putting good health into practice - nneccg …...title: nhs nottingham north and east clinical...

NNE CCG Commissioning Plan 2014/15 – 2015/16 of 36


Document Purpose: This document is the operational plan for 2015 – 2016 for NHS Nottingham North and East Clinical Commissioning Group

Title: NHS Nottingham North and East Clinical Commissioning Group Operational Plan 2015 – 2016

Editor: Dr Paul Oliver/Samantha Walters

Publication Date: February 2015

Target Audience: NHS England, Patients and Public

Circulation List: NHS North Midlands, Nottinghamshire Clinical Commissioning Groups, Nottingham North and East Clinical Commissioning Group’s People’s Council

Cross Ref: Nottingham North and East Clinical Commissioning Group Commissioning Plan 2014/15 – 2015/16 South Nottinghamshire Five Year Strategy 2014/15 – 2018/19 Nottinghamshire County Health and Wellbeing Strategy 2014/15

Superseded Documents: None

Action Required: Note

Contact Details: Samantha Walters Chief Officer NHS Nottingham North and East Clinical Commissioning Group Civic Centre Arnot Hill Park Nottingham NG5 6LU

For Recipient’s Use

Version control: Draft Version 1 February 2015 Draft Version 1.2 February 2015 Final Version 1.3 26 February 2015


Contents

1. Introduction ................................................................................................................................................................... 4 1.1. What is NHS Nottingham North and East Clinical Commissioning Group? ......................................................... 4 1.2. Our aims .............................................................................................................................................................. 4 1.3. Our business model ............................................................................................................................................. 5

2. Looking Forward: our Commissioning Strategy 2014/15 – 2018/19 ......................................................................... 5 2.1. Five Year Strategy 2014-2019 ............................................................................................................................. 5 2.2. Nottinghamshire Health and Wellbeing Strategy ................................................................................................. 6

3. But For Now: our Operational Plan for 2015 – 2016 ................................................................................................... 6 3.1. Better Care Fund ................................................................................................................................................. 7 Outcomes ................................................................................................................................................................... 8

Delivery across the five domains and seven outcome measures ....................................................................... 8 Improving health ............................................................................................................................................... 11 Reducing health inequalities ............................................................................................................................ 12 Parity of esteem ............................................................................................................................................... 16

Access ...................................................................................................................................................................... 17 Convenient access for everyone ...................................................................................................................... 17 Meeting the NHS Constitution standards ......................................................................................................... 21

Quality ...................................................................................................................................................................... 24 Response to Francis, Berwick and Winterbourne View, and plans to reduce the number of inpatients (for people with a learning disability)....................................................................................................................... 24 Patient safety.................................................................................................................................................... 25 Patient experience ............................................................................................................................................ 27 Compassion in practice .................................................................................................................................... 30 Staff satisfaction ............................................................................................................................................... 30 Seven day services .......................................................................................................................................... 31 Safeguarding .................................................................................................................................................... 32

Innovation ................................................................................................................................................................. 34 Research and innovation .................................................................................................................................. 34

Delivering Value ........................................................................................................................................................ 35 Financial resilience; delivering value for money for taxpayers and patients and procurement ......................... 35


1. Introduction

NHS Nottingham North and East Clinical Commissioning Group (NNE CCG) has been a statutory NHS organisation, responsible for commissioning health services for the population covered by the CCG area, since 1st April 2013. The CCG is led by general practitioners using their knowledge and understanding of patients’ needs, with the key principles of putting patients at the centre of the NHS and focussing on clinical outcomes. Pivotal to the success of the CCG is the requirement to continuously improve the quality and safety of care whilst ensuring that the available healthcare resources are used as effectively and efficiently as possible. This is at a time when the CCG, along with the wider NHS, is facing a significant financial challenge.

In October 2014 the NHS Five Year Forward View was published which sets out how health services need to change in order to meet the challenges facing the NHS as a result of people living longer and having more complex needs. This was followed in December 2014 by the publication of The Forward View into action: planning for 2015/16 which describes what NHS organisations need to do to make a start in 2015/16 towards delivering the vision set out in the NHS Five Year Forward View.

