CKWCB-12-87b_Updated_FINAL_OpP

Version 0.15

2012-2015

Operating Plan NHS Calderdale, Kirklees and Wakefield District

3 Operating Plan 2012-2015

Contents

Introduction 4

Section 1: Overarching 7

Section 2: Finance and QIPP Plans 14

Section 3: Quality 41

Section 4: Performance 58

Section 5: Workforce 66

Section 6: Informatics 77

Section 7: Transition and Reform:

Commissioning development: emerging Clinical Commissioning Groups (eCCGs) 80


Commissioning development: commissioning support 87


Commissioning development: direct commissioning 92

Section 10: Health and Wellbeing Boards 96

Section 11: Public Health 99

Section 12: Provider Development 103

Appendices Appendix 1 to 4: eCCG Summaries of Key Priorities

Appendix 5 to 7: Public Health Transition Plans

Appendix 8: Healthcare Associated Infection (HCAI) Actions

Appendix 9: People Transition Plan

Appendix 10: Glossary of Abbreviations

Introduction NHS Calderdale, Kirklees and Wakefield District (NHSCKW) presents our 2012-2015 integrated plan. This Cluster level plan outlines how we are ensuring a safe and effective transition to the new healthcare system whilst maintaining the continued delivery of high quality healthcare services. The plan builds on the existing Strategic Plans of our constituent Primary Care Trusts (PCTs) and supports the delivery of our Strategic Goals: Control, Close and Create.

• Ensuring the quality and safety of existing services

• Financial governance

• Scheme of delegation

• Ensuring key outcomes are delivered

• Hold statutory responsibility

Control

• Formal disestablishment of the Primary Care Trusts

• Destination of staff

• Ensuring legacy documents are in place and up to date

• Ensure robust plans are in place for a safe transition to the new healthcare system

Close

• Co-production of the new architecture

• Supporting emerging Clinical Commissioning Group (eCCG) empowerment and authorisation

• Pace for the implementation of the new architecture

• Engagement of all partners

• Innovation and doing things differently

• Establishment of Health and Wellbeing Boards

• NHS Commissioning Board

• New relationship with public

• Prioritise the top transformational initiatives and ensure they succeed as planned

Create


The integrated plan also supports the delivery of the Clusters seven Strategic Objectives:

The measurable differences in the system that will result from this plan are:

Delivery of £73m of efficiencies in 2012/13, of which 27.5m is through PCT Quality, Innovation, Productivity and Prevention (QIPP) commissioner initiatives;

50% of savings over the 3 year plan being transformational;

A sound basis against which further transformations can happened around our two major health economies;

Authorised Clinical Commissioning Groups (CCGs);

Successful Public Health (PH) transition; and

Safe transfer of functions to the NHS Commissioning Board (NHSCB).

Ensure continuous improvement in the quality of commissioned health services (Effectiveness, Safety and Experience)

Sustain the integrated finance, operations and delivery system

Provide strong health system management

Deliver the new commissioning system infrastructure

Maintain the capacity to carry out emergency planning and resilience during transition

Maintain full engagement in the provider development agenda to ensure effective partnership with current and future Foundation Trusts

Deliver high quality communications and engagement

The emerging Clinical Commissioning Groups (eCCGs) have led key aspects of planning and have developed their own plans covering their six domains of authorisation. Their priorities are threaded through this plan and are supported by our three PCTs. A one page summary of the eCCG key priorities are appended (Appendices 1 to 4) and the full plans will be shared on our Cluster intranet. In this plan we have focused on service quality, including patient experience and maintaining quality standards and delivery of key targets. Our transformational milestones are clearly defined and linked to key strategic initiatives to deliver Quality, Innovation, Productivity and Prevention (QIPP). Existing targets are described and we have described how we aim to address long standing quality, outcomes and health inequalities issues in the system. This integrated plan supports the various submissions by the three composite PCTs of finance, demand/activity and workforce plans, and our QIPP programme. We have encapsulated the key messages from the 2012 Operating and Outcomes Frameworks into our plans, and have a Programme Management Office (PMO) approach to delivery which sits alongside an integrated approach to QIPP delivery. We describe the opportunities around working as a Cluster specifically on our QIPP programme and synergies to be gained by working together. We outline our shared ongoing working relationship with our two main acute trust providers – Calderdale and Huddersfield NHS Foundation Trust (CHFT) and the Mid Yorkshire Hospitals NHS Trust (MYHT), particularly as MYHT works towards Foundation Trust status. These are the platforms around which our future innovation and transformation will happen. This will include conversations with the public about future service provision as new initiatives emerge, e.g. the potential for 7 day services in Acute Trusts. Our financial plans are described in Section 2 of this plan and they anticipate the additional risk associated with the level of current and future change at MYHT. We have assured ourselves that an increase in activity is supported by appropriate funding and is deliverable through the known workforce plans. For those areas where we have identified a potential risk to delivery this is described in full with mitigating actions where relevant. Appended to the plan are our more detailed three PH transition plans (Appendices 5 to 7).

Mike Potts Angela Monaghan Chief Executive Officer Chair

March 2012


Section 1

Overarching

1.1 Programme Management Office Approach In order to coordinate and ensure the delivery of the transition requirements of the Cluster Accountability Agreement and the Shared Operating Model for PCT Clusters a Programme Management Office (PMO) approach was established across the Cluster with six portfolios of work. The essential purpose of PMO is to provide assurance that the Cluster is on-track to deliver the outputs of transition and to meet the mandated milestones. It is done through an active process of performance review and assessment of evidence and reporting to the Executive Team and Cluster Board. This includes building the emerging commissioning architecture and new commissioning systems whilst the PCTs, which comprise the Cluster, continue to deliver their business-as-usual commissioning functions, including QIPP with ever increasing involvement of eCCGs. The portfolios are based on the 6 headings outlined in the Shared Operating Model for PCT Clusters which is also being used for the development of our Board Accountability Framework. The overall management of QIPP is delivered through Portfolio 1. A full time Project Manager has been appointed to lead the Commissioning Support Service (CSS). The PMO is also supported by a designated finance lead, workforce lead and governance lead.

As part of the development of the PMO, Sharepoint has been set up to enable the easy sharing, transfer and management of information across the Cluster around the

Executive Director of Commissioning and Service Development

Commisioning Support Offer Project Manager

PMO Manager

Integrated Finance, Operations and

Delivery

Commissioning Development

Ensuring Quality

Emergency Planning and Resilience

Commissioning Elements of Provider

Development

Communication and Engagement

areas covered. It also enables people from across the Cluster geography to work closely as a virtual team. The product is already supported and used by the NHS and offers a future flexible environment to work in as people move jobs and locations through the transition. It is also an excellent environment in which to capture the historic memory of the composite organisations and manage the items being transferred to the future architecture such as the NHSCB.

Portfolio 1- Integrated Finance, Operations and Delivery

• Meet QIPP challenge;

• Deliver Operating Framework measures;

• PCT integrated plans;

• Monitor contracts and hold providers to account;

• Ensure we meet statutory requirements, e.g. safeguarding;

• Good reporting on measures;

• Effective planning enabling eCCGs to lead planning in 2012/13;

• Audit and counter fraud; and

• Financial planning with eCCGs management 2% running cost headroom.

Portfolio 2 - Commissioning Development

• Authorisation of eCCGs and self diagnostic;

• eCCG development plans;

• Delegated budget reported and tracked through Operating Framework indicators;

• Support eCCG understanding and delivery on Public Sector equality duty and equality delivery system;

• Participation of eCCGs in Health and Well Being Boards (HWBB);

• Ensure eCCGs engagement in provider development;

• Development of Commissioning Support (full time Project Manager appointed);

• Cluster role in development of primary care commissioning model and transfer to NHSCB;

• Specialised Services;

• Prison Health; and

• Military Health.


Portfolio 3 - Ensuring Quality

• Taking account of National Quality Board reports;

• Develop eCCGs future role in respect of quality and improving outcomes;

• Assure provider quality and contract management quality;

• Alert on areas of non compliance with Care Quality Commisison (CQC) and avoid failures;

• Ensure good clinical governance;

• Ensure mechanisms to capture and act upon patient feedback experience;

• Ensure QIPP quality;

• Ensure providers can demonstrate safe workforce models and meet criteria set out;

• Review incidence, CQC quality and risk profiles and public feedback;

• Public health notices and central alerts;

• Systems for safeguarding;

• Risk summits and planned reviews;

• Patient complaints;

• Legacy documents;

• Involve and engage with HWBB and LINKS/Healthwatch;

• In partnership with Local Authority (LA) develop quality framework for public health services; and

• Equality and Diversity and use of Equality Delivery System.

Portfolio 4 - Emergency Planning and Resilience

• Resilience and effective planning;

• Meet Emergency Planning and Resilience (EPR) Cluster responsibilities;

• Ensure a mechanism for local organisations (particularly LA, Police and Ambulance Trusts) to access through a single point of contact, with 24/7 response to local incidents;

• Ensure mechanisms are in place to support local system wide response, including cross boundary mutual aid for emergency response;

• Continue to maintain provision to provide local system management for routine capacity issues, diversion and winter pressures; and

• Maintain Cluster capacity to provide 24/7 coordination to an incident via a suitably equipped control room for period of up to two weeks duration.

Portfolio 5 - Commissioning Elements of Provider Development

• Support Foundation Trust (FT) development/application;

• Ensure choice through Any Qualified Provider (AQP) - effective delivery of AQP including eCCG development of plan;

• Ensure sign up to activity in trust plans;

• Actions to ensure appropriate providers and models of care are available;

• Ensure effective procurement and contract management;

• Oversight of the failure regime where restructuring of services affect more than one PCT; and

• Support the successful establishment of Right to Request social enterprises.

Portfolio 6 - Communication and Engagement

• PCTs have statutory responsibilities for communication and engagement and Cluster leaders must assure themselves that PCTs in their Cluster can continue to meet these statutory responsibilities effectively e.g:

• Publishing accounts, holding AGMs, publishing plans etc;

• Consulting, involving and engaging on significant changes to and decisions about the local NHS;

• Providing information (for patients, on performance etc.) to facilitate the exercise of choice and to improve accountability; and

• Responding effectively to Freedom of Information (FOI) requests.

• Cluster Chief Executives must work with Strategic Health Authority (SHA) Directors of Communication (DoCs) as well as eCCG leaders to help inform the development of the locally delivered nationwide shared service for communication and engagement during transition; and

• When the service is launched in April 2012, with initial arrangements starting to be put in place from October 2011, Cluster communications and engagement staff will become part of it and it will support Clusters and eCCGs through the remainder of the transition period.


1.2 Governance Effective governance and assurance arrangements are essential to provide confidence that the organisation is focused effectively on the delivery of its most important (principal) objectives. High level risks have been identified and we have clear Cluster processes in place to identify and track risk through our Board Accountability Framework. The Board Assurance Framework (BAF) provides a structure and process that enables the organisation to focus on the risks to achieving its principal objectives and be assured that adequate controls are operating to reduce these risks to acceptable levels. The component parts of the BAF are therefore:

Principal objectives;

Principal risks;

Key controls;

Expected/planned for assurances on controls;

Board reports – positive assurances; gaps in control; gaps in assurance; and

Board action plan. Since 2001/02 all NHS Chief Executives have been required to sign a Statement on Internal Control (SIC) that has formed part of the statutory accounts and annual report. This amplifies the need for Boards to be able to demonstrate that they have been properly informed about the totality of their risks, both clinical and non-clinical. To provide this statement boards need to be able to demonstrate that they have been properly informed through assurances about the totality of their risks and have arrived at their conclusions based on all the evidence presented to them. To do this they need to be able to provide evidence that they have systematically identified their objectives and managed the principal risks to achieving them. The BAF fulfils this purpose. 1.2.1 Building the Board Assurance Framework The starting point for an assurance framework is the identification of the organisation‟s goals/priorities and principal objectives for the year. The Department of Health published the Shared Operating Model for PCT clusters in July 2011 and the Operating Framework for the NHS in England 2012/13 in November 2011. This guidance sets out a range of expectations in relation to what PCT Clusters should be delivering. The guidance has been used by the executive team to identify a revised set of principal objectives to serve the Cluster through to its formal disestablishment in April 2013. The NHSCKW BAF was drawn from and adapted from the approach taken by Merseyside Cluster of PCTs. The approach has been discussed with internal and external auditors and at the Governance Committee. A non executive director from each committee has provided support and challenge to the process. An executive director is assigned to each principal objective. The executive team worked to identify the principal risks associated with the delivery of seven principal objectives:

Ensure continuous improvement in the quality of commissioned health services (Effectiveness, Safety and Experience);

Sustain the integrated finance, operations and delivery system;

Provide strong health system management;

Deliver the new commissioning system infrastructure;

Maintain the capacity to carry out emergency planning and resilience during transition;

Maintain full engagement in the provider development agenda to ensure effective partnership with current and future FT; and

Deliver high quality communications and engagement. The BAF has been assessed against the criteria set out in the “Good Practice Briefing: Assurance for Boards” West Yorkshire Audit Consortium (2008). 1.2.2 Links to the Corporate Risk Register The BAF and Corporate Risk Register (CRR) are distinct but related documents serving different purposes. Whilst the purpose of the BAF is to provide assurance to the Board that risks to delivery of the organisations principal objectives have been identified and are being managed. The purpose of the CRR is to provide the Board with a summary of the principal risks facing the organisation, with a summary of the actions that are needed and being taken to reduce these risks to an acceptable level. The information contained in the CRR should be sufficient for the Board regarding prioritising and managing major risks. The risks described in the CRR will be more wide-ranging than those in the BAF, covering a number of areas. Where risks to achieving principal objectives are identified in the CRR or other risk registers, these should be added to the BAF; and where gaps in control are identified in the BAF, these risks should be added to the CRR. The two documents work together to provide the Cluster board with assurance and action plans on risk management in the organisation. A consistent approach to the risk management process has been agreed across the Cluster. Proposals were discussed and endorsed on the 31 October 2011 at the Governance Committee. The first eight week cycle of the new risk process has begun and will be presented as the high level corporate risks in a report to the March 2012 Board. 1.2.3 Review and Scrutiny The Governance Committee will review prioritised sections of the BAF at each meeting throughout the year as part of the work plan. Thereafter the BAF will be formally updated by the executive team, scrutinised by the Governance Committee and presented to the Board in April 2012 and October 2012 and March 2013. Lead officers will update the document whenever new assurance is available. The NHS Audit Committee Handbook (2011) recommends that the Audit Committee should consider the BAF in its entirety at least annually.


1.3 Equality and Diversity The cluster has developed and implemented its equality and diversity action plan as the framework for meeting NHSCKWs statutory requirements of the Equality Act 2010, the Public Sector Equality Duty and the specific duties as set out in regulation. The NHS Equality Delivery System (EDS) has been adopted and is being used as a tool to:

Assist in meeting the evidential requirements of the statutory Public Sector Equality Duty, including the involvement of patient (NHS Act 2006);

Improve equality performance across the cluster by embedding into mainstream commissioning processes; and

Formulate organisational equality objectives.

The action plan together with the EDS framework will be reviewed locally by the Audit and Governance Group, a sub group of the Clinical Commissioning Executive Committee, and progress updates will be received by the Cluster Governance Committee. 1.4 Communications and Engagement

A shared communications and engagement service for the Cluster has been operating since June 2011, which has strengthened resilience and made the most effective use of resources across the NHSCKW footprint. This has ensured that there is sufficient capacity and capability to continue to deliver high quality patient and public engagement in all aspects of work and ensure the Cluster PCTs meet their statutory duties in this respect. The Cluster is also overseeing two major reconfigurations of acute services and additional communications and engagement resource has been brought in to support an effective engagement and consultation process, without compromising other areas of work.

Section 2:

Finance and QIPP Plans 2.1 Summary 2011/12 Financial Position We are forecasting to deliver the 2011/12 combined income and expenditure Control Total surplus of £15m, and are planning on the basis that this will be returned to the PCTs in full in 2012/13.

2.2 Financial Plan for 2012/13 Summary Position We are planning to deliver a combined control total surplus of £13.3m for 2012/13. We have used the actual allocation and tariff inflation figures for 2012/13 and the updated estimates included in the SHA planning guidance for future years.

2.3 Summary of Initial Plans for Application of 2% Top Slice Each of the PCTs in the Cluster is planning to set aside 2% of their recurrent allocations to be used to fund non-recurrent initiatives in 2012/13 and amounts to £32.4m. Each PCT has a process in place to approve appropriate business cases for proposed expenditure from this funding. The use of the Non Recurrent (NR) funding will be prioritised for investment in transition costs, service re-design, and workforce re-configuration. 2.4 Generating Transformational QIPP Across the Cluster This section of our Cluster Plan articulates our actions to develop and delivery transformational change. The key elements of this work are:

3-year QIPP plans have been generated through the leadership of our eCCG commissioners;

We have embedded transformational QIPP in our eCCG strategic objectives for the future; and

We have been able to aggregate eCCG plans into 5 high level Cluster QIPP areas.

Our 5 high level Cluster QIPP aspirations are set out below:

Preventing unnecessary unplanned admissions to hospital – including supporting the management of long-term conditions;

Changing models and pathways in planned care to ensure the right care is provided in the right place;

Developing the role of assistive technology and risk stratification;

Developing alternative community services that reduce reliance on acute care and provide care closer to home; and

Strengthening and developing mental health and learning disability services.


The following table summarises the key financial plan requirements and compliance for each PCT NHS Calderdale NHS Kirklees NHS Wakefield

Does the plan reflect the expected level of SHA/PCT surplus drawdown (to be agreed)?

Yes - The plan reflects the positions shared with the SHA in January 2012.



Does the plan include any NHS Trust deficits? If so, are they in formal, agreed recovery, consistent with their NHS Foundation Trust pipeline plan and their TFA? If not, why?

No. MYHT is planning for a £15m I & E deficit in 2012/13. The PCT is working with the Trust, SHA and Stakeholders to develop a recovery plan and understand the implications on the Trust FT pipeline

Does the plan resolve all PCT legacy debt by the end of 2012/13?

No legacy debt in place No legacy debt in place No legacy debt in place

Has every PCT set aside 2% of their recurrent funding with the SHA for non-recurrent expenditure purposes? Is there a process in place to approve appropriate business cases for proposed expenditure?

Yes - Business cases will either be signed of as part of the plan approval, or in year in line with the PCTs normal business planning process and SFIs



Is the value of QIPP savings forecast for 2012/13 (and the full Spending Review period, ending in 2014/15) materially consistent with the four year integrated plan? If not, what steps are being taken to ensure the PCTs share of QIPP challenge will be delivered?

Yes Yes £30m over the 3 years. Yes

What assurance processes are in place to monitor and manage changes to planned QIPP savings and variations from plan?

Reported through Board, CCE, Finance & Performance Group and Senior Management Team meetings on a monthly basis. Monthly update reports produced for each scheme/area

QIPP progress is reported through Finance and Performance, the CCEs and the Cluster Board. Progress is monitored on a monthly basis, and leads for all areas are clearly identified.

Reported through Board, CCE, Finance & Performance Group and Senior Management Team meetings on a monthly basis. Monthly update reports produced for each scheme/area

Does the QIPP plan include sufficient headroom between the size of the challenge and the savings identified? If not, what is the reason, and how will slippage and underperformance be managed?

Yes - QIPP currently matches the challenge and provides a balanced budget subject to contract finalisation. All QIPP plans must be green or amber to be included in the plan. The Plan includes a contingency budget to mitigate any slippage

Yes at the Moment subject to finalisation of contracts. The QIPP plan is set at £9.5m, of which £6.5 is required to 'balance the books'.

Yes - QIPP currently matches the challenge and provides a balanced budget subject to contract finalisation. All QIPP plans must be green or amber to be included in the plan. The Plan includes a contingency budget to mitigate any slippage

Does the plan reflect delivery of target running cost savings?

Yes £1m saving included in the plan from HQ budgets.

Yes. £1.5m savings included. Yes. £1.5m savings included.

2.5 Local Context Primary Care Trusts within NHSCKW have a strong track record in managing within financial resources and delivering QIPP targets. CHFT, as a long-standing FT, has a history of managing within its financial resources. However, given the need to ensure that services are fit for purpose into the future – local commissioners have agreed to lead a refresh of the current Clinical Services Strategy across the acute footprint. MYHT is currently undergoing a recovery and improvement programme, which brings together; financial recovery, clinical performance improvement and transformation. This is more fully described within this section. This is the final year in which PCTs will take responsibility for the management of budgets - with all responsibility transferring to eCCGs and other commissioners in April 2013. We are committed to ensuring that our legacy is a sustainable position whereby eCCGs will have a balanced plan, including a contingency, and a clear plan to use the 2% non-recurrent funding to stimulate system-wide transformational change. Effective engagement with patients and the public is a key part of our approach to delivering the QIPP agenda. This has already led to successes in service transformation and will continue to be an integral part of all projects. Wherever possible, this is being delivered on a Cluster-wide basis by the shared communications and engagement team to ensure a joined up and consistent approach. Ongoing work includes engagement around Care Homes and Dementia. 2.6 Assumptions 2.6.1 Financial Assumptions The financial plans and resultant proposed annual budgets are based on anticipated resources, risks and developments known at this time and are subject to change pending management and mitigation of risks associated with contract negotiation and the impact of Payment by Results (PbR) tariff changes.

