the expected position in 2013-14. The CCG is
nd
now the top performer in the ONS cluster and has moved into the 2 quintile.
The England average is now 73.0; the CCG remains above (better than) this level.
Supporting Information & References
119
Outcome 3. Reducing the amount of time people spend avoidably in
hospital through better and more integrated care in the community,
outside of hospital
Trajectory
Blue = Actual
Red = Plan
Measure
Emergency admissions composite indicator - rate of admissions per 100,000 population
Numerator
Denominator
Total emergency admission for the any of
the conditions considered
Total CCG registered patients
Baseline year
Improvement means
2012-13
The rate lowers
Units
nd
The CCG was already in the 2 best quintile for this measure and consistently performed
nd
between the 2 and best quintiles since 2009.
The trajectory is based on moving the CCG into the top quintile by 2014-15 and beyond.
Rationale for
improvement
trajectory
th
Within the ONS cluster, the CCG was 4 out of the 14 other CCGs in the baseline year
(achieving 1643). Isle of Wight was the top performer and achieved a rate of 1121 in 201213.
The England average in the baseline year was 1994 and the CCG was lower (better) than this
level.
2013-14
change
Whilst the rate has increased into 2013-14, moving away from the planned trajectory, other
rd
similar areas have experienced larger rate increases meaning the CCG is now 3 out of 14 in
nd
the ONS cluster and in the 2 quintile nationally.
The England average is now 1963; the CCG remains lower (better) than this level.
120
NHS Coastal West Sussex CCG | Delivering the vision
Outcome 4. Increasing the proportion of older people living independently
at home following discharge from hospital
Trajectory
Blue = Actual
Red = Plan
Measure
Units
ASCOF 2B (i)
Older people at home 91 days after leaving hospital into reablement
(Local selected proxy measure – aligned to the Better Care Fund)
Numerator
Denominator
Number of older people (aged 65 and over)
discharged from acute or community
hospitals to their own home for rehabilitation
who are still there 91 days after discharge
Number of older people (aged 65 and over)
discharged from acute or community
hospitals to their own home for rehabilitation
Baseline year
Improvement means
2013-14
The rate gets higher
The Local Authority boundary is the unit of measurement for this outcome.
Rationale for
improvement
trajectory
The Local Authority achieved 74.4% in the baseline year. Lower than the all comparable
average (South East and similar Local authority).
As defined in the West Sussex Better Care Fund, the target is based on moving to the similar
Local Authority average of 83.2% in 2015-16 and then an annual 1% increase thereafter.
The England average is 82.5%, the Local Authority was lower (worse) than this in 2013-14.
2013-14
change
N/A
Supporting Information & References
121
Outcome 5. Increasing the number of people with mental and physical
health conditions having a positive experience of hospital care
Trajectory
Blue = Actual
Red = Plan
Measure
NHS CCG OIS 4b
Poor patient experience of inpatient care
Numerator
Denominator
Total number of 'poor' responses
Total number of respondents to the survey
questions
Baseline year
Improvement means
2012-13
The rate lowers
Units
The CCG was in the best quintile for this measure. The trajectory is based on maintaining
top quintile position, whist making annual 1% improvements up to 2018-19.
Rationale for
improvement
trajectory
th
Within the ONS cluster, the CCG was 4 out of the 14 other CCGs (achieving 107.7) South
Devon and Torbay CCG was the top performer and achieved a rate of 95.9 in 2012-13.
The England average at baseline year was 120 and the CCG was lower (better) than this level.
2013-14
change
The rate has decreased into 2013-14, accelerating beyond the planned trajectory. Despite
th
this, similar areas have experienced greater improvements meaning the CCG is now 6 out
of 14 in the ONS cluster.
The England average is now 119; the CCG remains lower (better) than this level.
122
NHS Coastal West Sussex CCG | Delivering the vision
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
Trajectory
Blue = Actual
Red = Plan
Measure
Units
Baseline year
NHS CCG OIS 4a ii
Poor patient experience of primary care
Numerator
Denominator
Total number of 'poor' responses
Total number of respondents to the survey
questions
Baseline year
Improvement means
2012-13
The rate lowers
rd
th
At the baseline the CCG was on the boarder of the 3 and 4 quintile for this measure. The
rd
trajectory is based on the CCG moving to middle of 3 quintile by 2018-19.
Rationale for
improvement
trajectory
th
Within the ONS cluster, the CCG was 12 out of the 14 other CCGs (achieving 6.3). South
Devon and Torbay CCG was the top performer and achieved a rate of 3.6 in 2012-13.
The England average at baseline year was 6.0 and the CCG was higher (worse) than this
level.
2013-14
change
The rate has increased into 2013-14, moving away from the planned trajectory. Despite
rd
th
this the CCG is now in the 3 quintile. It has also moved up to 10 in the ONS cluster. This
indicates other areas performance has worsened to a greater extent than the CCGs.
The England average based on the latest data for this measure is 7.0, the CCG is above
(worse than) this level.
Supporting Information & References
123
Outcome 7. Making significant progress towards eliminating avoidable
deaths in our hospitals caused by problems in care
Trajectory
Blue = Actual
Red = Plan
Note: There is currently no national measure for this ambition.
We will continue to work with national and local colleagues to establish
baseline and future trajectories as this measure is defined
Measure
Numerator
Denominator
Units
Rationale for
improvement
trajectory
124
NHS Coastal West Sussex CCG | Delivering the vision
Annex 2 – Workplan 2015-17
Introduction to the Workplan 2015-17
1.
This Workplan is a direct response to, and translation from, the Five Year Strategy
and in particular the Chapter – Two Year Operational Plan. It provides the detail
behind our ambitions with practical and measureable actions which will drive
delivery of the transformation of services toward our vision for 2019 in years two
and three, 2015-16 and 2016-17.
2.
The Workplan contains three main sections. The first contains detailed descriptions
of the portfolios of work (including priorities, milestones and where applicable
project information) for all of our commissioning work. The second is detailed
actions and milestones for our cross-cutting work, what we have called the
‘essentials’ such as quality assurance, medicines management and governance
alongside our own organisational development plans. The third element of the
Operational Plan contains further supporting information.
Section 2.1 – Commissioning
3.
Section 2.1 – Commissioning describes all of the work of our commissioning
portfolios over the next two years. The transformation areas are the same as are set
out in ‘Delivering the vision’ (Chapter 4) and they provide a detailed work plan for
the CCG and our teams in:







Urgent care
Proactive care and long-term conditions
Mental health
Learning disabilities
Planned care
Children, young people and maternity
Primary care
Supporting Information & References
125
Urgent care workplan
4.
Priorities for 2015-17:

We will, in partnership with providers, review and redesign the front door of
urgent care including out of hours primary care to simplify access, improve
patient flow and deliver better outcomes, proposing a new model before
September 2015

We will work with providers to develop One Call One Team underpinned by
Lead Provider arrangements from April 2015 which drive greater provider and
clinical leadership across a network of urgent care services

We will support the system to implement 7-day working improving patient
flow and outcomes

We will continue to work with providers to develop Ambulatory Care Areas
across local acute sites to improve same day emergency care

We will support the system to implement recommendations from the review
of discharge planning pathways, which will drive efficiencies in urgent and
emergency care
5.
Just like many areas of England, local urgent and emergency care services are facing
ever increasing demand and changing patterns of disease. Local evidence shows that
significant numbers of patients are still receiving care in hospitals that could be
delivered in the community. These findings are in line with national data (Keogh,
2013), which reinforces the need to shift care away from the hospital settings and
into the community.
6.
We have made significant progress in recent years designing and implementing One
Call One Team (OCOT) a rapid response service for those with urgent care needs in
the community. We will continue to build on this progress and continue to transform
the local urgent care system. The following key change projects have been identified
for the next two years;









7.
These are supported by also maintaining a focus on business as usual elements of
this portfolio specifically;



126
The front door of urgent care
Ambulatory Care
Discharge Planning
Enhancing OCOT
Community in-patient provision
Stroke Services
Patient Transport Service re-procurement
7-Day working
NHS 111 re-procurement
Operational Resilience and capacity planning
Out of Hours Primary Care
Ambulance and 999 services
NHS Coastal West Sussex CCG | Delivering the vision
8.
A&E is often the default place of care for the public, and pressure continues to grow
within our local departments. In order to tackle increasing demand we will, in
partnership with providers and stakeholders redesign the front door of A&E and the
rest of urgent and emergency care making sure the right service is the easiest place
for the public to access. Closely linked to this is project is the development of
Ambulatory Care Areas which will enable patients requiring rapid treatment and
acute input to avoid admission.
9.
One Call One Team (OCOT) remains the cornerstone of urgent care in Coastal West
Sussex ensuring patients avoid unnecessary admission with support in the
community wherever possible. We will work with the lead provider to ensure OCOT
has sufficient capacity and is focused to meet rising demand. We will consult with
stakeholders to understand the enhanced role of OCOT in a more networked model
of urgent and emergency care.
10.
There are a range of projects underway to improve patient flow across the urgent
care system, particularly around discharge planning. There are often failures when
patient transfer between services impacting both on patient outcomes and
operational flow.
11.
WSHFT and SCT have undertaken reviews of their internal processes and recently a
review of the discharge pathways across the whole pathway have been mapped to
understand bottlenecks and opportunities to improve efficiency. A programme of
work will be developed to implement the recommendations of this piece of work to
ensure resilience over this winter and longer term sustainability. We will work with
providers to ensure the changes are effective using a Plan Do Study Act (PDSA) cycle
to deliver continual improvement. This work will closely interlink with the
community bed review.
12.
The model of community bed provision is under review to ensure the right provision
is available in the right place. Additionally we are supporting SCT as they consult
stakeholders regarding changes to the configuration of the community hospitals to
ensure their long term sustainability. When the outcomes of the review are agreed
we will again work with SCT to plan and deliver the necessary improvements and
changes to provision. This will also include the bed capacity we currently commission
from independent providers.
13.
We will work with providers to agree the performance requirements which will be
used as a pre-requisite for accessing readmission funds. We will in the first instance
seek to understand the gains made by investment in service developments in 201415 which run into 2015-16.
14.
In line with national policy, we will work with providers to ensure services can be
delivered sustainably 7-days per week. We will offer system leadership around the
development of 7-day services, supporting providers in their planning by aligning
provider developments to ensure flow across the whole pathway wherever possible.
We will work with all providers to agree Service Development and Improvement
Plans (SDIPs) to define the next steps in meeting the clinical standards for 7-day
working. We will do this through a system wide planning process governed by our
Coastal Cabinet, who will in the first instance prioritise the 5 clinical standards to be
delivered first. This will be supported by full business case development by all
relevant partners to ensure that we maximise the benefits of 7-day working whilst
delivering the change within available resources.
Supporting Information & References
127
15.
An important part of this process will be understanding the full cost impact of the
changes and identifying appropriate investment funds to enable service
developments. This may include use of the Better Care Fund.
16.
Stroke services are also a key area of development for commissioners and providers
in Sussex. We will, working with patients, clinicians and partners across Sussex,
develop a stroke pathway that delivers high quality care and improved outcomes for
our patients, and supports a sustainable model of provision. The pathway will
subject to requisite public consultation and we will work with the all partner
communications teams to ensure this is undertaken effectively.
17.
We are committed to ensuring the public has a single point of access to urgent care
services when they are ill but don’t know which service to contact. NHS 111 was
established in 2013 but local experiences have been mixed. Across our region
considerable work has gone into improving performance of the service. We will
continue to work with the lead commissioner and NHS 111 to ensure it can direct
patients to the appropriate local services. The contract is due to expire in 2016 and
we will be part of the re-procurement of the service across the region working
closely with all stakeholders.
18.
Establishing sustainable year round capacity planning across is also important across
the whole system. We lead the system wide work to prepare for seasonal surges in
demand in line with the NHS England requirements. We will continue to coordinate
the Operational Resilience and Capacity Plan for the system and the resources
attached to this. The allocation for seasonal demand for the local health economy
will be £3.27m. The CCG fully expects to provide additional resource to support the
system during peak demand and we will work with providers to develop plans.
19.
As a system we will capture learning from the changes in demand in 2014-15 and
develop the Operational Resilience and Capacity Plan for 2015-16. This plan will be
available for implementation from the September 2015. We will work with providers
to ensure this is monitored, good practice is shared and key system risks are
identified to improve resilience. We will continue to work as a whole system to
manage demand during seasonal peaks in the meantime, ensuring capacity remains
enhanced until pressure returns to a sustainable level.
20.
As required in 2015-16 planning guidance Urgent and Emergency Care Networks,
built from existing System Resilience Groups, will be in place by April 2015. The
Network will oversee both planning and delivery of urgent care systems in Coastal
West Sussex including the process for A&E designation. We will prioritise, in
partnership with providers, how we will implement the urgent and emergency care
review.
21.
Under the Enhanced Tariff Option (ETO), the marginal rate providers are paid for
extra emergency admissions will increase from 30% to 70% in 2015-16. Therefore
the local health economy will have a 30% fund to reinvest in resilience and reducing
non elective admissions. We will work with all partners to ensure this investment is
allocated to improve system-wide resilience through existing governance
mechanisms including the new Urgent and Emergency Care Network.
22.
Out of Hours Primary Care services are now accessed by the public via NHS 111. The
service was procured and the new provider, Integrated Care 24 (IC24), commenced
in April 2014. We are working closely with IC24 to ensure they are integrated into
128
NHS Coastal West Sussex CCG | Delivering the vision
our system and delivering effective care. There is a Service Development and
Improvement plan in place with a range of developments for the life of the contract
to ensure a responsive local service.
23.
We will continue to work closely with the lead commissioner for Ambulance services
across Sussex and the region to improve performance of this vital service. During
2014-15 we will work with the lead commissioner to ensure the contract is
disaggregated from a regional (Kent, Surrey, Sussex) to a Sussex level contract. The
contract will be managed directly by Sussex affording us a closer relationship with
the ambulance trust and a greater focus on our performance issues and local
solutions.
24.
Key milestones for 2015-17 are:
Date
Milestone
Mar
2015
Discharge planning processes in place and
reporting across the whole system
Mar
2015
SDIP - agreed for 7-Day working business case
development process
Head of
Unscheduled Care
Apr
2015
Plans to spend the 30% marginal rate funding
published on the CCGs website
Head of
Unscheduled Care
Apr
2015
Local Urgent and Emergency Care Network in
place
Head of
Unscheduled Care
Apr
2015
SCT revised model for community in-patient
provision in place and reporting
Service
Development
Manager
May
2015
The wider admission avoidance potential of the
OCOT service scoped and agreed
Head of
Unscheduled Care
May
2015
Redesign process for front door of urgent care
begins
Head of
Unscheduled Care
Jul
2015
Agreement of enhanced OCOT provision and
implementation to commence
Head of
Unscheduled Care
Sep
2015
6 month system-wide evaluation of discharge
planning processes including agreed
developments based on PDSA cycle
Commissioning
Manager
Sep
2015
Operational Resilience and Capacity Plan agreed
for winter 2015-16
Head of
Unscheduled Care
Sep
2015
7-Day Business cases developed and signed off
by Coastal Cabinet
Head of
Unscheduled Care
Oct
2015
6 month evaluation of community bed model
Service
Development
Manager
Feb
2016
6 month evaluation of enhanced OCOT provision
Commissioning
Manager
Mar
2016
5 clinical standards for 7-day working operational
Head of
Unscheduled Care
Supporting Information & References
Accountable
Senior
Commissioning
Manager
129
Urgent Care
Front door of Urgent Care
Overview
part of BCF Plan
Description
of service
changes or
project and
aim
We will review and research the current Front Door Urgent Care model including A&E, Out of
Hours Primary Care, NHS 111 services. Based on our findings we will design, with partners, a new
way of managing patients into the urgent care system. This new model will ensure that patients
are triaged to the appropriate services first time.
Why change
or run the
project?
Demand remains high in A&E sometimes compromising national targets. Demand continues to
increase including a significant number of patients attending A&E requiring no treatment.
Patients and professionals report the system is complex to navigate.
Evidence to
support
service
changes or
project
 We are currently gathering local
evidence and national best practice
examples which will be used to
inform the new model
 This will include the Keogh review of
urgent care (2013)
Delivery
approach
 Service review and re-design with
stakeholders
 Supported by the Better Care Fund
Key risks
Current
C&DP
Phase
 Ensuring alignment with the
National A&E designation process
 Ensuring appropriate Provider
engagement
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Local patient health seeking behaviours study complete
April 2015
Review of A&E processed and flows complete
April 2015
Additional performance root cause analysis, including on-site info gathering complete
April 2015
Programme Board and Stakeholder Groups established
April 2015
Findings of review process shared with all stakeholders
May 2015
Redesign process begins
May 2015
National guidance on A&E designation process
Summer 2015
Design process complete and new model proposed to stakeholders
September 2015
Measures
Key delivery measure
Threshold
A&E attendance
Reduction
Other measures
Threshold
Cancelled elective appointments
Reduction
A&E 4-hour waits
Compliance
A&E and Ambulance handover times
Compliance
Impact
Q1
Costs (met by BCF)
Q2
Q3
Q4
£150,000
£394,500
£394,500
Q1
Q2
Q3
Q4
Efficiencies
Gross impact
130
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Urgent Care
Ambulatory Care
Overview
Description
of service
changes or
project and
aim
Why change
or run the
project?
Evidence to
support
service
changes or
project
Delivery
approach
part of BCF Plan
Ambulatory emergency care is an emerging, streamlined way of managing patients presenting to
hospital who would traditionally be admitted. Instead, they can be treated in an ambulatory care
setting and discharged the same day – offering benefits to patients, carers, support workers and
NHS trusts. We will continue to work with providers to develop Ambulatory Care Areas across
both acute sites to maximize patient outcomes and system flow.
Keogh describes the need to radically alter the delivery of urgent care services and ambulatory
emergency care is a fundamental component of this change (2013). Local increasing demand in
short stay admissions and evidence that patients could receive ambulatory or ‘same day’
emergency care as an alternative to admission.

Unable to monitor impact of
pathways effectively as current

The AEC Network has published
coding and recording of patients
examples of early adopters
is unclear and could also lead to
reporting: improved patient flow; 4
financial risk
hour performance improving;
Key risks
patients recording scores of over

Potential for inequity of service
95% in ‘Friends and Family’,
across both sites
reduction in the number of in
Potential perceived negative
patient beds (2014)
impact on Average Length of
Stay at Trust level
1 Project Foundation

Agree tariff and measurement
2 Research & Analysis
criteria in partnership with WSHFT
Current
C&DP
3 Co-Design