This Operational Plan has therefore been developed by NHS Nottingham North and East Clinical Commissioning Group in response to both the NHS Five Year Forward View and The Forward View into action: planning for 2015/16. It describes the CCG’s approach to delivery against the requirements as detailed in the aforementioned documents across a number of key areas during 2015/16.

1.1. What is NHS Nottingham North and East Clinical Commissioning Group? NHS Nottingham North and East CCG is one of seven Clinical Commissioning Groups in Nottinghamshire, including Nottingham City and Bassetlaw. The CCG is made up of 21 GP practices covering a population of approximately 148,000, organised collectively to commission health services for the patient population living in Arnold, Burton Joyce, Calverton, Carlton, Colwick, Daybrook, Gedling, Giltbrook, Hucknall, Lowdham, Mapperley, Netherfield, and Newthorpe.

NNE CCG’s vision is:

“Putting Good Health into Practice” This vision will be delivered through:

1. Improving the health of the community and reducing health inequalities 2. Securing the provision of safe, high quality services 3. Achieving financial balance and value for money

1.2. Our aims NNE CCG’s aims reflect its population profile and groups with the greatest need, whilst also ensuring that focus on the wider population is maintained.

For 2015 – 2016, NNE CCG’s key aims will continue to be to:

• reduce health inequalities in the local population by targeting those people with the greatest health needs

• drive up the quality of care in order to improve health outcomes and reduce unwarranted clinical variation

• direct available resources to where they will deliver the greatest benefit to the local population

• commission appropriate models of care for older and vulnerable people with complex needs, ensuring all patients are treated with dignity and respect

• ensure that patients are able to make choices about the care they receive and are seen in the right place at the right time by the right person.


1.3. Our business model

Figure 1: Our business model

2. Looking Forward: our Commissioning Strategy 2014/15 – 2018/19

2.1. Five Year Strategy 2014-2019 As a key requirement of ‘Everyone Counts: Planning for Patients 2014/15 to 2018/19’ and in response to the ‘Five Year Forward View’, a five year strategy has been developed by the South Nottinghamshire health economy which comprises twelve partner organisations across health and social care. This includes the four CCGs in the area – Nottingham North and East CCG, Nottingham City CCG, Nottingham West CCG, and Rushcliffe CCG, key local providers of health services (Nottingham University Hospitals NHS Trust, Nottinghamshire Healthcare Trust, community services providers) and the local authorities. All twelve organisations, known as the ‘Unit of Planning’, have agreed to work collectively over the next five years to support improvement in health and social care outcomes and have aligned their plans in line with the principles of the South Nottinghamshire Transformation Partnership.

The strategy recognises that the NHS is at a critical point in its history. It acknowledges and responds to the ever increasing demands being placed on health and social care services as a result of a rapidly ageing population (often with multiple complex mental and physical health needs) and in the context of pressures on limited NHS and social care resources going forward. This is coupled with rising citizen and patient expectations which will become increasingly more difficult to meet.

The strategy also recognises that if we are to continue to provide safe and effective care for our patients and citizens unprecedented changes will need to be made across all services to meet the


enormous future challenges. Organisations will need to work together collaboratively to redesign systems and streamline services. Services will need to be commissioned in a way that maximises the use our collective resource, focuses on improving patient and citizen outcomes and shares risk equitably between organisations.

The strategy therefore identifies how the local health community plans to transform health services across South Nottinghamshire to deliver care within the available resources and to meet the requirements set out in the planning guidance. This will be supported by a shift of resources from secondary care to primary and community care to help ensure a sustainable NHS for future generations.