Financial assumptions 2012/13 2013/14 2014/15

PCT allocations +3.0% +2.6% +2.8%

Tariff change -1.5% 0.0% 0.0%

Non-tariff price change -1.8% 0.0% 0.0%

CQUINs +1.0% 0.0% 0.0%


2.6.2 Activity Assumptions In constructing our plans, we have set activity assumptions for 2012/13 and beyond. In doing this we have:

Taken 2011/12 outturn as our starting point;

Built in predicted growth based on historical patterns;

Identified activity reductions to be delivered by our QIPP plans;

Ensured that the same assumptions are incorporated into demand planning for the CHFT contact and MYHT;

Looked at the activity assumptions in the light of any known bed-based changes; and

Considered whether the changes may have a negative impact on quality and safety, particularly Healthcare Associated Infections (HAIs) and privacy and dignity.

2.7 Cluster QIPP Plans Delivery of our financial plans is dependent upon the delivery of ambitious QIPP targets for the next 3 years and beyond. We plan for 50% of this to be through transformational QIPP schemes over the 3 years with 47% delivered in 2012/13 and in the two subsequent years 52% and 51%. These plans describe both our approach to system-wide transformational schemes, as well as transactional schemes which deliver efficiencies in our ways of working. Our high level Cluster QIPP Plans for 2012/13 are set out below:

Cluster £M

Calderdale £M

Kirklees £M

Wakefield £M

Primary Care 4.3 0.5 2.1 1.7

Community Care 3.3 0.9 1.3 1.1

Acute Care - Commissioner 15.6 3.0 4.4 8.2

Corporate/HQ 0.0 0.0 0.0 0.0

Running Costs 4.0 1.0 1.5 1.5

Other 0.3 0.1 0.2 0.0

Sub Total Commissioner 27.5 5.5 9.5 12.5

Sub Total All efficiencies 73.0 15.3 29.7 27.9

Of which the following are transformational:

Primary Care 0.0 0.0 0.0 0.0

Community Care 1.8 0.0 1.3 0.5

Acute Care – Commissioner 9.1 1.5 2.8 4.8

Corporate/HQ 0.0 0.0 0.0 0.0

Running Costs 0.0 0.0 0.0 0.0

Other 1.0 1.0 0.0 0.0

Sub Total Commissioner QIPP 11.9 2.5 4.1 5.3

QIPP Total All 34.4 8.3 12.8 13.4

Total % Transformational 47% 54% 43% 48%

The QIPP plans set out are slightly different from those submitted in our Integrated Plans last year. The differences mainly relate to a re-profiling of savings in Kirklees to bring forward £1.5m challenge into 2012/13 from the later years. There is also a presentational change in Wakefield‟s figures of around £10m. This relates to savings which were shown incrementally in last year‟s plan rather than annually. 2.8 Whole System Transformational Change We recognise that our QIPP plans will only be fully delivered through whole system transformational change. Transformational change is reliant on the integration of the strategic plans across the whole system. We now have a governance structure in place to deliver whole system change through the Transformation Boards. The executive representatives from health and social care are committed to strategic alliance and a focus on care closer to home. The system recognises that a focus on pathways, whilst delivering efficiencies, will fail unless system enablers such as assistive technology, e-consultation, integrated provision, case management and risk stratification are in place. Information sharing is vital and fostering a culture that shares information safely as required by the data protection act is the first step. Clinical strategy reviews across both acute footprints linked with integrated health and social care provision will allow us to reduce bed numbers at the same time as delivering more care closer to home. The strategy builds on some excellent pockets of transformation across NHSCKW by increasing the scale and pace of integration. This is demonstrated in the diagram below


Whole system integration

• E consultation

• Personalised care planning

• Case management

• Risk stratification

• Community care teams integrated health and social care on primary care footprint

• Virtual ward

• A/E navigation

• Mobile response

• Emergency plans .

• Single point of access

• community care teams

LACommunity

provider

Acute trusts

Primary care

Person first

E consultation TelemedicineVirtual wardCommunity consultants

In Kirklees there has been a focus on system enablers including assistive technology and Teleheath to reduce unplanned care and drive the self care self management agenda. The development stages over the last two years put NHSCKW in a strong position to mirror the savings identified through the recently published evaluation on the whole system demonstrator sites.

Vulnerable adult

Assistive technology

personalised care

plan / self care

Primary Care / case

management

single point access

PREDICTIVE RISK ANALYSIS

Quality data

Performance data

Financial data

REAL TIME ANAYLSIS

System Enablers

To support the process going forward the process will be managed by a programme director and the governance structure is shown in the diagram below:

Programme Director

Clinical /professional

option appraisal

design group

Planned Care Board

Unplanned Care Board

Integrated health and social care strategic transformation board

CHFTClinical services strategy group

Health and Well being Boards

Clinical commissioning Groups/cluster

Governance

A joint Unplanned Care Board accountable to the Transformational Board (one for each acute footprint) will be responsible for the roll out across the whole system with a particular focus on reducing unplanned admissions and delivering planned care in community and primary care settings supported by risk stratification high quality information and assistive technologies. There is in place a Cluster wide assistive technology work stream and a risk stratification work stream which will report to the Unplanned Care Board. 2.8.1 Examples of Early Success The e-consultation programme linking a consultant in diabetes with GPs at present limited to MYHT and North Kirklees; early indicators are showing a reduction in referrals of over 75%. Introduction of access to GP records by the consultant through SystemOne has reduced duplication and improved the quality of care making clinics more proactive and increasing time spent with the patient on promoting self care. Expansion of this across the whole system as part of the integration strategy will change the way planned care is delivered. Telehealth is being introduced to care homes to support them with end of life care and management of Long Term Conditions (LTC). Between 10-15% of emergency admissions come from care homes which can be prevented by rapid access to advice and support from clinicians. Telehealth is not fully utilised in the pathways where the evidence for quality improvement and cost savings is made nationally and internationally such as heart


failure and COPD. Despite roll out of 100 units scaling up the provision Telehealth across an integrated patient pathway it is still in its infancy and will be the focus of the next twelve months. Technology will support the delivery of QIPP and we will use levers such as CQUINS to incentivise system change. 2.8.2 Next Steps and Actions

Formation of Clinical Network to look at options for strategic change;

Listening exercise with public: o Setting out problem; and o Searching for solution.

Planned Care and Unplanned Care Board to maintain focus on QIPP;

Set timeline for strategic priorities and pace of implementation; and

Appointment of Programme Director. 2.8.3 Risk Stratification Tool The Cluster risk stratification workstream has been set up and will report to the Unplanned Care Board as previously described. The work is based on a risk stratification tool used successfully in Kirklees that encompasses 98.8% of the population and covers all age groups. This can be utilised at practice, eCCG or locality level. Work to date has focused around the following:

Comparative analyses of GP practice information, supported by different ways of relaying this in a meaningful way;

Diversity of approaches, including e-learning to support and embed understanding, exploration and development;

Risk matching caseloads to clarify the profile of patients cared for by a service, and empower supporting or challenging provision against service specification;

Development of impactibility assessment (guided by the Nuffield Trust) which highlights gaps in care (currently one of the leads in the UK);

Specific partnership working between Locala, Kirklees Council and NHS Kirklees has utilised risk stratification to identify approximately two thirds of individuals for the DH “Warm Home” initiative; and

Ongoing and diversifying utilisation across health (PH pilot with GP practices, children‟s commissioning, wellbeing and integration).

2.8.4 Benefits and Potentials

Delivers service configuration or decommissioning evidence base;

Quickly identify and manage more appropriately LTC patients, across health services;

Manage demand across primary and secondary care;

Target intervention at patient groups with high cost or gaps in care;

Partnership working and integration across health and social care, enabling smarter and potentially more cost effective delivery of services for patients

through shared knowledge of risk stratification and its application across the population;

Risk matching for the Virtual Ward/LACE pilot, demonstrating the potential value of community risk scores to acute care and their discharge process; and

Development of use and inclusion with other data sources to further embed and advance partnership working across different health and social care providers (e.g. Mental Health, Care Homes, Yorkshire Ambulance Service).

2.9 Transformation in the Acute Sector As indicated at the start of this chapter, work is ongoing across both the CHFT and MYHT acute footprints to continue our transformational change agendas. 2.9.1 CHFT Across the CHFT footprint there has been a long-standing Transformational Board arrangement which has brought together partners from across the local health and social care economy to drive change. Its main areas of focus have been delivery of system change in planned and unplanned care. This work has resulted in a strengthening of the alignment between QIPP and provider-driven CIPs, as well as bringing together QIPP plans from PCTs across the acute footprint into one single QIPP plan. Whilst this work has enabled both Commissioners and Providers to deliver their financial aspirations, it is recognised that – in order to deliver the challenges going forward - we need to again review the current configuration of services. This work started back in 2005, when the health community set out its 5-year vision. The work to refresh this vision has been agreed with commissioners, and will be Commissioner-led. The aims of the work are consistent with our QIPP aspirations as a Cluster, in that they will:

Ensure a strategy for the next 5 years to delivery high quality care the most appropriate setting;

Ensure care will be delivered in a system which is in the top 10% nationally for safe, reliable, patient-centred care – maximising technology to deliver and support care;

Maximise the advantages of the NHS reforms, and respond to demographic changes;

Focus on meeting the need of people living with long-term conditions; and

Create an affordable and sustainable model of service, where local leaders are recognised for their approach to partnerships and integrating care.

The timeline for this work is currently being detailed, however it is anticipated that public consultation will begin in November 2012, and that, final decisions on any significant change, will be taken in December 2013. A Programme Director and Programme Office will be developed to lead this significant change programme.


2.9.2 MYHT There is a strong history of joint working and delivery of service improvement programmes across the MYHTs footprint. However, it has been recognised that a financial turnaround and service transformation programme is required to ensure that local systems are fit for purpose into the future. The Cluster approach to Transformation and the development and delivery of QIPP plans are integral to the Mid Yorkshire Health Economy Foundation Trust (MY HEFT) Programme – now renamed Mid Yorkshire Partnership Programme. The Mid Yorkshire Partnership Board focuses on the three big programmes of work which will put the trust into a better position to achieve financial recovery, improve performance and achieve FT status. The programmes cover:

Transformation – whole system transformation and clinical services strategy;

Turnaround – financial recovery (trust efficiencies, PFI review, MYHT financial plans and longer term financial strategy) and performance improvement; and

FT application. The MY Partnership programmes are overseen by the Programme Director, on behalf of the Cluster and MYHT, through the Programme Management Office. The milestones set out in MYHT‟s Tripartite Formal Agreement to achieve FT status are factored into the programmes‟ plans. The transformational programme includes:

MYHT‟s Clinical Services Strategy – the Cluster, North Kirklees and Wakefield Alliance eCCGs and the SHA Cluster and other relevant stakeholders are all engaged and involved in testing and challenging those service reconfiguration options to ensure they emerge as clinically effective, will deliver the level of efficiencies required to support the trust‟s financial recovery and will provide services that patients want;

Urgent Care – ensuring coherent integrated services sitting behind 111 which includes optimisation of Pontefract General Hospital‟s services;

Care Outside Hospital - promoting integration between community services and local authority‟s intermediate tier services; and

Improving and enhancing primary care – which builds on what has been achieved so far and supports better demand management and reducing unplanned care needs.

The Programme Management Office has already delivered:

Stocktake of QIPP Plans (2011/12) – to capture QIPP plans within NHSCKW Cluster and provide a high-level estimate of the direct impact on finance and activity in MYHT;

Report on alignment to CIP Plans (2011/12) – work to test consistency between Cluster QIPP and MYHT CIP plans, highlighting areas to be resolved (e.g. CIPs based on assumed activity growth); and

Detailed Review of QIPP Plans – conducting a „confirm and challenge‟ process to assess the deliverability of QIPP plans which captured progress to date and

estimated impact for 2012/13. The three largest schemes affecting MYHT are as follows: o Primary Care Transformation (Wakefield) – recently agreed initiative to

increase primary care capacity and reduce A&E admissions and LTC admissions (8% and 5% respectively);

o Planned Care Schemes (Wakefield) – pathway redesign to shift activity out of hospital and improve cost-effectiveness, such as for Ophthalmology and Dermatology. In part these schemes address current imbalances in demand and capacity in MYHT; and

o Wellbeing and Integration Programme (Kirklees) – comprising nine schemes directly targeting disease areas and client groups, from rapid response urgent care in the community, to diagnostic, diabetes, rehab and chest pain pathways.

The Programme Management Office also designed and held an event in November 2011 for all partners to support the development of whole system Transformation across the health and social care economy. The outcome of that event led to agreement amongst partners on:

A set of principles and agreements on ways of working;

An overall vision with shared ambitions for improving health and healthcare in MYHT; and

A set of inter- dependent priorities to be delivered collaboratively, including but not limited to: o „Getting the basics right‟ – for effective and appropriate referrals and

discharges; o Developing care outside hospital – including the intermediate tier and

redesign of pathways for key areas including dementia and end of life care. This work was supported by a whole health economy event on 26 January 2012 to capture current activity and agree shared strategic objectives;

o Improving urgent and emergency care – to maximise use of current facilities, including Pontefract, and tackle high levels of access; and

o Improving quality and access to primary medical services. The MYHT HEFT Board reviewed progress on Transformation in January 2012 and supported the suggested approach to revise future governance arrangements and ensure appropriate attention is given to service improvement, Transformation and finance. The strategic approach to Transformation has been developed in 2011/12, including the wide stakeholder engagement required to support fundamental challenge to long-established patterns of activity and service delivery. The plans build upon a range of transformational and transactional initiatives already delivering benefits in both the Cluster and MYHT, with the former captured in the QIPP Tracker. The scale and complexity of the challenge in MYHT requires the rapid development of pace and scale during 2012/13 in delivering improvement through Transformation.


2.9.3 Cluster Consistency of Approach and Aspiration As set out in the previous section, although the context is very different across the two local acute footprints, there is a consistency in relation to key areas of focus and aspirations. The diagram below shows the consistency of key areas of focus, which are in line with the Cluster aspirations set out at the start of this section:

Calderdale & Huddersfield FT

Non-Elective Care (Urgent Care, Intermediate

tier,virtual ward, care homes)

Local, community alternatives (planned care

redesign)

Long-term conditions (telemedicine, risk

stratification, community models)

Mental health and learning disability pathway

redesign

Mid Yorkshire NHS Trust

Non-Elective Care (Urgent and Emergency Services,

building primary care capacity)

Local, community alternatives (planned care

redesign)

Long-term condiitions (9 targeted disease

areas/client groups)

Mental health and learning disability pathway

redesign

2.10 NHS Calderdale Summary Financial and QIPP Plan 2.10.1 Introduction This plan summarises how we will allocate and manage our financial resources to achieve our financial targets for NHS Calderdale (incorporating Calderdale eCCG), and address our strategic priorities. Whilst 2012/13 is the main focus of our plans, indicative positions for the following two years have been included in line with QIPP delivery plans. Our key financial targets for 2012/13 are:

Delivery of the income and expenditure surplus Control Total - we are planning on the basis of a control total of £3.6m as agreed with the SHA. The control total is equivalent to around 1% of the PCT‟s total resources;

Maintenance of 2% Recurrent Headroom (£6.7m to pump-prime transformational change); and

Delivery of QIPP savings (£5.5m). 2.10.2 Plans The 2011/12 closing position assumes that the PCT will have a recurrent underlying surplus of 3% i.e. £10.3m (£3.6m + £6.7m) – which we are assuming will be maintained throughout the next year and for the foreseeable future (transition to eCCGs) unless there are changes to resource allocations rules. Our financial plan is based on the following assumptions:

Description Forecast Outturn 2011/12

£m

Plan 2012/13

£m

Plan 2013/14

£m

Plan 2014/15

£m

Strategic Investment Fund 0 0 0 0

Reported Surplus 3.6 3.6 3.6 3.6

Control Total 3.6 3.6 3.6 3.6

Resources committed (non-recurrently)

6.7 6.7 6.8 6.8

% of recurrent resources 2% 2% 2% 2%

QIPP Commissioner cash releasing savings

6.0 5.5 4.8 5.3

QIPP Total transformational savings including Provider

8.3 8.0 8.0

% of QIPP which is transformational - 54% 55% 53%


NHS Calderdale is in recurrent financial balance going into 2012/13 and is planning to remain so. We do not plan to lodge any funds in the Strategic Investment Fund held by the SHA. In line with Operating Framework requirements, we will maintain financial headroom equivalent to 2% of our recurrent resources and this will be used for short term support for transformational change programs and to pump-prime QIPP initiatives. In 2012/13, this equates to £6.7m. 2.10.3 Planned Investments in 2012/13 Our plan reflects both local investment in services in line with our local priorities and investments associated with the Government‟s commitments, as set out in the Operating Framework. Investments are subject to the prioritisation process being led by the eCCG and maybe subject to change. The proposed specific investments included in the Financial Plan total £4.7m. Further business cases are being developed to deliver the strategic aspirations set by the eCCG. In addition we have provided further investment of £4.5m for demographic growth within our contracting assumptions, in line with predicted population trends and assessed needs for the next three years. This increase has been targeted at specific service areas and is consistent with our planned activity trajectories. 2.10.4 Planned Savings in 2012/13 and Beyond We have made good progress in delivering our savings targets to date with £6m being achieved in 2011/12 and £8.9m in 2010/11.

Over the next three years we need to deliver a further £15.6m of cash releasing savings to enable us to progress our investment programme as planned and to maintain our 2% financial headroom. The following table summarises where we expect to be able to make these savings:

2.10.5 Integration with eCCG Plans The refresh of our QIPP and financial plans have been underpinned by the 2012/13 business planning process, which has been led by the Calderdale eCCG. This process has ensured:

A top down assessment of national and local commitments and statutory duties;

A bottom up assessment of local issues and solutions – developed by our local practices;

Agreements on a set of strategic objectives and a criteria which stimulates the development of business cases which support delivery of those objectives;

A process of prioritisation which will identify how investment will be made in 2012/13; and

Budgets and the plan will all be signed off by eCCGs in advance of formal sign off by the Cluster Board.

2.10.6 Capital Programme NHS Calderdale has assessed its capital resource requirement on the basis that it will retain responsibilities for the management of its current property portfolio and for Information Technology (IT) equipment replacement (including transferred Community Services requirements). Back log maintenance has been completed in 2011/12 and therefore has no capital plans for the estates portfolio.

QIPP Commissioner Areas (£M) 12/13 13/14 14/15

Primary Care 0.5 0.5 0.5

Community Care 0.9 0.7 0.7

Acute Care 3.0 3.5 4.0

Running Costs 1.0 0 0

Other 0.1 0.1 0.1

Total 5.5 4.8 5.3

Transformational - Acute Care 2.0 2.0 2.0

Transformational - Community Care 0.5 0.2 0.2

Total transformational 2.5 2.2 2.2

% Transformational 45% 46% 42%


Therefore, the financial plan only includes an operating capital requirement of £0.1m to cover IT infrastructure replacement and investment. 2.10.7 Cash Requirements Cash availability is based on revenue and capital resources being cash backed with adjustments for depreciation, cost of capital and movement in working in balances. It is not anticipated that there will be a significant movement in working balances between 2011/12 and 2012/13. There are no significant risks in relation to cash. 2.10.8 Financial Risks We expect to describe and quantify the main financial risks associated with plan delivery on conclusion of the current contracting round. We will then be in a position to understand any remaining activity and performance target related risks. Whilst our QIPP programme only represents less than 1.5% of our recurrent resource baseline, there is a risk of slippage on savings delivery. To counter this risk, we are continuing to work with our emerging eCCG to refresh current QIPP plans and identify any further opportunities. Further financial risk cover is provided by the contingency reserve. Risks to delivery of the financial plan risks include:

Conclusion of the contracting round subject to the numbers included within the financial plan;

Increased Secondary Care expenditure – caused by increased demand for services or changes in contract currencies;

Prescribing – variability due to changes in National Contract prices;

Cost per case activity for high cost or long term placements;

Changes to the tariff – impacting adversely on the commissioner;

Significant additional demand in the system;

The QIPP plan does not deliver the required savings;

Loss of key personnel in view of transition and running cost savings required; and

System change leading to accountability and action becoming unclear.

These risks will be mitigated by ensuring there are robust financial and contract management processes in place and that:

Budget holders manage costs within resources;

Contract managers effectively manage costs and service delivery through contracts; and

Effective processes that identify and realise opportunities for disinvestment and reinvestment in healthcare to improve outcomes and make sure the money is directed where it can do most good.