Service specification included in
Phase
contract
4 Contracting & Procurement

Supported by the Better Care Fund
5 Effective Delivery
Milestones
Description
Due Date
ACA model and Service Specification agreed
May 2015
Tariff and financial model agreed with provider
July 2015
One Call direct to ACA pathways agreed and operational
October 2015
Measures
Key delivery measure
Threshold
Number of short stay emergency admissions for Ambulatory Sensitive conditions
Reduction
Other measures
Threshold
Occupied emergency bed days for Ambulatory Sensitive conditions
Reduction
A&E 4-hour waits
Compliance
Patient Satisfaction in Ambulatory Care Areas
>85%
Impact
Costs (met by BCF)
Q1
Q2
Q3
Q4
TBC
TBC
TBC
TBC
£110,723
£229,444
Efficiencies
Gross impact
2015-16
Supporting Information & References
£0.340m
Q1
Q2
Q3
Q4
2016-17
131
Urgent Care
Discharge Planning
Overview
Description
of service
changes or
project and
aim
Why
change or
run the
project?
We will, in partnership with providers, develop processes for proactive discharge planning across
health and social care, especially for those with complex health and social care needs, will ensure
people are returned to their homes as quickly as possible with all the rehabilitation and
reablement support in place to help them return to their previous state of wellbeing or better.
Current practice does not pro-actively commence discharge planning on admission which leads
to un-necessary delayed transfers of care.
Evidence
to support
service
changes or
project
 Jointly commissioned review of
current discharge processes has
identified numerous opportunities to
improve discharge planning
processes including trusted
assessment processes
Delivery
approach
 Design and implement changes to
the discharge process in partnership
with all stakeholders
 As required deploying appropriate
incentives to support new processes
 Supported by the Better Care Fund
Key risks
Current
C&DP
Phase
 Capacity to change during
sustained demand pressure
 Insuring the right incentives to
support new processes
 Different providers adopt
solutions which are not aligned
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Implementation plan agreed by Costal Cabinet
December 2014
First wave of new discharge planning processes in place
March 2015
6 month evaluation of new discharge planning processes complete
September 2015
Measures
Key delivery measure
Threshold
Delayed Transfers of Care
<3%
Other measures
Threshold
Patients medically fit for discharge but not yet discharged
Reduction
Number of days delayed due to patient choice
Monitoring
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
132
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Urgent Care
Enhancing OCOT
Overview
part of BCF Plan
Description
of service
changes or
project and
aim
OCOT will continue to provide an integrated service offering a single point of access and rapid
assessment and intervention for people with a need for urgent care. We will secure
accountabilities for OCOT delivery into the lead provider contract with Western Sussex Hospitals
Trust. The wider admission avoidance potential of the service will be scoped with the lead
provider.
Why change
or run the
project?
Local services have continued to experience increase in demand and rising number of emergency
admissions particularly for shorter lengths of stay in the older population.
Evidence to
support
service
changes or
project
 Lead Provider models offer the
integrator both the clinical and
financial accountability for the whole
programme of care and they can
develop the pathways that make
integrated care possible (RightCare
2012)
Delivery
approach
 Securing Lead Provider
arrangements into the Western
Sussex Hospitals NHS Foundation
Trust contract.
 Supported by the Better Care Fund
Key risks
Current
C&DP
Phase
 Lead provider arrangements will
be complex to agree due to
existing cost pressures and rising
demand
 Assurance on sub-contracting
mechanisms
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Contracts in place reflecting lead provider arrangements for OCOT
April 2015
The wider admission avoidance potential of the service scoped
May 2015
Elements of a refined and enhanced OCOT model in place
July 2015
6 month evaluation of enhanced OCOT provision
January 2016
Measures
Key delivery measure
Threshold
Reduction in emergency admissions
Other measures
Threshold
% Calls answered within 2 minutes
90%
% RAIT urgent referrals seen same day
90%
Number of referrals to GP in A&E
Monitoring
Number of attenders in RAC clinics
Monitoring
Impact
Costs (met by BCF)
Efficiencies
Gross impact
Q1
Q2
Q3
Q4
TBC
TBC
TBC
TBC
£179,428
£181,400
£181,400
£177,456
2015-16
Supporting Information & References
£0.720m
Q1
Q2
Q3
Q4
2016-17
133
Community
in-patient provision
Urgent Care
Overview
Description
of service
changes or
project and
aim
Why
change or
run the
project?
Community beds are integral to patient flow through enabling discharge from acute beds and
supporting patients’ rehabilitation. They also enable some patients to remain in the community
for their short term episode of care. We will review the current configuration and function of the
available community beds to ensure they are utilized to provide maximum efficiency and
enhanced patient flow.
Community hospital beds have been shown to have longer than expected lengths of stay and not
systematically offering an effective alternative to acute hospital admission locally and nationally.
Evidence
to support
service
changes or
project
Key risks
Delivery
approach
Current
C&DP
Phase
 Workforce retention and
recruitment
 Financial sustainability of units
 Loss of capacity when Darlington
st
Court contract ends on 31 March
2014
1 Project Foundation
2 Research & Analysis
3 Co-Design
4 Contracting & Procurement
5 Effective Delivery
Milestones
Description
Due Date
SCT plan for community bed provision agreed (including decision re: cohorting)
January 2015
SCT model for community beds in place and reporting
April 2015
6 month evaluation of community bed model
October 2015
Further changes to the model agreed and implemented
January 2016
Measures
Key delivery measure
Threshold
Other measures
Threshold
Readmissions to acute care from community beds
Reduction
Occupancy levels
88%
Average length of stay
21 days
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
134
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Urgent Care
Stroke Services
Overview
Description
of service
changes or
project and
aim
Why
change or
run the
project?
Evidence
to support
service
changes or
project
Delivery
approach
Working with patients, clinicians and partners across Sussex, we will develop a stroke pathway
that delivers high quality care and improved outcomes for our patients, and supports a
sustainable model of stroke provision across Sussex. The pathway will be supported by effective
clinical networks and governance.
We know that our stroke services sometimes fall short of accepted quality standards. Our local
providers have progressed from E (the lowest rating) to ‘D’, in the Sentinel Stroke National Audit
Programme over the last year, but further improvements will require redesign of current
services.
 Review by SCDT underway drawing
together evidence for best model of
provision
 Local multi-agency collaborative
Stroke Care Improvement Group,
involving patients and public
Key risks
 Public perception of changes
 Provider engagement
 Destabilising providers
Current
C&DP
Phase
1
2
3
4
5
Project Foundation
Research & Analysis
Co-Design
Contracting & Procurement
Effective Delivery
Milestones
Description
Due Date
Option development process underway led by the Clinical Reference Group (CRG)
April 2015
Final recommended Sussex option proposed to SCCEC
September 2015
Measures
Key delivery measure
Threshold
Improvement in 10 domains of SSNAP data: initially at acute end of pathway
Other measures
Threshold
Door to thrombolysis times
Reduction
% of patients admitted to stroke wards
Increase
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
135
Urgent Care
Patient Transport Services
Overview
Description
of service
changes or
project and
aim
Why
change or
run the
project?
Evidence
to support
service
changes or
project
Delivery
approach
The pan Sussex Patient Transport Service will be procured to commence April 2016. The revised
service spec aims to ensure safe and effective non-emergency transport for eligible patients
between a place of residence and NHS healthcare setting, in a timely manner, in order that they
receive the healthcare that they need. The new service will enable greater system integration
between health and social care and local authority transport providers.
The current patient transport provider has stated that it does not wish to continue to deliver the
existing contract under the current terms beyond March 2015.
 Evaluation of activity levels by
mobility groups and analysis of
current performance issues and
complaints has informed the new
service specification.
 Sussex-wide procurement during
2015 for new service commence
April 2016.
Key risks
 Coordination and agreement
across Sussex
 Mobilisation, potential changeover of provider
Current
C&DP
Phase
1
2
3
4
5
Project Foundation
Research & Analysis
Co-Design
Contracting & Procurement
Effective Delivery
Milestones
Description
Due Date
Procurement timescales to be agreed
December 2015
Procurement commences
April 2015
Decision regarding preferred provider
October 2015
Mobilisation
November 2015
Go live
April 2016
Measures
Key delivery measure
Threshold
Delayed discharges due to PTS
Reduction
Other measures
Threshold
Aborted journeys
Reduction
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
136
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Urgent Care
7-Day Working
Overview
Description
of service
changes or
project and
aim
Why
change or
run the
project?
Evidence
to support
service
changes or
project
Delivery
approach
part of BCF Plan
In line with national policy directives including the 7-day clinical standards, we will work with
providers to ensure services can be delivered sustainably; providing a responsive and patientcentred service 7-days per week. We will offer system leadership and align provider intentions
across the system.
There is significant variation in outcomes for patients admitted to hospitals at the weekend. This
variation is seen in mortality rates, patient experience, length of hospital stay and readmission
rates.
 Keogh (2013) Ten clinical standards
for 7 day working
 Currently undertaking local gap
analysis
Key risks
 Resource to ensure 7 day working
 Workforce issues
 Incentivising contracts to support 7
day working appropriately in the
context of tariff changes
 Working Groups within providers to
address 7 day requirement
 Supported by the Better Care Fund
Current
C&DP
Phase
Not applicable
Milestones
Description
Due Date
SDIP agreed for 7-Day working business case development process
March 2015
Coastal Cabinet prioritise 5 clinical standards for delivery in 2015-16
June 2015
Business cases developed and signed off by Coastal Cabinet
September 2015
Roll out of agreed business cases begins
October 2015
5 clinical standards for 7-day working operational
March 2016
Measures
Key delivery measure
Threshold
Delayed Transfers of care at the weekend
Reduction
Other measures
Threshold
Emergency admissions at the weekends
Reduction
Readmission rate of those admitted Saturday/Sunday
Reduction
Impact
Q1
Costs (met by BCF)
Q2
Q3
Q4
£200,000
£200,000
£200,000
£40,364
£103,538
Efficiencies
Gross impact
2015-16
Supporting Information & References
£0.144m
Q1
Q2
Q3
Q4
2016-17
137
Urgent Care
NHS 111
Overview
Description
of service
changes or
project and
aim
Why
change or
run the
project?
Evidence
to support
service
changes or
project
Delivery
approach
NHS 111 is a national service that provides a single point of access for the public who require
urgent care but are not sure which service they need. The contract for Kent, Surrey & Sussex
st
service will expire March 31 2016 and a decision about the future of the service is required, this
may include re-procuring.
The contract for NHS 111 will expire in 2016.
 Learning from existing model will be
used to specify future 111 service
 Region wide procurement
Key risks
 Coordination and agreement
across region
 Mobilisation, potential changeover of provider
Current
C&DP
Phase
1
2
3
4
5
Project Foundation
Research & Analysis
Co-Design
Contracting & Procurement
Effective Delivery
Milestones
Description
Due Date
Procurement or contract extension agreed across Kent Surrey Sussex
January 2015
Scope procurement approach if required
March 2015
Procurement commences
April 2015
Mobilisation commences
December 2016
Measures
Key delivery measure
Threshold
NHS 111 response times
Compliance
Other measures
Threshold
Abandoned Calls
<5%
Calls transferred to 999
<10%
Calls referred to A&E band A target
<5%
% of call backs within 10 minutes
~
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
138
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Proactive care and long term conditions workplan
25.
Top Priorities for 2015-17:

We will drive further developments of our Proactive Care Multidisciplinary
Team model, to ensure over 12,000 local patients have personalised and
shared care plans and care coordinators by October 2015

We will deliver better outcomes in Proactive Care through person-centred
co-ordinated care by working with WSCC Commissioners through Proactive
Care and working towards integrated personal commissioning (IPC)

We will review the Proactive Care model in light of the NHS Five Year
Forward View, specifically the concept of Multispecialty Community
Providers (MCP’s)

We will commission, with our Public Health partners, a model of self-care
support and guidance from November 2015, enabling patients with Long
Term Conditions to remain well and improve both patients and professionals
confidence to self-care

We will ensure all residents of CWS in the last year of life will be identified
and be on a practice level register (EPACCS) and have access to EOLC that
meets their health, social and wellbeing needs
26.
Proactive Care is the vehicle for integration in Coastal West Sussex. In 2013-14, the
Proactive Care programme successfully rolled out 13 multi-disciplinary teams (MDTs)
clustered around 4 or 5 GP practices. This change was funded utilising NHS Funds for
Social Care and governed under Programme Management Board comprising of
Executives from commissioners and providers. In 2014-15 this was enhanced
through establishing Sussex Community NHS Trust as Lead Provider working in
partnership with key providers.
27.
We supported this by purchasing and successfully rolling out a risk stratification tool
to help identify and case find patients at risk of admission. We are continuing to
refine the tool to better identify patients who are at risk and require support from
the Multi-Disciplinary Teams (MDTs) through a clinically led steering group.
28.
Additionally we have already started reviewing and designing new services models
for some long-term conditions and end of life care services and in 2015-16 will we
build on this and Proactive Care MDTs through our key change projects:







29.
Proactive Care Multi-Disciplinary Teams (MDTs)
Proactive In-reach
Joint Assessment and Support Planning
Self-care for Long Term Conditions
Diabetes
Heart Failure
End of Life Care
In 2015-16, we will ensure care coordination is firmly embedded within the
Proactive Care ethos to enable patients to be better supported when they are well
Supporting Information & References
139
and unwell, and ensuring that Proactive Care is the default for patients who require
more support in a crisis through a clearly defined case management role within the
MDTs. (Care co-ordination is supporting patients whoever is providing their care,
whether in the community or during an acute admission.) Evidence suggests that
through care co-ordination and case management, patients will access the service
they need, navigating across organisational boundaries through sharing of patient
information (with the patient’s consent) to ensure patients feel the benefit of telling
their story once and reducing often duplicated assessments.
30.
This change to be underpinned by generic training and development to equip staff
with the knowledge and skills they require to deliver integrated care with individual
patients. Develop a CQIN to ensure there is a whole system training programme to
deliver care coordination across organisational boundaries, measured through the
uptake of the training and in the patient’s experience of the coordinated care.
31.
In 2015-17, we expect to see Proactive Care having an overall impact on over 65
emergency admissions and will work with the Acute Providers on how Proactive
Care can help deliver the relative smaller acute footprint. To do so we will need to
ensure that community services (including community beds) are ready to meet more
demand through considering developing Complex and Simple MDT specifications
and exploring the opportunities of Multispecialty Community Providers.
32.
We will also re-tender Risk Stratification Tool in July 2015 to also in EPACCS (an end
of life care register), with the intention of identifying patients who are at risk of
deterioration in their conditions, at risk of acute admission or who require self-care.
33.
Our End of Life Project will enable better identification of patients entering their last
year of life, ensuring that practices keep an End of Life register (EPACCS). In End of
Life care, we wish to see the last year of life as a continuation of good assessment
and care and support planning, ensuring patient’s wishes and feelings are clear and
are accessible at times of crisis. This includes engaging with the public in how to
deliver better care for patients reaching end of life and ensuring the public
understand the need for change. A coordination solution for EOLC will be agreed
which delivers better outcomes for all patients identified as reaching their last year
of life. The EOLC project will ensure commissioned (both Health & Social Care)
services enable the patient to remain in their preferred place of death and have
access to specialist services if necessary.
34.
We have been working with WSCC Commissioners alongside other CCGs in West
Sussex to develop a Personalisation Framework during 2013-14. The project in 201415 is focused on embedding and delivering integrated care to people with long term
conditions and for older people who are frail with an increased risk of acute
admissions. The project is aimed at improving the quality of experience of patients
who use services, to ensure patients or people who access services have active
involvement in planning their care and support. Evidence of progress to date
demonstrates that patients supported by Proactive Care have decreased risk of
admission to hospital.
35.
Real-time IT solutions will need to be in place to improve communication and
collaboration between all providers. We, with our partner agencies, are working
towards an IT solution known as ROCI (Read Only Care Information). This enable
information to be viewed from key organisations IT systems to give a whole view of
the patients’ health and social care needs and the care and support that is in place
140
NHS Coastal West Sussex CCG | Delivering the vision
to meet their needs, improving clinical information for professionals who not know
the patients.
36.
Our key business as usual area is Community Nursing; over the next 2 years this
service will be combined with our Proactive Care Programme, to deliver the same
outcomes as Proactive Care for our patients.
37.
Key milestones for 2015-17 are:
Date
Milestone
Mar
2015
Agree CQuINs to support the new End of Life
Care model
Apr
2015
New Proactive Care Service Specification
supported by a Business Case agreed and
included in Lead Provider contract
Jul
2015
Review learning from Proactive Care in-reach
pilot and decide next steps
Nov
2015
Implementation of the new EOLC model begins
Dec
2015
Propose future service model for diabetes
Commissioning
Manager
Mar
2016
Model of integrated assessment and Care and
Support Planning in place
Senior
Commissioning
Manager
Supporting Information & References
Accountable
Head of Proactive
Care
Senior
Commissioning
Manager
Senior
Commissioning
Manager
Senior
Commissioning
Manager
141
Proactive Care
MDTs
Overview
part of BCF Plan
Description
of service
changes or
project and
aim
We will continue to commission, through a Lead Provider contract, 13 Proactive Care MDTs to
deliver integrated care to patients who are frail or complex long term conditions to reduce their
risk of being admitted to hospital in an emergency.
Why change
or run the
project?
We continue to see increases in emergency admissions for frail older people. Whilst different
organisations continue to transfer patients between services rather than supporting them to
navigate health & social care services, and an absence of shared care planning processes.
Evidence to
support
service
changes or
project
 Patients want services to work
together in an integrated way to
meet their needs. (National Voices,
2012)
 Evidence suggests supporting more
patients through integrated care,
could lead to a reduction in activity
in acute care.
Key risks
Delivery
approach
 New Proactive Care Service
Specification in place secured within
Lead Provider contract
 Aligning to National Enhanced
Services for emergency admissions
 Supported by the Better Care Fund
Current
C&DP
Phase
 IT is not in place to enable sharing
of information between different
organisations and
professionals/clinicians
 Shortage of GPs and nurses in the
community to enable the changes
needed
 On-going support from key
stakeholders
1 Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Revised Proactive Care Service Specification in Lead Provider contract
April 2015
Review of Proactive Care and Multispecialty Community Provider (MCP) model begins
October 2015
Measures
Key delivery measure
Threshold
Emergency admissions for patients on Proactive Care caseload
Reduction
Other measures
Threshold
Number of patients supported in Proactive Care
Increase to 12,200
Number of emergency admissions for people >65
On/below plan
Number of A&E attendances for people >65
On/below plan
Impact
Costs (met by BCF)
Efficiencies
Gross impact
142
Q1
Q2
Q3
Q4
£2,021,750
£2,021,750
£2,021,750
£2,021,750
£593,188
£828,279
£1,063,369
£1,298,460
2015-16
£3.783m
Q1
Q2
Q3
Q4
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Proactive Care
Proactive In-reach
Overview
part of BCF Plan
Description
of service
changes or
project and
aim
We are currently piloting a model whereby MDTs actively pull patients out of acute care through
their involvement in discharge decisions. We will review its effectiveness and consider how this
may work with other changes to discharge processes currently in development. Regardless all
solutions will involve the early identification of patients who have a care coordinator and uses
this to reduce length of stay.
Why change
or run the
project?
Community services, including social care, and acute services are not systematically working
together to reduce length of stay or utilise existing community care established for patients.
Evidence to
support
service
changes or
project
 Active Case Management is a key
component of supporting LTC and
frail older patients (Kings Fund,
2013)
Key risks
Delivery
approach
 Pilot project supported by full
evaluation
 Costs met within existing Proactive
Care investment
 Supported by the Better Care Fund
Current
C&DP
Phase
 Resources not aligned to support
more patients in the community
 Financial pressures felt by
commissioners and providers at a
time of austerity
 Sharing information is disjointed
and difficult for professionals
1 Project Foundation
2 Research & Analysis
3 Co-Design
4 Contracting & Procurement
5 Effective Delivery
Milestones
Description
Due Date
Evaluation of Proactive in-reach at Worthing Hospital
July 2015
Agree next steps on in-reach model with key stakeholders and providers
August 2015
Roll out of Proactive in-reach at local hospitals on admission, medical and older people’s
wards begins
October 2015
Measures
Key delivery measure
Threshold
Length of stay for patients supported by Proactive Care MDTs
Reduction
Other measures
Threshold
Delayed transfers of Care for patients supported by Proactive Care MDTs
Reduction
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
143
Joint Assessment and
Support Planning
Proactive Care
Overview
part of BCF Plan
Description
of service
changes or
project and
aim
We will develop Proactive Care MDTs so that patients identified through the risk stratification
tool, will have an integrated assessment of their health and social care needs; and active
involvement in formulating their integrated care and support plan that is shared and accessible
across the whole system. This will mean patients will be supported through a named Accountable
Lead Professional who has access to more specialist support if the patients’ needs require it. This
change to be underpinned by generic training and development to equip staff with the
knowledge and skills they require to deliver integrated care with individual patients.
Why change
or run the
project?
There are currently many duplicate care and support planning processes in use across various
settings and services, even with existing Proactive Care MDTs.
Evidence to
support
service
changes or
project
Delivery
approach
 Evidence review and model
development on-going
Key risks
 Task & Finish group approach
working in with WSCC
Commissioners and other West
Sussex CCGs.
Current
C&DP
Phase
 Professionals willing to adopt
more integrated care and support
planning approaches
 Adult Services ability to change
whilst meeting their duties under
the Care Act
 IT interoperability to deliver realtime access to patient information
and care plans
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Agree Project scope and timeframes with stakeholders
April 2015
Agree joint assessment framework with stakeholders
October 2015
Implement an agreed patient joint assessment framework
April 2016
Implement agreed information sharing protocols
April 2016
Measures
Key delivery measure
Threshold
Other measures
Threshold
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
144
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Self-Care for Long
Term Conditions
Long-term conditions
Overview
Description
of service
changes or
project and
aim
We will scope and develop patient centred, outcomes driven integrated care pathways for that
are aligned to the Year of Care philosophy and specifically self-care. This includes ensuring
appropriately trained professionals deliver support to patients that empower them to self-care.
Why change
or run the
project?
Current support planning for patients with long term conditions is disjointed and not universally
shared across health and social care providers; reactive rather than proactive in identifying goals
and self-care objectives.
Evidence to
support
service
changes or
project
 The House of Care model is shown to
deliver better outcomes through
person-centred co-ordinated care
Key risks
Delivery
approach
 Service specifications to be put in
place or updated as appropriate
 Scoping for larger scale service
redesign
Current
C&DP
Phase


1
2
3
4
5
Conflicting organisational
priorities compromise pathway
oriented care delivery
Alignment with other initiatives
and service changes
Project Foundation
Research & Analysis
Co-Design
Contracting & Procurement
Effective Delivery
Milestones
Description
Due Date
Scope models of self-care and report to CCE
June 2015
Specify outcomes for Proactive Care Lead Provider in regard to self-care
July 2015
Consider procurement options with WSCC commissioners for delivery of self-care model
July 2015
Measures
Key delivery measure
Threshold
Number of patients who have a self-care plan in place
Increase
Other measures
Threshold
Patients feeling supported to manage their condition
Increase
LTC Patients feeling involved in making decisions
Increase
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
145
Long-term conditions
Heart Failure
Overview
part of BCF Plan
Description
of service
changes or
project and
aim
The Heart Failure workstream will include; implementation of BNP blood testing to assist
diagnosis of heart failure; development of a new specification for Specialist Heart Failure Nurses
to manage more patients in the community, supported by consultant-led services. This will
enable increased access to timely services as well as pro-active and preventative care that
reduces the need for hospital admission, particularly for vulnerable elderly patients with complex
needs. In the longer term, there is also potential for future exploration of delivering services
within the MCP model in partnership with primary care.
Why
change or
run the
project?
Heart failure places a high demand on inpatient, emergency and hospital readmissions,
accounting for approximately 5% of all medical admissions, and 1 in 4 HF are re-admitted within
3 months. There is also inequity of specialist community nursing services within Coastal West
Sussex.
Evidence
to support
service
changes or
project
 Holistic and timely interventions
provided by a community nurse
specialist not only help to reduce
patient morbidity, but also potentially
prevent costly care episodes (Baxter
and Leary 2011, Procter et al 2012)
Delivery
approach
 Implementation of a defined clinical
pathway for suspected and established
heart failure (BNP blood testing &
access to community and acute based
clinics)
 Introduction of locally commissioned
services in Primary Care
 Supported by the Better Care Fund
Key risks
Current
C&DP
Phase
 Access to data to understand the
outpatient and community costs
to support the business case
 Alignment of community and
acute pathways
 Recruitment and workforce
development
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Outcome of CVD diagnostic report discussed at CCE
March 2015
Implementation of BNP blood testing
April 2015
Heart Failure Service specifications with clear and measurable KPIs signed off by CCE
July 2015
Business case signed off by CCE including the preferred delivery and contracting option
August 2015
Implement the preferred option for delivery
October 2015
Measures
Key delivery measure
Change
Number of emergency admissions and readmissions for patients diagnosed with Heart
Failure
Decrease
Other measures
Change
Number of acute outpatient follow up appointments in Cardiology
Decrease
18 weeks RTT compliance in Cardiology
Increase
Impact
Q1
Q2
Q3
Q4
Costs (met by BCF)
£1,678
£53,133
£103,903
£155,030
Efficiencies
£5,536
£10,338
£81,335
£112,903
Gross impact
146
2015-16
£0.210m
Q1
Q2
Q3
Q4
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Long-term conditions
Diabetes
Overview
Description
of service
changes or
project and
aim
Why
change or
run the
project?
Evidence
to support
service
changes or
project
Delivery
approach
We will commission a more integrated diabetes service model, where providers work
collaboratively across the system in the best interests of the patient, with secondary care
providing system-wide clinical leadership. An integrated performance management framework
has been developed setting out five year outcomes based targets. It describes how each
provider will contribute to achieving the targets. The service through earlier identification will up
skill staff and reduce the prevalence gap; therefore people with diabetes will be more tightly
managed, thus increasing the number of engaged patients, reducing the risk of complications
and increase the optimization of use of medicines.
A local review has shown that there is a mixed picture of service provision. The number of
diabetics is expected to grow with prevalence rate increasing from 4.5% to 9.9% by 2030.
Diabetes is a condition that undermines good health and underpins many other conditions. The
complications relating to diabetes are far reaching and costly. However, many diabetic
complications can be prevented or minimised with good blood glucose control
 Practice engagement and sign up
to the LCS
 Year of Care training taking place –

current trainer unavailable
Key risks
 Working relationship with Public
Health and Primary Care to find
people with pre diabetes
 Locally commissioned services
 Specifications included in provider
contracts
 Educational approach for clinicians and
patients
Current
C&DP
Phase
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Sign off Acute and Community service specifications
March 2015
Diabetes commissioning report 2015 recommendations adopted
April 2015
Secure and train Year of Care trainer
April 2015
Implement Year of Care education program
May 2015
Develop multi-agency steering group to steer the delivery for the diabetes pathway
May 2015
Propose the future service model for diabetes
December 2015
Measures
Key delivery measure
Change
Number of people with diabetes attending DESMOND education and training
Increase
Other measures
Change
Number of participating GP practices achieving target set in LCS
Increase
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
147
Long-term conditions
End of Life Care
Overview
Description
of service
changes or
project and
aim
Why change
or run the
project?
Evidence to
support
service
changes or
project
Delivery
approach
We will be agreeing how the new EOLC model will be delivered and by 2016 in the final phase of
implementing the new collaborative EOLC model which will include, identifying people in their
last year of life; coordinating their health and social care support according to their needs and
sharing this through a EOLC Plan; and a recommended competency based staff education and
training.
We currently see lower than expected levels of identification, and 90% of the local specialist End
of Life care services are used by those with a diagnosis of cancer, despite cancer being the cause
of 26% of death’s locally. Additionally residents aged 85+ are 10% more likely than the national
average to have an acute admission that ends in death.
 Evidence identifies that locality End
of Life care electronic registers
 Provider organisations unable to
(EPaCCS) improve care co-ordination
collaborate effectively
and outcomes (DoH, 2008).
Key risks
 Ability of providers to mobilise to
 NHS IQ state that by 2015 there
meet service changes, may not
should be a 70% roll out of EPaCCS
keep pace with the project
across England (2014)
 Collaborative redesign with partners
1 Project Foundation
and stakeholders to define a new
2 Research & Analysis
service specification
Current
3 Co-Design
C&DP
 As required changes to provider
Phase
contracts
4 Contracting & Procurement
 Potential support from Better Care
5 Effective Delivery
Fund
Milestones
Description
Due Date
Business case EOLC model presented to CCE
August 2015
Provider negotiations and contracts complete and in place
October 2015
Monitoring arrangements (including dashboards) in place
October 2015
Implementation of the new model begins
November 2015
Overall evaluation of new model begins (9 months post implementation)
August 2016
Decision about further commissioning of new model
October 2016
Measures
Key delivery measure
Threshold
Increase to 2125 per
annum
Levels of identification of those in the last year of life (compared to expected levels)
Other measures
Threshold
% of people identified with EOLC needs with a completed EOLC plan
90%
% of people identified with EOLC needs dying in their stated Preferred Place of Care
85%
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
148
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Mental health workplan
38.
Priorities for 2015-17:

We will improve support for people with dementia and their carers in a
crisis by commissioning increased capacity in the dementia crisis services
from April 2015

We will reduce delays in access to assessment, diagnosis and treatment by
redesigning the Memory Assessment Service

We will deliver improvements in ‘access to support before crisis point’ and
‘the right quality of treatment and care when in crisis’ implementing our
Crisis Care Concordat Action Plan from January 2016

We will design, deliver and monitor a Tier 2 Service to ensure accessible
support earlier in a person’s journey which is focused on prevention and
recovery which will be in place by September 2016

We will support the achievement of ‘Parity of Esteem’ by developing and
implementing faster access to; psychological services in primary care; to
treatment for first episode of psychosis; effective liaison services in acute
hospitals; proactive physical healthcare for those with a severe mental
illness and empowering people to know their rights regarding choice.
39.
Demand for mental health services is growing locally, as it is nationally. In recent
years the shift has been away from providing mental health care and support in a
hospital setting, to providing more within communities. Mental health care has
become an increasing priority both locally and nationally and this is reflected in the
Parity of Esteem agenda and the Mental Health Crisis Care Concordat. There is also
an increasing need and focus to integrate mental health and physical care, as well as
health and social care services in order to deliver better outcomes for patients.
40.
There is also an increasing need and focus to integrate mental health and physical
care, as well as health and social care services in order to deliver better outcomes
for patients. The need to improve physical health outcomes for people experiencing
mental health problems is underpinned by fact that someone with a mental health
condition will typically die between 15 and 20 years earlier than someone without,
and that people with intellectual disabilities continue to suffer unnecessarily with
untreated, or poorly managed, conditions. The important theme of improving
physical healthcare runs through all of our work streams with specific improvements
to be reinforced through a stand-alone CQuIN with our main Mental Health provider
during 2015-16.
41.
In 2015-17 we will continue to implement the 5 year Functional Mental Health and
Dementia Joint Commissioning strategic frameworks, focusing on developing,
delivering and sustaining accessible, responsive and high quality services designed to
meet the individual’s needs. These developments will be supported by improving
information and tools enabling people to exercise their right of choice.
42.
We have made good progress this year with the development of a new urgent care
pathway which means GPs are able to access mental health services quickly and
Supporting Information & References
149
effectively for patients who are in crisis and needing urgent care. The Time to Talk
service, which delivers counselling and other psychological therapies to people with
common mental health problems, continues to perform well. Developments to
speed up access are under discussion and a new ‘self-referral’ system is being
piloted in several areas.
43.
We are also working hard to ensure local services meet quality standards regarding,
safety, effectiveness and experience and include current mental health access time
measures, for example, urgent assessment and treatment within 4 hours, priority
(within 5 days), routine (within 28 days) and routine treatments within 18 weeks of
referral.
44.
In addition, we are working with providers to establish systems, based on existing
data, to accurately report on the new national standards; these will be added to
routine monitoring from April and we are planning in line with national guidance to
meet the targets before Q4 2015-16. These targets are;


Treatment within 6 weeks for 75% of people referred to the ‘Time to
Talk’ (IAPT) service, with 95% of people being treated within 18 weeks
Treatment within 2 weeks for more than 50% of people experiencing a
first episode of psychosis.
45.
Development and implementation of the Mental Health Crisis Care Concordat action
plan will improve the outcomes for people experiencing mental health crisis
reducing the occasions where people, including the young and vulnerable, are
assessed in police cells. This will be supported by a joint declaration from all
stakeholders supporting the concordat.
46.
The Dementia Crisis Service will have increased investment in order to offer more
capacity to support those patients with dementia, and their carers when in crisis. In
addition to extra staff within the Dementia Crisis Teams, there will also be extra
investment in the provision of short term social care packages to support avoidance
of admission to hospital and discharge from hospital when clinically indicated.
47.
The Memory Assessment Service has diagnosed and supported many patients since
its implementation. However, the pathway needs to be reviewed in order to
improve the patient journey and experience and to reduce unacceptable waiting
times. Therefore, the focus will be on redesigning the MAS pathway to ensure that
demand can be managed effectively.
48.
Prevention and early intervention will be strengthened with the redesign of Tier 2
‘Targeted Services’. This will primarily involve the services currently provided by our
3rd sector partners, but will require collaborative working with statutory NHS
providers. The pathway for rehabilitation and recovery within Sussex partnership
NHS Foundation Trust (SPFT) will also be reviewed to establish opportunities for
improvement and commissioning options.
49.
Progress has been made throughout 2014-15 in developing improved, clearer
pathways of support through Payment by Results in mental health. The focus for 1516 is three fold: a) implementing optimal cluster pathways across MH secondary
care, b) Develop a shadow tariff based on activity, quality and outcomes, and c)
monitoring of shadow arrangements. Payment by Results in mental health
represents an exciting opportunity to transform mental health services. Anticipated
gains include clear information for patients, families and carers to inform their
150
NHS Coastal West Sussex CCG | Delivering the vision
understanding of what to expect, an improved focus on quality and outcomes and a
mechanism to drive improvements in value as a return on investment in mental
health services.
50.
Key milestones for 2015-17 are:
Date
Milestone
Accountable
Senior
Commissioning
Manager
Senior
Commissioning
Manager
Dementia
Commissioning
Manager
Mar
2015
Mental Health Crisis Care Concordat Action Plan
signed off by all stakeholders
Mar
2015
Implementation of new contract currency in SPFT
MH contract, supported by the PbR Development
Programme
Apr
2015
Increased capacity in Dementia Crisis Services
Apr
2016
Tier 2 ‘targeted services’ model implemented
Commissioning
Manager
Apr
2017
Implementation of improved access for patients
and partner agencies requiring advice and
support in mental health crises.
Commissioning
Manager
Supporting Information & References
151
Mental Health
Dementia Crisis Service
Overview
Description
of service
changes or
project and
aim
Why change
or run the
project?
Evidence to
support
service
changes or
project
Delivery
approach
part of BCF Plan
We will commission additional practitioners across the 2 Dementia Crisis Teams in Coastal West
Sussex as well as increased capacity to deliver short term social care packages. The aim is to
increase capacity within the service against a rising prevalence and demand in order to deliver
care at home, reduce hospital admissions and facilitate discharge from hospital.
There are currently 13,000 people living in West Sussex with Dementia and this is set to grow by
14% by 2017 and by 26% by 2021, with an increased predicted associated social care cost of 25%
over the same period. This growth in demand means that the dementia crisis team are more vital
than ever, and expanding the team would allow them to focus on the whole urgent care
pathway, supporting teams such as proactive care on discharge, as well as consolidating their
current role in admission avoidance.
 Recruitment of additional staff and
 The 3 teams currently avoid 50
retention
admissions to acute care per month.
 Poor partnership working across
Increased capacity will support more Key risks
health and social care
patients, and their carers, and
 Discontinued financial support
potentially avoid more admissions.
from Better Care Fund post 15/16
 Contract Variation with Sussex
Partnership NHS Foundation Trust
 Supported by the Better Care Fund
Current
C&DP
Phase
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Securing of extra investment through Better Care Fund
January 2015
Recruitment of additional posts
February 2015
Implementation of enhanced service (part year effect)
February 2015
Full implementation of enhanced service
April 2015
Review of first year of enhanced service
April 2016
Measures
Key delivery measure
Threshold
Number of admissions to acute hospital avoided per month against a baseline (Feb 2014)
% Increase
Other measures
Threshold
Number of discharges from hospital to residential or nursing care against a baseline
% Reduction
Number of discharges facilitated per month against a baseline
% Increase
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
152
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Mental Health
Dementia Support Workers
Overview
part of BCF Plan
Description
of service
changes or
project and
aim
We will commission dementia support workers to work with people diagnosed prior to the
memory assessment service becoming operational in September 2012.
Why change
or run the
project?
Currently only people diagnosed after September 2012 have access to dementia advisers to
enable post diagnosis support for the person with dementia and their carer. This represents a
clear inequity in provision and a missed opportunity to provide a preventative approach to care.
This service has been recommended as a key development by HASC, CCG Boards and throughout
the public consultation for the West Sussex dementia framework.
Evidence to
support
service
changes or
project
Delivery
approach
Key risks
 There will be a Contract Variation to
an existing contract with the
Alzheimer’s Society
 Supported by the Better Care Fund
Current
C&DP
Phase
 Recruitment and retention
 Partnership working
 Discontinued financial support
from Better Care Fund after 201516
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Securing of extra investment through Better Care Fund
December 2014
Baseline activity set
December 2014
Recruitment of additional posts
February 2015
Implementation of enhanced service (part year effect)
February 2015
Full implementation of enhanced service
April 2015
Review of first year of enhanced service
April 2016
Measures
Key delivery measure
Threshold
Numbers of patients with Dementia, diagnosed pre-Memory Assessment Service,
supported within the service
% Increase
Other measures
Threshold
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
153
Mental Health
Payment by Results
Overview
Description
of service
changes or
project and
aim
The CCG will review progress to date and implement, where appropriate, the nationally
mandated programme of Payment by Results in mental health in line with national guidance, and
to improve quality and outcomes for patients using mental health services. This programme of
work will include all current providers of mental health services including Sussex Partnership NHS
Foundation Trust and Sussex Community Trust.
Why change
or run the
project?
Payment by Results is a key mechanism to deliver the transformational change needed within
mental health services and because data quality, especially around outcomes, is poor and block
contracts are not transparent.
Evidence to
support
service
changes or
project
Not applicable
Key risks
 Inaccurate/incomplete data from
the provider
 Tariff costs being over contract
value
 System readiness to move to PbR
 Opportunities to strengthen
quality & outcomes in provision
are not realised
Delivery
approach
 Proposed budget cap set out within
contracts
 PBR to run in shadow form
Current
C&DP
Phase
Not applicable
Milestones
Description
Due Date
SPFT contract renegotiated
March 2015
Development of appropriate data quality measures complete
March 2015
New contract currency implemented
April 2015
Monitoring of data quality and activity
Throughout 2015
Implement contractual changes as appropriate
April 2016
Measures
Key delivery measure
Threshold
Data quality (as a %) against baseline (Mar 2015)
Increase
Other measures
Threshold
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
154
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Mental Health
Crisis Care Concordat
Overview
Description
of service
changes or
project and
aim
We will achieve parity in the access to and quality of urgent Mental Health care in line with the
Mental Health Crisis Care Concordat. To improve the system of care and support so people in
crisis because of a mental health condition are kept safe and helped to find the support they
need – whatever the circumstances in which they first need help – and from whichever service
they turn first.
Why change
or run the
project?
It is recognised that in too many cases people find that services for patients experiencing a
mental health crisis, do not respond effectively. The concordat recognises the need for agencies
to work together to implement change
Evidence to
support
service
changes or
project
 Gap analysis against national
standards as identified in the
Concordat
 Specific changes not yet agreed
Delivery
approach
 In partnership with providers and
stakeholders, analyse and
understand where there are gaps in
current service provision
 Develop a detailed action plan based
on the 4 sections within the
concordat
Key risks
Current
C&DP
Phase
 Partners may not agree on the
locally identified priorities
 Difficulty recruiting staff
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Crisis Care Concordat Action Plan (including priorities) complete
June 2015
Project plans (and PIDs) each priority area complete
September 2015
T&F groups developed and in place for each priority area
December 2015
Implementation begins
January 2016
Measures
Key delivery measure
Threshold
Number of patients detained in custody suites
50% Reduction
Other measures
Threshold
Referral to assessment time for A&E liaison services
% Reduction
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
155
Mental Health
Tier 2 Mental Health Service Model
Overview
Description
of service
changes or
project and
aim
The CCG will redesign and strengthen the early intervention mental health support available in
primary care and community settings. By implementing Tier 2 ‘hubs’ where a holistic range of
needs can be met, providing an integrated and consistent pathway. A wide range of stakeholders
will be involved in this work including Sussex Partnership NHS Foundation Trust, but the majority
rd
of the services indicated sit within the 3 sector.
Why change
or run the
project?
During the Strategic Framework consultation work it was apparent that a wide range of
stakeholders, including service users, their carers and families, felt the current provision was
fragmented and confusing and to meet emerging need locally.
Evidence to
support
service
changes or
project
 Changes are designed based on the 5
key elements of a hub model (PWC,
2012):
o Speed
o Engagement
o Responsive
o Value
o Integration
Delivery
approach
 Redesign will be supported by
contract variation
 Re-commissioning if/as required
Key risks
Current
C&DP
Phase
 Lack of engagement by providers
 Lack of agreement regarding use
of MHLP resource
 Tender/procurement exercises
may delay delivery
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Draft Tier 2 Service Specification
January 2015
Consultation with stakeholders on draft specification
April 2015
Options for delivery of new model presented to CCE
July 2015
Re-design or procurement
December 2015
Implementation of new model
September 2016
Measures
Key delivery measure
Change
Patients satisfied or very satisfied with the service
80%
Other measures
Change
Referrals from primary care
% Increase
Referrals to secondary care
% Reduction
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
156
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Mental Health
Memory Assessment Service
Overview
Description
of service
changes or
project and
aim
To redesign the MAS pathway to ensure that rising demand does not cause unacceptable delays,
as well as supporting the development of greater capacity in primary care for primary care
assessment and diagnosis.
Why change
or run the
project?
Waiting times for assessment are currently too long due to higher than planned demand for this
service.
Evidence to
support
service
changes or
project
Delivery
approach
Key risks
Current
C&DP
Phase
 Redesign with providers
 Lack of investment to increase
capacity
 Increased impact on GP services
and acute care
 Focus on diagnosis unsustainable
demand on-going support
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Scope and appraise options for pathway redesign
June 2015
Agree redesign programme with Primary Care and Providers
December 2015
Complete implementation of redesign with Primary Care and Providers
June 2016
Evaluation of redesign with Primary Care and Providers
June 2017
Measures
Key delivery measure
Threshold
Waiting time from assessment to diagnosis
Reduction
Other measures
Threshold
Waiting times from referral to assessment
Reduction
Waiting times from diagnosis and support commencement
Reduction
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
157
Learning disabilities workplan
51.
52.
Priorities for 2015-17:

We will reduce health inequalities experienced by people with learning
disabilities and deliver a clear joined up strategy to ensure effective health care
and reduction in premature deaths as highlighted by the CIPOLD report

We will continue to develop our local response to the national Transforming
Care programme, with a clear focus around preventing admission to in-patient
settings and ensuring effective community services for people with challenging
behaviour

We will commission good quality accommodation and promote independence
and safety for people with learning disabilities

We will develop employment opportunities for people with learning disabilities

We will develop and commission services that promote choice and control and
citizenship for people with learning disabilities
We will reduce health inequalities experienced by people with learning
disabilities and deliver a clear joined up strategy to ensure effective health care
and reduction in premature deaths as highlighted by the CIPOLD report
A number of recent national reports and inquiries have clearly indicated that,
compared to the wider population, people with learning disabilities continue to
experience generally poorer health outcomes, premature death, lead less healthy
lives and experience relatively poor access to and quality of health care services.
The quality of local data however is poor, so the local evidence for health
inequalities is not clear.
53.
The aim of the LD Commissioning Framework is to build on what has already been
achieved and developed to ensure that local people with learning disabilities are
able to live longer and healthier lives, have good physical, mental and emotional
health and get access to the healthcare that they need.
54.
Develop our local response to the national Transforming Care programme
The West Sussex response includes a range of actions and initiatives, some of which
are now mandatory for all commissioning bodies and others which are local to West
Sussex and involve local commissioners working in partnership with local
stakeholders to ensure that a robust and joined up action plan is delivered and best
possible outcomes for customers are achieved. Its key actions and objectives
include ensuring clear leadership and accountability. A Named lead in place and
clear partnership arrangements between CCGs and WSCC, including clear process
and accountability for collation and submission of NHS England Assurance
information. Ensuring effective and joined up care coordination and review is also
key, to ensure a clear focus on effective assessment, support planning, review and
the prevention of in-patient admission wherever possible and facilitates on-going
review and discharge planning for customers residing in in-patient settings for
assessment and treatment. Through effective planning and joint commissioning, to
ensure appropriate, safe, high quality and best value accommodation & care and
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NHS Coastal West Sussex CCG | Delivering the vision
support services are available locally for people with learning disabilities, including
people with severe autism and people with learning disabilities who also have
mental health conditions or behaviours viewed as challenging.
55.
Developing employment opportunities and citizenship for people with learning
disabilities.
The LD Commissioning Framework sets out a range of plans and objectives to
promote and enable people with learning disabilities to play active roles in their
communities as full and equal citizens. This includes supporting people to take up
and sustain paid employment and volunteering opportunities. It also includes
supporting people to access their communities and to develop and sustain social
opportunities, friendships and relationships.
56.
Employment is widely acknowledged as a key means of achieving citizenship and
greater social and economic independence. Nationally people with learning
disabilities remain significantly underrepresented in the work place when compared
to the general population and also to other disabled people. In West Sussex there
are over 200 people with a learning disability known to be in some form of paid
employment. Some of these people have relatively lower support needs and are not
eligible for community care services. Many people in employment are also working
for fewer than 16 hours per week.
57.
Day services have a key role to play in enabling people with learning disabilities to
sustain and develop independent living skills, access their community, develop and
sustain social skills and friends and relationships and achieve full citizenship.
Currently in West Sussex there are a wide range of day services provided by both the
County Council and a range of independent sector organisations. There is work ongoing and future plans, set out in this Framework, to review day services provided by
WSCC. There are also plans to work with providers of day services in the
independent sector to support effective communication with the market place and
establish clear expectations between commissioners and providers around quality
and price, whilst at the same time promoting market development and innovation.
58.
A range of ‘prevention’ services are commissioned and are available to both
customers who meet eligibility for community care services and people with learning
disabilities who are not eligible for community care, but who may require
information, advice or support accessing community services. These services are
provided by local voluntary and community organisations. Like day services, these
services have a key role in enabling people with learning disabilities to develop social
opportunities, friendships and relationships and achieve full citizenship. They can
also promote social inclusion, self-help and resilience and help to prevent people
from requiring specialist social care support. Key to the successful delivery of this
objective will be the performance of My Network and My Network Plus and effective
partnerships with local community organisations and universal services.
59.
We will develop and commission services that promote choice and control and
citizenship for people with learning disabilities
The LD Commissioning Framework sets out a range of plans and objectives for
improving the choice and control people with learning disabilities have over their
support and their lives. This includes the on-going development of personalisation
and self-directed support, effective person centred planning and the provision of
advocacy, information and advice for customers and the wider population of people
with learning disabilities.
Supporting Information & References
159
60.
Key to improving choice is also the development of information and other
mechanisms that enable people with learning disabilities and their families to make
informed choices from a wide range of good quality and good value support options.
At present, some parts of the county have a better choice and range of services than
other parts. This Framework sets out plans to address this, such as reviewing the
provision of existing services, supporting and promoting the development of new
services and by working closely with existing service providers.
61.
We will commission good quality accommodation and promote independence and
safety for people with learning disabilities
The LD Commissioning Framework sets out a range of plans and objectives for
ensuring adults with learning disabilities are supported to lead as independent lives
as they are able to, but at the same time ensure their safety and wellbeing.
62.
This includes a range of measures to ensure the continuous improvement of the
learning disability assessment and support planning service and the range of
supports and interventions they offer people with learning disabilities and their
carers. This part of the learning disability service has a critical role to play in
assessing the support needs of adults with learning disabilities and their carers and
planning and coordinating support. At the time of transition into adulthood, there is
a particular focus on effective joined up assessment and support planning across
Adults’ and Children’s services and other agencies, to ensure customers and families
are well supported to plan for the future. The assessment and care management
service also has a lead role in the assessment and management of risk and mental
capacity. Ensuring risk is assessed in a positive manner, that support plans are
effective, cost effective and regularly reviewed, that key outcomes for customers are
being delivered and that vulnerable people are safeguarded from abuse is critical to
the effective delivery of support to people with learning disabilities and their carers.
63.
The LD Commissioning Framework includes accommodation services and recognises
the important role good quality accommodation has to play in delivering a range of
outcomes for people, such as health, wellbeing, independence and citizenship. The
Framework sets out how a suitable range of good quality, good value
accommodation and where appropriate assistive technologies, will be commissioned
and provided for people who require an accommodation service. We know, for
example, that today and in the future, more good quality, cost effective local
accommodation options will be required for older people with learning disabilities
and for people with the highest support needs who may also have challenging
behaviour.
64.
The LD Commissioning Framework highlights the critical priority of protecting
vulnerable adults from all types of abuse, in the wake of the Winterbourne View
scandal in 2011. In addition to ensuring safety and wellbeing within service settings,
this Framework also sets out plans and objectives to promote community safety and
prevent and respond to all forms of hate crime and discrimination experienced by
people with learning disabilities in their communities.
65.
Supporting carers, who provide significant amounts of care and support to people
with learning disabilities in their own homes and communities, is critical to
promoting and maintaining people’s independence and safety. The LD
Commissioning Framework sets out a range of plans and objectives in relation to
carers, to ensure their needs are assessed and met, to ensure they have access to
the advice, information and support they need and to ensure they are effectively
involved in planning and commissioning of services.
160
NHS Coastal West Sussex CCG | Delivering the vision
66.
Key milestones for 2015-17 are:
Date
July 2015
July
2015
Apr
2016
Apr
2016
Apr
2016
Milestone
Agree Joint LD Commissioning Framework and
delivery plans for 15/16 & 16/17
To review the Learning Disability Partnership
Board to ensure the effective engagement and
involvement of customers, carers and other
stakeholders in the development of services and
future plans.
Develop an Employment Strategy that sets out
clear priorities and plans for promoting
employment opportunities and services that
enable people with learning disabilities to
develop work related skills, develop their
confidence and self-esteem and to find and
sustain employment.
Increase the numbers of people with learning
disabilities having an annual health check, so
that each year 1500 people have a health check
and a Health Action Plan.
To complete the review and retendering of the
Supported Living & Personal Support
Framework Agreement
Supporting Information & References
Accountable
LD Joint
Commissioner
LD Joint
Commissioner
LD Joint
Commissioner
LD Joint
Commissioner
LD Joint
Commissioner
161
Planned care workplan
67.
68.
Priorities for 2015-17:

We will deliver the elective care rights and pledges set out NHS Constitution.
Working in partnership with providers, we will deliver demand and capacity
(action) plans to reduce the waiting list and deliver aggregate compliance in
Q3

We will work with our member practices and referrers to ensure, where
appropriate, patients can be supported outside of acute settings thereby
improving choice and reducing demand; this will be supported by the full
launch of e-Referral in May 2015

We will continue to integrate MSK pathways in line with our vision for
services; we will begin implementing service changes from October 2015

We will support earlier cancer diagnosis through commissioning and
implementing one stop and direct to test pathways by June 2015, aiming to
reduce our mortality rate in key specialties.
We have set ourselves a challenging work plan for 2015-17 that will ensure we
reduce variation within our services across the Coastal West Sussex and provide
patients with a positive experience of care whilst supporting our ambitions for
greater integration along care pathways and ultimately better outcomes for patients
in planned care into four main areas:




Delivering the NHS Constitution
Demand management
Cancer
MSK
69.
In the past year we have focussed on managing demand and delivering the 18 weeks
standard set out in the NHS Constitution. Significant investment has been made with
Western Sussex Hospitals NHS Foundation Trust by the CCG and NHS England for the
specific purpose of reducing the backlog and achieving aggregate compliance across
all three measures of managing the patient waiting list.
70.
Despite investment with our providers to address long waiting times in 2013-14 and
2014-15, it has remained challenging to ensure all patients are seen within the
required timeframe; specifically in ENT, General Surgery, Ophthalmology, Neurology
and Cardiology. We will therefore continue to support local providers to meet; the
rights set out in the NHS Constitution and will also explore other avenues such as
other NHS and independent sector capacity to ensure patients have the treatment
they expect within 18-weeks.
71.
There is an recovery trajectory in place with our main acute provider, and supported
by IMAS, which describes the some of actions we will take collectively to recover the
current RTT position December 2015 (Q3). Further work will be undertaken to
complete a full action plan for approval by the Tripartite body on 31st March 2015.
Diagnostic waiting times have not been met consistently in 2014-15 but with our
162
NHS Coastal West Sussex CCG | Delivering the vision
support local providers have been outsourcing to the independent sector to ensure
on-going compliance through 2015-16.
72.
Additionally, we acknowledge that for specific conditions within Cardiology and
Neurology, patients can be better managed proactively closer to home; thereby
reducing demand on secondary care services and supporting RTT compliance.
73.
We also intend to strengthen our approach to Demand Management with the
launch of the e-Referral system in 2015 supporting the vision that the NHS will run a
paperless referral system by 2016. We will manage implementation of this system so
that 80% of GP referrals are sent electronically by March 2016. We have worked
extremely hard with our GP practices and local providers, who have been supported
via a CQUIN payment, to ensure all planned care clinics become available on the eReferral system for directly bookable slots thereby improving access and choice to
patients and reduce wasted appointments. We will consider the development a
referral hub to build on the launch of e-Referral.
74.
Furthering our demand management approach we will work actively with Primary
Care to enhance and streamline pathways that will allow better patient experience.
This will include; the introduction of BNP blood testing for suspected heart failure
patients; working with Optometrists to provide greater access to care closer to
home; and utilising specialist nurses to better manage urological conditions.
75.
We continue to have plans to improve the current MSK services by providing more
Integrated Care. The new service arrangements will offer a more joined-up health
system for patients that are focused on achieving excellent patient outcomes.
76.
We intend to work with our GPs through regular education and peer review and
with our Providers to deliver one stop shop services that support early diagnosis of
cancer; this includes opening a new endoscopy suite at Worthing Hospital to support
improved patient flow. In response to national drive towards achieving early
diagnosis in cancer we, with Macmillan, have already jointly employed a lead
Clinician to focus specifically on reducing variation across Coastal West Sussex. The
intension is to work together as a whole system health economy to achieve cancer
waiting times and 18 weeks RTT compliance and to improve patient outcomes in
four key areas of bowel, breast, lung and prostate cancers through our new joint
Cancer Board. Our primary focus in 2015-16 will be on reducing mortality rates;
tracking one year survival rates to better understand local needs and impact in early
diagnosis; whilst also stabilising the RTT position on 62-day waits.
77.
Early detection of acute kidney injury (AKI) will be a key priority to the CCG. NICE
have estimated that 20-30% of cases of AKI are regarded partially or fully
preventable. In Q1 the CCG will pull together a plan committing to increased
education and reduced numbers of preventable cases. Evidence suggests a lack of
education about AKI among healthcare workers.
Supporting Information & References
163
78.
164
Key milestones for 2015-17 are:
Date
Milestone
Accountable
Apr
2015
NHS Constitution plan for 2015-16 in place
Head of Planned
Care
May
2015
Communicate the launch of the new NHS eReferral system to Practices and Providers
Delivery Manager
May
2015
Draft Business Case for Referral Hub considered
by PLG
Head of Planned
Care
Dec
2015
Aggregate RTT compliance
Head of Planned
Care
NHS Coastal West Sussex CCG | Delivering the vision
Planned Care
Cancer
Overview
Description
of service
changes or
project and
aim
We aim to improve outcomes for patients diagnosed with cancer by streamlining pathways to
support earlier diagnosis, linking with screening programmes and commissioning ‘one stop’ and
‘direct to test’ pathways (starting with a ‘one stop’ colorectal service). We will also work with
primary care to improve appropriate referrals under the two week rule by reviewing referral
proforma’s and addressing GP education issues in key specialty areas.
Why
change or
run the
project?
The JSNA shows that in Coastal West Sussex cancer is the most common cause of premature
death for people under 75 and we have more premature deaths than in similar areas. Outcomes
for our patients with colorectal cancer are also worse than the England average. The Macmillan
State of the Nation report highlights that there are a high number of patients being diagnosed as
an emergency presentation and this results in poorer outcomes for patients.
 Impact on activity from Be Clear on
 Evidence demonstrates the
Cancer Campaigns
importance of earlier diagnosis on
patient outcomes, and the
 Ensuring increases in patients
Key risks
introduction of one stop and direct
included in screening programmes
to test pathways enables earlier
are offset by commissioned
diagnosis of patients with cancer.
activity and treatments
 Contract for ‘one stop’ colorectal
1 Project Foundation
clinics with existing providers
 Education and peer review in
2 Research & Analysis
Current
Primary Care to reduce 2WR
variation
3 Co-Design
C&DP
 Ensure referral process compatible
Phase
4 Contracting & Procurement
with e-Referral
 Maintain engagement with Cancer
5 Effective Delivery
Strategic Clinical network
Evidence
to support
service
changes or
project
Delivery
approach
Milestones
Description
Due Date
Cancer Diagnostic Report complete and signed off at PLG
February 2015
All 2 Week Rule Proforma available for use via e-Referral
March 2015
Undertake GP education event (ENCIRCLE) on new pathways and best practice referrals
April 2015
First meeting of the new joint Cancer Board and approval of action plan for 62 day waits
May 2015
Colorectal ‘one stop’ clinic on the Worthing Hospital operational
June 2015
Measures
Key delivery measure
Threshold
Outpatient follow ups for colorectal cancer patients
Reduction
Other measures
Threshold
One year survival rates for all cancers
Increase
62-Day waiting time from urgent referral to first definitive treatment
Compliance
Conversion rate for 2 Week Rule referrals
Increase
Impact
Q1
Q2
Q3
Q4
Costs
£1,713
£2,654
£2,613
£2,531
Efficiencies
£8,680
£13,448
£13,241
£12,827
Net impact
2015-16
Supporting Information & References
£0.038m
Q1
Q2
Q3
Q4
2016-17
165
Planned Care
Demand management
Overview
Description
of service
changes or
project and
aim
Our aim is to ensure that all referrals that are made to any provider services are appropriate,
have the necessary information and are assessed correctly in terms of priority. We will scope the
need for a referral hub to assist management of elective demand, and increase the usage of eReferral in readiness for the NHS to be paperless by 2016. In addition we will increase the
number of patients involved in their treatment through incentivising Shared decision-making
(SDM) and informed choice.
Why change
or complete
the project?
According to the Kings Fund up to 40% of GP referrals in England are avoidable and locally there
has been significant pressure on elective care services to meet 18-week standards.
Evidence to
support
service
changes or
project
 e-Referral has been identified
nationally as a cost-effective referral
management process.
Key risks
 Some Practices may not engage
fully in the process
 Providers do not comply with CCG
patient access policy and guidance
Delivery
approach
 The use of e-Referral will be
mandatory in future standard
provider contracts
 On-going education and training
programme with practices
 Utilisation review - patients who did
not need to be treated in hospital
because alternative services were
available
Current
C&DP Phase
Not applicable
Milestones
Description
Due Date
Direct referral via NHS.net to Optometrists and Private Providers available
March 2015
Communicate the launch of the new NHS e-Referral system to Practices and Providers
May 2015
Draft Business Case for Referral Hub considered by PLG
May 2015
Measures
Key delivery measure
Threshold
GP referrals to secondary care
<2.3% growth
Other measures
Threshold
Number of patients using BNP pathway instead of existing HF diagnostic pathway
Increase
% of GP referrals sent through e-Referral
80%
Impact
Q1
Q2
Q3
Q4
£445,338
£445,338
£445,338
£445,338
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
166
2015-16
£1.791m
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Planned Care
Delivering the NHS Constitution
Overview
Description
of service
changes or
project and
aim
Why change
or complete
the project?
Evidence to
support
service
changes or
project
Delivery
approach
We will work with providers to agree operational changes, capacity and activity plans in line with
demand and trajectories to restore compliance with all 18 week standards and other NHS
Constitution standards for elective care. We will focus on key specialties including
Ophthalmology, ENT, General Surgery, Neurology, Cardiology and Urology. We will seek to
achieve proportionate evidence based service redesigns enabling more care closer to home and
improving value and outcomes.
Despite investment in elective care capacity and activity, performance against 18 week standards
has declined in 2014-15. We also know the aging population is likely to increase pressure in
specialities such as Ophthalmology. Additionally there is inequity of provision in community
services for specialties including Neurology and Cardiology.
 Evidence suggests more integrated
care outside of hospital such as
 Capacity may not be mobilised
specialist nurse-led/GPSI-led services
Key risks
quickly enough to restore
can avoid unnecessary hospital
compliance in 2015-16
admissions (Baxter and Leary, 2011,
Procter et al, 2012)
 Aligned capacity, activity and
contract plans
 Ensure all contract levers are
properly applied
Current
C&DP Phase
Not applicable
Milestones
Description
Due Date
Whole system elective recovery plan in place (aligning capacity, activity and demand)
April 2015
New ophthalmology pathways in place (via Optometrist Locally Commissioned Services)
April 2015
Community Headache clinics in place
October 2015
Admitted pathways compliant
September 2015
Non-admitted pathways compliant
December 2015
Measures
Key delivery measure
Threshold
Aggregate performance for all 18 week standards
Compliance
Other measures
Threshold
Performance against diagnostic waiting time standards
Compliance
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
167
Planned Care
MSK
Overview
Description
of service
changes or
project and
aim
Why
change or
run the
project?
We have plans to improve the current MSK services by providing more Integrated Care. We will
introduce new service arrangements which aim to offer a more joined-up health system for
patients that are focused on achieving the best possible patient outcomes
MSK services within our current system are disjointed inefficient and slow. A review of our
existing pathways has shown significant complexity of our current system which involves a large
number of referral letters and transfers of care for many patient journeys through the system.
T&O RTT has not always been compliant in recent years.
Evidence
to support
service
changes or
project
 Integrated care models enable
resources to move within the
pathway and support more
improved outcomes for patients
(The King’s Fund, 2014)
Key risks
Delivery
approach
 Options appraisal currently
underway
Current
C&DP
Phase
 The independent impact
assessment identifies a financial
risk to the current acute hospital
that need to be reflected in any
future decisions
 Financial risk around delivery of
QIPP due to the need to reflect on
the independent impact
assessment
1 Project Foundation
2 Research & Analysis
3 Co-Design
4 Contracting & Procurement
5 Effective Delivery
Milestones
Description
Due Date
Contract extensions negotiated with current providers until Oct 15
February 2015
Review of approach to be completed and signed off by CCE
Service changes begin
February 2015
October 2015
Measures
Key delivery measure
Threshold
18-weeks standards in trauma and orthopaedics
Compliance
Other measures
Threshold
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
168
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Children, young people and maternity workplan
79.
Priorities for 2015-17:

We will deliver the new service model for CAMHS and emotional well-being
which will ensure better outcomes for children and young people from
January 2016

We will increase the control children, young people and their families have
over their continuing health care budget through offering personal budgets
to all eligible families from April 2015

We will develop the capacity of children’s NHS at home and community
nursing support so each GP practice has a named nurse by October 2015

We will deliver improved community therapy service through a detailed
needs assessment, best practice review and developing a new service model
to be proposed by December 2015
80.
Commissioning for positive outcomes for children and young people requires all
commissioning organisations to effectively work together to shared goals. Coastal
West Sussex CCG and West Sussex County Council share the priority of promoting
effective early intervention and support, focusing on a good start in life, keeping well
and taking a whole family approach. The Commissioning Intentions are built on and
from the local drivers about early help, supporting troubled families, reforms in
supporting children with SEND (Special Educational Needs and Disabilities) and
maintaining family health and resilience and use of hospital settings only where
appropriate.
81.
We also intend to build on the principles of integration, supporting both physical and
emotional wellbeing and ensuring clear pathways and information is available. We
will also ensure that there is a clarity of provision across the life course, particularly
ensuring that the transition from children’s to adult’s services is as smooth and well
managed as possible including for those with the most complex needs.
82.
Key to achieving these successes is close and integrated working across the
children’s health, education and social care system and achieving the cultural and
systemic changes needed to do this is fundamental bedrock of the commissioning
intentions for 2015-16 and beyond.
83.
There have been a number of important changes during 2014-15 including delivering
on our promise to support those children and families historically care for in the
Cherries and also the first phase of the development of the children’s community
nursing service.
84.
For example, in CAMHS and emotional well-being services have recently been given
a much higher national and local profile and there is a strong wish to see change
across all stakeholders. Commissioners have focused this year on getting better
performance data from providers, introduced a number of pilots and analysed
current and future user needs. During 2014-15, the needs assessment has been
published as well as a more intensive scrutiny of performance of all our providers
Supporting Information & References
169
(including SPFT (our main provider)). We have clear plans to redesign and invest
resources in improving CAMHS services.
85.
We have completed service reviews, including the role and future of primary health
care workers. In addition, practical changes on the ground have been introduced
including online counselling in schools, counselling in Find It outs Shops and peer
mentoring. These important changes have created a foundation for our more radical
redesign of services for 2015 and beyond.
86.
We are also focussed on reducing the amount of time children spend in hospital
unnecessarily through developments in Children’s Community Nursing and
specifically PATC2H (Paediatric Acute Care Team Closer To Home) which will be
piloted in 2015-16 and evaluated to understand if it can be a sustainable solution in
supporting more children and young people with urgent care needs in the
community.
87.
We will build on the recent review of maternity services undertaken across Sussex
through our Collaborative Delivery Team to ensure we have fully mapped the
choices available to mothers for both ante and post-natal care. We already know
that we need to work with our local providers to offer greater choice of birth options
in the Worthing area and will continue to this process. This extended review of ante
and post-natal choices will inform future commissioning in this service area.
88.
Key milestones for 2015-17 are:
170
Date
Milestone
Accountable
Apr
2015
CAMHS delivery plan complete (pending the
decision by CCGs and WSCC)
Oct
2015
Review of how joint personal budgets (with social
care) are working and health outcomes
Jun
2015
Children’s community nursing service phase 2
programme plan developed with CYP, families
and provider
Nov
2015
Therapy review findings completed
CAMHS
Commissioning
Manager(s)
Lead Nurse for
Children's
Continuing
Healthcare
Children’s
Community
Commissioning
Manager and Lead
Nurse for Children's
Continuing
Healthcare
Children’s
Community
Commissioning
Manager
NHS Coastal West Sussex CCG | Delivering the vision
Children, Young
People & Maternity
CAMHS and
emotional well-being
Overview
Description
of service
changes or
project and
aim
We will redesign CAMHS provision to offer improved experience and outcomes for the increasing
number of local children and young people requiring emotional and mental health support. We
are currently developing and evaluating our potential solutions for the challenges identified
through the needs assessments and other stakeholder feedback. These include (but are not
limited to); single point of access (and closer working with the Early Help Front door); enhanced
early intervention services supported by invest to save business cases; greater support on
line/web based services; enhanced training provision across universal and other relevant staffing
groups; looking at how we can bring together different sources of funding (from several
stakeholders) into shared and pooled budgets.
Why
change or
run the
project?
Nationally and locally there is an increasing demand for services for children and young people
who require emotional and mental health support. Service users, key referrers into the system
and other stakeholders have outlined their concerns about the current system.
Evidence
to support
service
changes or
project
Delivery
approach
 Creating consensus for change
beyond the NHS and WSCC
 Identifying appropriate procurement
approaches
 Impact of external processes such as
the recent Parliamentary Heath
Committee Report
1 Project Foundation
2 Research & Analysis
3 Co-Design
4 Contracting & Procurement
5 Effective Delivery
 National policy, literature reviews
and good practice point to the
importance of early intervention
in the lives of CYP who require
emotional well-being support
 To be decided, but expected
Contract Variation and
Procurement
Key risks
C&DP
Phase
Milestones
Description
Due Date
Implementation Plan
April 2015
Tier 2 Procurement Complete (dependent on decision making in Mar 15)
December 2015
Measures
Key delivery measure
Threshold
Other measures
Threshold
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
171
Children, Young
People & Maternity
Control through Personalised
health Project care in CHC
Overview
Description
of service
changes or
project and
aim
Why
change or
run the
project?
Evidence
to support
service
changes or
project
Delivery
approach
We will introduce Personal Health Budgets instead of a conventional care package for all families
and children with NHS funded Children’s Continuing Care. This will support the aim of
empowering patients to make their own decisions about their care and integrating support from
Health and Social Care.
This improvement is a national and local policy priority as service users wish to take greater
control over their health and care services.
 An initial local trial of this approach
to joint personal budgets and direct
payments has been well-received by
families who have asked for an
expansion of the policy
 Adopting the same PHB mechanisms
as Adult CHC
 Supported by required contract
changes with providers who are paid
through PHB
Key risks
 Increased workload on finance and
children’s CHC
 The need for further joined up
protocols for budget setting with
WSCC
C&DP
Phase
1
2
3
4
5
Project Foundation
Research & Analysis
Co-Design
Contracting & Procurement
Effective Delivery
Milestones
Description
Due Date
All eligible families are and given information about how to choose a PHB
April 2015
Joint personal budgets with social care reviewed and outcomes identified and measured
October 2015
Measures
Key delivery measure
Threshold
% of eligible families will have been offered a PHB when assessed as eligible
100%
Other measures
Threshold
% of eligible families who have a PHB in place
Increase
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
172
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Children, Young
People & Maternity
Children’s community nursing
Overview
Description
of service
changes or
project and
aim
We will undertake the changes necessary to move the children’s community nursing service to
the NHS at home model. This will provide high quality Children’s Community Nurses, responsive
to the community health needs of children, young people, their families and carers, focusing on;
children with acute and urgent care needs; children with long term conditions including asthma;
children with disabilities and complex conditions, including those requiring continuing care and
neonates (in conjunction with neonatal care); children with life limiting and life threatening
illness, including those requiring palliative and end of life care.
Why
change or
run the
project?
As a result of improved clinical management and a greater understanding of complications
associated with chronic childhood illnesses, many children with complex medical conditions are
now living well into adolescence and adulthood. A joined up, efficient community nursing service
is vital to ensure that the needs of these children and their families are supported.
Evidence
to support
service
changes or
project
 A comprehensive CCN Services
plays an essential part in the
development of community nonacute services for CYP (based on
national policy, literature and
good practice)
Key risks
Delivery
approach
 Contract Variation with SCT for
new model and service
specification
C&DP
Phase
 Capacity of the provider to make any
necessary changes identified by best
practice review
 Coordination with acute care
providers and other commissioners
 Identifying the changes to funding as
a result of the new model
1 Project Foundation
2 Research & Analysis
3 Co-Design
4 Contracting & Procurement
5 Effective Delivery
Milestones
Description
Due Date
Design phase complete
July 2015
All GP practices have a named CCN
October 2015
CCNs aligned to existing urgent care pathways and services
March 2016
Measures
Key delivery measure
Threshold
Other measures
Threshold
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
173
Children, Young
People & Maternity
Best practice therapy and
support services
Overview
Description
of service
changes or
project and
aim
We will undertake a needs assessment and review of therapies and other key community health
services (including occupational therapy, physiotherapy, and wheelchair services).
Why
change or
run the
project?
Growing need and changes in other complementary services means that there is a urgent need
to change the outcomes and performance we wish to commission. Additionally, therapy support
is an area that has not been reviewed recently and is a key priority given that the strategic
change in SALT services are now becoming business as usual.
Evidence
to support
service
changes or
project
 Comprehensive, effective and
modernised therapy services are
essential to diagnostic and care
delivery of most packages of care for
CYP in the community
Key risks
Delivery
approach
 Co-production with local clinicians
and service users
 Potential Contract Variation(s)
C&DP
Phase
Following review specifications will be developed to deliver best practice models. Any changes
necessary to the current service model will be implemented in-year if appropriate. Outcome
based KPIs will be developed and monitored with the provider.
 Capacity of the provider to make
any necessary changes identified
by best practice review
 Funding needs identified but
funding not available to
implement changes.
1 Project Foundation
2 Research & Analysis
3 Co-Design
4 Contracting & Procurement
5 Effective Delivery
Milestones
Description
Due Date
Interim specifications complete, describing current practice in West Sussex
March 2015
Implementation of review findings underway
March 2015
Full needs assessment and service review complete
October 2015
A full set of KPIs developed are being reported to commissioners
December 2015
Measures
Key delivery measure
Threshold
Other measures
Threshold
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
174
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Children, Young
People & Maternity
PATC2H Project
Overview
2
Description
of service
changes or
project and
aim
We will pilot a Paediatric Acute Care Team Closer To Home (PATC H) model which will offer care
for children and young people with urgent care needs. Aligned to the national NHS at Home
policy for children’s community nursing in urgent care the service will include a primary care led
front door service (based near A&E) supported by a Children’s Community nursing (CCN) team
support to essentially allow assessment, care and follow up closer to home.
The model aims to improve quality and patient experience and provide support at peak demand
times in A&E. It will promote self-care; reduce A&E attendance and emergency admissions;
facilitate earlier discharge; and lead to increased staff competence and resilience across the
Whole System.
Why
change or
run the
project?
National and local figures suggest that a significant proportion of attendances at A&E by children
require no intervention and no treatment; numbers of children attend A&E are also increasing.
Evidence
to support
service
changes or
project
 Evidence from DH funded pilots of
similar schemes and services in
Manchester, Liverpool suggest
improved rates of A&E attendance
and emergency admissions for
children
Delivery
approach
 Pilot project with existing providers
 Some financial support (£20k) for
monitoring and evaluation provided
by Strategic clinical Networks
Key risks
 Recruitment of CCN nursing staff
to a pilot service
 Dependent on excellent
collaborative working with existing
providers
C&DP
Phase
1
2
3
4
5
Project Foundation
Research & Analysis
Co-Design
Contracting & Procurement
Effective Delivery
Milestones
Description
Due Date
COMPASS Clinic at St Richards up and running
January 2015
Lessons learned report based on the implementation
May 2015
Outcome review with Stakeholders
June 2015
Measures
Key delivery measure
Threshold
A&E attendance for children from practices served by St Richards hospital
Reduction
Other measures
Threshold
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
175
Children, Young
People & Maternity
Wheelchair service review
and redesign
Overview
Description
of service
changes or
project and
aim
Why
change or
run the
project?
We will undertake a review of the children’s wheelchair service, focusing on defining the service
and contract value so it is distinct from the adult service. We will work with the SEN
commissioning team, SCT and Whizzkids to plan service redesign and improvement. This will be
supported by clear and defined KPIs and incorporate regular monitoring into performance
management meetings.
The children’s wheelchair service is currently a part of the adults wheelchair service, and does
not have its own specification and KPIs. This means that it is difficult to monitor performance,
define service parameters and plan improvement on a strategic scale.
There are also performance issues reported anecdotally from a number of sources, and in order
to understand where the issues may be and how to resolve them, a review and improvement
process will be undertaken.
Evidence
to support
service
changes or
project
 National policy and the views of
wheelchair users and their
families in West Sussex supports
this project
Delivery
approach
 Co-production with local clinicians
and service users
 Contract Variation with SCT for
new model and service
specification
Key risks
 Capacity of the provider to make any
necessary changes identified by best
practice review
 Identifying any changes to funding as
a result of the new model
C&DP
Phase
1
2
3
4
5
Project Foundation
Research & Analysis
Co-Design
Contracting & Procurement
Effective Delivery
Milestones
Description
Due Date
KPIs complete and dataflow underway
July 2015
Research of best practice models and stakeholder engagement complete
August 2015
Proposal for redesign complete and presented to CCE
October 2015
Measures
Key delivery measure
Threshold
Other measures
Threshold
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
176
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Primary care workplan
89.
Priorities for 2015-17:

We will develop and begin implementing a Primary Care Strategy from May
2015 that defines the future of primary care in Coastal West Sussex, and
ensures sustainability and drives the continued transformation of wider NHS
services and aligned to the NHS Five Year Forward View

We will work in partnership with NHS England to agree effective cocommissioning arrangements to ensure a smooth transition of responsibilities
trough 2015-16

We will conduct a Practice Visiting Programme to support the CCG’s Tripartite
Agreement and maintain member practice engagement with commissioning
priorities

We will review and re-commission GP services for our homeless population, to
ensure equitable access for this patient group across Coastal West Sussex with
changes implemented from June 2015
90.
Data shows that over 50% of GPs in the UK are providing more than 40 consults a
day – demand is continuing to grow as the population ages and patient expectations
rise and the pressure grows as more expectation is placed on general practice to
deliver broader solutions for a struggling health system.
91.
There is evidence of a looming GP workforce crisis - supply forecasts, modelled by
the Centre for Workforce Intelligence (2014), have shown that even if the
government’s recruitment target of 3,300 new entry level GP positions is met, the
GP workforce will only continue to grow if GPs rejoin at historical levels (680 per
annum). However, there is currently little evidence to suggest this will be the case.
92.
As part of our response we will work with member practices to develop a primary
care strategy, based on grass root opinion and deliverability, for the future model(s)
of primary care and general practice across Coastal West Sussex. This could
potentially include models of collaborative or federated systems of provision and
consideration of common infrastructure e.g. inter-operability of IT systems. The NHS
Forward View (2014) provides a solid case for change and advocates NHS
organisations having the freedom and flexibility to adapt various models to the
circumstances in which they find themselves. In response our local strategy will set
out strategic aims across the following themes:






Workforce – recruitment, retention, support and development
Education and training – skill mix and sharing expertise, identifying training
needs
Sharing expertise and better communication – sharing administration /
policies/ information and knowledge/ locality blogs/ website use
IT systems – shared systems / data
Patient Education – promoting self-care/ meaningful patient participation
Estates and clinical infrastructure – understanding our capacity / flexibility
to use estate differently and collaboratively
Supporting Information & References
177


Collaborative working with other primary care providers – locality
collaboration
Working collaboratively with partners – integration of care with local
authorities/ community and secondary care
93.
We will continue to manage the commissioning and performance management of
Locally Commissioned Services (LCS). In addition to re-commissioning the LCS to
ensure high quality, cost effective, provision of services to patients, we will seek to
maximise opportunities to use LCS as a key commissioning tool. To ensure all
services are clinically up to date and appropriate, good value and being undertaken
by the most appropriate provider there will be an annual review of all specifications
and the development of new ones as appropriate. The responsibility for steering
and scrutinising the work programme will remain with the Locally Commissioned
Services Group, which will continue to meet 6 times per calendar year.
94.
Co-commissioning offers an opportunity to work more closely with member
practices in improving and transforming primary care services. It may encompass a
wide spectrum of activity including delegated responsibility for Direct Enhanced
Services and decision making on matters such as practice mergers/closures and
boundary changes.
95.
At this point there are still many questions to answer, for example regarding the
resources to do this work, and issues to work through, including how we will manage
the conflict of interest as it commissions services from its member practices.
Therefore we will work in partnership with NHS England and the Area Team to agree
effective co-commissioning arrangements by April 2015 and to ensure a clear
understanding of, and where acceptable, a smooth transition of responsibilities.
However, there a task and finish group has been implemented to work through
these issues and to drive forward the plan to enable CWS CCG to work in shadow
delegated form from September 2015. This will include identifying budgets, defining
work streams and delivering regular communications about the process.
96.
In order to support the CCG’s Tripartite Agreement and maintain member practice
engagement with commissioning priorities we will continue to conduct an annual
Practice Visiting Programme. This will include a member of the Primary Care
Development Team and nominated clinician visiting each practice during the year to
facilitate exploration of performance and future plans.
97.
The planning process for the programme will begin in June to enable full
engagement from the Primary Care Development Team, clinical leads for primary
care and locality directors. Practice feedback from the previous year’s visits will also
influence future visits. Visits will be conducted between October 2015 and March
2016 with individual localities being the focus for a single month.
98.
NHS England has pledged an annual £250 million fund to improve GP infrastructure.
which will be available from April 2015. To qualify for a share of this fund, England’s
8,500 GP practices must increase the number of appointments they offer, increase
patient contact time and improve their care of older patients. Surgeries will also be
expected to make much better use of technology to monitor patients’ health as a
way of reducing their need to seek direct care from a doctor. We will support
practices to apply for this fund to ensure improves in local practices for patients.
99.
Additionally, three localities (Cissbury, Adur and Regis) have submitted bids under
the Prime Minister’s Challenge Fund, Wave 2 initiative. Both focus on implementing
178
NHS Coastal West Sussex CCG | Delivering the vision
Minor Injuries and Minor Illness (MIAMI) clinics. The CCG will support practices
through a Working Group, should they be successful, ensuring alignment with the
CCGs strategic objectives and delivery of the plans.
100. Key milestones for 2015-17 are:
Date
Milestone
Feb
2015
Co-commissioning discussed at all Locality Board
meetings
Mar
2015
Co-commissioning arrangements for 2015-16
finalised with NHS England
Mar
2015
LCS contracts sent to practices
Apr
2015
LCS contracts signed and returned to practices
Apr
2015
Outline Primary Care Strategy presented to CCE
Apr
2015
Practice visits 2014-15 wash up meeting
Apr
2015
Co-commissioning arrangements begin
May
2015
Annual LCS report to Localities & CCE
May
2015
Begin implementation of Primary Care Strategy
Jun
2015
Key stakeholder planning meeting for Practice
Visiting Programme 2015-16
Jul
2015
Take proposals for 2015-16 Practice Visiting
Programme to Locality Boards
Sep
2015
Begin annual LCS specifications review
Oct
2015
Give notice on all LCS specifications
Oct
2015
Commence 2015-16 Practice Visiting Programme
Nov
2015
Clinical Leads & Heads of to sign off all LCS
specifications as clinically up to date and confirm
decision to recommission
Supporting Information & References
Accountable
Primary Care
Development
Manager
Primary Care
Development
Manager
Primary Care
Development
Manager
Primary Care
Development
Manager
Clinical Lead for
Primary Care
Strategy
Primary Care
Support
Manager
Primary Care
Development
Manager
Primary Care
Development
Manager
Clinical Lead for
Primary Care
Strategy
Primary Care
Support
Manager
Primary Care
Support
Manager
Primary Care
Development
Manager
Primary Care
Development
Manager
Primary Care
Support
Manager
Primary Care
Development
Manager
179
180
Date
Milestone
Accountable
Dec
2015
CCE to approve all LCS specifications
Dec
2015
LCS specifications to be sent to Providers
Jan
2015
Providers confirm which LCS services they will be
providing
Mar
2016
LCS contracts sent to Providers
Mar
2016
2015-16 Practice Visiting Programme ends
Primary Care
Development
Manager
Primary Care
Development
Manager
Primary Care
Development
Manager
Primary Care
Development
Manager
Primary Care
Support
Manager
NHS Coastal West Sussex CCG | Delivering the vision
Primary Care
Primary Care Strategy
Overview
Description
of service
changes or
project and
aim
We will develop a Primary Care Strategy for the CCG that defines the future of primary care
provision in Coastal West Sussex that ensures the sustainability and drives the continued
transformation of NHS services. Using the NHS Forward View as a catalyst for stakeholder
engagement and discussion.
Why change
or complete
the project?
The current pressures and challenges in primary care are widely recognised and action must be
taken if we are to ensure a robust and sustainable model of primary care in the future.
Evidence to
support
service
changes or
project
 There is emerging evidence of
models such as Multispeciality
Community Providers and large
federated/groups of practices being
effective in managing care outside of
hospital (NHS England, 2014)
Key risks
 Managing conflict of interest
 Ensuring full membership
engagement
Delivery
approach
 Stakeholder engagement focused on
member practices and localities
 Partnership working with NHS
England
Current
C&DP Phase
Not applicable
Milestones
Description
Due Date
Recruitment of clinical lead
November 2014
Begin scoping
December 2014
Outline strategy signed off at CCE
April 2015
Commence implementation of strategy
May 2015
Measures
Key delivery measure
Threshold
Other measures
Threshold
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
181
Miami Clinic
Primary Care
Cissbury and Adur
Overview
Description
of service
changes or
project and
aim
part of PM Challenge Fund Bid
The aim of the Worthing and Adur MCP (WAM) Project is to provide four MIAMI clinics (Minor
Injuries and Minor Illnesses) offering additional urgent appointments, a walk-in service for
children between 4 pm and 8 pm and to provide pre-bookable routine appointments at the
weekend.
A total of 10,400 urgent appointments outside core hours (i.e. 6.30 p.m. to 8 p.m.) and 1,840
weekend appointments will be provided in the first year. In year 2, when all 4 sites are fully open
appointment capacity will increase by a further 6,000 during the week and by a further 1,800 at
weekends.
Why change
or complete
the project?
There are different levels of pressure across current primary care providers which means
additional pressure on some General Practices and results in more patients attending A&E.
There is also limited provision of primary care services after 6 pm and at weekends.
Evidence to
support
service
changes or
project
 We will build a local evidence base
during the delivery and change
process
Delivery
approach
 Supported by investment from
Prime Ministers Challenge Fund
Key risks
Current
C&DP Phase
 Not support by Prime Ministers
Challenge Fund
 Recruitment of clinical staff
 Sustaining the model post
Challenge Fund
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Funding confirmed
March 2015
Appoint project manager if application successful
March 2015
Open site 1
April 2015
Open site 2
June 2015
Open site 3
October 2015
Open site 4
January 2016
Measures
Key delivery measure
Threshold
A&E attendances for patients registered to included practices
Reduction
Other measures
Threshold
% of appointments/attendances at MIAMI clinics
Increase
FFT results for MIAMI clinics
>85%
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
182
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Primary Care
Locally Commissioned Services
Overview
Description
of service
changes or
project and
aim
We will continue to manage the commissioning and performance management of Locally
Commissioned Services (LCS) to ensure all services are clinically up to date and appropriate, good
value and being undertaken by the most appropriate provider.
Why change
or complete
the project?
To ensure all services are clinically up to date and appropriate, good value and being undertaken
by the most appropriate provider
Evidence to
support
service
changes or
project
Delivery
approach
 The responsibility for steering and
scrutinising the work programme
will remain with the Locally
Commissioned Services Group
Key risks
 Lack of team resource to manage
the workload
 Potential conflict of interest
 Activity increase could result in a
budget overspend
Current
C&DP Phase
Not applicable
Milestones
Description
Due Date
Signed LCS contracts returned to providers
April 2015
LCS annual report to CCE
May 2015
All specifications reviewed
September 2015
Give notice on all specifications
October 2015
Clinical Leads and Heads of to sign off specs and agreement to commission
November 2015
Send specifications to practices and request confirmation of provision
December 2015
Signed LCS contracts returned to providers
April 2016
Measures
Key delivery measure
Threshold
LCS budget performance
On plan
Other measures
Threshold
Impact
Q1
Q2
Q3
Q4
£33,394
£33,394
£33,394
£33,394
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
£0.134m
2016-17
183
Primary Care
Co-Commissioning
Overview
Description
of service
changes or
project and
aim
The CCG will work in partnership with NHS England and the Area Team to agree effective cocommissioning arrangements by April 2014 and to ensure a clear understanding of, and where
acceptable, a smooth transition of responsibilities.
Why change
or run the
project?
Government policy highlights opportunities for CCGs to have an expanded role in primary care
and how this might enable them to drive up the quality of care, cut health inequalities in primary
care and help put their local NHS on a sustainable path for the next five years and beyond.
Evidence to
support
service
changes or
project
 Localities have agreed to express an
interest in finding out further
information about the opportunities
of co-commissioning
Key risks
 Lack of resources to manage the
potential workload
 National operating model and
timescales yet to be fully defined
Delivery
approach
 Working in partnership with NHS
England and member practices
Current
C&DP
Phase
Not applicable
Milestones
Description
Due Date
Update provided at Locality Boards
February 2015
Co-commissioning arrangements for 2015-16 finalised with NHS England
March 2015
Commence co-commissioning arrangements
April 2015
CCE agree structure of primary care co-commissioning committee
April 2015
Workstreams and budgets defined and agreed
July 2015
Shadow form for delegated commissioning
September 2015
Measures
Key delivery measure
Threshold
Other measures
Threshold
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
184
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Primary Care
Practice Visit Programme
Overview
Description
of service
changes or
project and
aim
We will continue to conduct an annual Practice Visiting Programme, which will result in every
practice being visited by a member of the Primary Care Development Team and a nominated
clinician to discuss CCG commissioning priorities, practice performance and development
opportunities.
Why change
or run the
project?
In order to support the CCG’s Tripartite Agreement and maintain member practice engagement
with commissioning priorities and providing support for practice development.
Evidence to
support
service
changes or
project
 Feedback from the previous year’s
visits indicates some changes would
be beneficial to the programme
Key risks
 Lack of agreement over visit
structure/content
 Capacity of Performance Analyst
might be stretched during peak
visiting periods
Delivery
approach
 Collaborative approach with
Localities and Locality Directors
Current
C&DP Phase
Not applicable
Milestones
Description
Due Date
‘Wash up’ meeting following end of 2014-15 programme
April 2015
Key stakeholder planning meeting
June 2015
Proposals for 2015-16 programme taken to Locality Boards
July 2015
Commence 2015-16 visits
October 2015
‘Wash up’ meeting following end of 2015-16 programme
April 2016
Measures
Key delivery measure
Threshold
% of Practices who reported positive experience of Practice Visits
95%
Other measures
Threshold
Rolling average of Practice Visits per month
4.5
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
185
Specialist Service for
Homeless People
Primary Care
Overview
Description
of service
changes or
project and
aim
We will review primary care services for homeless people and implement a solution that will
address the current inequality between the east and west areas of Coastal West Sussex, in
parallel we will establish a best practice model for on-going provision and development.
Why change
or run the
project?
There is currently significant inequity of current provision across Coastal West Sussex and there is
insufficient provision in primary care means additional pressure on some General Practices and
results in more patients attending A&E.
Evidence to
support
service
changes or
project

Key risks
Delivery
approach
 Collaborative approach with
Homeless Charity (Stone Pillow) and
current providers of the services
(WMG and Bersted Green Surgeries)
Current
C&DP Phase
 Being able to recruit the clinical
staff required to provide the
services
 Access to adequate premises to
host the services
 Currently no budget to implement
what is envisaged to be the
minimum necessary to bridge the
gap between east and west
1 Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Project Initiation Document approved
May 2015
Develop service specification and engage providers
June 2015
Business Case presented to CCE
July 2015
Measures
Key delivery measure
Threshold
Number of homeless patients accessing the service
Increase
Other measures
Threshold
Primary care attendances for Homeless people in Bognor
Reduction
Number of referrals to alcohol and substance misuse services for homeless people
Increase
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
186
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Section 2.2 – The essentials
101. Section 2.2 – The essentials describes the crucial cross-cutting work for the next two
years. The areas are the aligned to ‘Delivering the vision’ (Chapter 5) and provide a
detailed work plan for the CCG and our teams in:









Quality and safety
Medicines management
Continuing Healthcare
Communications and engagement
Contracting, performance and finance
Planning and programme management (P3O)
Information management and technology (IM&T)
Corporate business and governance
Organisational development
Quality and safety workplan
102. Priorities for 2015-17:

We will continue to develop and embed the quality assurance process in
existing and newly commissioned services

We will continue to promote the commissioning of services which prioritise
the safety and welfare of children and adults at risk through local
partnership arrangements and discharge their functions having regard to the
need the safeguard and promote the welfare of vulnerable individuals