During 2015/16 the CCG will deliver transformational changes, local to the organisation, as well as enabling / achieving whole system change, where required through the Partnership, with a focus on:

• taking steps towards the joining up of commissioning across the local system with progress being achieved towards a system that is commissioned and contracted on an outcomes basis with the expectation that a group of providers will respond, taking on responsibility for providing all care for a given population being accountable for achieving the outcomes agreed within a given budget or expenditure target

• providing system leadership, including through the South Notts Critical Friend, for providers in coming together in both developing new integrated models of care (in keeping with the Five Year Forward View) and establishing robust governance mechanisms (such as joint venture arrangements)

• delivering a range of improvement interventions from the collective transformation work-plan with a specific focus on urgent care, planned care as well as integrated health and social care (including the Better Care Funds).

Transformation is underpinned in South Notts by successful collaborative working, with further progress planned for 2015/16 in accordance with a system development framework, comprising six components ranging from shared purpose to the agreed approach for managing risk and benefit, and supported by a Critical Friend.

2.2. Nottinghamshire Health and Wellbeing Strategy The Nottinghamshire Health and Wellbeing Board (HWB) brings together key local stakeholders including CCGs, local councils and the public with a shared aim of working together to improve health and wellbeing. The main responsibility of the Health and Wellbeing Board is to identify current and future health and wellbeing needs, and to develop a Health and Wellbeing Strategy. The most recent strategy was approved at a meeting of the Health and Wellbeing Board in March 2014.

In summary the strategy has four ambitions:

1. A good start – for everyone to have a good start in life 2. Living well – for people to live well, making healthier choices and living healthier lives 3. Coping well – that people cope well and that we help and support people to improve their

health and wellbeing, to be independent and reduce their need for traditional health and social care services when we can

4. Working together – to get everyone working together

3. But For Now: our Operational Plan for 2015 – 2016

The previous section describes the CCG’s longer term commissioning strategy and priorities, whilst also providing an overview of the end state and vision to be delivered collaboratively across the South Nottinghamshire area.

This section sets out how, during 2015/16, the CCG will make progress across a number of key areas in respect of:

• implementation of the Nottinghamshire Better Care Fund plan


• delivery against the requirements detailed in The Forward View Into Action: Planning for 2015/16

• fulfilling the vision set out in the NHS Five Year Forward View.

3.1. Better Care Fund The Health and Wellbeing Board is responsible for developing, approving and delivering plans associated with the Better Care Fund (BCF). The BCF was announced in June 2013 within the Government’s spending review. It was described as creating a national £3.8 billion pool of NHS and local authority monies intended to support an increase in the scale and pace of integration and promote joint planning for the sustainability of local health and care economies. The fund is ‘a single pooled budget for health and social care services to work more closely together in local areas, based on a plan agreed between the NHS and local authorities’.

The Nottinghamshire Better Care Fund plan was signed off by NHS England as “Approved” in December 2014 following further work to provide assurance around programme governance in relation to monitoring and delivery of the plan. The focus of work now is to ensure the Section 75 pooled budget is in place for 1st April 2015 with the appropriate governance structures in place at County level to allow for transparency of reporting.

The Better Care Fund will:

• provide an opportunity to transform care so that people are provided with better integrated care and support

• help deal with demographic pressures in adult social care • assist in taking the integration agenda forward at scale • support a significant expansion in care in community settings.

As part of the planning for 2015/16, CCGs have the opportunity to revise their non-elective trajectories based on 2014/15 forecast outturn and QIPP assumptions. This is for CCG agreement, though any changes will also be presented to the HWB for oversight of the impact at the County- wide plan level. For NNE CCG the non-elective trajectory for 15/16 is currently under review.

On 27th January, Nottinghamshire County was announced as a Wave 2 Pioneer site, one of eleven areas to join the existing fourteen sites in the national Pioneer programme. The pioneer covers Nottinghamshire County Council, the two mid Notts CCGs and the three CCGs in the south of the County. Pioneer status recognises the innovative and transformational work that has already been undertaken within the region to develop integrated services improving outcomes for the population. As a pioneer, Nottinghamshire will have access to tailored support to implement our plans including system leadership, freedoms to develop new commissioning models and flexibilities with information sharing between partner agencies.