2.10.9 Assurance Assurance on delivery of our Finance and QIPP plans will be undertaken via:

Monthly meetings between our senior management team and QIPP leads to test delivery and challenge progress;

Monthly written updates to the Clinical Commissioning Executive (CCE);

Monthly written reports to our Finance & Performance Group, plus quarterly meetings involving QIPP leads;

Regular updates to our Cluster Board via performance reports and presentations; and

Monthly reporting of QIPP progress on the SHA high level QIPP tracker. In addition we have:

An Senior Responsible Officer (SRO) for each QIPP scheme; and

A nominated QIPP lead for the organisation that links to other QIPP leads across the Cluster and the Cluster Director of Finance (DoF).

We believe that we have sufficient governance of our schemes to ensure that we are aware of their progress at any time during the year. We also believe we have sufficient input from our eCCG Board to ensure that they are fully engaged and understand the QIPP agenda. 2.10.10 Summary The financial plan above represents a sound basis for delivering our key financial targets in 2012/13. Known cost pressures, demographic pressures and Operating Framework requirements have been appropriately funded and there is a realistic QIPP programme. There is a risk of slippage on QIPP programme delivery, but effective counter measures are being put in place and the PCT is holding a contingency reserve. Delivery of the plan will provide the eCCG with a firm foundation for the future, and will support it through the authorisation process. 2.11 NHS Kirklees Summary Financial and QIPP Plan 2.11.1 Introduction This plan summarises how we will allocate and manage our financial resources to achieve the key financial targets for NHS Kirklees (incorporating both NKHA and GHCCG), and address our strategic priorities. Whilst 2012/13 is the main focus of our plans, indicative positions for the following two years have been included in line with QIPP delivery plans. Our key financial targets for 2012/13 are set out below:

Delivery of the income an expenditure surplus Control Total - we are planning on the basis of a control total of £6.6m as agreed with the SHA. The control total is equivalent to around 1% of the PCT‟s total resources;


Maintenance of 2% Recurrent Headroom (£13.3m); and

Delivery of QIPP savings (£9.5m). 2.11.2 Plans The 2011/12 closing position assumes that the PCT will have a recurrent underlying surplus of over 3%, i.e. £21m (£8.3m + £12.9m) – which we are assuming will be maintained throughout the next year and for the foreseeable future (transition to eCCGs) unless there are changes to resource allocations rules. Our financial plan is based on the following assumptions:


£m

Plan 2012/13

£m

Plan 2013/14

£m

Plan 2014/15

£m





12.9 13.3 13.5 13.8



13.3 9.5 10 10


12.8 13.7 13.7

% of QIPP which is transformational 43% 46% 46%

NHS Kirklees is in recurrent financial balance going into 2012/13 and is planning to remain so. We do not plan to lodge any funds in the Strategic Investment Fund held by the SHA. 2.11.3 Planned Investments in 2012/13 Our plan reflects both local investment in services in line with our local priorities and investments associated with the Government‟s commitments, as set out in the Operating Framework. These will be subject to the prioritisation process being led by the eCCG and will be subject to change. Further business cases are being developed to deliver the strategic aspirations set by the eCCG, and these plans will continue to be developed.

The proposed investments included in the Financial Plan are:

eCCG £m

North Kirklees Health Alliance 5.2

Greater Huddersfield CCG 6.5

Total 11.7

2.11.4 Planned Savings in 2012/13 and Beyond We have made good progress in delivering our savings targets to date with £13.3m being achieved in 2011/12, building on the £15m delivered in 2010/11. Over the next three years we need to deliver a further £29.5m of cash releasing savings to enable us to progress our investment programme as planned and to maintain our financial headroom. The following tables summarise where we expect to be able to make these savings: North Kirklees Health Alliance






Other 0.1 0.1 0.1

Total 4.1 4.3 4.3






Greater Huddersfield CCG

2.11.5 Integration with eCCG Plans: The refresh of our QIPP and financial plans have been underpinned by involvement of Greater Huddersfield and North Kirklees eCCGs. This process has ensured:


Agreements on a set of strategic objectives and a criteria which stimulates the development of business cases which support delivery of those objectives; and


2.11.6 Capital Programme Our initial capital plan is focused on completing schemes commenced in 2011/12, addressing back log maintenance on primary care estate, and investing in fit for purpose IT infrastructure. We are still planning to dispose of 2 properties which were originally expected to be disposed of in 2011/12. These are now anticipated to be completed in 2012/13.





Running Costs 0.9

0 0

Other 0.1 0.1 0.1

Total 5.4 5.7 5.7





A summary of the revised capital plan for 2012/13 is shown below: 2.11.7 Summary of Capital Plan

Capital Funding

£M

Capital Receipt 0.8

Capital Allocation Requirement 0.5

Total Funding Available 1.3

Application of Funding:

Sub Total Estates 1.0

IT Infrastructure 0.3

Total Application 1.3

Source: Medium Term Financial Plan The application of operational capital and retained capital receipts shown above is all in respect of estate that will remain operational. 2.11.8 Cash Requirements Cash availability is based on revenue and capital resources being cash backed with adjustments for depreciation, cost of capital and movement in working in balances. It is not anticipated that there will be a significant movement in working balances between 2011/12 and 2012/13. There are no significant risks in relation to cash. 2.11.9 Financial Risks We expect to describe and quantify the main financial risks associated with plan delivery on conclusion of the current contracting round. We will then be in a position to understand any remaining activity and performance target related risks. Whilst our QIPP programme represents less than 1.5% of our recurrent resource baseline, there is a risk of slippage on savings delivery. To counter this risk, we are continuing to work with our emerging eCCGs to refresh current QIPP plans and continue to identify further opportunities. Further financial risk cover is provided by the contingency reserve of £5m. Risks to delivery of the financial plan risks include:

Conclusion of the contracting round in line with the numbers included within the financial plan;







The QIPP plan does not deliver the required savings;


System change leading to accountability and action becoming unclear.

These risks will be mitigated by ensuring there are robust financial and contract management processes in place and that:






Monthly written updates to the CCE;

Monthly written reports to our Finance & Performance Group;



An SRO for each QIPP scheme; and

A nominated QIPP lead for each eCCG who links to other QIPP leads across the Cluster and the Cluster DoF.

We believe that we have sufficient governance of our schemes to ensure that we are aware of their progress at any time during the year. We also believe we have sufficient input from our eCCG Boards to ensure that they are fully engaged and understand the QIPP agenda. 2.11.11 Summary The financial plan above represents a sound basis for delivering our key financial targets in 2012/13. Known cost pressures, demographic pressures and Operating Framework requirements have been appropriately funded and there is a realistic QIPP programme. There is a risk of slippage on QIPP programme delivery, but effective counter measures are being put in place and the PCT is holding a contingency reserve.

Delivery of the plan will provide the eCCGs with a firm foundation for the future, and will support them through the authorisation process. 2.12 NHS Wakefield Summary Financial and QIPP Plan 2.12.1 Introduction This plan summarises how we will allocate and manage our financial resources to achieve our financial targets for NHS Wakefield (incorporating Wakefield Alliance eCCG), and address our strategic priorities. Whilst 2012/13 is the main focus of our plans, indicative positions for the following two years have been included in line with QIPP delivery plans. Our key financial targets for 2012/13 are set out below:

Delivery of the income and expenditure surplus Control Total;

Maintenance of 2% recurrent headroom; and

Delivery of QIPP savings. 2.12.2 Plans

The 2011/12 closing position assumes that the PCT will have a recurrent underlying surplus of 2.5% i.e. £15.1m (£3.1m + £12.0m) – which we are assuming will be maintained throughout the next year and for the foreseeable future (transition to eCCGs) unless there are changes to resource allocations rules. Our financial plan is based on the following assumptions:


£0,000

Plan 2012/13

£0,000

Plan 2013/14

£0,000

Plan 2014/15

£0,000





12.0 12.4 12.6 12.6



12.2 12.5 11.4 11.4


13.4 14.9 14.9

% of QIPP which is transformational

48% 55% 54%


NHS Wakefield District is in recurrent financial balance going into 2012/13 and is planning to remain so. The reported surplus represents the continued carry-forward of underspends generated prior to 2011/12 of £3.1m, which is also our Control Total. We do not plan to lodge any funds in the Strategic Investment Fund held by the SHA. In line with Operating Framework requirements, we will maintain financial headroom equivalent to 2% of our recurrent resources and this will be used for short term non recurring support for transformational change programs and for pump-priming initiatives. In 2012/13, this equates to £12.4m 2.12.3 Planned Investments in 2012/13 Our plan reflects both local investment in services in line with our local priorities and investments associated with the Government‟s commitments as set out in the Operating Framework. In particular, we are continuing to increase investment in Family Nurse Practitioners and Mental Health services. The proposed investments included in the Financial Plan total £7.3m.

2.12.4 Planned Savings in 2012/13 and Beyond We have made good progress in delivering our savings targets to date with £12.2m being achieved in 2011/12. Over the next three years we need to deliver a further £35.3m of cash releasing savings to enable us to progress our investment programme as planned and to maintain our 2% financial headroom. Plans are being put in place to enable these savings to be achieved.

2.12.5 Integration with eCCG Plans The refresh of our QIPP and financial plans have been underpinned by involvement of our two eCCGs. This process has ensured:


Agreements on a set of strategic objectives and a criteria which stimulates the development of business cases which support delivery of those objectives; and


2.12.6 Capital Programme The PCT has assessed its capital resource requirement on the basis that it will retain responsibilities for the management of its current property portfolio and for IT equipment replacement (including transferred Community Services requirements).






Other 0 0 0

Total 12.5 11.4 11.4


Transformational - Community Care 0 0 0




We expect to complete the disposal of one property during 2012/13 which will contribute to the capital resources required in 2012/13. 2.12.7 Cash Requirements Cash availability is based on revenue and capital resources being cash backed with adjustments for depreciation, cost of capital and movement in working in balances. It is not anticipated that there will be a significant movement in working balances between 2011/12 and 2012/13. There are no significant risks in relation to cash. 2.12.8 Financial Risks We expect to describe and quantify the main financial risks associated with plan delivery on conclusion of the current contracting round. We will then be in a position to understand any remaining activity and performance target related risks. Whilst our QIPP programme only represents 2.0% of our recurrent resource baseline, there is a risk of slippage on savings delivery. To counter this risk, we are continuing to work up additional savings schemes with appropriate clinical/eCCG input. Further financial risk cover is provided by the contingency reserve. Risks to delivery of the financial plan risks include:

Conclusion of the contracting round subject to the numbers included within the financial plan;






The QIPP plan does not deliver the required savings – Benchmarking information would support that opportunities for service redesign savings exist but will be challenging to realise in practice;


System change leading to accountability and action becoming unclear. These risks will be mitigated by ensuring there are robust financial and contract management processes in place and that:






Monthly written updates to the CCE;

Monthly written reports to our Finance & Performance Group;



An SRO for each QIPP scheme; and

A nominated QIPP lead for the organisation that links to other QIPP leads across the Cluster and the Cluster DOF.

We believe that we have sufficient governance of our schemes to ensure that we are aware of their progress at any time during the year. We also believe we have sufficient input from our eCCG Board to ensure that they are fully engaged and understand the QIPP agenda. 2.12.10 Summary The financial plan represents a sound basis for delivering the PCT‟s key financial targets in 2012/13. Known cost pressures, demographic pressures and Operating Framework requirements have been appropriately funded and there is a realistic QIPP programme. There is a risk of slippage on QIPP programme delivery, but effective counter measures are being put in place and the PCT is holding an increased level of contingency reserve. Delivery of the plan will provide eCCGs with a firm foundation for the future.


Section 3

Quality 3.1 Overview The CCEs across the Cluster have a delegated responsibility for scrutinising and gaining assurance in relation to the three domains of quality; safety, effectiveness and experience. To discharge this responsibility a Quality Group has been established as a subgroup of each CCE. Each Group across the Cluster is chaired by a clinical commissioner and includes at least two other clinical members of the CCE, along with a Non Executive Associate. Its remit considers the three domains of quality together with provider quality arrangements and provides assurance to the CCE. There are robust quality governance arrangements in place with main providers through Clinical Quality Boards as part of contract management arrangements. These will continue with clinical commissioner input strengthened from the CCEs where necessary. These forums exist for a number of contracts, including CHFT, MYHT, SWYPFT, Yorkshire Ambulance Service (YAS), West Yorkshire Urgent Care (WYUC), Locala and Spectrum. All providers (who provide regulated activities) are expected to be compliant with the Essential Standards of Quality and Safety and meet the registration requirements of the CQC. The Quality Groups will continue to receive regular reports which collate information about quality, safety and experience from various sources. National information such as CQC quality risk profiles and compliance reviews, National Reporting and Learning Service data, Patient Reported Outcome Measures (PROMs), annual patient surveys and national audits triangulated with local intelligence from provider Quality Accounts, incidents reports, and feedback from public and patients through complaints and real time patient experience will give a „picture‟ of the quality of services commissioned by the eCCGs. The ability to strengthen quality assurance processes, respond where quality is below standard and drive continuous quality improvement will be key to ensuring that the eCCG delivers its responsibility for quality and safety. Quality governance and the identification and mitigation of risk is assured through the Cluster Board which receives a bi-monthly quality and patient safety paper which includes performance against national and local quality indicators, regulatory activity and issues of escalation from CCEs and Clinical Quality Boards. Strategic focus on quality is strengthened by Director of Nursing and Medical Director membership on both Calderdale and Huddersfield Health economy Clinical Services Strategy Board and Mid Yorkshire Health Economy Strategy Board. Provider cost improvement initiatives are risk assessed for impact on patient quality and safety they require board level sign off by the respective medical and nursing directors.

3.2 Patient Experience Patient experience has historically received less attention from commissioners and providers than the other two components of quality and has been identified as a specific domain in the NHS Outcomes Framework. Patient experience has been highlighted as a key driver for quality improvement and commissioners, as well as providers, are required to demonstrate that the patient perspective is reflected in its activities for meeting health needs through effective commissioning and provision of services.

The eCCGs recognise the need to secure continuous improvements in the quality and outcome of services commissioned and are articulating how they will actively seek the views of patients, carers and the wider community about current services (experience) and service developments (engagement). When triangulated alongside the range of experience information available (including complaints, PALS, national surveys, relevant CQUIN indicators and NHS Choices feedback) intelligence on the quality and experience of services can give assurance or identify areas for improvements for commissioners to address. The recently established CCE Quality Groups have a key role in ensuring CCEs learn from and identify improvements as a result of patient experience feedback.

In 2011, NHS Calderdale and NHS Kirklees participated in the West Yorkshire Audit Consortium review of patient experience with specific recommendations identified for each organisation. NHS Wakefield District was included in the review as part of the development of the subsequent Good Practice Briefing. The learning from the review and briefing is guiding the development work with CCGs.

There is already some good practice within each PCT which will be strengthened through the eCCGs and shared across the Cluster as relevant including:

Co-authored action plan for commissioner assurance of performance improvement with a provider categorised as „Performance under Review‟ for patient experience;

Public Involvement and Patient Experience Committee (PIPEC);

Quarterly Patient Experience Report;

Standing agenda item at Clinical Quality Board/Review Group meetings;

Commissioning for Quality and Innovation (CQUINs) Schemes indicators relevant to patient experience in all acute, community and mental health schemes, including independent sector providers;

Quality schedule included in contract documentation sets out quarterly reporting of patient experience; and

Analysis and reporting against national patient surveys.

An initial scoping exercise has commenced, which will lead to the development of a patient experience strategy and delivery plan for eCCGs in line with the recommendations in the Good Practice Briefing and Dr Foster Intelligent Board 2010 guidance on Patient Experience.


The strategy will include:

Governance arrangements including leadership, monitoring and reporting;

Building on existing systems and process to strengthen the use of patient experience information to improve the quality of commissioned services;

Mapping existing information sources and improve triangulation of information with other sources of data/intelligence;

Embedding patient experience into the commissioning cycle to become an integral element; and

Exploring potential Information Technology solutions to support analysis and triangulation.

The associated delivery plan will identify practical actions to deliver the strategy and will include:

Direct validation of patient experience with providers through quality assurance visits/walkabouts;

Collaboration with work programme of Local Involvement Network (LINKs) and emerging HealthWatch;

Standardise contractual requirements and strengthen regular monitoring across providers;

Analysis and triangulation of trends and themes through regular reporting of all patient experience information (including national surveys, real time feedback and complaints) to CCE Quality Groups;

Utilise experience and resources of Yorkshire and Humber Public Health Observatory (YHPHO) such as quadrant charts for patient experience, development of composite patient experience reports, and attendance at regional workshops;

Proactively acting on and responding effectively to patient experience information; and

Strengthen patient experience information from primary care providers in line with expectations from other providers.

3.3 Health Visitors and Family Nurse Partnerships The SHA and PCT Cluster are working together to deliver the number of Health Visitors (HV) required as part of the Government commitment to increase the number by 4,200 by April 2015. The following table sets out the Cluster Health Visitor target to increase the Health Visitor resource between 2011 and 2015. Workforce plans include projections in relation to retirement, normal „churn‟ in the system and the need to recruit to the additional posts. Electronic Staff Record (ESR) information is used to monitor workforce on a monthly basis this includes full time students/part time students/return to practice/number of community practice teachers/number of mentors/Whole Time Equivalent (WTE) HVs in post/funded vacancies.

WTE Agreed

Baseline 2011/12 2012/13 2013/14 2014/15 Total

Additional posts

NHS Calderdale Additional posts agreed and funded each year

2.5

5.0

5.0

5.0

17.5

41.5 44.0 49.0 54.0 59.0

NHS Kirklees Additional posts agreed and funded each year

7.0

5.63

5.63

5.63

23.9

(plus 2.35 vacancies)

77.8 (75.45 in post, 2.35 vacancies)

84.8

90.43

96.06

101.69

NHS Wakefield District Additional posts agreed and funded each year

-2.1

14.2

14.2

14.2

40.5

65.7 63.6 77.8 92.0 106.2

NHSCKW Total 81.9 (+ 2.35

vacancies)

3.3.1 Gap Analysis A stock take of Health Visiting services was undertaken in 2011 by each of the three constituent PCTs this included workforce planning, variance against the WTE baseline set in May 2010 and a gap analysis. Actions to address identified against gaps have been incorporated into the local implementation plans, agreed with providers and submitted to the SHA on 17 February 2012. Performance against plans is managed via contract management boards. 3.3.2 Key priorities 2012-2013

Commissioners and provider leads are working with the SHA Senior Public Health Nurse, to plan for additional students ensuring there are sufficient quality Community Practitioner Teacher (CPT) capacity in the system;

Leads in each area identified to champion the building community capacity programme; linking the professional mobilisation work stream;

Support the 2012/13 - 245 Higher Education Institute (HEI) Commissioned placements (NHSCKW) supporting 11 placements from the March 2012 cohort);


Reviews of early intervention services with the LAs are underway to ensure integrated provision and early intervention is in place as part of the agreed Early Intervention Strategy;

Service specification development to include regionally agreed quality standards within quality schedules to commission the 4 tier health visiting programme. This includes the development of a core offer with the LA in line with local early intervention reviews; and

Working with public health teams to set out how the delivery of the Healthy Child Programme and the Family Nurse Partnership model will contribute to the Public Health Outcomes Framework 2013-2016 outcomes; to increased healthy life expectancy and reduced differences in life expectancy and healthy life expectancy between communities. For example indicators in relation to: o Breastfeeding; o Under 18 conceptions; o Excess weight in 4-5 year olds; o Smoking prevalence in adults; o Child development at 2–2.5 years; o Children in poverty; o School readiness; and o Vaccination and immunisations.

3.3.3 Healthy Child Programme and the Family Nurse Partnership (FNP)

Programme The increase number of HV will ensure improved support for families through the delivery of the Healthy Child Programme and the FNP programme. Existing delivery will be maintained and continue expansion of the FNP programme in line with the commitment to double capacity to 13,000 places by April 2015, to improve outcomes for the most vulnerable first time teenage mothers and their children.

NHS Calderdale (NHSC) is a wave 2 FNP site with a FNP established in Calderdale since 2007. During 2011, Calderdale was successful in securing small scale permanency for the FNP and investing in an additional 1.0 WTE FNP resource, to rebalance the FNP capacity following a provider led reduction in this service. Calderdale continues to deliver the FNP according to the licensing requirements set by the Department of Health (DH). The increase in capacity brought about by the additional investment will reduce caseload sizes while at the same time increasing capacity to provide more targeted and longer-term interventions to those children and families that need it. Performance metrics have been developed to monitor the HV caseload by NHS Calderdale and the Calderdale Safeguarding Children. Work is ongoing to improve service provision against the standard set in the Healthy Child Programme 2011, particularly focussing on reinstating the 3-5 year HV contacts. NHS Kirklees (NHSK) has reviewed the Early Intervention Services with the LAs to ensure integrated provision and early intervention is in place as part of the agreed Early Intervention Strategy.