We will progress the multidisciplinary, health economy programme for
reducing Clostridium difficile infection (CDI) and continue to promote zero
tolerance to MRSA blood stream infections across Coastal West Sussex
103. We already have a clear quality assurance process in place that is applied equitably
to all providers from whom services are currently commissioned. In addition quality
is an integral feature of the design and procurement of new services. We plan to
continue the development of the quality assurance process, recognising the need to
strengthen the proactive elements of the process whilst retaining the ability to react
to local challenges and/or changes in national guidance in a timely manner.
104. We will use CQC reports to both assure quality and also to learn from where care is
good or outstanding to support services that need to improve. In addition we will
ensure that providers of NHS care demonstrate improvements that are measurable
gained from their own staff experience in order to improve patient experience.
105. We will specifically continue to work with both existing and new Providers to further
develop culture of openness and transparency in relation to quality and safety, with
the expectation that both commissioners and providers embed best practice by
having a named clinician across care settings. We expect all providers to ensure that
they have systems in place to provider electronic structured, coded discharge
summaries, ahead of the legal requirement in October 2015.
Supporting Information & References
187
106. We also recognise the need to consider quality, including patient safety across the
health and social care spectrum including vulnerable groups and will work in
partnership with West Sussex County Council and key stakeholders to align patient
safety initiatives so as to improve patient/service user experience across the
spectrum (this will include consideration of feedback from primary and secondary
care). We will take part in the Local Patient Safety Collaborative and have already
joined the ‘Sign up to Safety’ campaign.
107. Patients and Services users have a valuable contribution to make to the quality
assurance process and the quality team continue to strengthen this involvement
throughout 2015-17 that was started in 2014 via attendance at our Patient
Reference Panel and the regular attendance of HealthWatch at our Quality
Committee.
108. We will also ensure implementation of the Caldicott Review recommendation for all
health care providers to audit themselves against NICE Clinical Guideline 138,
specifically against the quality statements for sharing information for patient care in
order to improve patient experience. We will drive this through our Quality Review
Meetings with providers requesting a self-assessment and action plans as
appropriate.
109. The vision for safeguarding adults and children across West Sussex is to maintain
safe and effective safeguarding services and to strengthen arrangements for
safeguarding adults and children, working collaboratively with partner agencies. We
believe that safeguarding adults and children is an integral feature of quality and
should be considered in all commissioning decisions, as well as in the on-going
assurance processes of commissioned services. In addition we will work to support
the standards set out in the prevent agenda. To that end we have invested in
safeguarding provision so as to ensure that we have access to appropriate specialist
advice this will mean that safeguarding of children and adults is embedded internally
and that expectation of providers in this area is clear.
110. We will continue to fully engage in the collaborative delivery of the West Sussex
Safeguarding Children and Safeguarding Adults Boards strategic priorities through
the Board and Sub Group membership as set out in statute.
111. During 2015-17 we will continue to promote the planning and provision of a range of
safeguarding training to enable staff to recognise and report safeguarding issues and
for children in accordance with the Intercollegiate document (2014). We will
proactively implement any changes set out in the Care Act (April 2014) that sets out
the first ever statutory framework for adult safeguarding, working collaboratively
with partner agencies to ensure the CCG statutory function is understood and
executed.
112. We have a clear plan to further reduce the burden of healthcare associated infection
(HCAI) in both primary and secondary care; this recognises the importance of
working across the health and social care economy to achieve real change in
practice. Our main focus will be to progress the collaborative programme of work to
reduce incidence in Clostridium difficile infection (CDI) across the health economy.
113. Similarly we will support providers to meet the requirements set out in the national
CQuIN for sepsis. We will aim to build on this using data gathered to improve sepsis
care to other areas of acute care. Additionally we will work with providers to
188
NHS Coastal West Sussex CCG | Delivering the vision
establish where they are against the six key actions in sepsis care published by the
Sepsis Trust.
114. This will focus on identifying lapses in care have and sharing lessons learned. We will
review our existing infection control resource to ensure we can be effective and
responsive to any new directives set out by NHS England and Public Health England.
115. We will work with the Organisational Development team to devise strategies which
will allow members of the Quality & Safeguarding teams to recognise and develop
their contribution to the commissioning and delivery of high quality sustainable
services. Strategies may include reflections on patient stories and personal
experiences as users of local health services
116. Key milestones for 2015-17 are:
Date
Milestone
Accountable
Assurance
Jan
2015
Jan
2015
Jun
2015
Participation in patient safety collaborative
facilitated by NHS England Surrey and Sussex Area
team so as to embed incident reporting and
patient safety in primary care.
Begin participation in the CWS CCG Public
reference Panel to ensure communication and
information related to patient experience informs
the quality agenda (bi-annual thereafter)
All providers instructed to undertake selfassessment against NICE Clinical Guideline 138 in
relation to patient experience
CWS Clinical
Director & Head
of Quality
Head of Quality &
People Public
Engagement
Manager
Head of Quality
Safeguarding Children & Vulnerable Adults
Mar
2015
Mar
2017
Mar
2015
Mar
2016
Review safeguarding elements of all existing and
new provider contract in light of the Care Act
(2014).
All staff have undertaken safeguarding training to
enable them to recognize and report safeguarding
issues in accordance with the Intercollegiate
Document (2014) and the Care Act (2014)
Annual training for the CCG Governing Body’s role
in relation to the statutory responsibilities
identified within the Children Act (1989 & 2004)
and the Care Act (2014). Providing leadership and
oversight of safeguarding issues across the health
services in West Sussex
All staff have undertaken safeguarding training to
enable them to recognize and report safeguarding
issues in accordance with the Intercollegiate
Document (2014) and the Care Act (2014)
Supporting Information & References
Designated Nurses
for Adult and
Child Safeguarding
and Head of
Quality
Designated Nurses
for Adult and
Child Safeguarding
Designated Nurses
for Adult and
Child Safeguarding
Designated Nurses
for Adult and
Child Safeguarding
189
Date
Mar
2016
Mar
2016
Dec
2015
Apr
2015
Apr
2015
Jun
2015
Milestone
Accountable
Regular attendance at the Harmful Traditional
Practices (HTP) Management Group to provide
strategic leadership in relation to HTP and modern
slavery across Sussex
Regular attendance at the Pan Sussex and West
Sussex Domestic and Sexual Violence Boards to
support strategic priorities to strengthen services
across Sussex
Following the Rotherham Report (2014), work with
members of the West Sussex Safeguarding Children
Board to support health providers to deliver against
the action plan and strengthen the West Sussex CSE
strategy.
Support the health contribution of the Early Help
Action Plan to provide help and support at the
earliest opportunity to families experiencing
problems
Ensure arrangements are in place for the CCG to
commission a health needs assessment and health
plan for any child looked after by the local authority
Following the Orchid View Serious Case Review
work with members of the West Sussex
Safeguarding Adults Board to support providers to
deliver against the action plan, and acknowledge the
recommendations for commissioners
Designated Nurses
for Adult and
Child Safeguarding
Designated Nurses
for Adult and
Child Safeguarding
Designated Nurses
Safeguarding
Children and
Looked After
Children
Designated Nurse
Safeguarding
Children
Designated Nurse
Looked After
Children
Designated Nurse
Safeguarding
Adults
Healthcare Associated Infections
190
Jun
2015
Develop detailed CDI reduction plan with leads and
timeframes
Aug
2014
Produce a system and process for Root Cause
Analysis completion by GPs
Jul
2015
Produce on-going data base to enable practice
sensitive information for HCAIs
Jul
2015
Align CDI Action plan with IC24 and Pro-active care
plans to ensure sustainability and full pathway
engagement for high risk groups.
May
2015
Annual Report on progress of reduction of HCAIs
presented to CCE and then GB
Mar
2016
Evidence compliance with Public Health England
and the national work-plan and guidance on HCAI
published in March 2015
Clinical Director &
Infection Control
Specialist
Practitioner
Clinical Director &
Infection Control
Specialist
Practitioner
Clinical Director &
Infection Control
Specialist
Practitioner
Clinical Director &
Infection Control
Specialist
Practitioner
Clinical Director &
Infection Control
Specialist
Practitioner
Clinical Director &
Infection Control
Specialist
Practitioner
NHS Coastal West Sussex CCG | Delivering the vision
Quality Assurance
CDI Reduction
Overview
Description
of service
changes or
project and
aim
Why change
or run the
project?
Evidence to
support
service
changes or
project
Delivery
approach
We will support Primary Care providers to undertake individual reviews of each confirmed
infection to identifying and sharing learning and opportunities for improving patient safety
through changed prescribing, stool specimen collection and sending for example. Through this
we aim to reduce the rate of CDI in Coastal West Sussex.
Local rates of CDI are among some of the highest in England and are not falling as expected.
Primary Care has been identified as having a greater proportion of CDI than in other sectors
locally.
 Failure to engage GPs and Out of
Hours services
 Evidence indicates that individual
 Capacity of medicines
reviews are an effective method of
management for Antimicrobial
Key risks
promoting improved practice in
Stewardship
infection control
 Capacity of Infection Prevention &
Control nurse to support practices
to learn from individual reviews
 CDI rates are included in annual
1 Project Foundation
practice visits
 Providing practices with support and
2 Research & Analysis
tools to undertake individual reviews
Current
3 Co-Design
 Working with Primary Care team, OD
C&DP Phase
team and Locality Directors to
4 Contracting & Procurement
support CDI project
 CDI Group meeting monthly to
5 Effective Delivery
review learning and agree actions
Milestones
Description
Due Date
Align CDI work-plan with work-plan of GP Quality and Prescribing Leads
March 2015
Annual review of CDI performance and benchmarks to evaluate actions to date
April 2015
Increase IC Nurse Capacity to 4 days per week
April 2015
Medicines Management named Antimicrobial pharmacist lead agreed
April 2015
Review of the CDI action plan at CDI Review Group
June 2015
Review HCAI information database including practice sensitive data
April 2015
Annual review of CDI performance and benchmarks to evaluate actions to date
April 2016
Measures
Key delivery measure
Threshold
Reduction toward
national median
CDI rates
Other measures
Threshold
Themes from individual review findings
N/A
Practice compliance with local CDI individual review process
Sustained 98%
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
191
Medicines management workplan
117. Priorities for 2015-17:

We will introduce an IT governance system with our providers for
managing the Payment-by-Results excluded (PbRE) drugs and high cost
drugs (HCD)

We will implement a Medicines Optimisation plan for prescribing and
medicines management

We will develop a plan to implement the principals of ‘Deprescribing’ in
Primary Care

We will implement an Antimicrobial stewardship (AMS) program in primary
care

We will introduce a Medicines Optimisation support program for patients
residing in nursing homes

We will aim to reduce the pharmaceutical waste from medicines use.
118. We will continue to provide medicines management advice and support to other
CCG commissioning teams, through collaboration with health system partners, and
through existing and new project streams. They will require us to work together with
partner organisations, but provide leadership in understanding medicines issues
across health services and ensure effective arrangements are in place for optimal
medicines use and best possible outcomes for patients.
119. Our projects are set out below and on the following pages in more detail.
120. Payment by Results Excluded (PbRE) Drugs IT system. We will introduce an IT
system for managing the Payment-by-Results excluded (PbRE) drugs and high cost
drugs (HCD). We will continue to work with our partner organisations across Coastal
West Sussex to develop a robust system of governance and assurance for PbRE
drugs and for High Cost Medicines that are administered to patients in a hospital
setting, or which are delivered to the patient through Homecare Services, to ensure
safe and effective medicines use that is an efficient use of NHS resources.
121. Medicines Optimisation in primary care. This is our systematic process of improving
prescribing and medicines use in primary care, ensuring that patients get the right
choice of medicine, at the right time, in the right place. Our medicines management
team will be working alongside General Practice to progress this project according to
our ambitious timelines. This work is the backbone of our Medicines Management
approach.
122. Antimicrobial Stewardship. This is a coordinated programme that promotes the
appropriate use of antimicrobials (including antibiotics), improves patient outcomes,
reduces the threat from microbial resistance, optimises healthcare costs and
decreases the spread of infections caused by multidrug-resistant organisms. We will
continue to work together with antimicrobial specialist pharmacists in our partner
organisations, with GP practices and with CCG colleagues to develop and deliver a
192
NHS Coastal West Sussex CCG | Delivering the vision
stewardship programme in primary care that will include tools and resources,
education, patient information leaflets, research and guidelines. We will also
develop and publish care pathways for medicines to ensure that medicines are
prescribed and dispensed for patients in the right place, to ensure best use of
resources, safe and high quality care, and improved outcomes.
123. Implementation of ‘deprescribing’ processes in Primary Care. Deprescribing is the
process of tapering, stopping, discontinuing, or withdrawing drugs, with the goal of
managing polypharmacy and improving outcomes. Inappropriate prescribing and
polypharmacy in older persons are associated with increased risks of falls, adverse
drug events and hospital admissions. Given these potential risks, it is imperative to
find ways to manage the care of such patients. We will work with stakeholders to
embrace the concept of deprescribing and implement a local plan.
124. Medicines Optimisation in care homes: The aim will be to commission medicines
support for nursing home patients from specialist pharmacists. The remit of the
project will be based on a gap analysis of local services and supported by financial
data from similar schemes. Many other localities already have care homes
pharmacists in post as they have demonstrated to improve the quality and costeffective use of medicines. This will also support implementation of and compliance
with NICE guidance ‘Managing Medicines in care homes’.
125. Reducing waste from medicines use. The CCG will work with provider organisations,
GP practices, other primary care contractors, patients and other partners to identify
areas where medicines waste occurs, analyse systems to identify areas for
improvement, and implement system change to reduce waste.
126. In addition, Medicines management work streams that continue to underpin all
projects include:








An out-patient prescribing project
Medicines safety and Governance
Partnership and interface working
Prescribing advice for primary care
Formulary and local decision making
Shared care policies between providers and primary care
Patient Group Directions
Matrix support to all commissioning activities.
127. Key milestones for 2015-17 are:
Date
Feb
2015
Mar
2015
Mar
2015
Milestone
Medicines Management Pharmacists /
technicians working 60% of time within General
practice.
Formal agreement to proceed with Blueteq
implementation plan with Western Sussex
Hospitals FT
Funding secured from ‘Better Care Fund’ to
commence nursing home project.
Supporting Information & References
Accountable
Head of Medicines
Management
Head of Medicines
Management
Head of Medicines
Management
193
194
Date
Milestone
Accountable
Mar
2015
All pharmaceutical rebate schemes agreed
Head of Medicines
Management
Mar
2015
Launch of AMS dashboard.
Head of Medicines
Management
Apr
2014
Circulate PQRS to GP practice’s
Head of Medicines
Management
Apr
2015
Commence PbR excluded drugs applications to
CCG via BlueTeq.
Head of Medicines
Management
Apr
2015
PQRS scheme for 2015/16 circulated to GP
practices.
Head of Medicines
Management
Apr
2015
Scriptswitch medicines profile refreshed and relaunched.
Head of Medicines
Management
May
2015
Senior pharmacist recruited to support QIPP
work.
Head of Medicines
Management
Jun
2015
Nursing home Pharmacists and Dietician
recruited.
Head of Medicines
Management
Sep
2015
All GP practices signed up to 2015 / 2016 PQRS
scheme.
Head of Medicines
Management
Sep
2015
Medicines Management commissioning
intentions / work plan refreshed.
Head of Medicines
Management
NHS Coastal West Sussex CCG | Delivering the vision
Medicines
Management
PBR excluded and high
cost drugs
Overview
Description
of service
changes or
project and
aim
We will engage with provider partners to develop a cross heath care IT system (Bluteq) for
prescribing, validation, management and review of Payment by Results Excluded (PbRE) Drugs
and High Cost Drugs (HCD). The CCG will also engage with commissioner partners on
underpinning commissioning systems for PbRE drugs and HCD.
Why change
or run the
project?
There is currently sub-optimal management of PbRE drug validation and review undertaken,
which could be leading to higher than expected spend and/or worse patient outcomes.
Evidence to
support
service
changes or
project



Delivery
approach


This is in line with systems and
processes in other CCG’s and with
NHS England
Task and Finish Group to make
recommendations to Area
Prescribing Committee and
Medicines Optimisation Delivery
Board (MODB)
Procurement of management (IT)
system as required
Joint working with neighbouring
CCG’s
Key risks
Current
C&DP Phase

Lack of engagement from
providers
Service unable to mobilse new
processes to support new system
by 1st April 2015
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Develop a CQUIN to incentivise Trust participation
February 2015
Meeting with Trust Gastroenterology team at Western to discuss implementation
March 2015
Blueteq IT training day for providers
March 2015
Providers commissioned to submit PbRE drug applications for pre-selected new patients.
April 2015
Providers commissioned to submit PbRE drug applications for all new patients.
January 2016
Providers commissioned to submit PbRE drug applications for pre-existing patients.
March 2016
Measures
Key delivery measure
Threshold
Expenditure on high cost drugs and home care medicines
% Reduction
Other measures
Threshold
Invoice challenges from providers
% Reduction
Inappropriate GP prescribing of specialist drugs
% Reduction
Adherence to NICE TA guidance for HCD
% Increase
Impact
Costs
Efficiencies
Net impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
£1,250
£1,250
£1,250
£1,250
£1,250
£1,250
£1,250
£1,250
£20k
£25k
£30k
£35k
£40k
£40k
£40k
£40k
2015-16
Supporting Information & References
£0.105m
2016-17
£0.155m
195
Medicines
Management
Medicines Optimisation in
Primary Care
Overview
Description
of service
changes or
project and
aim
Why change
or run the
project?
Evidence to
support
service
changes or
project
We will work alongside primary care and community staff to improve the efficiency of primary
care prescribing. This will be achieved by working in practices with GP practice staff and working
together with community Health Care Professionals to support cost effective prescribing.
We will focus on organizational and therapeutic outliers, to ensure consistent implementation of
recommended good practice, peer review and engagement. The aim will be to reduce the overall
budget expenditure on specific prescribed medicines.
On-going requirement to deliver of financial balance and optimum efficiency, as recommended
by best practice, national policy and NICE guidance.


Delivery
approach


Local benchmarking data suggests
that there are prescribing
efficiencies to be made when
compared to other CCG’s
Key risks
Leadership through Area Prescribing
Committee, Medicines Optimization
Delivery Board and CCG Locality
Prescribing Groups
Direct and on-going support to GP
prescribers
Current
C&DP Phase

External cost pressure (outside of
CCG control) exceeds growth
Lack of capacity from GP’s to
engage with initiatives
Not applicable
Milestones
Description
Due Date
Agreement of QIPP priority areas for 2015-16
March 2015
PQRS scheme launched to GP practices
April 2015
Adult Sip and Paediatric Nutrition: Formulary updated and rolled out to all stakeholders
April 2015
Commence dietetic reviews within primary care
April 2015
Continence Formulary: Updated and rolled out to all stakeholders
April 2015
Stoma nurses to have completed clinical reviews in 5 GP practices
April 2015
Dressing’s formulary: updated and launched to prescribers
June 2015
Locality prescribing meetings (x6) to discuss QIPP projects
July 2015
Measures
Key delivery measure
Threshold
Net ingredient cost (NIC) for specific targeted areas
5% Reduction
Other measures
Threshold
Net ingredient cost (NIC) / ASTRO PU’s
% reduction
% of prescriptions of non-formulary medicines
Reduction
Impact
Q1
Q2
Q3
Q4
£500k
£500k
£500k
£500k
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
196
2015-16
£2.000m
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Medicines
Management
De-prescribing
Overview
Description
of service
changes or
project and
aim
Minimising the harm from inappropriate prescribing in older populations is a major urgent
concern for modern healthcare systems. In everyday encounters between prescribers and
patients, opportunities should be taken to identify patients at high risk of harm from
polypharmacy and reappraise their need for specific drugs. Attempts to reconcile life
expectancy, comorbidity burden, care goals and patient preferences with the benefits and harms
of medications should be made in every patient at significant risk.
As such we will work alongside key stakeholders to implement the principles of De-prescribing to
ensure all GP’s have a robust practice plan in place to address de-prescribing.
Why change
or run the
project?
Evidence to
support
service
changes or
project
Delivery
approach
Local intelligence suggests that with Coastal West Sussex population demographic that ‘poly
pharmacy’ is an issue which needs addressing.
 We will adopt guidance on
addressing polypharmacy as set out
in Polypharmacy and Medicines
Optimization (Kings Fund, 2013) and
NHS Scotland Polypharmacy
Guidelines
 Leadership through Area Prescribing
Committee, Medicines Optimization
Delivery Board, De-prescribing task
and finish group and CCG Locality
Prescribing Groups
 GP practices to be incentivized to
develop a plan via the PQRS scheme
Key risks
Current
C&DP Phase
 Lack of capacity from GP practices
to participate in PQRS
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Set up task and finish group to produce de-prescribing project plan
January 2015
Produce draft PQRS
February 2015
Circulate PQRS to all GP practices
March 2015
Measures
Key delivery measure
Change
Other measures
Change
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
2015-16
Supporting Information & References
2016-17
197
Medicines
Management
Antimicrobial Stewardship in
Primary Care
Overview
Description
of service
changes or
project and
aim
Why
change or
run the
project?
Evidence
to support
service
changes or
project
Delivery
approach
We will develop and implement a primary care Antimicrobial Stewardship (AMS) programme,
this is to include appropriate control and targeting of antimicrobial therapy, influencing
prescriber and patient behaviour, highlighting variation in anti-microbial prescribing within
primary care. The aim will be to reduce the risk of healthcare acquired infections, resistance to
antimicrobials and avoiding waste of resources.
Antibiotic resistance poses a significant threat to public health, particularly because antibiotics
underpin routine medical practice in both primary and secondary care. Additionally, local rates of
antibiotic prescribing for high risk antibiotics is higher than expected.
 Primary care antimicrobial
stewardship is supported and
required by DH policy, emerging
NICE Good Practice
 Engage with pharmacist specialists
from partner provider organisations;
microbiologists; commissioner
colleagues and GPs through Task and
Finish Groups
 Antimicrobial Stewardship principles
will be set out within local antibiotic
guidelines
Key risks
C&DP
Phase
 Lack of engagement from
prescribers e.g. (Primary care,
community, Secondary care,
OOH’s practitioners)
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Roll out of IT pop up messaging for GP practices to highlight at risk C.Diff patients
April 2015
AMS performance dashboards into Quarterly GP locality prescribing meetings
April 2015
Measures
Key delivery measure
Threshold
Compliance to the Coastal West Sussex Local Health Economy Antimicrobial policy
80%
Other measures
Threshold
Number of antimicrobial prescriptions issued by GP practices
Reduction
Number of prescriptions issues for at risk antibiotics (Quinolones, Cephalosporin’s)
Reduction
Number of reported cases for C.Diff infection
Reduction
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
198
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Medicines
Management
Medicines Optimisation
in care homes
Overview
part of BCF Plan
Description
of service
changes or
project and
aim
We will commission a pharmacist led service to undertake Medication Optimization reviews with
patients in care homes. The aim will be to reduce waste, improve efficiency and reduce errors.
This will also contribute to a reduction in emergency admissions to secondary care.
Why
change or
run the
project?
There is national evidence of high risk of medication errors, medicines waste and poor outcomes
due to poor medicines optimisation in care home settings.
Evidence to
support
service
changes or
project
Delivery
approach
 Evidence from North Staffordshire
CCG shows that a clinical pharmacist
review led to optimized therapy and
efficiencies. Over a 12 month period
an average efficiency of £161 per
patient was observed from medicines
optimisation.
 Secure a contract for the employment
of pharmacists
 On-going performance management
of service
 Opportunity to be supported by the
Better Care Fund
Key risks
Current
C&DP Phase
 Lack of funding to proceed with
service
 Inability to recruit suitably
experienced pharmacists
 Lack of engagement with
partners, such as care homes and
GP practices
1 Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Secure funding to commission pilot service
April 2015
Develop job description and identify pharmacist to deliver pilot
April 2015
Work with key stakeholders to identify care homes to take part in pilot
April 2015
Pharmacist to begin clinical reviews in selected care homes
June 2015
Based on pilot results refine job description and begin recruitment
October 2015
Launch new service across Coastal West Sussex
December 2015
Begin evaluation of service against KPIs
March 2016
Measures
Key delivery measure
Threshold
Costs of prescribed medications for patients in care homes
Reduction
Other measures
Threshold
The number/cost of prescribed medications in patients residing in care homes
Reduction
Compliance with bulk prescribing systems introduced to care homes
90% compliance
Impact
Q1
Q2
Q3
Q4
Costs
£7k
£7k
£77k
£77k
Efficiencies
£11k
£11k
£116k
£117k
Net impact
2015-16
Supporting Information & References
£0.087m
Q1
Q2
Q3
Q4
2016-17
199
Medicines
Management
Reducing waste from
medicines use
Overview
Description
of service
changes or
project and
aim
We will work with provider partner organisations, GP practices, primary care contractors,
patients and other partners to identify areas where medicines waste occurs, analyse systems to
identify areas for improvement, and implement system change to reduce waste; to support
patients with taking medicines to reduce unintentional waste and ultimately to reduce the
amount of medicines waste incurred by the CCG.
Why change
or run the
project?
Non-compliance of a medicine is a waste of NHS resources, and can cause avoidable hospital
admissions. It is thought that as many as 50% of all patients with chronic conditions end up using
their medicines in a way that is not fully effective. Up to 75% of older patients fail to comply with
prescribed medication.
Evidence to
support
service
changes or
project
 The report ‘Improving the use of
medicines for better outcomes and
reduced waste’ (DoH), defines how
to make more effective use of
medicines all care settings.
Delivery
approach
 Leadership through Area Prescribing
Committee, Medicines Optimisation
Delivery Board and CCG Locality
Prescribing Groups
 Implementation supported by
consistent implementation of
recommended good practice, peer
review and engagement, and
support from CCG medicines
management team
Key risks
Current
C&DP Phase
 Lack of engagement from patients
 Lack of engagement from
Community pharmacists
1
Project Foundation
2
Research & Analysis
3
Co-Design
4
Contracting & Procurement
5
Effective Delivery
Milestones
Description
Due Date
Distribution and promotion of materials
March 2015
Waste amnesty ‘campaign’ begins
April 2015
Patient Survey pre-project undertaken
April 2015
Community Pharmacy Audit complete
June 2015
Locality RoadShows take place
June 2015
Patient Survey post-project undertaken
September 2015
Evaluation published
October 2015
Measures
Key delivery measure
Threshold
Estimated cost of returned medicines
5% reduction
Other measures
Threshold
Impact
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Costs
Efficiencies
Net impact
200
2015-16
2016-17
NHS Coastal West Sussex CCG | Delivering the vision
Continuing Healthcare workplan
128. Priorities for 2015-17:

We will ensure that by March 2017, the majority of our clients will say that
they experienced high service quality, and a positive customer experience.
We will achieve this by working closely with multi-disciplinary teams and
listening carefully to our clients.

We will, over the next two years, build productive relationships with care
providers. We will achieve this by working closely with our stakeholders to
shape a safe and thriving market that effectively meets the quality of care
our customers expect.

We will strengthen our team identity and team effectiveness. We will
achieve this by supporting each other through service improvement
initiatives, innovation and continual professional development.
129. Our overarching mission is to provide a positive eligibility assessment process for all
clients referred to NHS Continuing Healthcare. The team will work with partners to
ensure the care we commission is personalised, good quality, fair for all and affords
better health outcomes for patients.
130. Quality Framework
In October 2014 CHC set out to West Sussex CCGs its intention for quality to be its
cross-cutting theme from 2015. Illustrated below is a table showing the breath and
scale of CHC’s ambition. This will inform the development of a Total Quality
Framework that covers every aspect of CHC business.
Stakeholders
Business
Function
Service User
Purchaser /
customer
“Quality”
Manager
Service Provider
CHC / FNC
Eligibility
Assessment
Invest in Customer
Services; skills,
techniques,
awareness.
Satisfaction
Clinical
Governance
Equality
Sustainability
Fairness
National CHC
Framework
Compliance
/ performance
management
Delivery Model /
process
Complaints
Appeals
Benchmarking
Commissioning
for CHC Health
and Wellbeing
Outcomes
Service user
experience;
Collect feedback
Measure impact of
commissioned
care
Delivering agreed
health and
wellbeing
Outcomes
Service
specifications
Positive risk
management
Contracts &
Reviews
Provider Quality
Assurance
Procurement
Safety /
Safeguarding
131. Clinical Commissioning
All the care categories below have their own set of stakeholders who share our
ambition to personalise care and support; including WSCC, WS CCGs, GP Practices,
care co-ordinators, MDTs, Care Providers, Social Care, family carers,
independent/third sector. The CHC team commissions care for many types of care
groups, in both residential and domiciliary settings. Listed below are some aspects of
next year’s work plan aligned to these care categories;
Supporting Information & References
201









Palliative Care / Specialist Palliative Care
 Invest in dedicated nurses to lead on the CHC fast track referral
process and undertake review of nursing needs - three months
following eligibility decision
 Work with existing hospice services in developing palliative care at
home services and pilot personalised care and support plans
Long Term (Physical) Conditions
 Ensure that sufficient time is dedicated to appropriate training and
development of staff and stakeholders
Acquired Brain Injury
 Ensure commissioning processes are dovetailed around the patient,
working in partnership with Adult Services and NHS England in a
seamless way
Learning Disabilities
 To review current provision and consider more creative commissioning
solutions
Rehabilitation
 Discuss with providers and partners how service developments can be
taken forward
Nursing Care
 Conclude the audit of all West Sussex nursing care beds
 Implement a single, integrated FNC contract & review process
 To continue to roll-out new procurement and review framework for
continence products
Children’s CHC
 Implement the action plan (following the CQC inspection) to improve
local processes for transition from childhood to adulthood.
Mental Health
 Work with partners to undertake a review of MH commissioned care
Retrospective Reviews
 Following the redesign of the decision-making process to increase
throughput from approximately 50 eligibility decisions a year to 100+
132. Supporting Strategies
In addition we will support our workplan through on-going improvement work
across other business processes and functions as detailed here:






202
Revise governance and assurance framework in line with Annual Business Plan
2015-16
Continue to improve financial planning and expenditure control systems
Continue to invest in infrastructure to improve efficiencies and reduce waste,
including a significant reduction in the use of office paper
Redesign our web-site as part of a wider communication and stakeholder
engagement plan
Invest in good people management, staff training and development
Undertake a comprehensive workforce analysis following recommendations of
CHC Review published in June 2014.
NHS Coastal West Sussex CCG | Delivering the vision
133. Key milestones for 2015-17 are:
Date
Milestone
Accountable
Jun
2015
To ensure 40% of clients requiring a placement
review are reviewed within the same month the
review was due.
Head of CHC
Oct
2015
Implement processes that ensure referrals into
the department are processed in a timely
manner
Head of CHC
Oct
2015
Action plan in place to reduce the number of
poor quality or incomplete documentation
received from referrers
Head of CHC
Dec
2015
50% of eligible CHC clients to have a
personalized care support plan
Head of CHC
Jun
2016
Mirroring the implementation of a new
framework for Care and Support at Home
Head of CHC
Jun
2016
Implement, in partnership with WSCC, a revised
commissioning framework for clients in a
residential care environment
Head of CHC
Dec
2016
All “closedown” clients know the outcome of
their retrospective eligibility assessment
Head of CHC
Supporting Information & References
203
Communications and engagement workplan
134. Priorities for 2015-17:

We will enhance engagement knowledge and abilities through introduction of
an Engagement Toolkit, along with the roll out of toolkit training across CCG
teams

We will revise and publish CCG wide communications and engagement
strategy and publish a web development strategy

We will continue Let’s Talk programme of public events – ensuring
commissioning projects and corporate objectives are built into the
programme

We will increase CCG E-Panel membership and ensure commissioners and
colleagues across the CCG use the engagement hub to engage and consult
with patients and public before service change or pathway development

We will establish stakeholder engagement strategy and processes with regular
engagement meetings built in to Executive diaries

We will Implement Equality Duty Summary (EDS2) and review and improve
our Equality and Diversity objectives
135. During 2014-15 the communications and engagement team implemented the CCG’s
Let’s Talk programme of stakeholder and public/community events with three
stakeholder workshops and six community roadshows. These began what will be ongoing dialogue opportunities with our patients, public, communities and
stakeholders.
136. Much effort has also gone into enabling our commissioners and the whole
organisation to fully engage with patients, the public and also colleagues. To this end
we have established a number of engagement mechanisms that have now been built
into a toolkit.
137. We aim to make it as easy as possible for patients and public to engage with our
commissioning and be involved in more decision making. Our commissioners are
aware of the need to engage, but not always aware of how to. That’s why we will
develop and roll out the Engagement Toolkit to support them by identifying types of
engagement and how to use them. We will work with our Organisational
Development Team to set up training on the Toolkit and engagement more widely.
138. We will continue to further develop the E-Panel, increasing membership and asking
members to become involved in specific engagement activities that relate to specific
commissioning decisions.
139. The information on the CCG website has been static for some time. The web strategy
will ensure that web based information is owned across the organisation and that
pages and sections are updated more regularly.
204
NHS Coastal West Sussex CCG | Delivering the vision
140. We are committed to meeting with our patients, the public and our other partners in
health and will continue with the Let’s Talk programme through 2015-16. We will
first agree the programme in January 2015, with events likely to take place in the
summer and autumn.
141. We have appointed our Clinical Director as our Caldicott Guardian. This role supports
work to enable information sharing where it is appropriate to share, and advises on
options for lawful and ethical processing of information. The role is also a key
member of the CCG’s Quality Committee and therefore can advise on the
recommendations of the Caldicott Review in relation to patient experience.
142. The Caldicott Guardian also has a strategic role, which involves representing and
championing Information Governance requirements and issues at Board or
management team level and, where appropriate, at a range of levels within the
organisation's overall governance framework.
143. Even though almost all CCG staff have no routine patient contact, we ensure all staff
have a thorough understanding of patient confidentiality, data protection and
subject access requests. To help achieve this all CCG staff must undertake
mandatory IG training to ensure their awareness of IG, patient confidentiality and
data breaches. The IG training is carried out using nationally recommended IG toolkit
system.
144. We also publicly identifies its approach to personal information; an approach which
is in line with the recommendations of the Caldicott review. This is highlighted in the
CCG’s Fair Processing and Privacy Notice which was recently reviewed (February
2015) and uploaded to the CCG website.
145. Key milestones for 2014-16 are:
Date
Milestone
Jan
2015
Engagement Toolkit complete and launched to
staff website
Jan
2015
Let’s Talk Programme 2015 agreed
Feb
2015
Web Development Strategy published
Mar
2015
Roll out of PPE training sessions begins
Jun
2015
Let’s Talk events
Public Engagement
Manager
Jul
2015
Implement EDS2 and complete review of
Equality and Diversity objectives
Public Engagement
Manager
Sep
2015
Processes for web updates designed and in place
Supporting Information & References
Accountable
Head of
Communications &
Engagement
Head of
Communications &
Engagement
Senior
Communications
Manager
Head of
Communications &
Engagement
Senior
Communications
Manager
205
Date
Milestone
Accountable
Oct
2015
Let’s Talk events
Public Engagement
Manager
Dec
2015
Increase E-Panel membership and use
consultation software for at least three
commissioning projects
Public Engagement
Manager
Dec
2015
Report back to CCG on EDS2
Head of
Communications &
Engagement
Contracting, performance and finance workplan
146. Priorities for 2015-17:

The CCG will manage its finances to ensure it meets its statutory
responsibilities to contain expenditure within its agreed resource and cash
limits.

We will manage the annual performance, contracting and financial planning
processes to support the development of the CCGs operational plans and
enable appropriate contracts to be established with providers

We will create and implement a CCG Information Strategy and Action Plan to
improve how the teams utilise information to inform commissioning
decision making

We will support the implementation of the new MSK contract to ensure
appropriate activity reporting and quality and outcome measurement

We will actively monitor all Providers to ensure compliance to national
Quality and Performance Standards, as set by NHS England, and agreed local
standards.
147. Every year the CCG must undertake operational planning activities to ensure that we
set the right level of ambition for our KPIs and purchase the correct amount of
activity from our provider.
148. The Performance Team will produce a CCG Information Strategy which will outline,
the current state of information provision, the intermediate state in terms of what
we really need to change and the eventual end state. Linked to this is the
development of an action plan which will breakdown the actions required into
constituent parts to ensure momentum is maintained to get us to where we need to
be. This will include a training and development plan for staff which will be deployed
in partnership with the Organisational Development Team. This strategy will also
align data between the commissioner and providers to ensure meaningful
engagement regarding performance, by establishing more systematic use of
common data sets, which will include the use of the NHS number as the primary
identifier, which is a contractual requirement on all Providers from 1 April 2015.
149. The Contracting Team will particularly focus on providing assurance to the CCG
regarding the efficacy of the contract management and associated services provided
206
NHS Coastal West Sussex CCG | Delivering the vision
by NHS South Commissioning Support Unit. This will involve regular reviews and
reporting by service leads against national and local quality and performance
standards.
150. The Contracting Team, in partnership with the Quality & Safety Team and
Commissioning Teams, will co-ordinate the development of CQUINs to improve the
quality of services provided to patients and support the CCGs strategic and
operational plans.
151. The Performance, Contracting and Finance Teams will actively support the transition
to the new MSK contract. This will involve base-lining activity and performance for
new pathways; ensuring new data collections are established; establishing new
contract management arrangements and reporting delivery against agreed outcome
measures.
152. The Performance, Contracting and Finance Teams will continue to support
Commissioning Teams to undertake service reviews and develop new service
models; specifically supporting the development of Business Cases and monitoring
arrangements.
153. The Finance Department will agree budgets with the Chiefs and Budget Managers
prior to the beginning of each financial year and provide monitoring information and
analysis on a monthly basis. The aim will be to ensure that the CCG meets its
statutory obligations to stay within its delegated resource and cash limits.
154. The Finance Department will complete all statutory monitoring returns accurately
and in a timely manner and produce reports for the CCE and the Governing Body in a
format that enables the CCG to both understand the key financial issues and take
appropriate action.
155. The Finance Department will support Commissioning Managers with advice and
financial expertise to ensure that Business Cases and QIPP schemes are financially
robust and have received the appropriate level of financial scrutiny. No investments
shall take place and no QIPP schemes shall be approved without the explicit consent
and sign off of the Finance Department.
156. The Finance Department will be responsible for ensuring value for money can always
be demonstrated by the CCGs for its use of resources, they will ensure financial
records are maintained and the annual financial accounts are submitted on time and
of a suitable quality to enable the external auditors to complete their work and
agree a final set of accounts in line with the national time scales.
157. Key milestones for 2015-17 are:
Date
Milestone
Accountable
Feb
2015
Agreed CWS Information Strategy and Action
Plan
Head of
Performance
Feb
2015
Development of local CQUINs for all Providers
complete
Head of Contracting
Feb
2015
Completed Operational and Demand Planning
processes
Head of
Performance
Supporting Information & References
207
208
Date
Milestone
Accountable
Feb
2015
Draft budget presented to CCE
Chief Finance
Officer
Mar
2015
Contracts to be signed by all main providers
Chief Finance
Officer
Mar
2015
Final budget presented to CCE
Chief Finance
Officer
May
2015
Performance Team to have completed training on
web technologies and SQL Server Reporting
services
Head of
Performance
May
2015
Agree scope of 2015-16 Counting and Coding
Audit
Jun
2015
Final account presented to CCE And GB and
submitted to NHS England
Aug
2015
Implementation and launch of outputs in relation
to Information Strategy
Aug
2015
Co-ordination of review of Quarter 1 CQUINs
reports
Oct
2015
Half Year Review of Performance against stated
objectives and plans
Nov
2015
Co-ordination of review of Quarter 2 CQUINs
reports
Dec
2015
Draft budget submitted to NHS England
Dec
2015
Completion of 2016-17 Contract Negotiation
Strategy
Head of Contracting
Feb
2016
Development of local CQUINs for all Providers
complete
Head of Contracting
Feb
2016
Co-ordination of review of Quarter 3 CQUINs
reports
Head of Contracting
Feb
2016
Draft budget presented to CCE
Chief Finance
Officer
Mar
2016
Completed Operational and Demand Planning
processes
Head of
Performance
Mar
2016
Contracts to be signed by all main providers
Chief Finance
Officer
Mar
2016
Final budget presented to CCE
Chief Finance
Officer
May
2016
Agree scope of 2016-17 Counting and Coding
Audit
Jun
2016
Final account presented to CCE And GB and
submitted to NHS England
Head of Contracting
Head of Finance
Head of
Performance
Head of Contracting
Head of
Performance
Head of Contracting
Head of Finance
Head of Contracting
Head of Finance
NHS Coastal West Sussex CCG | Delivering the vision
Date
Milestone
Accountable
Oct
2016
Half Year Review of Performance against stated
objectives and plans
Head of
Performance
Dec
2016
Operational Plan Refresh and Demand Planning
processes
Head of
Performance
Feb
2017
Completed Operational and Demand Planning
processes
Head of
Performance
Mar
2017
Contracts to be signed by all main providers
Chief Finance
Officer
Planning and programme management (P3O) workplan
158. Priorities for 2015-17:

We will support Executives to review, refine and republish the CCGs 5 year
strategy ensuring alignment with existing policy and CCG ambitions

We will review, then enhance and embed an agreed commissioning
programme management workflow, documentation and decision making so
good practice becomes common practice across transformational priorities

We will develop a model of delivery management that aligns commissioners,
performance and contracting teams and improves operational delivery

We will, in partnership with the Performance Team deliver a more
integrated reporting and information system to drive both planning and
delivery
159. Over the last two years we have been able to put in the place the foundations of a
strong management approach to enable clinical commissioning through; improved
governance known around our portfolios of work; auditable and evidence-based
project processes and documentation; and greater alignment between project
planning and annual planning. This framework keeps us focussed on:




Delivery against key milestones
Immediate critical tasks to drive transformation and mitigate risks
Monitoring progress against our stated outcomes and financial delivery
Constantly reviewing and prioritising resources and attention into high
impact areas
160. Through 2015-16 the team will continue to focus on improving and embedding this
approach and requisite processes further into our CCGs commissioning workflow.
Following an initial review of the current model, securing Executive level agreement
the team will publish a refreshed model to support transformation programmes and
also support staff to adopt these ways of working through an on-going training
programme in partnership with our Organisational Development Team.
Supporting Information & References
209
161. We will also need to ensure the governance architecture around commissioning
teams is working effectively and offering clear benefits to commissioning teams and
Executives. We will therefore review the current model and implement changes as
required.
162. A key task in 2015 will also be to review our annual planning model and develop it
further so it offers absolute clarity over accountabilities, responsibilities and
timelines. Much of this knowledge will be gathered from past experience and the
process in 2014-15. This will support the new Planning Manager post to have
complete autonomy to drive the internal planning process each year.
163. Working with the Performance Team, the P3O will ensure Public Health support in
strategic planning and prioritisation as well as in project and programme
development, through designing and agreeing systematic ways of working,
embodied in the local CCG and Public Health Memorandum of Understanding
(MoU).
164. We have also started the process of integrating project, quality, performance and
financial reporting through an Integrated Corporate Report that feeds from the
existing Project Reporting System, and whilst have more work to do to realise its
potential, it will continue to offer the same clear benefits as the current approach,
these include:


Transparency of QIPP delivery information and risk values
Accelerated senior support regarding risks and opportunities through
escalation to the ‘Operational Committee’ and reporting into CCE
165. Key milestones for 2015-16 are:
210
Date
Milestone
Accountable
May
2015
Refined management processes commissioning
teams agreed
May
2015
Dates for 2015 training agreed with OD Team
May
2015
Review of annual planning approach complete
Jul
2015
Refreshed 5 year strategy published and
communication plan implemented
Jul
2015
New Annual Planning Roadmap Published to all
CCG staff
Head of Planning &
Programme
Management
Jul
2015
Staff engagement on new Annual Planning
Roadmap begins
Planning Manager
Sep
2015
Commissioning Intentions for 2016-17 published
Chief Operating
Officer
Dec
2015
Refreshed Operational Plan presented to Clinical
Commissioning Executive
Chief Operating
Officer
Head of Planning &
Programme
Management
Head of Planning &
Programme
Management
Planning Manager
Chief Operating
Officer
NHS Coastal West Sussex CCG | Delivering the vision
Date
Milestone
Accountable
Mar
2016
Final refreshed Operational Plan presented to
Clinical Commissioning Executive
Chief Operating
Officer
Sept
2016
Commissioning Intentions for 2017-18 published
Chief Operating
Officer
Dec
2016
Refreshed Operational Plan presented to Clinical
Commissioning Executive
Chief Operating
Officer
Mar
2017
Final refreshed Operational Plan presented to
Clinical Commissioning Executive
Chief Operating
Officer
Information Management & Technology (IM&T) workplan
166. Priorities for 2015-17:

We will improve patient outcomes by making clinical and social care
information readily available at the point of care, irrespective of organisational
boundaries through an IT integration project to build a real time, read only,
record viewer (ROCI) with data sources from both health, and social care

We will improve the quality, reliability and speed of the IT infrastructure within
GP practices

We will enable GP practices to use the Electronic Prescription service (EPSr2) to
allow the electronic transfer of prescriptions to community pharmacies

We will use IT to improve the internal organisational capability of the CCG by
deploying tablet and selected replacement of PC and laptop equipment and
supporting a move to electronic HR admin

We will provide professional IT and business change advice to commissioners
for procurement and contracting clinical services and commissioning CSU IT
services