Key Area What we plan to do

Outcomes

Delivery across the five domains and seven outcome measures

The NHS Outcomes Framework, which sets out how improvements in clinical and patient outcomes will be introduced into the accountability framework for CCGs, is seen as a catalyst for driving quality improvement and outcome measurement throughout the NHS. Throughout 2015/16 the CCG will continue and enhance the use of outcome measures by:

a. Illustrating how outcome measures will be used to inform clinical commissioning decisions b. Supporting patients in making clinically-supported, intelligent choices about their care options c. Prioritising those services for which outcome measures will be introduced first d. Determining how the development of new outcome measures will be prioritised and integrated alongside existing

measures e. Agreeing a modular approach for the introduction of refined outcome indicators with clinicians to empower them in

introducing new pathways and changes in clinical practice f. Working with providers and other stakeholders to reach agreements on the level of improvements g. Incentivising providers through CQUIN targets h. Monitoring and publishing outcome measures in the public domain i. Putting in place processes for continual review and improvement of outcomes

A by-product of the successful improvement of service quality and outcomes for patients will be the achievement of the CCG’s Quality Premium.

Delivery against the five domains Preventing people dying prematurely • NNE CCG will work proactively with the local authority and other key stakeholders to address risk factors associated with

lifestyle choices (diet, smoking, exercise, alcohol consumption and sexual health). Opportunities to support patients to make healthy lifestyle choices will be maximised by continuing to promote ‘every contact counts’. Much of our efforts will be promoted through the Health and Well Being Board, but also through NNE CCG’s Partnership Group, membership of which includes representatives from all district/borough councils included within the CCG area.

• People with serious mental health problems and learning difficulties are more likely to die prematurely, and through better quality of care these deaths could potentially be avoided. The CCG will work with the local authority and partner CCGs to improve the care of people suffering from dementia and will take steps to reduce the gap in life expectancy of people with learning difficulties. We will support efforts to improve early diagnosis of dementia and support patients and carers whose lives are affected by the disease.



Enhancing the quality of life for people with long term conditions • The CCG will prioritise the effective management of long term conditions in the community through on-going

implementation and refinement of integrated health and social care delivered through locality community teams. This will include improved support and advice to patients, their families and carers, and GPs, and greater use of the voluntary sector and other community services.

• The CCG will work with patients and carers to improve self-care and patient responsibility, and reduce dependency on health and social care. This will be supported through the continued development of our patient and public engagement capacity.

• The aim is to deliver a reduction in the number and severity of relapses experienced by patients, resulting in fewer hospital admissions, reduced length of stay when patients are admitted to hospital, and fewer beds required for the treatment of patients with common chronic illnesses.

Helping people to recover from episodes of ill health or following injury • NNE CCG will continue to work with hospital providers to reduce avoidable readmissions. Working in partnership with our

community and hospital providers, social care, and other local CCGs, we will develop services designed to safely and effectively rehabilitate patients in a community setting as soon as is possible after an acute hospital admission. These will include the extension and development of our comprehensive geriatric assessment programme.

• We will work with hospital and mental health providers to ensure that people admitted to hospital with a pre-existing mental health condition do not experience longer hospital stays than people without those conditions.

• These services will increase the need for responsive and comprehensive community, in-reach, and out-reach services whilst reducing the need for acute hospital beds by reducing the average length of stay for hospital admissions.

Ensuring that people have a positive experience of care • NNE CCG’s ambition is that patients, their families, and carers will experience a seamless transition between health and

social care services where required. This will be achieved by far closer integration of community health services and also between health and social care services, and will support our plans to improve delivery of rehabilitation, long term conditions, NHS continuing care, end of life, and mental health care.

• Integration of care will also be supported by the ambulance service, which will have an increasing role in ensuring patients receive high standards of care without emergency admissions to hospital.