NHS Wakefield District (NHSWD) with its team of 4 nurses and one supervisor, is being delivered out of Children's Centres and is working closely with Barnardos Young Families, Midwifery and Mental Health Services. Following detailed analysis, the area identified from which the first cohort of mothers will be drawn is Castleford and will stretch to Pontefract and Knottingley depending on the availability of eligible mothers. 3.4 Dementia Care for Older People PCT Clusters should ensure that all providers have a systematic approach to improving dignity in care for patients, to giving staff appropriate training and to incorporating learning from the experience of patients and carers into their work. The three individual PCTs in the Cluster have ensured clauses are included within their provider contracts regarding the improvement of quality of care for service users. Contracts are monitored quarterly and reported through the Quality Boards of the respective organisations. Standards measured include defined CQUIN indicators, Elimination of Mixed Sex Accommodation (EMSA), annual audit of staff training and patient/carer satisfaction and experience. Working collaboratively with their individual LAs, each PCT has produced a joint Dementia Strategy that is published on each of the PCTs websites. The action plans, within the Strategies, are refreshed annually. Agreed CQUIN goals are available as public documents and are published by the PCTs. These goals, whilst already in place, will be expanded and enhanced for the 2012/13 contracting process across the local Mental Health and Acute Trusts, including the addition of the new national goal for Acute Trusts. For NHSWD, progress against the Dementia Strategy is systematically reviewed through the Wakefield Dementia Strategy Board. NHSC has a Dementia Implementation Group that meets regularly and is responsible for delivering the Dementia Strategy Implementation Plan. It has representatives from the LA, PCT, SWYPFT, CHFT and the Voluntary Sector (Alzheimer‟s society). For NHSK, Dementia Services are a priority area for both eCCGs and dementia pathways are under review. Work with SWYPFT continues regarding the specialist organic pathway service offer and this is currently included within the provider service consultation. New funding has been secured recurrently to enhance the admiral nursing service. Stretching CQUINS have been included within all contracts to deliver whole system quality improvement which have been built upon previous years indicators. Joint working with Kirklees LA continues to review existing joint contracts, service specifications which are to be tendered during 2012/13. There is also ongoing work regarding utilising Sc 256 and Sc 75 agreements and the joint Dementia action plans supporting the delivery of the joint strategy are currently under review for 2013/13 (all business cases are predicated on these joint plans). All main providers Quality Accounts are received and approved by the individual PCTs prior to the submission of the Quality Account and supporting commentary is included from the PCTs. In addition, the Commissioners will receive and review the SWYPFT Quality Account through the Cluster-wide Quality Board. SWYPFT reports


quarterly on its compliance with National Institute for Health and Clinical Excellence (NICE) Guidance and this will be extended to include consideration of relevant NICE Quality Standards. Commissioners are working with GP practices to secure ongoing improvements in the quality of general practice and community services so that patients only go into hospital if that will secure the best clinical outcome. Ongoing work with eCCG involvement, is underway to refresh 2011/12 plans for 2012/13 onwards. Transformational service redesign includes improved rapid response community provision, commissioned jointly with the LA, facilitated through enablement funding. Also transformational change through the care home agenda is ongoing, with an anticipated new service tender during 2012/13. Commissioners ensure that the needs of general practice are fully represented within the individual PCTs annual planning processes to secure ongoing cost effective/clinical effective improvements in line with national and local policies. The PCTs and LAs have complied with all national clinical audits and these have been published on a national and regional level.

Plans are developed and currently undergoing implementation to reduce inappropriate antipsychotic prescribing for people with dementia. Baseline mapping has been undertaken across primary, secondary care, mental health services and within Care Homes. Partners are working together to implement transformation changes.

Commissioners continue to build on the work already undertaken to increase the awareness of the impact of the prescribing of anti-psychotic medication with initiatives such as "The Right Prescription" campaign in Wakefield being adopted through all Wakefield pharmacies. An anti-psychotic prescribing checklist is being used with prescribers to ensure that only appropriate medication is instigated in addition to providing support and information to people already in receipt of medication in seeking a review. Diagnostic rates are included within the eCCGs performance metrics which are reported quarterly at both an eCCG and individual practice level - within the eCCG the information is used to identify outliers & drive up quality of provision. Development Plans are in place across a range of partners to improve early diagnosis and through transformational programmes improve access rates for appropriateness of diagnostic referrals. Other outcomes focused on this area of delivery include emergency admissions and readmission rates. The “emergency admissions for acute conditions that should not usually require hospital admission”, inappropriate emergency admission rates, together with, emergency admission rates, are included within the eCCGs performance metrics which are reported quarterly at both an eCCG and individual general practice level. Within the eCCGs the information is used to identify outliers and drive up quality of provision. These outcomes/measures are also included within the Cluster and the

individual PCTs internal routine performance monitoring/reporting processes with action plans to address as appropriate. For 2011/12, thresholds and penalties relating to the non-payment for emergency readmissions within 30 days of discharge following an elective admission are agreed locally between Commissioners and Providers and taken forward through the contracting process. However, thresholds and payment penalties for 2012/13 are under discussion and agreement with the DH due to lack of clarity for the revised national definition of this outcome/measure. 3.5 Carers Commissioning recommendations from Joint Strategic Needs Assessments (JSNA), as well as working with LA partners and stakeholders, have influenced what services have been prioritised for Carers locally within the NHSCKW. A number of programmes to enhance services for unpaid carers across the Cluster have been implemented and some of the initiatives have been in operation since 2009/10. During 2011/12 the individual PCTs Carers Strategies were refreshed in line with the national Carers Strategy and the requirements of the 2011/12 NHS Operating Framework and the Strategies are available on the PCTs websites. A similar exercise will take place in 2012/13.

The process for prioritisation of investment in 2012/13 will again be based on the outcome of the JSNA and the refreshed priorities identified within the individual PCTs Carers Strategy. The revised Strategy will be considered by the eCCGs and potential initiatives evaluated. In addition, the guidance on Carers anticipated later this year will be used to inform next steps, along with the wider requirements of the NHS Operating Framework for 2012/13 (together with the NHS Outcomes Framework 2012/13) and the financial context of the individual PCTs. For the NHSCKW, any investment for all future services will be determined by eCCGs. Currently, Carers within the NHSCKW have access to a range of support and services, for example:

Carers Gateway;

Carers Personal Budgets;

Carers Breaks Services (Crossroads and St. Annes);

Shared Lives;

Dementia Carers Support (Alzheimer's Society);

Admiral Nurse Service ;

Carers Advocacy Service (Cloverleaf);

Elderly Mentally Infirm (EMI) Day Care;

Carers Emergency Support Service; and

Local Support Groups and Projects. The Calderdale Carers Strategy and action plan were approved by Calderdale Health and Social Care Partnership Board in 2009. The current action plan is monitored through the multi agency Carers Strategy Group. A range of commissioned services are available for carers, e.g. Respite, Calderdale Carers


Project, Calderdale Alzheimer‟s Society. The 2009-2012 Carers Strategy was successful and has improved support for carers. The amount allocated for provision of breaks for Carers is taken directly from the Carers Grant in Calderdale, which totals £643,770. NHSC currently contributes approximately £84,000 to the grant scheme through existing contracts. The indicative number of carers breaks for NHSC is 1,822. For NHSWD, the financial contribution to support Carers will be identified and published on the PCT and LA websites during 2012/13. This will include as a minimum the £400k recently identified to support an increase in the available of short breaks for carers and the number of breaks that this is being used to support. This is in addition to the support already provided through existing services such as the recently commissioned STAR Project. NHSK carers services are currently supported by the Joint Strategic Carers Board. The action plans are jointly agreed and through this process lead organisation are identified regarding the priority area. There are a range of joint funded services in place and there is ongoing work to look at appropriate transfer of funds from PCT to LA via Sc 75 or Sc 256 agreements. The PCT has also built in proposed new funding allocations to support their lead areas. Business cases are currently being developed against this jointly with the LA. Based on DH financial formula calculations, NHSK national share of Carers resource is 0.8% - NHSK annual budget commitment for 2014 onwards should be in the region of £3.2 million. During March 2011, there was agreement that financial plans for 2011/12, 2012/13 and 2013/14 would include identification of indicative new investment of £400,000 recurrent per year. The NHSK Carers Breaks Spend is identified as £1.324m.

For NHSK, the minimum indicative number of 17,447 respite breaks should be available in 2012/13, however, the number of breaks is based on the current services available in Kirklees that Carers access the service assesses and determines, in collaboration with the individual Carer, the appropriate type of 'break' to meet the individual's needs, i.e. residential - long or short breaks, educational course, etc.

Total spend on Carers Breaks and the Number of Carers Breaks will be incorporated within the revised Carers Strategies Implementation Plans and performance updates that will be made available on the individual PCTs and NHSCKW websites by the given deadline. 3.6 Military Heath and Veterans Primary Care for Armed Forces personnel is generally the responsibility of the single service primary healthcare organisations for the Army, Royal Navy and Royal Air Force known as the Defence Medical Service (DMS). This single service includes both in-house provision and some outsourcing to independent healthcare providers and to NHS trusts. Responsibility for secondary care for Armed Forces personnel

rests with the NHS for normal elective care, but for specialist secondary care the DMS has an arrangement with the NHS to pay for this specialist treatment through direct contracting with NHS organisations. A key requirement for NHSCKW is to ensure that military Veterans receive priority access to NHS secondary care for any conditions which are likely to be related to their service, subject to the clinical needs of all patients generally. This means that GPs‟ referrals and treatment by secondary care clinicians should prioritise this group of patients where the disorder is related to their service. To enable this, it includes the use of Choose and Book (C&B) and an ongoing programme for the direct transfer of medical records to GPs when individuals leave the Armed Forces. The basic principle for Armed Forces‟ dependents and Veterans is that generally they are the responsibility of the NHS in the same way as normal residents. Where a member of the Armed Forces is referred for NHS secondary care via a standard NHS pathway (including non-elective care) the PCT where the Military of Defence (MoD) medical centre of the resident Armed Forces population is located should fund this care. However, the MoD is required to fund secondary care services where the requirement varies from the standard NHS pathways, i.e. either the treatment requested or for specific management requirements, e.g. fast-track care or non-standard treatment. 3.6.1 New Commissioning Arrangements Commissioning responsibility for Military Health will become the responsibility of the NHSCB. Statutory duties for this are subject to the passage of the Health and Social Care Bill through Parliament and will mean that current NHSCKW responsibilities in relation to healthcare for HM Forces and their families (who are registered to MoD medical centres) will be transferred to the NHSCB who may in turn delegate some of these to eCCGs. The NHSCB will receive the secondary and community allocation for resident Armed Forces personnel and the full allocation for families registered at military medical practices. This allocation will be managed collaboratively between the NHSCB and the MoD (Joint Medical Command). Note, there are presently no MoD medical centres across the NHSCKW patch. To manage this change programme all regions were required to establish an Armed Forces Network (AFN) with representation from the SHA, the Armed Forces‟ Defence Medical Service and NHS PCT Clusters. NHSCKW is represented on the regional AFN. 3.6.2 Military and Veterans Health Programme Key Milestones NHSCKW will continue to take account of its current responsibilities during 2012/13, and specifically the requirement to ensure that the responsibilities outlined in the Priority Treatment policy for Veterans continues to be delivered. Further guidance is expected from the DH to clarify new responsibilities for Military Health within the proposed NHSCB operating model. Key outputs by NHSCKW to date are:


Ensuring military Veterans receive priority access to NHS secondary care for any conditions related to their service, subject to the clinical needs of all patients;

Implementation of a framework which establishes the responsibility of commissioning an individual‟s patient care within the NHS;

Establishing a full Secondary and Community allocation for Armed Forces residents and their families at military medical practices (where this is applicable);

Agreeing Community Covenants with each local authority (Calderdale, Kirklees and Wakefield District) in partnership with NHSCKW;

Business justification to take the Veteran‟s Mental Health Out-reach Model initiative forward; and

NHSCKW representation at the Armed Forces Network.

Planning and delivery The NHSCB Operating Model for Military Health which NHSCKW is taking forward is predicated on four key areas of delivery:

Understanding needs;

Priority outcomes defined;

Delivery and support; and

Accountability against outcomes.

NHSCKW has identified a senior manager with responsibility for commissioning Military and Veterans‟ health as part of the broader Commissioning Development portfolio. Comprising this new programme are the following elements:

Strategic needs assessment;

Understanding secondary care usage activity;

Ensuring military Veterans receive priority access to NHS secondary care for any conditions related to their service;

Delivering a mental health outreach project,

Ensuring the NHS‟ contribution to local Community Covenants across the cluster patch; and

Building Military Health into commissioning intentions as part of this year‟s annual commissioning and contracting round.

Understanding need NHSCKW is working with Public Health units from each of the three PCT/local authorities (Calderdale/Kirklees/Wakefield) to build into the JSNA process a requirement to consider Armed Forces personnel and Veterans as a specific vulnerable group. NHSCKW is also working with NHS York and North Yorkshire that has considerable experience of needs assessment in this area because of its large military presence at Catterick Garrison. Early work has been to flag Military Health into the JSNA refresh process to help us to understand the size of the relevant population groups across the NHSCKW footprint and carry out a review of any previous public health research in this area. After information is gathered then a more detailed health needs assessment, including gap and resource analysis, will be undertaken. This will enable a better

understanding of this cohort‟s health need so NHSCKW can commission services effectively. Contracting teams across NHSCKW have already been working closely with our main mental health provider to develop accessible services for this group and have made provisions within equality and diversity impact assessments. 3.6.3 Armed Forces Network The Operating Framework 2012/13 states: „SHAs should maintain and develop their Armed Forces Networks to ensure the principles of the Armed Forces Network Covenant are met for the armed forces, their families and veterans. The Ministry of Defence/NHS transition Protocol for those who have been seriously injured in the course of their duty should be implemented, meeting veterans’ prosthetic needs and ensuring improvement in mental health services for veterans. NHS employees should be supportive to those staff who volunteer for reserve duties.’ NHS North England has established a multi-disciplinary Armed Forces Network that meets quarterly. The network sets the local agenda for Yorkshire and Humber to deliver the outcomes of the Armed Forces Covenant and provides a forum for open discussion to identify issues, problem solve, agree the work plan and prioritise actions. NHSCKW is represented at the Network from a commissioning perspective.

3.6.4 Armed Forces Community Covenant This is a voluntary statement of mutual support between a civilian community and its local Armed Forces Community. It is intended to complement, at local level, the Armed Forces Covenant, which outlines the moral obligation between the Nation, the Government (includes the NHS and LA) and the Armed Forces. The aim of the Community Covenant is to encourage local communities to support the Service community in their area and promote understanding and awareness amongst the public of issues affecting the Armed Forces Community. The Community Covenant Grant Scheme invites communities to apply for funding to run projects which strengthen the bonds between the armed forces and the public. £30m of Government funding has been allocated to help communities undertake projects that promote greater understanding between the military and civilian population demonstrable benefit to both the armed forces and the civilian community and as a result the MoD will pay the one-off project costs. Across the Cluster footprint, NHSCKW is working with each of its three district councils to agree a local Armed Forces Community Covenant. The emphasis will be on designing and constructing a Covenant agreement that reflects the local picture to meet local need. Once this is better understood then robust business cases for available funding can be made. Productive working relationships have been developed between NHSCKW and each respective local authority to take the covenants forward.


3.6.5 Mental Health Outreach Project NHSCKW is working with NHS North England to develop a Veteran‟s Mental Health Out-reach Model as part of the Murrison Review, „Fighting Fit‟, published in 2010. This is designed to improve mental health and wellbeing of service personnel and veterans and £150,000 funding has been made available as an initial annual running cost for each current SHA area for four years, starting with the financial year 2011/12. This project aims to deliver a new fast-track mental health service for Veterans across the Yorkshire and Humber region. The key benefits from this will be to increase access to mental health services for Veterans through early identification and intervention for improved mental health outcomes. Other benefits will be that Veterans can be signposted to the appropriate healthcare professional thereby reducing risk of deterioration in mental health and reducing risks of suicide, alcohol and substance misuse problems. At a regional level commissioners have worked with the SHA throughout 2010/11 to support the development and implementation of Improving Access to Psychological Therapies (IAPT) services at Catterick Garrison (Army base in North Yorkshire). Each PCT across Yorkshire and Humber committed a portion from their respective IAPT development allocations to support this service development. At a local level mental health contracts negotiated during 2011 specifically identify Veterans as a priority group and assure no exclusion thresholds to limit activity. All joint PCT/LA contracts have a requirement to monitor performance activity for Veterans and also include some specific „stretch‟ targets to improve performance going forward. 3.6.6 Prisoners who are Veterans NHSCKW commissions health services for a large high security prison, HMP Wakefield, and a number of the prisoners there are also Veterans. Work is underway to better understand the needs of prisoner-veterans so as to better plan prison health services accordingly. This will be built into subsequent prison health needs assessments. 3.6.7 Military Health Proposed Operating Model The DH has published a proposed NHSCB Military Health Operating Model. The key features of the Operating Model are as follows: Understanding needs: National: Latest intelligence on military and Veterans health need assessed from Public Health England and other sources including Joint Medical Command, Care Quality Commission reports, independent research, NICE, expert reports; Local: Joint Strategic Needs Assessment overseen by local authority Health and Wellbeing Boards, gap analyses, serious incidents, Defence Medical Services

Centres experience, DPH annual reports, provider insights, and patient and veterans groups. Priority outcomes defined: National: DH sets Public health outcomes framework and NHSCB sets Commissioning Outcomes Framework and equivalent for NHSCB commissioned services; NHSCB sets military health business targets (including outcomes); planning and investment priority-setting; Local: Joint health and well-being strategy defines priorities for locality (NHS and LA); priorities for local health investment co-ordinated across Local Authorities, eCCGs and NHSCB outposts. Delivery and support:

National: NHSCB maintains partnerships between Ministry of Defence, DH and other government departments; NHSCB maintains oversight responsibility for the commissioning of all health services for military personnel, their families and Veterans and drives convergence; Local: NHSCB sectors maintain oversight of all services for military personnel through Armed Forces Networks, including national commissioning of specialist prosthesis and rehabilitation services for amputee veterans; eCCGs commission general health services and continuing care for military personnel, their families and Veterans; LAs commission relevant public health-related services for personnel.

Accountability against outcomes: National: Setting minimum standards and assurance mechanisms and metrics; performance management regime in place for all Armed Forces Networks; Local: Armed Forces Networks ensure that local arrangements are responsive to needs of armed forces and broker between providers, eCCG commissioners and Joint Medical Command to ensure „no disadvantage‟. NHSCKW will build the proposed operating model into its strategic commissioning plans for the transition period.


3.7 Elimination of Mixed Sex Accommodation (EMSA) 3.7.1 Breaches – December 2011

Provider Q1 Jul 2011 Aug 2011 Sep 2011 Oct 2011 Nov 2011 Dec 2011

CHFT 0 0 0 0 2 1 NHSC 1 NHSK

30 13 NHSC 17 NHSK

6 3 NHSC 3 NHSK

MYHT 94 6 2 NHSWD

4 NHSK

19 3 NHSWD 14 NHSK

2 NHSL

2 2 NHSWD

11 3 NHSWD

8 NHSK

9 2NHSWD

7NHSK

5 1 NHSWD

4 NHSK

SWYPFT 0 0 0 0 0 0 0

The contracting team is including the contractual financial penalties in the monthly financial challenges. CHFT, MYHT and SWYPFT completed the declaration exercise on 31 March 2011, including undertaking a self-assessment, generation of a plan, which indicates areas of weakness and describes clear activities and timescales for corrective action, and made declarations clearly visible on their websites. Work continues to ensure plans are implemented and breaches are eliminated.

3.8 Healthcare Associated Infection (HCAI)

Meticillin-resistant Staphylococcus Aureus (MRSA)

Clostridium difficile (C.diff)

Objective Dec YTD Objective Dec YTD

NHS Calderdale 6 0 4 54 5 40

NHS Kirklees 13 0 10 104 8 111

NHS Wakefield District 11 2 10 138 44 110

CHFT 5 0 5 58 4 30

MYHT 7 1 11 101 6 85

3.8.1 NHS Kirklees and NHS Wakefield District Health Economy The Cluster approach is to work on both Acute Trust footprints. The individual PCT Public Health Infection Prevention and Control Teams (ICTs) will continue to work closely with the Trusts, including the regular formal meetings with the Director of Infection Prevention and Control (DIPCs) (PCT and Trust) which cover the respective footprints. The Cluster ICTs work together and share expertise and learning. Medicines Management are involved in this work; concerning amendments to the antibiotic formulary, audits and campaigns. The arrangements concerning the

MYHT footprint are described below. The CHFT footprint arrangements include monthly meetings of the ICTs from Calderdale and Kirklees PCTs with the ICT from the CHFT. The Calderdale Director of Public Health (DPH) chairs the formal meeting of the DIPCs from the footprint which includes the ICTs and Health Protection Agency. This currently meets bi monthly. The Annual work programmes are being finalised and will build on this years programme to cover further work on viral gastroenteritis flu, E Coli, CDI and MRSA infection in secondary care as well as community settings, and other emerging infection issues. There will be further work on patient awareness, patient held information, case management, Root Cause Analysis (RCAs) will continue to be reviewed and learning disseminated. Education initiatives will be continued including work with the care home sector. 3.8.2 Actions to Improve Performance The table attached (Appendix 8) provides detail about the actions in progress/for development within the health economy to improve compliance. A microbiologist has reviewed the pre-48 hour RCAs from August 2011 for NHSK and NHSWD and confirmed that there are no gaps in the management of the patient with appropriate antimicrobial prescribing.