We will support inter CCG and regional projects by helping to develop a
coordinated Sussex IT strategy through the Sussex Collaborative Delivery Team
167. The Strategic IT service is hosted by Coastal West Sussex CCG and works for all CCGs
in West Sussex. The service has a wide knowledge of NHS clinical and social care
systems, the commissioning intentions of the CCGs, and how IT can be an enabler of
better outcomes for patients. The service devises and runs projects supporting front
line clinicians as well as IT projects that support internal CCG functions.
168. Our biggest project during 2015-17 will be the ROCI (Read Only Care Information)
project. This is an ambitious IT integration project which will have data sources from
both health and social care. This will assist urgent and emergency care by making
clinical and social care information readily available at the point of care, irrespective
of organisational boundaries. ROCI will improve patient safety with less need for
patients to remember and recite their medical history and medications. It will also
help to avoid repetition of tests or additional prescribing that patients do not benefit
Supporting Information & References
211
from. We anticipate that ROCI will also support the multi-disciplinary working of our
Proactive Care initiative.
Over the next two years we plan to grow the data sources and the functionality of
ROCI so that it becomes a vital tool in direct patient care. To do this we will have to
work with providers to develop their IT infrastructure providing leadership and
guidance in creating a truly connected local health and social care economy. ROCI is
the local embodiment of the national strategy for fully interoperable digital records.
169. The Strategic IT service also manages the GP IT budget delegated from NHS England.
In the coming years we plan to support GP practices moving to hosted clinical
systems under the provisions of the GPSoC contract, and to use available funding to
improve the quality, reliability and speed of the IT infrastructure within GP practices.
In 2014 we implemented GP2GP; a means of transferring electronic patient records
between GP practices when a patient moves between practices. In 2014 we also
implemented Summary Care Records (SCR). During the 2015/16 financial year we
aim to enable 60% of GP practices with the Electronic Prescription Service (EPSr2).
170. Internally the CCG is currently reliant on email as the means for sharing documents
and collaboration; the infrastructure is based on server file shares. We plan to
investigate more effective solutions such as enterprise cloud solutions that will make
it easier to collaborate with others both inside and outside of headquarters.
171. The CCG is also reliant on a range of paper forms for administration, such as expense
claims and holiday cards. We plan to work with colleagues in Corporate Affairs to
investigate time saving electronic workflow solutions to some of these processes.
172. The Strategic IT service is well placed to advice and support commissioners with
many of the change programmes outlined in the CCGs Strategy. We will continue to
act as the ‘informed customer’ on a range of procurements and projects in support
of the clinical commissioning intentions.
173. Key milestones for 2015-17 are:
Date
212
Milestone
Accountable
Mar
2015
Electronic correspondence from BSUH to
constituent practices implemented
Head of Strategic
IT
Mar
2015
ROCI pilot live at BSUH allowing critical
information from primary care to be available in
ED
Head of Strategic
IT
Mar
2015
Clinical system migration to Emis Web (x3) TPP
S1 (x1) complete
Head of Strategic
IT
Mar
2015
Tablet and selected replacement of PC and
laptop equipment deployed
Head of Strategic
IT
Mar
2015
Electronic Prescription Service. Pilot and
evaluation of EPSr2 at one practice complete
Head of Strategic
IT
Mar
2015
Coordinated Sussex IT strategy through SCDT
published
Head of Strategic
IT
Mar
2015
Enabling GP IT elements of WSHfT Order Comms
complete
Head of Strategic
IT
NHS Coastal West Sussex CCG | Delivering the vision
Date
Milestone
Accountable
Mar
2015
Assist IT planning of WSCC adult social services
management by health
Head of Strategic
IT
Jul
2015
Investigation into a move to corporate cloud
technology complete
Head of Strategic
IT
Oct
2015
Ensure electronic discharge summaries are in
place between hospitals and GP practices
Head of Strategic
IT
Mar
2016
Roadmap for fully interoperable digital records
will be in place
Head of Strategic
IT
Mar
2016
60% of GP practices enabled to send
prescriptions electronically to pharmacies
Head of Strategic
IT
Mar
2017
100% of GP practices enabled to send
prescriptions electronically to pharmacies
Head of Strategic
IT
On-going
To improve the quality, reliability and speed of
the IT infrastructure within GP practices.
Head of Strategic
IT
On-going
Running EPR accreditation and data quality
activities
Head of Strategic
IT
On-going
Commissioning CSU IT services
Head of Strategic
IT
Corporate business and governance workplan
174. Priorities for 2015-17:

We will deliver a consistent business service across the CCG to support
effective delivery and embedding of good governance

We will ensure all CCG statutory duties and functions are delivered in
accordance with the framework of current legislation

We will establish an effective and efficient framework and reporting
mechanism to give sufficient, continuous and reliable assurance on
organisational stewardship and the management of major risks to
organisational success
175. The corporate business team is responsible for ensuring that the core business and
strategic priorities of the organisation are carried out in a timely and logical manner
and in accordance with our constitution and within the guidelines of the Department
of Health.
176. The team supports this process with responsibility for the implementation of
numerous areas of governance, due diligence and corporate affairs, such as
information governance and adherence to legal and statutory frameworks as well as
implementation of Caldicott Review recommendations.
177. To ensure good governance is embedded across the organisation the corporate
business team drives forward a suite of corporate management tools within a
Supporting Information & References
213
defined governance architecture, which supports the operation of the organisation.
This is done by the management of the business assurance framework, corporate
risk register and overview of the corporate performance report to assess progress
against strategic priorities.
178. The team works with all staff to ensure effective awareness and implementation of
corporate regulations and requirements, through a suite of templates and training
programmes.
179. Key milestones for 2015-17 are:
Date
214
Milestone
Accountable
Apr 2015 &
2016
Review, develop and refine suite of corporate
management tools
Head of Corporate
Business
Mar 2016 &
2017
Governance architecture embedded to
support cycle of corporate meetings
Head of Corporate
Business
Nov 2015 &
2016
Review and update CCG Constitution to
reflect any significant changes
Assistant Head of
Corporate Business
Jun 2015 &
2016
Coordinate and produce annual report
Assistant Head of
Corporate Business
Mar 2016 &
2017
Corporate meetings effectively supported
and delivered – supporting paperless agenda
Corporate Business
Manager and
Officer
Jul
2015
Establish and embed corporate filing
structure and system to comply with good
governance standards
Corporate Business
Manager
Biannual
Biannual update of Declaration of Interest
and Gifts and Hospitality Registers
Corporate Business
Officer
Mar 2016 &
2017
Compliance with statutory framework
regarding Information Governance toolkit
Corporate Business
Manager
Mar 2016 &
2017
Compliance with Information Governance
mandatory training
Corporate Business
Officer
Sep 2015 &
2016
Undertake self-assessment of core standards
for Emergency Preparedness Resilience and
Response
Assistant Head of
Corporate Business
Mar 2016 &
2017
Coordinate the management and
maintenance of the corporate risk register
Corporate Business
Manager
NHS Coastal West Sussex CCG | Delivering the vision
Organisational development workplan
180. Priorities for 2015-17:

We will continue to develop membership engagement to ensure practices and
localities play a leading role in the commissioning process

We will ensure a comprehensive development programme is in place to
support all teams and individuals to maximise their potential and deliver their
objectives

We will ensure our structure continues to meet the needs of our developing
organisation

We will support the organisation and work streams in its prioritization process

We will manage the contract for HR service provision and ensure delivery of
the full service specification and best value for money
181. During 2014-15 we have continued to support the development of the 6 localities
and Locality Directors across Coastal West Sussex to ensure they are empowered to
take a leading role in commissioning decisions of our CCG; embedded a robust
development programme for staff; delivered a successful ENCIRCLE programme
aligned to CWS commissioning intentions in which all practices are engaged;
commenced the roll out of team development programme, using the MBTI tool, with
the aim of supporting teams to effectively work together and improve performance.;
and completed the clinical remuneration review and supported the engagement of
clinicians in key programmes of work. We will build on these achievements, during
2015-16 by focussing on:
182. Membership
We will agree and implement a membership strategy that will provide a framework
for us to develop our existing membership engagement. We will continue to
improve the provision of locality support to ensure that the locality Boards are
functioning commissioning Boards, and will also include a development plan for
Locality Directors. To support our engagement with localities and their practices we
will also plan and deliver two strategic events for our members. We will continue to
deliver the ENCIRCLE programme that is aligned to our commissioning intentions.
183. Development
Our staff are our greatest asset. So we know that supporting them to do their best is
crucial to getting great outcomes for patients. With this in mind we will agree and
implement a talent management strategy that will assist us in nurturing talent within
the organisation bringing benefits for the individual, the team and organisation as a
whole. Every member of staff will have an appraisal and an output of this will be a
personal development plan. We will also, in line with national policy, review our
existing policy regarding staff who have caring responsibility. This will enable
Organisational Development to complete a training needs analysis so that we can
design a comprehensive development programme for 2015-16 that will meet the
specific needs of the organisation. The development programme will include offers
off coaching, mentoring and shadowing as well specific training programmes.
Supporting Information & References
215
184. We will also continue to roll out the team development programme using the MBTI
tool and supporting teams to address specific business issues and work together to
enhance their team performance.
185. In order to support individuals and teams we will continue the development of the
Staff Engagement Group (SEG) and ensure it is the voice of our staff and focuses on
improvements to issues raised. We will use the staff survey to gain feedback on key
issues such as leadership and management, communication and staff satisfaction.
We will benchmark against 2013 and 2014 data and ensure and action plan is in
place to address the issues raised.
186. We will work towards the Investors in People standard during 2015-16 as we
recognise our people are at the heart of the organisations success.
187. Structure
We will ensure that our structure is able to support the delivery of the organisations
objectives. This will include a review of the CWS support team structure, in terms of
roles and capabilities.
188. Prioritisation
We will use the OD strategy to help the Executive Teams shape and re-shape how
staff are deployed flexibly in line with the priority work streams in partnership with
the Planning & Programme Management team.
189. HR Service Provision
We will continue to work with CSU south to ensure that the full service specification
is met and we receive best value for money. A development plan is in place and this
will be monitored and reviewed to ensure agreed actions are completed.
190. Workforce planning
We will work with the Local Education Training Board (LETB) on workforce planning.
We have already established strong links and are committed to work together to
address the system wide workforce issues and ensure a sustainable workforce for
the future. We will also focus on our workforce, and in particular we will examine
how the CCG compares against the first NHS Workforce Race Equality Standard due
to be published in April 2015. The standard will require us to demonstrate progress
against a number of indicators of workforce equality, including a specific indicator
to address BME Board representation.
191. Key milestones for 2015-17 are:
216
Date
Milestone
Accountable
Feb
2015
ENCIRCLE programme published
Mar
2015
Review Clinical Leadership structure
Mar
2015
Review CWS support team structure
Chief of Corporate
Affairs
Mar
2015
Capacity and capability review
Chief of Corporate
Affairs
Head of
Organisational
Development
Head of
Organisational
Development
NHS Coastal West Sussex CCG | Delivering the vision
Date
Milestone
Mar
2015
Process and tools in place to manage talent within
the organisation
Mar
2015
Formal review HR contract
Chief of Corporate
Affairs
Apr
2015
Membership development strategy in place
Chief of Corporate
Affairs
Apr
2015
Strategic event (system wide)
May
2015
2015-16 Staff Development Programme published
Jun
2015
Phase 1 Team development / MBTI roll out
completed
Sept
2015
Review of all HR policies complete (will include
review of carers policy)
Oct
2015
Strategic Event (membership)
Nov
2015
Staff Survey
Apr
2016
Phase 2 Team development / MBTI roll out
completed
Dec
2016
Investors in People Standard achieved
Supporting Information & References
Accountable
Head of
Organisational
Development
Head of
Organisational
Development
Head of
Organisational
Development
Head of
Organisational
Development
Head of
Organisational
Development
Head of
Organisational
Development
Chief of Corporate
Affairs
Head of
Organisational
Development
Chief of Corporate
Affairs
217
Section 2.3 – Supporting information
192. Section 2.3 contains information regarding:



CQuINs
Better Care Fund
Quality Premium
CQuINs
193. For 2015-16 we aim to improve alignment of locally defined CQuINs across providers
so that patient outcomes are systematically improved and they effectively support
national and local policy.
194. This will be achieved by aligning as many local CQuINs as possible to a set of priority
areas. These priority areas are:





Urgent and proactive care
Mental Health Risk Assessment
End of Life Care
Mental Capacity Assessments
Physical health within mental health services
195. CQUINs for providers, whilst aligned to these priority areas, will all be tailored to
their services and remain subject to assessment against national policy objectives for
CQUIN which are: improved patient experience; improved safety; improved clinical
effectiveness; and supporting innovation.
196. We will also use and support all national mandated CQuINs including those which
will further the urgent and emergency care review. Taking the total CQuIN offer to
all provider up to 2.5% of their contract value.
197. Presented below is a list of local CQuINs proposed currently in negotiation.
Provider
Western Sussex
Hospitals NHS
Foundation Trust
218
Proposed Local Measure
Weight
Seven Day Working
Progressive compliance with the 10 clinical standards outlined
in the NHS Seven Days a Week paper
0.25%
Improved care for Inpatients with Dementia
Continuation and embedding of the structured clinical change
programme initiated in 2014/15 ensuring best practice
regarding the treatment and optimising patient experience for
high risk dementia patients.
Supporting Patients during End of Life Care
Supporting patients by improving levels of identification of
those in the last year life.
0.20%
0.20%
NHS Coastal West Sussex CCG | Delivering the vision
Provider
Proposed Local Measure
Mental Capacity Assessment
To improve quality of care and reduce harm of people
identified as lacking capacity admitted to hospital/care setting.
To increase compliance with the Mental Capacity Act 2005 in
Health environments and to increase Health organisations
professional expertise in the area.
Medication Safety Thermometer
The Medication Safety Thermometer is a measurement tool
for improvement that focuses on Medication Reconciliation,
Allergy Status, Medication Omission, and Identifying harm
from high risk medicines in line with Domain 5 of the NHS
Outcomes Framework.
Ward Accreditation
To launch and undertake the first year of Ward Accreditation
Programme supporting the Patient First initiative. The aim is
to ensure all wards are delivering excellence across a range of
measures, such as patient experience, safeguarding, patient
safety, medicines management and nutrition and hydration.
Total CQUIN for Local Measures
Payments by Results Programme (Pan Sussex CCGs)
- To develop and deliver a Work Programme preparatory to
implementation of PBR for mental health services in Sussex
from 2016/17.
Sussex Partnership
NHS Foundation
Trust
Improve physical health of patients with Severe Mental
Illness (Pan Sussex CCGs agreement to enhance national
CQUIN)
Development of infrastructure to support greater and more
regular access to physical health care monitoring for patients
with SMI who find access difficult.
Improvement and Development of Services for People with
Personality Disorders
(West Sussex CCGs)
Audit of patients diagnosed with BPD and gap analysis.
Develop plan for introduction of specialist PD pathway.
Patient Safety Framework
(Pan Sussex CCGs)
Implementation of the Sign Up to Safety Framework Toolkit,
which is is designed to help realise the ambition of making the
NHS the safest healthcare system in the world by creating a
system devoted to continuous learning and improvement.
Improving access for people experiencing a mental health
crisis (West Sussex CCGs)
Complete option appraisal and recommendations with
evidence of stakeholder engagement.
Develop plan for introduction of Single Point of Access,
including piloting scheme in Quarter 4.
Total CQUIN for Local Measures
Supporting Information & References
Weight
0.20%
0.20%
0.20%
1.25%
0.50%
0.25%
0.40%
0.20%
0.40%
1.75%
219
Provider
Sussex Community
NHS Trust
Proposed Local Measure
Improve Transition Arrangement for Young People
transferring to Adult Services (West Sussex CCGs)
To ensure the smooth transition where required of children
and young people with physical, learning disability or a
complex health need from children’s to adult health care
services.
Introduction of Mental Health Screening Matrix Tool
(West Sussex CCGs)
Improve Mental Health Assessments in community through
the implementation of a Mental Health screening matrix.
Introduction of East Kent Outcome System (EKOS)
(West Sussex CCGs)
Implementation of outcomes scoring tool to improve quality
standards within children’s speech and language therapy
services.
Supporting Patients during End of Life Care
Supporting patients by improving levels of identification of
those nearing the end of their life.
Proactive Care –Discharge Planning
Continuation of 14-15 schemes to improve the efficiency of
patient discharge from the acute provider and from
community inpatient units to the community provider,
including the sharing of information for the proactive care of
patients.
Total CQUIN for Local Measures
South East Coast
Ambulance NHS
Foundation Trust
Weight
0.25%
0.30%
0.45%
0.50%
0.25%
1.75%
Impact of delayed R1/R2 responses and handover times on
outcomes.
Better enable monitoring of clinical outcomes directly or
indirectly impacted upon by Red1/Red2 response times and/or
Time to Handover at Hospital through production of a
dashboard at CCG level
1.00%
Supporting Patients during End of Life Care
Supporting patients by improving levels of identification of
those nearing the end of their life.
0.50%
Urgent and Emergency Care
(Pan CCGs agreement to enhance national CQUIN) Reduction
in the rate per 100,000 population of ambulance calls that
result in transportation to a type 1 or 2 A&E Department.
0.25%
Total CQUIN for Local Measures
1.75%
Better Care Fund
198. The West Sussex Better Care Fund plan is available on the CCG and West Sussex
County Council websites.
220
NHS Coastal West Sussex CCG | Delivering the vision
Quality Premium
199. For 2015-16 our CCG has selected, in partnership with stakeholders, the following
measures to be used as part of the Quality Premium. Those shaded in grey are
mandatory measures.
Quality Premium
1
2
3
PYLL
Urgent and
Emergency Care
Mental Health
%
Value
£
Value
10%
£0.24m
Measure
Reducing potential years of lives lost through causes
considered amenable to healthcare
Delayed transfers of care which are an NHS
responsibility (15% - equal weighting)
30%
30%
£0.72m
Increase in the number of patients admitted for nonelective reasons, who are discharged at weekends or
bank holidays (15% - equal weighting)
£0.72m
Reduction in the number of patients attending an
A&E department for a mental health-related needs
who wait more than 4 hours to be
treated/discharged/admitted
4
Improving
Antibiotic
Prescribing
10%
£0.24m
Reduction in the number of antibiotics prescribed in
Primary Care
Reduction in the proportion of broad spectrum
antibiotics prescribed in Primary Care
Secondary Care providers validating their total
antibiotic prescription data
5
Local Measure 1
10%
£0.24m
Access to psychological therapy services by people
from BME groups (CCG OIS 2.10)
6
Local Measure 2
10%
£0.24m
Total health gain as assessed by patients for elective
procedures - knee replacement (CCG OIS 3.3b)
100%
£2.4m
Supporting Information & References
221
Annex 3 – Reference List
Centre for Workforce Intelligence. In Depth review of the General Practitioner Workforce.
London: Centre for Workforce Intelligence; 2014.
Department of Health. End of Life Care Strategy. London: Department of Health; 2008.
Department of Health. Innovation Health and Wealth: Accelerating adoption and diffusion
in the NHS. London: Department of Health; 2011.
Department of Health. Health visitor implementation plan 2011-15: a call to action.
London: Department of Health; 2011.
Department of Health. The NHS Constitution: The NHS belongs to us all. London:
Department of Health; 2012.
Department of Health. Better Procurement, Better Value, Better Care: A procurement
development programme for the NHS. London: Department of Health; 2013.
Keogh, B. Transforming urgent and emergency care services in England - Urgent and
Emergency Care Review End of Phase 1 Report. Leeds: NHS England; 2013.
The King’s Fund. Commissioning and contracting for integrated care. London: The King’s
Fund; 2014.
Marmot, M. Fair Society, Healthy Lives: Strategic review of health inequalities in England
post-2010. London: The Marmot Review; 2010.
National Audit Office. Tackling inequalities in life expectancy in areas with the worst health
and deprivation. London: National Audit Office; 2010.
NHS England. Outcomes benchmarking support packs: CCG level. Leeds: NHS England;
2012.
222
NHS Coastal West Sussex CCG | Delivering the vision
NHS England. A Call to Action: Commissioning for Prevention. Leeds: NHS England; 2013.
NHS England (a). CCG Outcomes Tool [online].2013. Available from:
http://ccgtools.england.nhs.uk/ccgoutcomes/flash/atlas.html
NHS England (b). Commissioning for Value Tool [online].2013. Available from:
http://ccgtools.england.nhs.uk/cfv/flash/atlas.html
NHS England (c). Everyone Counts: Planning for patients 2014-15 to 2018-19. Leeds: NHS
England; 2013.
NHS England (d). The NHS belongs to the people: a call to action. Leeds: NHS England;
2013.
NHS England (e). Transforming participation in health and care: The NHS belongs to us all.
Leeds: NHS England; 2013.
NHS England. Five Year Forward View. Leeds: NHS England; 2014.
NHS Improving Quality. Electronic Palliative Care Coordination Systems (EPaCCS) [online].
2014. Available from: http://www.nhsiq.nhs.uk/improvement-programmes/long-termconditions-and-integrated-care/end-of-life-care/coordination-of-care.aspx
Price Waterhouse Coopers. Transforming the citizen experience: One stop shop for public
services. Australia: Price Waterhouse Coopers; 2012.
Rightcare. Rightcare Casebook: The Accountable Lead Provider Developing a powerful
disruptive innovator to create integrated and accountable programmes of care [online].
2012. Available from:
http://www.rightcare.nhs.uk/downloads/Rightcare_Casebook_accountable_lead_provider
_Aug2012.pdf
Royal College of Paediatrics & Child Health. Facing the Future: Standards for Paediatric
Services. London: Royal College of Paediatrics & Child Health; 2010.
Supporting Information & References
223
West Sussex County Council. West Sussex Joint Health & Wellbeing Strategy. Chichester:
West Sussex County Council; 2013.
West Sussex Public Health. West Sussex Joint Strategic Needs Assessment: CCG Data Pack
2013. Chichester: West Sussex County Council; 2013.
224
NHS Coastal West Sussex CCG | Delivering the vision
NHS Coastal West Sussex Clinical Commissioning Group
The Causeway
Goring-by-sea
Worthing
BN12 6BT
T: 01903 708400
NHS Coastal West Sussex Clinical Commissioning Group is the clinical commissioning group covering Adur, Arun,
Chanctonbury, Chichester, Cissbury (Worthing) and Regis Localities.
Supporting Information & References
225