• We will continue to improve access to clinical services. This will include facilitating improved access to primary care, commissioning waiting times for acute care in line with commitments and pledges set out in the NHS Constitution, and enhancing the availability of locally accessible services for diagnostics and specialist opinion where appropriate.

• Treatment of mental health issues will increasingly focus on early intervention and effective treatment and recovery in a community setting, reducing the need for inpatient treatment and rehabilitation. Where specialised treatment is necessary, this will be provided more locally and more cost effectively than at present with far fewer out of area referrals.



• In all sectors, patients will be encouraged to make positive choices about their healthcare and we will continue to increase the number of service providers available where this will have a positive impact on service quality. People receiving NHS continuing care and some patients with long term conditions will be able to manage their own healthcare budgets where they would like this.

Treating people in a safe environment & protecting them from harm • Working with care homes, providers of community services and hospital providers, NNE CCG will develop services to

support a significantly greater proportion of people to die at home, when this is their choice at end of life. This will reduce unplanned hospital admissions but will require additional capacity and better integration in community-based services.

• We will continue to drive up standards of care by all providers, and will use CQUIN flexibilities to incentivise best practice. This will further support our intention to commission services on the basis of outcomes rather than input. There will be continued emphasis on reducing healthcare-acquired infections, pressure sores, and never events.

Delivery against the seven outcome measures The CCG is confident of delivery of the national requirements in respect to both the 5 domains of the NHS Outcomes Framework as described above, and the seven specified outcome measures – five of which are relevant to commissioners – and will do so by redesigning pathways to optimise quality, effectiveness, and patient experience. Where relevant this will be supported through the inclusion of outcome measures in health services contracts to hold providers to account across sectors.

The approach taken by the CCG is for the CCG’s outcomes to improve, both in real terms and in relative position to the national benchmark. The ambition is that there will be improvements in the quintile performance for the CCG compared to the national range. Specifically:

1. Outcome Ambition 1 (Potential Years of Life Lost) – the CCG aims to achieve the required 13.7% reduction 2. Outcome Ambition 2 (EQ-5D score for LTC patients) – will be achieved and move the CCG from the second quintile to

the third quintile performance compared to the national benchmark 3. Outcome Ambition 3 (Emergency Admissions composite) – the CCG’s ambition is to move from the second quintile

into the first quintile performance compared to the national benchmark 4. Outcome Ambition 5 (Poor Patient Experience in inpatient care) the CCG plans to move from the second into the first

quintile performance compared to the national benchmark 5. Outcome Ambition 6 (Poor Patient Experience of General Practice and OOH) – will be achieved and maintain the

CCG’s position in the first quintile performance compared to the national benchmark

This will be achieved through the continued implementation of the CCG’s Outcomes Implementation Strategy, which aims to deliver the nationally-required improvements in clinical and patient-report outcomes, introduces some stretch targets for further improvements, and adds some local outcome indicators aligned to the local ambitions of the CCG.



All health services contracts now include outcome measures above and beyond the minimum national requirements, and form part of the regular dialogue at Quality Scrutiny Panels.

The CCG and its partners in the health and social care community believe a fundamental part of improving outcomes is to provide the necessary infrastructure to provide clinicians and other professionals with the right tools to make the right decisions. Across Nottinghamshire we will invest in the architecture to facilitate the sharing of clinical information between different health care providers and this will be a common ambition across acute, primary care, community and mental health providers in 2015/16. In future years this will be extended to social care organisations.

Lastly, the CCG has used, and will continue to use, local information derived from the existing JSNA to determine key priority areas where patient outcomes could be improved. The CCG has used the Right Care Commissioning for Value insight pack to identify priority areas which offer the best opportunities to improve healthcare for our population. This is both in terms of improving the value that patients receive from their healthcare and improving the value that populations receive from investment in their local health system. During 2015/16 the CCG will continue to use the pack to:

• support the identification of local opportunities for improvement in health outcomes, patient experience or spend • access, analyse and understand relevant clinical data • understand how the CCG compares when outcomes are benchmarked against similar populations elsewhere • identify the most beneficial intervention and service change opportunities through clinical, financial and workforce

modelling.