MYHT had sought external support from a regional microbiologist to review three post 48 hour cases reported in August 2011.

The main messages from the review were to:

Strengthen the RCA process, with a focus on the root cause, as well as the source of infection;

Reaffirm adherence to practice, challenge wards reporting 100% compliance with aseptic technique where this is identified as an issue;

Analyse/audit incidence of MRSA resistance;

Improve the role of the microbiologist in the RCA process, to challenge clinicians on antimicrobial prescribing; and

Review use of certain antibiotics.

There has been an increase in C.difficile cases since MYHT implemented the revised testing algorithm that includes glutamate dehydraogenase (GDH) (a sensitive assay which identifies more cases than previous tests) testing, in line with Department of Health and Health Protection Agency guidance. From 12 December 2011, MYHT changed the algorithm and this has been shared with GPs in Kirklees and Wakefield. MYHT has had an increased incidence at Dewsbury District Hospital (DDH) in two areas; the cases are not linked and enhanced control measures are in place.


3.8.3 HCAI Governance Arrangements MYHT Director of Infection Prevention and Control (DIPC) panel is attended by the Chief Nurse, DIPC, Infection Control Doctor and relevant lead clinicians where an RCA has occurred. The panel meets weekly to review RCA cases, assess HCAI risks and agree a clear working strategy for the clinical service groups for the coming week. This group is accountable to the Chief Executive at MYHT. The Health Economy Operational Group meets every three weeks (chaired by the Deputy DIPC NHSK, and attended by the Assistant DIPC (MYHT), and lead nurses from MYHT and the NHSCKW Cluster). They develop and implement the work programme, and are accountable to the HCAI Strategy Group who in turn is accountable to the Cluster Board. The strategy meeting is attended by DIPC at MYHT, NHSK and NHSWD and the Assistant/Deputy Directors of IPC. This group is responsible for ensuring the implementation of the work programme.

Section 4

Performance 4.1 Organisational Performance The Cluster has an established approach to performance improvement which is integrated in all aspects of its work. There are clear performance and improvement frameworks with a scorecard of indicators that are reported against on a regular basis. Areas of poor performance are reported on an exception basis to the Executive Team and the Cluster Board on regular basis with the full scorecard reported quarterly. These scorecards include a range of measures looking at outcomes and business processes to provide in-year indication of whether the Cluster is in a position to deliver its expectations. Each PCT has a Finance and Performance Committee that meets monthly and reviews performance. Performance issues are also escalated to the CCEs. Provider performance is reviewed at the Contract Management Groups (CMG) where organisational level issues are raised and addressed on a monthly basis. Areas of performance that cannot be resolved are escalated to the Executive Contract Board (ECB) level for our main providers and decisions to rectify poor performance are agreed and implemented. Benchmarking is integral to the Cluster way of working and we have robust mechanisms that compare and challenge how we measure up nationally and locally. We utilise the tools, databases and comparators available to the NHS on our desktops and actively seek best practice from other areas that are doing better than us to see if we can implement ideas locally to improve performance. The following provides a report on the key performance risk areas:

Outcome Measure Cluster Calderdale Kirklees Wakefield

MRSA

Clostridium Difficile

EMSA

18 Weeks RTT admitted

A&E 4 Hour Wait

TIA

Smoking Quitters

NHS Health Checks

Choose and Book

Note: MRSA, Clostridium Difficile and EMSA are reviewed in the Quality section of the plan


Issue Action Outcome

18 Weeks

MY

HT

Concern regarding the 18 week performance target continues to be addressed with MYHT to reduce the 18 week Referral to Treatment (RTT) backlog and bring waiting times back in line with national requirements.

An executive led local health community 18 week Programme Board continues to meet to oversee all provider and commissioner actions that are taking place to address the backlog, and to determine what further actions are required to further mitigate the risks associated with 18 week delivery. It is the intention of the Cluster to use the Access monies to support MYHT to recover the admitted and non admitted RRT targets by the end of this financial year.

Trajectories have been submitted to the SHA which show performance will be achieved in March 2012.

CH

FT

All necessary action is being taken, by both Provider and Commissioner, to reduce the numbers of unnecessary long waits for diagnostic tests at CHFT to ensure no-one waiting longer than 6 weeks by the end of March 2012.

Additional non-recurrent monies are to be deployed in 2011/12 to support the improvement of waiting times for diagnostics services in the final quarter of the year. The improvements will be delivered through provision of additional capacity, via a mobile MRI unit and additional evening and weekend sessions.

By March 2012 waiting times for MRI will be reduced to 4 weeks, Ultrasound and CT 5 weeks and Neurophysiology 6 weeks.

A & E 4 Hour Wait – 95% Waiting Time Standard

MY

HT

The current unvalidated (February 2012) MYHT performance position including primary care walk in activity is 94.96% year to date. The MYHT performance position excluding primary care walk in activity is 93.7% year to date.

Commissioned additional 3,450 emergency admissions spells at 100% tariff through additional 76 general medicine beds at DDH; Clinically appropriate diversion of some emergency activity in the south east of the district to acute hospitals in Barnsley and Doncaster; Piloted the use of experienced local GPs working out of hours in the Emergency Department at Pinderfields; Primary care incentive scheme in Wakefield to reduce demand; Commissioned a primary care streaming service within the Dewsbury A&E; Integrated with A&E and increased the hours of the (nurse led) Walk in Centre (DDH);

A turnaround project has been implemented similar to the 18 Week Programme Board. The estimated quarter 4 end of year position is below 95% and it is anticipated that the position will stabilise and the target achieved from Quarter 1, 2012.


Transient Ischaemic Attack (TIA) M

YH

T

Delivery of the TIA indicator (target - 60%) by the end of Quarter 4, (Quarter 3 performance: 22% Trust wide, 24% NHSWD, 20% NHSK)

The presence of the Stroke Assessment Nurses (SANs) continues to have a positive impact. The full impact of the move to 24/7 for both stroke and TIA will not be demonstrated until Quarter 4 onwards.

A recovery trajectory and action plan has been produced by MYHT and these are monitored on a monthly basis through the CMG. It is anticipated that the recovery trajectory will not be delivered in year.

CH

FT

Out of 26 patients, 13 patients breached the TIA standard for the following reasons:

2 due to patient choice;

3 due to timeliness of GP referral;

6 due to timeliness of blood test results; and

2 due to timeliness of referral from A&E.

The NHS Kirklees Lead Manager for Stroke is intending to launch an awareness raising and education exercise in Primary Care around the stroke an TIA pathways and planning will closely involve GPs and other Primary Care professionals to ensure greater spread and success.

If the 2 patient choice patients had been seen then performance would have resulted in 58% achievement and if the GP referrals had been within time, performance would have exceeded the 60% national standard at 69%.

Smoking Quitters

NH

SC

Reported smoking quitters to date are on target.

Calderdale has submitted a bid for additional resources to undertake a programme of tobacco control within routine and manual workers working in the local authority; Tobacco programme aimed at eastern European community - a community which has high smoking prevalence; A scheme aimed at reducing second hand exposure commissioned; and The Calderdale Tobacco Control Group has been re-established.

Achievement of the end of year target is anticipated.



Smoking Quitters N

HS

K

Reported quits to date are below target at 1,334. This is partially due to a combination of an aspirational and challenging target and the delayed reporting system for the Intermediate Advisor Service.

Increase usage of the Intermediate Service and thus improve quit numbers; The Locally Enhanced Service Schemes have been reviewed for both GP practices and pharmacies and a new pricing structure is to be introduced; A voucher scheme to improve access to Nicotine Replacement Therapy (NRT); A Stop Smoking Locally Enhanced Services (LES) for Dental Practices introduced; and Training for Intermediate Advisors is being promoted widely among other workforce groups to offer new routes to quit.

The current end of year forecast outturn is 2,001 against a target of 2,677.

NH

SW

D

Reported smoking quitters to date are below target at 2,104.

Healthy workforce initiative; Every Contact Counts training; Review service specification and Local Enhanced Services; Work with MYHT on smoking cessation before elective surgery; Social norms pilot in Featherstone; E-learning training for brief advice in smoking cessation; and Smoking cessation in secondary care pilot. This is further supported by a commissioning review on all smoking cessation services provided in Wakefield with the development of a revised specification.

The current end of year forecast outturn is 3,156 against a target of 3,399.

Coverage of NHS Health Checks

NH

SC

On behalf of NHSC, the Cluster Board accepted a target of 18% on advice from the centre in June 2011. The take up rate is expected to be 90%. NHSC has developed a local plan to offer NHS Health Checks to 10.7% of the eligible population for 2011/12. Of those offered a health check, 64% are expected to take up the offer.18% coverage was not expected to be delivered due to the time needed to negotiate a LES.

24 practices signed up to scheme; Lead manager will contact those practices not yet signed up to the scheme to encourage better participation; and Lead manager will liaise with primary care via practice management group re: process of implementation December 2011.

The end of year forecast outturn is 4%. 2012/13 funding will be available to ensure practices are incentivised to achieve the target.


NH

SK

When the service was commissioned a target of 7,000 (1,750 per quarter) Health Checks was set for 2011/12.

However, as part of the national formal monitoring return, the PCT was required by the SHA to sign-up to offering Health Checks for 18% of the eligible population, which was calculated at 4,542 per quarter. Significant underperformance was highlighted during the 2011/12 Integrated Performance Measures Return (IPMR). Quarter 1 reported 240 Health Checks provided, against an NHSK target of 1,750; quarter 2 reported 437 against an NHSK target of 1,750 and quarter 3 reported 402 against an NHSK target of 1,750.

Performance has been discussed at a recent CMG meeting and Locala has been asked to produce an action plan around how they intend to increase numbers. The service has limited capacity to deliver Health Checks. The service operates with only 3.61 WTE cardiac nurses at full capacity, currently with vacancies this is down to 2.2 WTE.

2012/13 funding will be available to ensure practices are incentivised to achieve the target. The end of year forecast outturn is 2,158 NHS Health Checks against a target of 18,171.

NH

SW

D

The NHS Health Checks were launched nationally in 2009, by March 2011 Wakefield had delivered 45,000. The numbers of patients who have had a health check delivered is approximately 50% of the offered which is an achievement. Total Health Checks is over 50,000 (Quarter 2 2011/12.)

There have been 10 training sessions delivered to practitioners across Wakefield to ensure that there is an understanding of the programme and a standard delivery model. The Health Trainers were included in the training sessions to ensure they have the basic understanding of assessing cardiovascular risk and are able to signpost clients to their local GP practice for a formal assessment and any treatment options. The Health Trainers will support the clients to make healthy lifestyle choices, for example weight management and stop smoking. Standard operating procedures and a contract specification were updated in March 2011 to ensure providers of the service were aware of the service delivery components and the targets set.

The numbers of clients who have been offered an NHS Health Check is on track to delivering the 4.5% offered each quarter (18% annually).



Proportion of GP referrals to first outpatient appointment booked using Choose and Book (C&B)

NH

SC

Data from December 2011 indicates that 67% of the patients whose referral requests were made via C&B are „converted‟ into an outpatient appointment.

The „Optimising Electronic Referrals' (OER), West Yorkshire wide project, sponsored by WYCOM aims to help make further improvements where the national C&B programme had not yet succeeded. NHSC is part of this project. Making improvements to the local secondary care provider has proved successful as CHFT now offers Advice and Guidance (A&G), currently at no cost. A&G allows one clinician to seek advice from another. The GP can attach documents to the advice request - diagnostic results, scanned images (e.g. ECGs) or correspondence related to the patient. The CHFT clinician is then able to review the request, add attachments if required and send a response back to the GP.

It is anticipated that the target of 90% will not be achieved by the year end.

NH

SK

Performance for Kirklees continues to be below both National and Regional Average, standing at 49.8% (provisional figure) for December 2011.

The C&B team continues to meet with practices, especially those with low utilisation rates to resolve issues and increase use of C&B worklists as part of daily routine. Both CCGs are engaged with the C&B team and leading/supporting this work.


NH

SW

D

Current performance continues to be over 60% and the PCT has a plan agreed with the SHA to try and lift this to between 80% and 90% by year end – though this will depend on a number of external factors improving such as MYHT slot availability and issues regarding the way utilisation is calculated.

Appointment Slot Issues (ASI‟s) at the Trust continue to be an outlier within the region and nationally with the latest week‟s figures showing slot issues in 20% of cases when compared to a national target of 4%. This is now being considered monthly at the OER Board meeting.


4.2 NHS Innovation Review The 2012/13 NHS Operating Framework makes it clear that the NHS must prioritise the adoption and spread of effective innovation and best practice. The NHS Chief Executive‟s Innovation Review (Innovation Health and Wealth, Accelerating Adoption and Diffusion in the NHS) published in December 2011, makes further recommendations on how this can be taken forward over the longer-term with an immediate start on the following High Impact Innovations:

From 1 April 2013, compliance with these High Impact Innovations will become a pre-qualification requirement for CQUIN payment. In addition, Calderdale eCCG is involved in the innovation network in Jonkoping, Sweden. Together with colleagues from SWYPFT, CHFT and Calderdale Council, there is a plan to take the learning from Jonkoping and develop a Quality Academy for sharing and learning improvement methodologies. Early ideas are to develop specific integrated approaches to patient/user pathways across the intermediate tier and dementia. 4.3 Local Compliance 4.3.1 Telehealth and Telecare Technology Within NHSCKW there has been a focus on assistive technology and telehealth to reduce unplanned care and drive the self care self management agenda .The development stages over the last two years put us in a strong position to mirror the savings identified through the recently published evaluation on the whole system demonstrator sites. This is covered in more detail in Section 2 as one of the transformation QIPP programmes.

The rapid spread of telehealth and telecare technology

Improving the quality of children's wheelchair services

The routine use of fluid monitoring technology

Provision of Carers breaks for those looking after people with Dementia


4.3.2 Children’s Wheelchair Services The LA is the lead partner for wheelchair services. The individual PCTs are actively working collaboratively with the individual LAs to ensure this outcome/measure is taken forward through the Learning Disabilities agendas and the Children and Young People‟s agendas for consideration/feasibility of local compliance. 4.3.3 Fluid Monitoring Technology This outcome/measure is being taken forward through the annual contract negotiations and local business planning processes for 2012/13. 4.3.4 Dementia – Carers Breaks The national Dementia Strategy and Carers Strategy are currently being implemented within NHSCKW. The „carers breaks‟ outcome/measure is cross-referenced within each of the Strategies and monies ring-fenced to address this outcome/measure in 2012/13. 4.3.5 Next Steps

NHSCKW implementation of the actions set out in Innovation Health and Wealth, Accelerating Adoption and Diffusion in the NHS Report through the local planning processes;

Further development/alignment of Cluster wide clear action plans to improve the uptake of NICE technology appraisals as part of existing PCT Clinical Governance arrangements; and

Working with all partners to develop local plans for the formation of Academic Health Science Networks.

Section 5

Workforce 5.1 Overview The Human Resources and Organisational Development Shared Service (HRODSS) coordinates workforce information, planning and assurance on behalf of its client PCTs and CCGs. HRODSS is a shared service that since April 2011 has operated as a single HR&OD team across the NHSCKW. As well as the workforce assurance role described below; HRODSS also provides a full range of HR&OD services to the PCTs in NHSCKW, including the provision of dedicated HR&OD support to the organisational change associated with transition to the new NHS system. After 2012/13, it is planned that the same services will be provided to eCCGs by HRODSS as part of a broader Commissioning Support Service (CSS). 5.2 Transition to the New NHS System The NHSCKW approach to the transition during the period to 31 March 2013 is summarised in its People Transition Plan (Appendix 9). Developed in partnership with Trade Union colleagues, this plan sets out a blueprint for the workforce elements of the expected transition to the new NHS architecture. The People Transition Plan has been carefully developed to be responsive to evolving national and local requirements and to the passage of the Health & Social Care Bill. The People Transition Plan, currently in Phase 2, is on target and has achieved all deadlines to date, including the introduction of transitional assignments at senior levels in each eCCG and the CSS. Each strand of our transition programme has senior HR support to manage its workforce elements. Transition-related workforce risks are identified in project planning documentation and reviewed regularly to ensure appropriate mitigation is in place. An escalation methodology ensures that where appropriate risks are brought to the attention of the relevant Project Board. From March 2012 a People Transition Group comprising senior workforce representatives from the NHSCKW and the NHS Airedale, Bradford & Leeds Cluster, will oversee the workforce elements of each strand, ensuring consistency and scrutiny at the highest professional level. Wherever possible, consistency in approach will be followed between the Clusters, particularly in relation to the ongoing development of a robust CSS. Within the Cluster, robust function and destination mapping is undertaken on a regular basis to maintain a constantly refreshed understanding of the architecture and make-up of the future NHS system.


Staff engagement is paramount during the transition period. Regular consultation takes place via the formal Staff Partnership Forum. Staff engagement and consultation is actively sought during monthly staff briefings, team meetings and online forums. 5.3 Workforce Reporting and Assurance 5.3.1 Workforce Reporting Mechanisms Regular workforce reports, including key metrics for Provider and Commissioner workforces, ensure that Senior Management Teams at eCCG, PCT and Cluster level are fully appraised of workforce issues, trends and challenges. Workforce metrics are set against historic trends and expected trajectories, to clearly identify whether organisations are delivering the expected performance levels. A bi-monthly Cluster Board report on the health economy workforce position ensures that the Board has the opportunity to scrutinise and challenge all aspects of workforce metrics and risk management, both in relation to Cluster and Provider workforces. Board reports also provide assurance that specific concerns are reported, together with the measures in place to address them. Our core intention is to ensure that the current and future workforce in our health economy is safe, affordable and achievable; and can deliver high quality, cost effective care for our local populations. 5.3.2 Annual Workforce Risk Assessment Cycle HRODSS continues to lead the annual cycle of workforce risk assessment across the Calderdale, Kirklees and Wakefield District health economy. This cycle is now in its fourth year and has the active engagement of the 6 NHS organisations currently in the local health economy. It identifies shared and/or major workforce risks across the healthcare system and ensures that these are mitigated at the appropriate level. The 2011 health economy risk assessment is available on request. In 2012 the risk assessment process is seeking to expand, to include new healthcare organisations Locala Community Partnerships and Spectrum, and to involve eCCG leads. 5.3.3 Workforce Assurance of Providers As part of the important workforce assurance role, HRODSS works closely with NHSCKW‟s major Providers to monitor and scrutinise workforce plans and metrics. This assurance process links in with the broader Transformation Programmes associated with our main Providers, ensuring that workforce considerations, risks and progress are integral to the overall programmes and management. During 2011/12 the assurance relationship with Providers has been reviewed and strengthened in order to ensure that NHSCKW (and in due course eCCGs) can be

assured that provider workforces are safe, affordable, and capable of delivering high quality care in line with commissioning expectations. In particular the following assurance measures have been put in place:

Regular workforce assurance meetings between workforce leads. These are scheduled to take place quarterly with Providers; more frequently with those Providers whose workforce or associated risks give cause for concern. Such meetings enable “deep dives” to take place in areas of concern as well as providing a regular monitoring opportunity and a forum for Providers to raise their own concerns. For example, in relation to a specific staffing risk identified Emergency Care in one of our main Acute Providers, detailed assurance meetings took place to ensure appropriate action and mitigation was in place. This enabled the Commissioner to check that clinical quality and safety was the highest priority and that the mitigation put in place enabled their maintenance. Another example from the workforce assurance meetings is the identification of a potential risk for Providers associated with commissioning decisions; in particular where decisions made by commissioners could have unforeseen consequences on provider workforces, including in the worst (hypothetical) case scenario a requirement to make redundancies. This risk is now being explored in partnership between provider and commissioner. Where major workforce changes are planned, we seek assurance from the Provider that appropriate communication and engagement strategies are in place. For example, we are seeking such assurance in relation to a current Provider‟s developing Clinical Services Strategy. Please note that the workforce assurance meetings are in addition to the health economy workforce risk assessment cycle. Key feedback from the workforce assurance meetings are reported to the Cluster Board and relevant leads in order to ensure triangulation with finance and activity; and linkages with other regular Provider reviews.

Introduction of new template for Provider workforce metrics. A new workforce metrics template now ensures that consistent metrics are received from Providers, enabling appropriate triangulation to take place. The metrics relate to information schedule measures being negotiated into Provider contracts for 2012/13. Previously, Provider workforce metrics were principally monitored via iView (a national database tool) which shows data approximately 3 months in arrears. The new template ensures more timely data and therefore a swifter identification of potential issues, for example in relation to sickness absence. For example, the high sickness absence and variable spend figures associated with one of the main Acute Providers in NHSCKW has prompted the commissioner, as part of the regular assurance meetings, to seek and receive


detailed assurance from the Provider of the actions being undertaken to address areas of concern. The workforce metrics template must be signed off by key leaders in the Provider organisation (the HR Director, Medical Director and Nursing Director). This helps to demonstrate Board and clinical oversight of the data. The new template enables workforce number trajectories Full Time Equivalent (FTE); paybill, sickness absence and variable spend to be monitored against planned trajectories. This will facilitate an increased level of assurance of workforce performance against plans, and provide early indication of areas of concern.

Regular and shared updates of workforce plans. As part of the regular workforce assurance meetings, Providers are asked to supply refreshed workforce plans twice a year. In the event that these give cause for concern (for example if plans appeared to show a reduction in key clinical staffing areas); the concerns would be raised and addressed as part of the workforce assurance meetings.

Clinical ownership of workforce plans is required of Providers, who must demonstrate that Medical Directors, Directors of Nursing and HR Directors have been involved in the production of workforce plans and have signed them off prior to their submission. The same level of authorisation is required of the Cluster‟s own workforce plans.

Strong working relationships between Commissioner and Provider help to ensure that where potential issues or workforce risks are emerging, the Commissioner is made aware of them at an early stage.

Workforce assurance tool We are working with our main providers towards the use of a single workforce assurance tool that has been developed and successfully used by NHS organisations elsewhere in the country. We are currently assessing together how the tool could provide a range of mutually beneficial workforce data for monitoring and assurance purposes, with a view to using it as a primary source of workforce data and assurance.

All of the above ensures that the Cluster is well-sighted on workforce issues across its health economy. 5.4 The Health Economy 2012/13 The biggest providers in NHSCKW health economy are CHFT and MYHT. Other key providers include SWYPFT and Locala Community Partnerships CIC. During 2012/13 the paybill across this health economy is expected to increase by approximately 4% as a consequence of incremental pay increases, whilst the directly employed workforce is expected to remain within 0.5% of its current size.

Meanwhile a significant reduction is expected in the health economy‟s variable spend; that is the spend on bank, agency and locum workers. The reduction is equivalent to almost 20% compared with the projected outturn spend for 2012/13. 5.5 The NHSCKW Workforce The graph below shows the change in paybill associated with the directly-employed staff of the NHSCKW PCTs between 1 April 2012 and 31 March 2013. The reduction shown equates to a proportional reduction in excess of 2% over the course of the year. The 2012/13 reduction in paybill is a continuation of the steady reduction in workforce across NHSCKW that has been ongoing since the 2010/11 financial year.

The carefully managed reduction in numbers at NHSCKW, currently on target against its expected trajectory, should ensure the maximum reduction in cost and workforce size for a minimum reduction in capacity. The Cluster is alert to risks associated with reducing staff numbers and high turnover during this period of organisational change. Such risks are managed, mitigated and monitored through organisational risk management procedures. As part of the mitigation, robust vacancy control processes remain in place at PCT and Cluster level and all proposed recruitment is carefully scrutinised to ensure that business critical vacancies are filled if no other alternative or opportunity for increased efficiency is available. The use of fixed term/temporary contracts where new/replacement business critical resource is required helps to minimise ongoing employer liability and related costs.

1,960

1,970

1,980

1,990

2,000

2,010

2,020

2,030

2,040

NHSCKW Paybill 2012/13 (£000s)


The Cluster has a strong focus on maintaining resilience. A wide range of supportive measures are in place for staff, including:

Career development seminars;

Team and individual resilience courses;

“Leading through uncertainty” management development programmes;

Pensions and financial advice seminars; and

Health and wellbeing programmes. The success of such measures is monitored using indicators such as sickness absence figures and staff surveys. Well-established staff reference groups or Investors in People groups are in place in each of the Cluster PCTs to ensure that resilience issues and matters of importance to staff are reviewed and addressed. 5.5.1 Sickness Absence The sickness absence graph below shows the Cluster‟s sickness absence dating back to April 2010.

The Cluster is on target to achieve its 2.5% sickness absence target for 2011/12; and sickness absence has significantly reduced compared with 2010/11. We will continue our proactive sickness management and staff health and wellbeing measures, with the aim of reducing sickness even further, to an average of below 2% during 2012/13. 5.6 The CHFT Workforce CHFT has confirmed that a combination of productivity gains and natural attrition has enabled them to bring their FTE workforce down to during 2011/12. The organisation is on target to continue to reduce its size during 2012/13, aiming for an overall reduction of 3.3% between 31 March 2012 and 31 March 2013. A similar decrease in activity levels is forecast over the course of the year.

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

NHSCKW Sickness

2010-11 2011-12 Target (2.5%)

CHFT‟s workforce plans confirm that managerial and administrative functions are the primary focus for reductions in workforce numbers. Staff numbers in key clinical groups will remain stable, whilst the number of qualified midwives is planned to increase over the course of the 2012/13 by almost 5%. Regular workforce assurance meetings with CHFT, together with the annual workforce risk assessment cycle provide the Cluster with the opportunity to receive assurance that the decreasing workforce size will not result in reductions in the quality of services received by patients. Such assurances can be triangulated with regular performance and activity data. 5.6.1 Sickness and Turnover Sickness and turnover at CHFT since April 2010 has remained consistently within acceptable levels. Turnover is stable at between 10% and 12%. Sickness absence in particular is at a lower level in 2011/12 than in some comparable acute organisations, and is, on average, below the 4% level of absence expected in Provider organisations during 2011/12. CHFT plans to reduce its sickness absence further during 2012/13. We continue to work with CHFT towards receiving assurance information related to their actual/projected paybill and variable spend. Whilst CHFT have not provided any paybill or variable spend information for 2012/13, citing Schedule 6 of their Terms of Authorisation which can be accessed from the following link: (http://www.monitor-nhsft.gov.uk/sites/default/files/Schedule%206%20v46%20-

%2020%20January%202012.pdf) They have confirmed that they will seek to provide such information in future. Current Information Schedule negotiations with CHFT include a request for them to provide paybill and variable spend information on a regular basis. Such information will complement the workforce information CHFT already shares with us on a regular basis. 5.7 The MYHT Workforce Following a steady increase during 2011/12, MYHT‟s workforce began to contract from December 2011, and is expected to continue to reduce slowly to its projected outturn position at the end of 2012/13. The following graph shows the expected change in paybill associated with the directly-employed staff of the MYHT between 1 April 2012 and 31 March 2013. Whilst forecast to begin reducing from January 2012, the overall increase shown equates to a proportional increase of 4.5% between April 2012 and March 2013.

http://www.monitor-nhsft.gov.uk/sites/default/files/Schedule%206%20v46%20-%2020%20January%202012.pdf

http://www.monitor-nhsft.gov.uk/sites/default/files/Schedule%206%20v46%20-%2020%20January%202012.pdf


The projected small decrease in workforce size does not correspond to the projected decrease in activity during 2012/13, and in fact results in an increase in the monthly paybill over the course of 2012/13, as a consequence of incremental pay increases. Nevertheless this position represents an improvement on previous annual increases in workforce size and cost. It should be noted that during the course of 2012/13 the size and cost of MYHT‟s managerial and administrative workforce is expected to reduce, whilst the clinical workforce shows some increases. Notable increases in the clinical workforce are expected to occur in health visiting (a projected increase of 19 FTE health visitors), with proportionally smaller increases taking place in the medical & dental workforce, allied health professions and qualified midwives. Similarly MYHT‟s variable spend projections for 2012/13, whilst significant at a total of £9.5m, represent a reduction in cost by comparison to similar spend in 2010/11 and projected outturn spend in 2011/12. 5.7.1 Sickness and Turnover Sickness absence is an area where the MYHT figures are at present above the required target. Sickness levels in the organisation were at an average of 4.8% per month during 2010/11, whilst the expected average sickness absence rate by the end of 2011/12 is expected to be 5.1%. MYHT plans to reduce these figures at a rate of 0.5% year on year, commencing in 2012/13 with an expected average sickness absence rate of 4.6% by the end of that year. Whilst 4.6% remains above target levels for provider organisations in our health economy, it is recognised that this represents an achievable rate of improvement for MYHT. Their eventual goal is to achieve sickness absence levels that are consistently 3.5% or less. Turnover levels in MYHT are at levels consistent with a stable organisation.

22,800

22,850

22,900

22,950

23,000

23,050

23,100

23,150

23,200

MYHT Paybill 2012/2013 (£000s)

5.7.2 Measures for Improvement Regular workforce assurance meetings are in place between the Cluster and MYHT‟s new Director of Human Resources regarding the management of the MYHT workforce and the development of a robust workforce plan. The new Director of Human Resources has been in post for a relatively short time, and has made visible progress towards the development and implementation of a range of workforce monitoring and control processes. These processes have started to bring about tangible changes, as can be seen from the recent downturn in MYHT‟s FTE numbers following the introduction of a new vacancy control process. The assurances provided by the new Director, together with those introduced by the CKW Cluster are outlined below:

Increased frequency of workforce assurance meetings between MYHT and NHSCKW (bi-monthly) to provide support and challenge to MYHT progress in workforce metrics, risks and planning;

Development of strategic workforce strategy during 2012/13, enabled by new, emergent MYHT Clinical Services Strategy;

Jointly agreed schedule for increasing the sophistication of regular workforce assurance metrics provided by MYHT to the Cluster, culminating in the delivery of a full, costed workforce plan. This enables metrics to be monitored and correlated;

Sign and bolstering of MYHT Senior HR&OD team to provide strong, focused and visible leadership of workforce improvements. This includes the introduction of a Workforce Performance Lead and an Organisational Wellbeing Lead. The HR&OD Directorate is moving towards a business partnership model, which should ensure that workforce considerations become integral to MYHT‟s business decisions and planning;

Detailed re-engineering of sickness management processes, including comprehensive integration of proactive case management with Occupational Health support. A strong, positive focus on organisational wellbeing will also see the introduction of psychological support workers to provide direct and timely interventions where required;

Review of key employment policies to drive increased effectiveness in practice – starting with the sickness absence policy;

Review of consultant job plans, led by the MYHT Medical Director, with an agreed framework for assessment; and

A range of robust workforce control and scrutiny measures introduced internally, ensuring local ownership combined with corporate challenge: o Monthly Finance & Service Recovery Board (FSRB) at MYHT provides

monthly scrutiny of key workforce metrics, including variable spend; o MYHT workforce plans, metrics & budgets agreed at Clinical Service Group

Level and monitored by MYHT central HR team and FSRB; o FSRB plans and decisions checked/balanced by Medical and Nursing

Directors to ensure clinical oversight; o Robust vacancy control measures in place, covering both variable spend and

substantive vacancies;


o Bank, agency & locum reduction plans in place at CSG level; monitored centrally;

o E-rostering being implemented to maximise staffing level efficiency; and o Staff survey action plans in place at CSG level.

MYHT has seen significant change in its senior team, with a new Chair and Chief Executive for 2012/13. As described above, the HR Director is also new in post, following a period of change where the post was covered on an interim basis for some months. Significant benefits associated with the assurances described above have yet to be realised, and a high level of scrutiny and challenge will remain in place between the Cluster and MYHT. However, we believe they provide a strong indication that the ongoing management of the MYHT workforce will be constructive and robust, with the potential to ensure the organisation reaches a stronger position by the end of 2012/13. Our focus remains on ensuring the correct skill mix, productivity and quality levels are in place to ensure the continuity of high quality care. 5.8 Support Staff Training and Development Together with our provider partners, we are committed to the development of support staff across our health economy; and we play an important role in ensuring that such development takes place. As part of this, NHSCKW chairs a local partnership arrangement with CHFT, MYHT, SWYPFT, Locala Community Partnerships CIC and Spectrum. This group, known as the Cluster SSLDF Group, is responsible for agreeing the health economy priorities for learning and development for and submitting funding bids for courses, providers, projected numbers and costs. Its aims are as follows:

Working towards the development of a fully qualified workforce across health and social care and commissioning functions;

Promoting excellence in the quality of care, improving the patient experience and reducing the incidence of harm;

Transforming the way we deliver services by maximising our operational efficiency and productivity and exploiting new technologies;

Work closely with our partners to support care pathways for patients through the provision of competency based learning and development for our staff; and

Working to develop our staff to continuously improve our services. Associated learning priorities in our health economy include:

Leadership and Management;

Apprenticeship;

Awards at Certificate and Diploma level (NVQ); and

Other accredited learning in line with the business needs of individual organisations.

The partnership arrangement we have in place is a positive move towards ensuring that we can make the best representation to the new LETBs for a continuation of money to support the development of support staff across our health economy.


Section 6

Informatics 6.1 Introduction The use of informatics is a key enabler of choice, in various forms, to be offered to patients as well as a key component of the delivery of key projects such as Telehealth/Telemedicine and Risk Stratification. Choice for patients in our Cluster is being delivered in 3 ways: 6.1.1 Access to a named consultant team

Our two main providers are currently delivering at 97% (CHFT) and 92% (MYHT), significantly in excess of the required standard. As any new providers are commissioned, the same requirement will be required of them.

6.1.2 Patient access to primary care electronic medical records

Choice and access to information for patients is being enabled by giving patients better access to their primary care electronic medical records. There are five key elements to this:

Access to view/request medication;

Access to test results and letters;

Access to a summary or subset of the full medical record;

Access to a full medical record; and

Book/cancel GP appointments. The benefits of this include increased choice for patients in terms of times of access, ease of access and choice of appointment in primary care. Additional benefits for Primary care organisations are efficiency gains for staff and reduction in wasted appointments. We will bring forward plans in 2012/13 to enable our eCCGs to deliver against the target requirement of delivering patients‟ ability to access their primary care records by 2015. Our GP practices use primary care systems procured under national contracts. At the moment not all these systems are capable of supporting all the 5 elements described above. In parallel to capable versions of software become available we will work with our practices to identify and implement the business changes and training needed to enable full patient access as a planned programme of work.

6.1.3 Patient access to Summary Care Records

The Summary Care Record (SCR) is a central electronic summary of key health information for NHS patients across England supporting clinical interventions by legitimate staff in a manner which ensures secure access on a consent and need to know basis. The SCR thus provides healthcare staff treating patients with faster access to their patients' key health information, ensuring joined-up care and better

health interventions and outcomes. It complements the detailed care records held in individual systems. As we deploy TPP SystemOne to more and more care settings this detailed information is also increasingly available to a wider community of healthcare staff, with, of course, the requisite levels of audit and controls on access. In support of patient access to information we will continue on our trajectory to deliver against the SCR requirement of 100% of eligible practices supplying summary care information by March 2013. Currently over 55% of our eligible practices have created SCR, which equates to just under 0.5 million of our registered GP patients. Of course, the quality of data in our systems is paramount, whether they are patient accessible or not. In addition to the work we do on an ongoing basis with our Provider organisations (e.g. around the continued use of NHS number), we also have a strong focus on Primary Care Data Quality. Primary Care Data Quality is essential to underpin quality and safety particularly when information is shared and used across organisations. The Information Management and Technology (IM&T) Directed Enhanced Services (DES) defined the data quality standards required to ensure data is „fit for sharing‟ in preparation for the sharing of SCR and other national initiatives. It is important that the quality of data held within general practice data is complete, accurate, relevant, accessible and timely to be shared to other care providers. The Data Quality (DQ) teams within Calderdale, Kirklees and Wakefield District will continue to promote primary care data quality by:

Supporting practices to achieve data accreditation standards defined by the IM&T DES;

Developing and sharing clinical templates to ensure consistent data recording across different health providers to agreed standards;

Developing and sharing electronic referral letter templates;

Promoting the use of the NHS number standards in all patient and clinical correspondence;

Facilitating practices to record accurately and maximise value from clinical systems e.g. recall/review of disease registers;

Facilitating and encouraging practices staff to continue to improve their data quality through use of audits, benchmarking tools;

Encouraging practices to undertake regular audits and identify practice specific areas for improvement;

Providing specialist advice and training to practices;

Supporting practices with system upgrades to new/improved systems that facilitate sharing of information;

Promoting sharing of good practice through SystemOne user group to ensure effective use of clinical systems;

Working with provider organisations to support shared agendas e.g. electronic discharge summaries from hospitals, referral protocols etc;


Locally implementing and supporting practices with national initiatives e.g. Summary Care Record, Electronic Prescription Service, GP2GP, Personal Demographics Service, Flu reporting, National Diabetes Audit , DES/LES requirements; and

Providing DQ support to risk stratification projects. We will continue to develop and deploy the use of aggregate information by our eCCGs enabling them to access the vital information they need to commission and monitor the effective delivery of services. This programme will clearly be informed by the forthcoming NHS Information Strategy, which will enable specific developments to be proposed, either within an eCCG or via the planned Commissioning Support Services. We will continue to use information safely and appropriately per the requirements of the Information Governance Toolkit as it develops and strengthens. We will also support our eCCGs as they take on this Information Governance responsibility as part of the transition process. The local informatics capability to deliver all the above initiatives forms a part of our annual contract discussions with our main provider of Informatics services, the Health Informatics Service (THIS). As such we are less at risk of resilience issues and are confident that through a proper programme and project management approach that we will continue to deliver against the Informatics requirements identified in the Operating Framework.

Section 7

Transition and Reform: Commissioning development – emerging Clinical Commissioning Groups (eCCGs) The eCCGs have been engaged in all aspects of the planning process and have produced their own 5 year plan for health services. We have included relevant elements within the PCT Cluster plan. 7.1 Cluster Support for eCCG Development Toward Authorisation There are currently four viable eCCGs within the Cluster footprint with a further two practices in the Wakefield District that may join to form a further eCCG.

eCCG Population Practices

Wakefield Alliance Clinical Commissioning Group RATED GREEN

318,117 38

Greater Huddersfield Clinical Commissioning Group RATED GREEN

238,000 40

North Kirklees Health Alliance RATED GREEN

185,000 31

Calderdale Clinical Commissioning Group RATED GREEN

212,886 28

South Wakefield Commissioning Partnership TO BE ASSESSED

36,000 2

Discussions are continuing with the two practices in the South East of Wakefield that were risk assessed as red for their configuration. Joint meetings with the Wakefield Alliance eCCG are arranged in February to explore the possibility of the two practices joining this eCCG and developing a geographical model in the future. Each eCCG has a director assigned to it to support their development and a top tier of staff at Heads of Service level. The following sets out the critical path for the development of eCCGs in 6 key stages from September 2011 through to October 2012 and progress to date. The next six months are seen as critical in enabling eCCGs to have appropriate evidence to support their application to be authorised.


The six points on the pathway with the latest date by which each one should be completed are described below along with progress made and planned actions: 7.1.1 Stage 1 October – December 2011 Configuration of eCCGs The eCCG self assessments were completed and supported eCCGs risk assessed as green. The eCCGs have been supported by the Cluster to develop Organisational Development (OD) plans utilising where appropriate the national tools:

National Pathfinder Learning Network;

Self-assessment diagnostic tool; and

National Leadership Development Framework.

The OD plans for the 4 green rated eCCGs have been signed off by the Cluster and will be reviewed in April 2012. The eCCGs have been accessing training and development resources in response to the requirements identified in their plans. The diagnostic checklist for each eCCG was completed and a scheme of delegation and new governance arrangements have been put in place for the 4 green rated eCCGs. This includes being formally established as a sub committee of the Cluster Board. As part of the Cluster assurance framework, Board to Board challenge-and-confirm meetings were undertaken and the outcomes of these are described later in the text. 7.1.2 Stage 2 December 2011 – January 2012 eCCGs lead the planning process for 2012/13 by developing a clear

and credible plan The eCCG have developed clear and credible plans a summary page is attached as Appendix 1 to 4. Provisional eCCG Budget allocations have been identified and the eCCG plans set out a clear approach to delegation. The Cluster has developed a checklist which is being used to assess eCCG readiness for authorisation to help them prepare for establishment and to identify development needs. 7.1.3 Stage 3 January 2012 – March 2012 Commissioning intentions should be clearly identified as part of the

planning process The eCCG commissioning intentions are identified in their plans. A provisional management structure has been identified with eCCGs. There is also provisional agreement of which commissioning support functions each eCCG would want to buy, build or share and the model of CSS delivery for these services is under development in line with CSS timetable. The eCCG are represented on the key contracting groups and are actively involved for the second year in the development of the commissioning intentions for the main provider contracts.

7.1.4 Stage 4 March – September 2012 New contracts led by eCCGs and signed by 15 March 2012. This

would include a block contract between each eCCG and the CSU by April 2012.