Improving health The CCG will work with HWB partners to develop agreed outcomes from taking the five steps recommended in the Commissioning for Prevention Report. The Joint Strategic Needs Assessment and the final draft of the HWB report on health inequalities to be published in May 2015 will guide the development process.

In response to our local population and their health needs, the CCG is committed to:

• working with partners to improving the health and the lives of children and vulnerable families • meeting the challenge of an ageing population, ensuring that effective health and social care is commissioned to support

older people to remain at home and prevent unnecessary admissions to hospital • engaging with families and carers when planning and commissioning services, for all age groups • targeting resources where need is greatest • preventing escalation and deterioration of patients’ conditions through managing patients in primary and community

settings • promoting positive lifestyle choices, especially relating to smoking, alcohol, diet, sexual health, teenage pregnancy,

physical exercise and substance misuse.

The CCG will actively promote the obesity prevention and weight management services commissioned by Nottinghamshire



County Council and provided by Everyone Health, which goes live in April 2015.

In addition, the CCG is working closely with the Children’s Integrated Commissioning Hub to ensure locally-commissioned services best meet the needs of children and young people in the NNE area. Considerable work has been undertaken to understand the needs of children with specialist needs, including extensive engagement with children, young people, and families. As a result, the Nottinghamshire Integrated Community Children and Young People’s Healthcare (ICCYPH) Programme has been developed and will be procured during 15/16.

The CCG is also a member of both the Gedling Health Forum and Broxtowe Health Partnership, which has agreed an action plan for 2014-16.

Reducing health inequalities

Identification of people within the CCG area that have worse outcomes and experience of care The CCG is actively participating in the challenge to improve health and reduce health inequalities. In order to do this, a multi-faceted approach has been adopted:

• The CCG routinely considers equity of access and uptake in its commissioning of local services, and in actively supporting the work of other parts of the system (e.g. screening and immunisation team). At a county-wide level this includes working with other stakeholders in the Nottinghamshire Health and Well Being Board on the wider determinants of health, as we well as having a direct role in health care associated interventions. Locally the CCG engages on wider determinants work through local partnership arrangements involving the district councils.

• Inequalities are not just expressed as an issue of life expectancy but also in morbidity. There are many diseases which may not cause death but cause a significant health burden and have a negative impact on quality of life e.g. musculoskeletal problems and mental health. The CCG is active in managing these in a proactive way either within a primary care setting and/or by working with local experts, e.g. IAPT.

• The CCG will continue to work closely with its member practices to identify areas of worse health outcomes and experiences of care. In 2015/16 member practises will continue to utilize eHealthScope to review referral patterns and highlight quality issues. The CCG will also implement Map of Medicine which will also support identification of health outcomes and help shape the development of appropriate pathways of care.

• The CCG has sponsored and is leading on C2, Connecting Communities, in two distinct geographical areas of the CCG. C2 uses insights from complexity science as the theoretical lens through which to view, understand and deliver transformative community change. C2 is also based on compelling biological evidence that the lack of any sense of influence or control over one’s immediate environment, coupled with poor social networks, causes catastrophic health behaviours. The CCG identified two areas to launch the C2 programme through crime, health and wellbeing data and in agreement with the relevant district/borough councils. The focus in these areas is on collaborative health creation to harness the collective creative powers of residents working as equals with Police, Education, Housing Associations and District/Borough Councils across the spectrum. The benefits in partnership working were immediately evident and the end



result will be self-managing, well supported, stronger and healthier communities. This is achieved within 12-18 months using the practical C2 7-Step Framework to create new relationships between residents and agencies, embedding the values of trust, humility, compassion and respect from ‘high level to street level’. As its full title suggests, C2 connects communities in three different ways: • Within themselves -creating networks and mutual co-operation • With local service providers -building a parallel ‘community’ • With other C2 communities across the UK, getting and giving inspiration and peer learning directly from one place to

another • NNE CCG is enthusiastic about the programme of work, the opportunity to expand throughout the CCG and the fact that it

is sustainable. Delivery of this initiative has commenced in recent months and will continue during 2015/16.