The eCCGs are leading QIPP programmes of work and are key stakeholder in latest contracting round, leading the contract negotiations for the main acute trust contracts. All eCCGs are involved in co-producing the CSS offer and service level agreements and are on track to achieve this in accordance with the national timetable. 7.1.5 Stage 5 September – October 2012 Operational period (this would be for the period April through to

September 2012 to enable eCCGs to develop their track records) The checklist developed by Cluster will be used as a tool to prepare and support eCCGs for authorisation and to help them to identify areas for development, further support required and the collation of an evidence file. 7.1.6 Stage 6 October 2012 Commencement of formal Authorisation process with the NHSCB The eCCG applications for authorisation will be supported through the evidence collected using the Cluster checklist further Board to Board meetings and outputs and actions from critical friend reviews through each stage of the process. A scheme of delegation has been agreed by the Cluster Board via which, the newly established CCE receive early responsibility and accountability for commissioning decisions and use of resources to enable them to build a track record of delivery. A series of Board to Board „confirm-and-challenge‟ meetings between individual eCCG Boards and the Cluster Board have been set up and the first in the series took place in early December 2011. 7.2 Board to Board Meetings with eCCGs The first Board to Board meetings took place on 8 and 9 December 2011 and were extremely productive. Future Board to Board meetings will coincide with key points in the authorisation process. The purpose for setting them up was to:

Provide an opportunity for the Cluster Board to understand eCCG development to date;

Understand how each eCCG self-assessed using the risk assessment and their development of an organisational development plan;

An opportunity to challenge and confirm governance arrangements;

Understand how the Cluster can further support the eCCGs in their development; and


Identify what evidence will need to be provided for each domain as part of the authorisation process.

7.2.1 Feedback from the Sessions The key positive themes included:

The eCCGs have a clear vision and values with a focus on creating a reflective learning culture;

There is strong practice engagement; There are clear roles for clinical leads;

Good links are being developed between primary and secondary care clinicians; There is a strong commitment to involving local people; and Within the eCCGs there is strong commitment of those leading the process.

Areas identified where the eCCGs would welcome further Cluster support included:

Sharing of the minutes from the Cluster Board meetings; Clarification on the future role of the NHSCB; Share good practice identified from other eCCGs, get an understanding of what

„excellence‟ looks like from the DH perspective and promote good practice identified locally;

The Cluster Board acting as an umbrella sheltering the eCCG and giving it the freedom to develop and to help the eCCG to identify things that no longer need to be done as the transition progresses;

Support the local managerial teams as they may become over stretched and develop a plan for dealing with potential gaps as structures develop; and

Set up some development work with managers, to help them to better understand how to work with GPs.

Common themes for the further development of the eCCGs included:

Further development of relationships and behaviours with the LA and the development of a plan for this area of work that incorporates the use of the JSNA, and a statement of what the eCCGs want to achieve through participating on the HWBB and their role;

Develop next layer of clinical leadership;

Identification of risks for the eCCG, and clearly articulate them with a plan of how they intend to manage these risks; and

Ensure that leads for areas of work share the load by identifying additional clinical leads to support them.

7.3 eCCG Engagement in the Development of Plans As part of the eCCG plans there is a clear commitment to engagement with all partners in the planning process. eCCGs are keen to promote their role within the local community and to build sustainable

and effective relationships with its constituent practices, staff, local politicians, the LA, Local

Involvement Network/Healthwatch, NHS organisations, the media and other partners as well

as patients and the public. To this end they have developed their engagement plans. The

eCCGs are also developing a key partnership with the LA and PH through their active role in

the HWBBs and this is described in more detail in Section 10.

7.4 Patient Engagement There is recognition that commissioning in the NHS is increasingly locally driven and the eCGGs are clear that high quality commissioning needs to be informed by the experiences and views of local people. As an organisation that is responsible for investing funds on behalf of local people, the eCCGs actively seek the views of patients, local communities and the public to inform their commissioning decisions. They are aware of their statutory duties related to Patient and Public Involvement (PPI), particularly the NHS Act 2006 (Section 242), and NHS Constitution 2009, and the Equality Act (2010) (Specific Duties) Regulations (2011). The eCCG plans describe engagement with three „cohorts‟ of people:

Those who have direct experience of services (patients, carers);

Members of the wider public; and

Those who represent communities. The main structures for ensuring that patients and the public are effectively represented are:

Practice patient groups;

Overview and Scrutiny Committees;

Health and Wellbeing Boards; and

Local Involvement Networks/HealthWatch. 7.5 Practice Engagement A „bottom up‟ approach where the views of all constituent practices has been developed in each eCCG. Nurse Forums and Practice Manager Forums have been set up to ensure cross eCCG working relationships are developed further. The formulation of the eCCGs key priorities and Commissioning Plan have been managed through the eCCG which have ensured practice views are represented. eCCGs have also hosted events to engage with PCT staff so they can meet eCCG Board members and ask questions. 7.6 Provider Engagement

The eCCGs recognise the need to maintain and build further relationships with all Providers

including testing the market with new Providers to build strength and competition, develop

and stimulate a range of choice in care and support services in the local area. The eCCG plans

cover relationships with:

Calderdale and Huddersfield Foundation Trust (CHFT);

South West Yorkshire Partnership Foundation Trust (SWYPFT);


Other Acute Providers and Special Commissioning Group (SCG); and

Locala Community Partnership and Spectrum.

Engagement with these providers is currently undertaken in many formats:

Executive Contract Boards;

Local Medical Committee Liaison meetings;

Performance management meetings; and

Service redesign projects.

7.7 MYHT

There is commitment to working with and supporting the MYHT to:

Develop local optimisation plans;

Develop a five-year clinical services strategy;

Improve performance and reduce waiting times;

Drive up overall service efficiency through the transformation of elective and urgent care pathways;

Complete the required process to FT status by April 2014, which includes supporting the Trust to deliver the milestones set out in the tripartite formal agreement;

Co-produce service redesign e.g. Ambulatory Care Group 2011/2013;

Continue to meet with consultants through the Medical Leaders Forum to discuss strategy, healthcare reform and transformation; and

Work with the Trust and wider partners through the Mid Yorkshire Partnership Board and the agreed whole system programmes and workstreams.

7.8 Other Private Providers

A series of other private national and local providers are utilised by patients, including: Spire,

BUPA and BMI. Some of these providers are in place to deal with capacity issues where

activity demands exceed plan or a lack of resource in existing provision is preventing wait

time to be met. The Any Qualified Provider (AQP) procurement is intended to grow this

group further and is described in more detail in Section 12.

7.9 Assurance of Delegation to eCCGs To assure effective delegation of appropriate commissioning budget each of the four eCCGs across the Cluster has been formally established as a sub-committee of the Cluster Board called a Clinical Commissioning Executive (CCE). Terms of Reference and the scheme of delegation have been signed-off formally by the Cluster Board.

The scheme of delegation gives each of the four eCCGs 100% of the appropriate commissioning budget i.e. minus all direct commissioning and specialised commissioning budgets. This represents a progressive trajectory for the transfer of responsibility from NHSCKW to each respective eCCG and successfully builds on the level of delegation to CCEs. Each CCE has a Finance and Performance group

which monitors the detailed monthly finance and performance reports and a Quality Board for each of the main NHS acute providers, MYHT, CHFT and SWYFT. In terms of delivery, the four eCCGs are leading and implementing the Business Plan and Operating Plan for 2012/13, including leading all QIPP schemes and agreeing their own commissioning intentions. The eCCGs are also actively involved with the HWBBs across the three local authorities, to ensure a whole health system approach is adopted for their respective areas. To support eCCGs‟ development and their journey toward authorisation the eCCGs leadership capacity has been secured with assigned directors to each eCCG and an agreed indicative management structures which is currently being implemented. This work is facilitating good workforce transition planning for the transfer of staff from their respective PCT to the respective eCCG. As described above, there are clearly four viable eCCGs and all practices are within these eCCGs with the exception of two practices who aspire to become an eCCG themselves. These two practices have come together as South Wakefield Commissioning Partnership and are being supported by a Director to develop their aspiration to become an eCCG. The Cluster is supporting further discussions to identify the most appropriate configuration of eCCGs across Wakefield District and until a viable configuration is agreed, will not be setting up a fifth sub committee of the Cluster Board. The Cluster is aware of the need to agree this as soon as possible and is giving this issue a high level of priority and support.


Section 8

Transition and Reform: Commissioning development – commissioning support 8.1 Commissioning Support Services (CSS) Development The first phase of the Cluster‟s approach to developing commissioning support has focused on working in partnership with eCCGs to form a view on what they want to build, buy or share. A key decision was to develop a CSS on a West Yorkshire footprint that would cover both, Airedale, Bradford, Leeds Cluster and Calderdale, Kirklees, Wakefield Cluster. This would offer commissioning support services to the current 11 eCCGs, covering a population of 2.3 million. 8.2 CSS Programme Structure A formal project management structure with CEO sponsorship and a Project Director and Project Manager are in place. A customer reference group and specific task groups complete the project structure; commercial support from Ernst & Young has been secured. The programme of work is being co produced with eCCGs from across West Yorkshire.

CCG/Customer Reference Group

Programme Board Project Team

Finance

Human Resources

Governance

Service Offering

Operating Model

Commercial Strategy

Organisational Development

Business Plan

2aaaa

The broad roles of the seven task and finish groups are as follows:

The vision for our CSS is being developed with eCCGs, based on their feedback and the key priorities that they have outlined through our engagement with them. It is also supported by input from our staff where relevant to help inform the discussions.

Finance

• Financial model

• Cost analysis

• Revenue

• Pricing models

Human Resources

•Human Resource

•Transition framework

•Role definitions

•Job Descriptions and grading

•Staff and Trade Union engagement

Governance

•Governance structure

•Terms of reference

•Delegated authority

•Accountability framework

Service Offering

•Prospectus

•Service specifications

•Service Level Agreements (SLAs)

Operating Model

•Service delivery model

•Relationship management

•Quality control

•Infrastructure (Estates, IM&T)

Commercial Strategy

•Customer base

•Competitor analysis

•Marketing strategy

Organisational Development

•Staff development

•Transition support

Business Plan

•Development and authoring of the business plan


A review of the milestones and checkpoints for developing a CSS shows that we are compliant with the requirements to date and have structures and plans in place to continue to achieve the requirement of the national timetable. A timetable for agreement and delivery has been developed to meet the overarching milestones set by the DH as outlined below.

Jan 2012 Submit 1st draft of outline business plan

Feb 2012 Sign Service Level Agreements with eCCGs

Feb 2012 Submit 2nd draft of outline business plan

Mar 2012 Submit outline business plan

Mar 2012 Outline business plan approved (Checkpoint 2)

Jun 2012 Submit full business plan (detailed delivery model)

Aug 2012 Full business plan approval (Checkpoint 3)

Apr 2013 Fully operational

We have produced a service prospectus an early draft of which was shared with eCCG leaders across the Cluster. The prospectus is a dynamic tool tailored to address the diverse needs of individual customers and delivering the functions required by each eCCG or the NHSCB. The exact mix and level of integration of the range of services to deliver customer outcomes will be developed in partnership with them through the next phase of the project. The CSS Programme Board recognises that each customer may, dependant on their emerging vision, size and scale of their organisation, wish to engage with us for different levels of service. We expect to work closely with our customers to support and influence the most effective and efficient solutions to meet their aspirations. The Programme Board recognises that the establishment of commissioning support services that meet varied needs is challenging and has a number of inherent risks. At this stage the following key risks have been identified:

Dependencies on eCCGs achieving the required progress towards authorisation and articulating their requirements as „intelligent customers‟;

Affordability of desired service levels from a eCCG perspective;

Organisation capability and capacity to achieve the „transformational change‟ from current ways of working to very different models of delivery across the geographical footprint, within the required timescales; and

Impact of the ongoing development of the operational model for the NHSCB. The West Yorkshire CSS Programme Board will maintain a proactive approach to managing these risks and identifying new risks in response to the programme development.

Feedback to date on the West Yorkshire approach has been good with the following identified as areas of good practice in our approach:

The prospectus has been widely recognised as an excellent example and shared by SHA in draft form across the region;

Positive feedback from CCG partners during SHA 360° feedback; and

Excellent framework for cooperation and joint working. We are currently on track to hit the February 2012 deadline to submit the outline Business Plan (second draft). Key actions delivering this target are:

We have held an event at the end of January that brought together eCCG leaders from across West Yorkshire to engage further on commissioning support development;

The draft service specifications for West Yorkshire are developed;

We have recruited to an „Interim Managing Director‟ for the West Yorkshire CSS;

We have developed options for the model of delivery for the CSS;

Confirmed resources available via SHA for £10K and £30-£40K to support organisation development and have scoped our requirements;

Shared possible options and approaches for the delivery model of the CSS to understand key features required from a eCCG perspective; and

Continued discussions with eCCGs re the functions/commissioning support services required from the CSS and explore areas of commonality or variation.

We are on line to submit the outline business plan by the January to March deadlines. We continue to engage with eCCGs to understand their requirements and define what services and models of delivery will best meet their needs and are developing service agreements with eCCGs based on our understanding of eCCG requirements and the service specification. The focus of the next phase of CSS development will be on creating the organisation and this will be lead by the newly appointed Interim Managing Director. The management structure and an organisational development plan are under development.


Our proposed business model is shown in the following diagram:

CSS Business Model

CSS

Nationally provided services

e.g. Communications

Strategic Business Partners

(CSSs, private sector, third

sector partners)Suppliers

(Products and Services)

CCG CCG CCG

Section 9

Transition and Reform: Commissioning development – direct commissioning 9.1 Overview The Operating Framework for the NHS in England 2012/13 sets out clear expectations for delivering the changes to build the new delivery system. The Framework describes how this means „developing an NHSCB with a relentless focus on improving outcomes and delivering value for money‟. In response to the Operating Framework requirements and to deliver the transition and reform agenda, NHSCKW has established a PMO to coordinate the transition and reform programme for Direct Commissioning. The scope of this approach has already been described in Section 1 of the plan and is managed through Portfolio 5. Commissioning Development has been established as a portfolio of the PMO. A key workstream within that portfolio is the Direct Commissioning programme. As a response to delivering the Direct Commissioning workstream the PMO has constructed an effective transition programme from „current state‟, i.e. PCT cluster, to „future state‟, i.e. NHSCB. This transition programme aims to enable a common model of commissioning delivered against a trajectory of key milestones. Senior managers from across the three PCTs comprising NHSCKW are working collaboratively to achieve the outputs required of the direct commissioning workstream. Key outputs include oversight and responsibility for the management of 2012/13 contracts and delivery of the Operating Framework‟s mandatory requirements. This involves overseeing negotiation of 2012/13 contracts in partnership with eCCGs and negotiating and preparing the arrangements for services to be directly commissioned by the NHSCB. A key milestone is that by March 2012 NHSCKW will be operating direct commissioning functions in line with an agreed shared operating model. The NHSCB will directly commission services such as primary care, specialised services, prison/offender health and military health. Further guidance is expected from DH during 2012/13 on the operational requirements for the transfer of these responsibilities from PCTs to the NHSCB. NHSCKW will respond to any new guidance through the PMO programme delivery arrangements and respective portfolio leads. 9.2 Prison Health A key responsibility for NHSCKW is to maintain prison health services during the transition programme, which are covered in Section 3 of this plan. Once fully established commissioning of prison health will transfer to the NHSCB. Key deliverables of the prison health commissioning programme are to deliver:

Stocktake of staff and capacity to deliver prison health commissioning;

Contract transition readiness;

Ensure current Prison heath needs assessments remain fit for purpose and revise them accordingly for use in the 2012/13 commissioning round;


Identify secondary care activity usage by prison and custodial services from new data flows and use it to inform commissioning plans;

Identify prison health secondary contract activity by services, specialty/Healthcare Resource Group (HRG) value in order to allow 2012/13 contracts to separately identify shadow NHSCB and eCCG responsibilities;

Complete cataloguing existing contracts for prison, custodial and offender health, setting out the broad contents of the contracts and their state of readiness for handover to the NHSCB; and

Identifying and measuring all relevant secondary care usage activity, e.g. prisoner‟ hospital escorts and bedwatches.

Progress is well underway to meet these expectations and the following tasks have been completed:

Stocktake of staff and capacity to deliver all direct commissioning functions;

New prison health needs assessments completed;

Secondary care activity usage by prisoners quantified and assessed to inform commissioning plans, including enabling what will be the responsibility of eCCGs and what will be the responsibility of the NHSCB; and

Cataloguing of existing contracts for prison, custodial and offender health, setting out the broad contents of the contracts, risk assessment of each contract and their state of readiness for handover to the NHSCB. Outputs from this contract transition work have driven a key procurement for a new prison health service.

A QIPP initiative to introduce telemedicine aligned to procuring new intermediate care provision for HMP Wakefield is underway with the objective to bring hospital escort and bedwatch costs back into line with NHSCKW‟s allocation. Contract transition has confirmed a plurality of commissioning contracts are in place, the vast majority of which are relatively stable, but a small number have required corrective action. Work has been delivered to stabilise those contracts at risk through contract management operational review and benefits realisation gateway process. 9.3 Prison and Offender Health Proposed Operating Model DH has published a proposed NHSCB Prison and Offender Health Operating Model which NHSCKW will adopt as its delivery model going forward. The key features of the Operating Model are as follows: 9.3.1 Understanding needs: National: Latest intelligence on offender health need assessed from Public Health England and other sources including HM Inspector of Prisons, Care Quality Commission reports, independent research, NICE, aggregated data from prison health/GP IT systems; Local: Joint Strategic Needs Assessment overseen by local authority Health and Wellbeing Boards, gap analysis, serious incidents, Prison Partnership Boards, DPH annual reports, provider insights, and prisoner and third sector views and experience;

9.3.2 Priority outcomes defined: National: DH sets Public health outcomes framework and NHSCB sets Commissioning Outcomes Framework and equivalent for NHSCB commissioned services; NHSCB sets offender health business targets (including outcomes); planning and investment priority-setting; Local: Joint health and well-being strategy defines priorities for locality (NHS and LA); priorities for local health investment co-ordinated across LAs, eCCGs and NHSCB outposts.

9.3.3 Delivery and support:

National: NHSCB maintains partnerships between criminal justice system, DH and other government departments; NHSCB maintains oversight responsibility for the commissioning of all health services for offenders and drives convergence; Local: NHSCB commissions all services for those in prison and other detained settings, including specialist commissioning of forensic mental health/personality disorder; and eCCGs commission for all offenders in contact with, but not detained by, criminal justice system and community-based services which prisoner‟s access; NHSCB responsible for commissioning public health services for prisons, delivered in partnership with local LA/PHE commissioning arrangements e.g. substance misuse. 9.3.4 Accountability against outcomes: National: Setting minimum standards and assurance mechanisms and metrics; performance management regime in place for all NHSCB outposts; Local: PHE publishes accessible data on local outcomes; HWBBs hold local partners to account for delivery of strategy and outcomes; Use of quality surveillance tools and Prison Health Performance and Quality Indicators.

NHSCKW will build the proposed operating model into its strategic commissioning plans for the transition period. 9.4 Primary Care

Key deliverables of the primary care commissioning programme are to ensure that there are robust arrangements in place in readiness for the transfer of primary care to the NHSCB. This has included a stocktake of primary care staff and capacity and a stocktake, review and stabilisation of all primary care contracts liable for novation to the NHSCB. Contract transition work was successfully completed by the end of January milestone. All primary care contracts were collated, reviewed and risk assessed. Primary Care teams determined that there are no NHS Medical Service


(NHSMS) NHS Dental Service contracts (NHSDS) in existence for primary care provision so there is no need for an explicit divestment plan for this type of contract. Other key workstreams have included the cataloguing and assessment of primary care estates premises being taken forward by NHSCKW‟s Health Property Management team in partnership with primary care commissioners. All premises have now been assessed and development of a new estates strategy is well underway. NHSCKW‟s estates strategy will be congruent with the DH‟s latest plans to establish a new host organisation for PCT estate across England. Locally, commissioners are working with GP practices to undertake a full review of practice registered patient lists, ensuring any patient anomalies are identified as soon as possible and where identified these will be corrected by March 2013. Heads of primary care are working collaboratively across NHSCKW to deliver this work and this is overseen as part of the Commissioning Development portfolio of the PMO. Primary care leads across NHSCKW are working to rationalise primary care commissioning to create economies of scale across NHSCKW and will aim to maintain existing core Family Health Services functions. Work is underway to standardise primary care commissioning in preparation for handover to the NHSCB by ensuring capacity and capability including sufficient resilience is in place across NHSCKW footprint. 9.5 Contract management Contract management arrangements will see the implementation of the first phase of a fundamental review of the NHS Standard Contracts as signalled in the NHS Operating Framework 2011/12. During 2012/13, work will continue on the preparation of the transfer of the clinical contracts from current commissioners to the new commissioning authorities as planned as part of the NHS reforms. This work is well underway and will be completed within the specified timescales. A critical transition activity has been the delivery of the contracts transition implementation plan. The first stage of this workstream was to develop a programme plan for local transition management and agree robust governance arrangement including executive sponsorship by the NHSCKW Director of Finance. Initial planning included the completion of a transition readiness assessment to measure each PCT‟s (comprising NHSCKW) readiness in terms of contract transition. Two key areas for further development were identified as transition governance and organisational systems and processes. Work is underway to make improvements in these areas. The first phase of this work was to catalogue all direct commissioning contracts, then to undertake a full risk assessment of all the contracts, and finally to stabilise those contracts needing further attention. This work was taken forward by the respective contracting teams across NHSCKW and has delivered against the specified milestones.