In addition, the CCG has used, and will continue to use, local information derived from the existing JSNA to determine key priority areas where patient outcomes could be improved. The CCG has also used the Right Care Commissioning for Value insight pack to identify areas where the local population has worse outcomes compared to other comparable CCG areas. The Commissioning for Value pack also enables the CCG to identify priority areas which offer the best opportunities to improve healthcare for the CCG population. This is both in terms of improving the value that patients receive from their healthcare, and improving the value that populations receive from investment in their local health system. During 2015/16 the CCG will continue to use the pack to:

• support the identification of local opportunities for improvement in health outcomes, patient experience or spend • access, analyse and understand relevant clinical data • understand how the CCG compares when outcomes are benchmarked against similar populations elsewhere • identify the most beneficial intervention and service change opportunities through clinical, financial and workforce

modelling.

Overall demographic and health information does not identify any specific areas where the CCG population varies significantly to the Nottinghamshire or England average. However, whilst areas such as Woodborough and Burton Joyce are among the least deprived in England, other areas, including parts of Hucknall, Netherfield, Porchester, and Killisick Estates, experience higher levels of deprivation, and are identified as being in the 10% most deprived areas in England. There are also significant variations in life expectancy across the CCG area. Life expectancy in Gedling is 79.5 years for men, and 83 years for women; both are higher than the England average – in men, significantly so. Life expectancy is 7.2 years lower for men in the most deprived areas of Gedling than in the least deprived areas.

Building on this, when compared with other areas in England, the population of Nottingham North and East CCG has a higher percentage of both men and women aged 45 and older, and a lower percentage aged less than 30. 19.6% of the registered population of NNE CCG is over the age of 65 years (HSCIC April 2014), higher than the average across all South Nottinghamshire CCGs (including Nottingham City) of 15.6%. These higher than average numbers of older people within the area suggest that there will be higher than average levels of long-term and life threatening conditions. During 2015/16 the CCG



will therefore focus on integrating care for older people and those with long-term conditions, including those residing in care homes.

Implementation of the five most cost-effective high impact interventions The main causes of mortality are cardiovascular disease, cancers, and respiratory disease, all of which are underpinned by the use of tobacco. Half of the gap in life expectancy is due to tobacco, and preventing or stopping smoking is therefore the single most important intervention in reducing this.

It is estimated that 15-20% of the life expectancy gap can be directly influenced by healthcare interventions. The National Audit Office and Public Accounts Committee report into tackling inequalities in life expectancy identified five high-impact interventions

• Increased prescribing of drugs to control blood pressure • Increased prescribing of drugs to reduce cholesterol • Increase smoking cessation services • Increased anticoagulant therapy in atrial fibrillation • Improved blood sugar control in diabetes

The approach the CCG is taking to address these is highlighted below.

The CCG is active in primary prevention which includes ensuring smoking cessation services are accessible, and raising the importance of regular exercise as well as the dangers of alcohol and other drugs through brief interventions and support for the Making Every Contact Count initiative. The CCG’s role in secondary prevention focuses on slowing the progress of disease in its earliest stages. During 2015/16 our GP practices will continue to support the NHS Health Check program which is designed to detect potential problems before they do real damage, and actively working with patients to reduce risks. Some patients will develop long-term health problems such as diabetes, heart disease, or cancer. In these cases the CCG’s focus will be on preventing further physical deterioration whilst maximizing quality of life. The management of these diseases will include the use of drugs to reduce cholesterol and blood pressure, as well as anticoagulant therapy in atrial fibrillation and blood sugar control in diabetes, and will often involve working with disease specialists.

Implementing EDS2 NHS Nottingham North and East CCG had implemented the original EDS, which therefore provided an established framework to take forward EDS2. In recognising the opportunities to focus on local issues and problems and to ensure a robust plan to deliver against the four goals within EDS2, the south Nottinghamshire CCGs and Nottingham University Hospitals NHS Trust are working in partnership.