Section 10

Health and Wellbeing Boards Health and Wellbeing Boards (HWBB) are established across the three PCT footprints and are being used to develop joint commissioning priorities as part of the planning process. 10.1 Calderdale eCCG Close partnership working with Calderdale's HWBB is seen as a key to achieving the strategic outcomes for Calderdale eCCG. The HWBB leads on the strategic co-ordination of commissioning across Calderdale. This includes; local health services, social care for both children and adults, and public health services. All organisations working in these areas are currently developing a shared understanding of local need and agreeing the best strategy to meet that, within the funding and resources available. Calderdale HWBB Board is planning to publish its first Health and Wellbeing Strategy by March 2012. The early work on strategic priorities has informed this year‟s eCCG Commissioning Plan. Work continues to achieve a strong alignment between the Health and Wellbeing strategic priorities and the eCCG Commissioning Plans through active participation on the HWBB, and the Calderdale Assembly. 10.2 North Kirklees Health Alliance (NKHA) The eCCG is focusing on how the local HWBB understands the importance of inclusion of services such as Mental Health and Learning Disability within their Joint Health and Wellbeing strategy, as well as social care and hospital care. The local board, established between Kirklees Council and jointly shared with NKHA and GHCCG looks at all health and care needs together, and has a role to create health and well-being strategies jointly with other eCCGs. The eCCG is building upon the existing mature relationships and strong track-record of collaboration between health and social care agencies, to develop and implement the vision for joint commissioning and seeking to improve the:

Integration of health and social care;

Efficiency of commissioning functions and teams;

Planning and prioritisation process across health and social care; and

Efficiency of in cost spending across health and social care. The purpose and functions include, but are not limited to:

Overseeing and assisting with the authorisation of the eCCG;

Evaluating delivery mechanisms to deliver joint strategic objectives;

Develop shared understanding of terminology and language around the health and wellbeing agenda;

Providing a governance structure for local planning and accountability of health and wellbeing related services; and

To deliver the ambitions of people living in Kirklees, which also delivers the vision and values of NKHA.


10.3 Greater Huddersfield eCCG (GHCCG) Kirklees council is also GHCCG‟s LA partner. It provides a full range of local services to a population of 420,000 people in Kirklees, across both GHCCG and NKHA. A history of mature partnership working exists between the NHS and LA, particularly in relation to children and young people, mental health, learning disability, and substance misuse. There are strong individual working relationships between senior officers. The new HWBB is gaining shape and GHCCG is ready for the opportunities and challenges of joint planning and joint commissioning. Two Board members and the shadow Accountable Officer from the eCCG are members of the established HWBB. Including the delivery of public health objectives, engagement with the LA is seen as a crucial component for future successful commissioning. GHCCG‟s aim is to ensure that the eCCG and Kirklees Council‟s commissioning plans will be firmly underpinned by a shared understanding of the needs of the community, through joint strategic needs assessment. The JSNA published (September 2011) continues to highlight the challenges in the district. It is envisaged that both the eCCG and LA have a shared strategy which addresses those needs within the collective resources available through the joint health and wellbeing strategies. 10.4 Wakefield Alliance eCCG The HWBB is established and meeting regularly with an agreed work programme in place and is accepted as a Pathfinder. The JSNA is subject to a refresh process with an initial report to the HWBB for September and final report by March 2012. The Health and Wellbeing Strategy is under development with scoping work commenced, although the project will not be formally initiated until findings from the JSNA are clear and the HWBB has provided a project mandate for this work. In terms of Public Health transition, there has been an internal director level meeting with key stakeholders to oversee the programme of transition. The eCCG has already formed close working relationships with these partners through the establishment of the HWBB at which the eCCG is well represented and has joint responsibility to lead and shape the JSNA refresh and the Joint Health and Wellbeing Strategy (JHWS). Wakefield Council is their LA partner. It provides a full range of local services to a population of 315,000 people in Wakefield and the five towns: Castleford, Knottingley, Featherstone, Normanton and Pontefract. A history of mature partnership working exists between the NHS and LA, particularly in relation to children and young people, mental health, learning disability, and substance misuse. There are strong individual working relationships between senior officers. The eCCG commits to increasingly closer collaboration with Wakefield Council on the following key issues:

Improving the health and well-being of children and young people;

Greater integration of commissioning of adult services;

Out of hospital and intermediate care; and

Ensuring the effectiveness of PH through the emerging HWBB. Discussions are continuing with the two practices in the South East of Wakefield that were risk assessed as red for their configuration. Joint meetings with the Wakefield Alliance eCCG were arranged in February to explore the possibility of the two practices joining this eCCG and developing a geographical model in the future. Both of the two practices in the South East of Wakefield are represented through GPs on the HWBB. 10.5 HealthWatch All eCCGs are committed to working with their developing HealthWatch locally as the voice of citizens and communities and as a vehicle to strengthen their engagement plans. A designated lead has been appointed by the LA in Calderdale and in Kirklees to head up a project to procure HealthWatch. A steering group has been established to achieve this and the eCCGs are members of the advisory steering group. The papers are ratified through the HWBB on which representatives from each eCCG sit. A programme is in place for this establishment and the close down of LINK – the procurement process begins on the 1st April 2012. The information from both the advisory steering group and the HWBB meetings are shared with the CCEs. Wakefield Alliance CCG has a member of the CCE and Wakefield Alliance CCG Board who is a LINks/HealthWatch leader.


Section 11

Public Health 11.1 Overview There is an understood and agreed set of arrangements for how the local public health system will operate during 2012/13 in readiness for the statutory transfer in 2013 across each of the three PCT footprints within the Cluster. The three Public Health (PH) functions in Calderdale, Kirklees and Wakefield District each have a transition plan (Appendix 5 to 7) that were developed in partnership with the Local Authority that clearly reflects the components of the PH transition checklist, this will be signed off by March 2012. The PH functions will continue to be accountable to the NHS Cluster Board during the transition year. Locally the governance of the process will be overseen by the joint Transition Board meetings with each LA.

11.2 Public Health Transition in Calderdale There is a joint Calderdale Council/PCT transition board in place which is overseeing the transition arrangements in Calderdale. The Calderdale Shadow HWBB has been operating in public since June 2011. In November 2011 the first Calderdale Assembly was held, which also saw the launch

September 2011

PH engagement in Commissioning Consortia Group

developmentJanuary 2012

Transition Steering Group Risk Register to

be established

March 2012

Final integrated Primary Care Trust Cluster Plan to

be submitted

Agree local transition planJune 2012

Department of Health deadline to agree local

vision for PH and delivery

September 2012

Agree arrangements on PH programme

information requirements / governance

October 2012

Test arrangements for

Emergency Planning esp. the role of the DPH and LA based PH staff,

plus Screening + Imms

December 2012

DH deadline for all PH to be operating from LA

December 2011

Confirmation of functions to be transferred

March 2012

Engagement and comms plan developed

June 2012

Agree approach to development and delivery

September 2012

Health & Wellbeing Strategy

October 2012

Early draft of legacy + handover documents

DH deadline for 70% of PH staff to be operating from

LA

Formal assessment of progress from PCT to LA by

SHA

March 2013

Formal handover and transfer of PH

January 2013

Ensure final legacy and handover documents

produced including formal governance.

March 2011

Health & Wellbeing Board Established in shadow

form

Public Health Transition Timeline 2011 – 2013

of the updated 2011 Calderdale Needs Assessment. Work is now underway to develop the Calderdale Wellbeing Strategy. Calderdale has a Public Health Transition Group which will direct and supervise the transition of the PH function from NHSCe to Calderdale Council. The main responsibilities of which are to:

To provide overall direction and management of the Public Health transition;

To hold accountability for the success of project;

To provide the „project voice‟ to the outside world, disseminating information from and conveying external information to the project;

To ensure required resources are available;

To provide direction to workstream leads;

To monitor progress of work streams through their reports to Public Health transition Working Group;

To approve all major plans and authorise changes;

To provide an escalation point for key unresolved project issues that have not been able to be resolved through the normal process of dialogue and investigation between interested parties; and

To maintain a risk register. Locally the governance of the process will be overseen by the Joint Monthly Calderdale Council/NHS Calderdale Directors meeting as the Transition Board. The Transition Group will report to this Board as well as to the Calderdale CCE and the Calderdale, Kirklees and Wakefield Board. The Director of Public Health remains jointly accountable to the Chief Executives of Calderdale Council and NHSCKW. 11.3 Public Health Transition in Kirklees In Kirklees there is a joint Programme vision and associated work streams for the transition of PH to the LA. By April 2013 (in shadow form during 2012/13) PH in Kirklees will:

Be fully established within the LA in respect of responsibilities;

Have clear structural relationships with Public Health England (PHE) and the NHS commissioning architecture; and

Comprise the appropriate organisational forms and relationships to best deliver its responsibilities in the LA, PHE and NHS commissioning architecture.

The scope of the programme is to manage the transition of PH into the LA and the relationship with PHE and the NHS commissioning architecture to ensure it delivers its responsibilities. This includes:

Accountability and governance including performance monitoring;

System design to embed all relevant elements of PH responsibilities as described nationally with local interpretation for the best fit;


Influencing the design of NHS commissioning architecture and PHE so that we are able to relate to it effectively in Kirklees and West Yorkshire with the emerging CSS;

Budget planning and setting;

Alignment of staff and related HR issues, including any staff transfers into PHE;

Managing relationships and expectations;

Management of delivery and risks during transition;

Ensure effective collaboration with the LA, NHS Cluster and eCCGs and emerging West Yorkshire PHE unit and West Yorkshire CSS;

Creation of a PH legacy handover document for 2012/13; and

Ensure key PH functions are managed and are delivering during transition.

The working processes in Kirklees are developing well with a programme management approach and workstreams that capture key elements such as outcomes, risks and governance. The Council Directors Public Health Transition Board will oversee the transition as will the NHSCKW. The latter is accountable to the SHA and PHE nationally for ensuring PH transition plans are robust and effective. 11.4 Public Health Transition in Wakefield The PCT has been working with LA, PCT, Clinical commissioners and other partners to ensure that plans are in place. This work was established early 2010 and built on the closer partnership working and integration set in train in 2009 with the appointment of a Joint Director of Public Health, the subsequent development of the Joint Public Health Unit and the integration of intelligence and emergency preparedness functions. Led by a strategic planning group made up of council and PCT senior managers the plan for transfer of staff and contracts is underway. A draft transition plan has been developed. Three sub groups have been established that will report to the strategic group including Human Resources consultation and communications, finance, IT and accommodation. The group will also oversee due diligence. To date the PCT and LA have:

Identified staff that will move to LA. All staff received notification of alignment/assignment in January 2012;

Developed a framework that identifies core functions and maps services against those functions;

Secured accommodation for staff in the LA, staff will move in 3 phases which commenced in July 2011;

Made significant steps in establishing connectivity for all staff who will be transferred; and

Consulted with staff throughout the process using a range of opportunities both in the LA and PCT.

In addition to joint working with the LA the public health team has taken a lead role in the region in developing the PH response to the CSS.

The Wakefield Public Health transitional steering group will provide the leadership required to ensure governance arrangements are in place. Cluster, SMT and CCE governance arrangements will provide support to these arrangements as will the governance arrangements established within the LA. The EPBC team is already integrated into the LA and we have strong evidence of the benefits of this arrangement in terms of how we have responded to recent community issues e.g. explosion, fire and political unrest. In addition we have taken a key role in working with the DPRR lead DPH developing the EPBC core offer with our West Yorkshire partners. A risk profile is being developed to assist the Wakefield Public Health Transitional Group, DPH, SMT and CCE in managing and mitigating against risk. The public health team will continue to engage with governance arrangements and provide public health input to support the identification and investigation of SUIs. The PCT cluster DsPH have requested a skills analysis to ensure that we are able to fulfil the core offer. There is recognition that capacity and capability may be an issue in areas such as health economics. DsPH are working together to address this. A robust communication and engagement plan is being developed by the workforce sub group.


Section 12

Provider Development 12.1 Any Qualified Provider (AQP) There is a plan to undertake a phased implementation of patient choice of Any Qualified Provider. The Cluster, supported by eCCGs, engaged with patients, patient representatives, HWBB, healthcare professionals and providers on local priorities for extending choice of provider. In addition, the three PCTs comprising the Cluster have engaged with their key provider organisations, mostly through the existing contract management board arrangements. The following stakeholders were engaged as part of the process:

Patients, carers and relatives, general public;

Voluntary and Community Groups;

GPs, practice staff and patient reference groups;

Local Involvement Networks;

Staff;

Health and Wellbeing Boards;

Providers;

Clinical Commissioning Groups;

Town & Valley Committees/Ward Forums;

Elected members/Councillors;

Overview and Scrutiny Offices;

Local Medical Committees, Local Pharmaceutical Committees, Local Dental Committees and Local Ophthalmic Committee; and

Media. A shortlist of preferred services was prioritised and the final choice for NHSCKW includes:

1. Adult hearing services in the community (to cover Wakefield District, North

Kirklees, Greater Huddersfield, Calderdale eCCGs); 2. Diagnostic tests closer to home (to cover Wakefield District, North Kirklees,

Greater Huddersfield, Calderdale eCCGs); and 3. Primary care psychological therapies (adults) (to cover Calderdale eCCG).

The prioritised services are suitable for an AQP approach because:

They are discrete and capable of being chosen individually by patients and/or referrers;

There is no unacceptable clinical risk associated with a multiple and potentially diverse provider landscape;

There is no strong interdependence between them and any other clinical services that would make it advantageous to have them provided by the same provider;

The overall activity levels versus fixed costs mean that an AQP model is likely to be commercially viable for providers;

The prioritised services are all on the national menu. The cluster has experience of procuring using an AQP model and the capability to do so. Resource has been identified within the cluster to lead the AQP process and a high-level project plan and timeline has been developed to scope the level of resource required;

Patient safety issues were considered as part of the process of selection of priority services and the selected services do not have significant associated patient safety issues. In particular the need for specific Safeguarding Board discussion has been considered and determined not to be required for the prioritised services. Further assessment of patient safety issues and any required mitigation will be considered before signing off detailed specifications and accreditation requirements; and

National implementation packs have been issued for all of the national priority services. The specifications for diagnostics, adult hearing services and IAPT are being reviewed by cluster eCCGs to inform the level of engagement in centrally-managed qualification processes.

12.2 Implementation Trajectory: The National process for coordinating and supporting phase 1 AQP processes is clearer now. For services on the national priority list, where local commissioners agree to be part of the centrally-managed process, there will be a single advert and timescale designed to meet the needs of all participating commissioners. The current expectation is that service lines for Diagnostics (non-obstetric ultrasound and MRI), IAPT and Adult Hearing Services will be advertised on the Supply2Health website after 1 February with intention to agree the new AQP contracts and commence services in Calderdale, Kirklees and Wakefield District in August and September 2012. NHSCKW has elected to adopt the national specification as per implementation pack for each of the AQP services. We have also opted for the relevant „Qualification Centre of Excellence‟ (QCE) to operate stage 2 of the evaluation (service-specific review of providers against the criteria for qualification) on our behalf.

AQP phase 2 – Although there is a clear expectation that AQP will be expanded to additional services in a phase 2 and beyond, there is not currently any substantive guidance about the number or nature of additional services that each cluster will be expected to roll-out in phase 2, or the timescales for this (beyond an expectation of 2013/14). A delivery trajectory will therefore be developed for phase two once further information is available.

Consideration has also been given to a high-level trajectory for delivery of further AQP services. This will be refined on receipt of further national guidance about 2013/14 and beyond requirements. Progress against the project trajectory is on-track with the high level delivery plan aiming for commencement of delivery of all three services from 3 September 2012. However, it has also been decided that commencement of the Adult Hearing Service be brought forward for two reasons, firstly due to its straightforwardness of service provision and secondly, because an early implementation will provide for an


opportunity to learn lessons for the other two remaining AQP phase 1 services, and going forward, for delivery of phase 2 AQP services. 12.3 Transition of Yorkshire Ambulance Service (YAS) to Foundation Trust

(FT) Status YAS plans to become an FT by December 2012. The public consultation process finished on 4 December 2011; this important organisational change for YAS is supported by NHS Airedale, Bradford and Leeds (ABL) as the lead commissioner for the YAS Emergency & Urgent Ambulance Services contract.

Overall YAS is performing well and recognises where it needs to make adjustments and address issues proactively, and sensitively. YAS is confident that it will achieve compliance with year-end performance standards. There are still some issues regarding the performance of the Patient Transport Service (PTS) but these will be dealt with by looking at the potential to have a „health transport contract‟ to incorporate PTS from 2013.

The underpinning issue will be achieving and maintaining identified efficiencies, particularly around reducing conveyance and altering the skill level balance (and cost), including securing 111 and retaining the PTS operation. The re-structuring and re-focussing of the YAS executive team indicates a commitment to achieve the organisational structure and ethos to support effective financial management. 12.4 MYHT’s HEFT Programme Update At the end of September 2011 agreement was reached between MYHT and the Yorkshire and Humber Strategic Health Authority (now NHS North of England (NHSNE) and NHSCKW to work towards submitting its application to become an FT in April 2014. To support this transition, the MYHEFT programme was set up with four key workstreams summarised in the schematic below. Governance is provided through the MYHEFT Board which meets every two months and the smaller executive group which meets every fortnight. In January the MYHEFT Programme Board, supported by MYHT‟s Board and Cluster Board agreed to some changes to strengthen the governance arrangements of the programmes and separate and thus give greater emphasis to the work on finance and performance recovery and whole system transformational change.

Mid Yorkshire Health and Social Care Economy Partnership ProgrammeBoard / Executive / PMO

Foundation

Trust

Application

Transactional

processes

Partner PCTs:

NHS Leeds

CKW Cluster Board

NHS North of England

Wakefield Council

Kirklees Council

Recovery and Improvement

Programme Board

• Financial recovery

• Service improvement

Transformation Programme

Board

• Care outside hospital

• Urgent care

• Clinical services strategy

• Primary medical services

MY Hospitals Trust Board

Cross Cutting: Communications and Engagement; Clinical Leadership;

Quality and Safety; PMO Governance and Risk Management

Partner Trusts:

SWYPFT, Locala

CCGs: Wakefield

North Kirklees

12.5 Transformation Workstream HEFT Board partners recognised that the best way to help each partner organisation meet some of the significant challenges for the whole health economy in future was for all the key stakeholders (commissioners and providers) to work together in a productive and collaborative way. A whole system event was held over a day and a half on 2 and 3 November 2011 to explore this further. The agreed aims for the event were to develop:

A shared understanding and vision of the key priorities and how they would be achieved in a time of real financial challenge;

A shared strategy to deliver the compelling vision;

The key elements of the strategy;

An agreement on the commitment of each partner to work together; and

An agreement on how partners were going to develop and implement the strategy.

The event was attended by representatives from all key partners including clinicians. The sessions were facilitated by the Centre for Innovation in Health Management, University of Leeds. The agreed key areas on which partners will focus and which will influence business planning for the future were identified:

Developing integrated, appropriate and prompt intermediate and community services;

Improving and enhancing primary care services;

Improving management of demand for urgent and emergency care services;

Exploiting information and technology for patients‟ benefit;

Influencing public expectations of the NHS and how they access health services; and


„Getting the basics right‟ –through improved primary and secondary care clinical leadership and engagement.

The next stage is to start to make progress in these areas, building on existing forums and groups, plans and activities. The HEFT board Programme Management Office (PMO) will support colleagues to ensure appropriate reporting mechanisms and governance is developed around their action and which will report into the PMO. 12.6 Finance and Service Recovery

The work to examine the robustness of QIPP and Cost Improvement Programme (CIP) plans continues. The PMO has carried out a confirm and challenge exercise of commissioners‟ QIPP plans relevant to MYHT and has reported back to NHSCKW. Alongside this, MYHT has contracted with Ernst Young to carry out a similar exercise to look at CIPs. The plan is to take the output from both exercises and carry out an analysis, the outputs of which will be incorporated into business planning for 2012/13 and the development of future QIPP and CIP plans. 12.7 Clinical Services Strategy

We are coming to the end of the pre-consultative stage of the clinical services strategy. A wide range of meetings and listening events have been held including with local MPs and elected members. The Communications and Engagement team is now pulling together a summary report of the outputs and learning from this stage to support the next. Several facilitated sessions have taken place with GPs from the eCCGs and MYHT consultant clinicians to work through and refine the options set out in the strategy in order to reach agreement on the proposals which will go to public consultation. The current plan is that these refined service reconfiguration options will be presented for approval to the Trust Board and Cluster Board in February/March 2012. If approved, the public consultation exercise will commence in May 2012 - though the timetable continues to be under review. 12.8 FT Application Process

Structures are in place to support the transactional aspects of the FT application process. Delivery of this workstream remains wholly dependent on the delivery of the others. The trust‟s Tripartite Formal Agreement with the SHA and DH sets out a number of milestones to support progress to FT. The Cluster is working closely with the trust through the MY Partnership Programme to support delivery.

CKWCB-12-87b_Updated_FINAL_OpP

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