We have jointly identified key actions that ensure a local approach against the outcomes to deliver the goals. These actions have both a CCG focus and a wider approach relative to our overall local patient population. Our action plan sets out clear



steps in order to ensure delivery against each goal. Progress against each action is monitored on a quarterly basis, both as individual organisations and jointly.

With respect to grading, as the EDS2 is a new approach, the CCGs and Trust agreed to start from a neutral position with a clear commitment to reach the ‘Excelling’ level as soon as is practicable. An initial self-assessment puts us at ‘Developing’ across the four goals. We have begun the grading process with patients, service users, and staff.

EDS2 has provided the CCG with a comprehensive framework, and working in partnership has allowed us to develop a robust action plan ensuring that we are competent and effective in meeting our equality duty.

Specific elements that are embedded within the CCG and are being supported through the action plan include:

• Commissioning accessible interpretation and translation services to people who do not have English as a first language. The CCG has commissioned sign languages services. The CCG has also signed up to a British Sign Language Charter, which includes 5 pledges to ensure health services are more accessible for this group.

• The CCGs have established and maintained a governance structure to ensure there is accountability in advancing and mainstreaming equality into our business. As a sub-group of the Quality and Risk Committee, the Equality and Diversity Forum is chaired by a lay member and includes patient engagement and governance.

• The Equality and Diversity Forum links into wider equality networks and has representation on the Nottinghamshire NHS Equality and Engagement Network, which is a network of equality, leads across the Nottinghamshire health community.

• The CCG ensures that equality impact assessments are carried out on all initiatives and changes.

Workforce Race Equality Standard The CCG has carried out an initial review of how the organisation compares against the Workforce Race Equality Standard and recognises the need to progress against the indicators. Our population is approximately 6% BME and our workforce is representative at approximately 11%. The CCG has approximately 5% BME staff and Governing Body members at bands 8-9 and VSM. The Governing Body is representative of the CCG BME population as well as other protected characteristics, with the opportunity to further enhance through appointments over the coming year.

The CCG continues to strive to be representative of the community it serves, and takes pride in being an equal opportunities employer. The CCG treats all job applicants and employees (including trainees, agency workers, those on Government employment schemes and students) equitably. The CCG has been accredited for the ‘Positive about disabled people ‘two tick’ scheme, and ‘Mindful Employer’, which promote positive attitudes to disability and mental health respectively.

The CCG actively encourages development of staff members who fall within one of the protected characteristics through the ‘Liberating the Talents’ programme. This is a leadership and development training programme aimed at NHS staff in Bands 1-6 who feel that they have faced barriers in their career progression relating to their protected characteristic status.

The CCG’s efforts to promote equality and eliminate discrimination will only succeed if its staff fully understand the principles of



inclusion, exclusion, equality and discrimination. To that end the CCG continues to ensure all staff have access to learning and development opportunities. The CCG has invested in training through the high quality ‘equality essentials’ e-learning package, as well as classroom-based training for all staff at every level of the organisation.

Parity of esteem Investment in mental health The CCG’s programme budgeting mental health and learning difficulty expenditure for 2013/14 was 13.3%, compared with a national average of 13%.

For 2015/16, modest investments will support the CCG’s strategy of improving primary/community care, with additional funding for mental health in line with national expectations and parity of esteem.

In line with the planning guidance 2015/16, the CCG is planning real-terms increases in mental health spend in line with the CCG’s overall real-terms funding increase of 4.71%.

Investment and action taken to support Parity of Esteem during 2014/15:

• No mental health financial QIPP imposed in 14/15 • Investment in 24/7 Rapid Response Liaison Service in NUH • 2014/15 additional investment in Street Triage (two year pilot will roll forward to 2015/16) • Primary Care Psychological Therapies on target to deliver 15% coverage • Opening of 3rd sector crisis house

In 2015/16 the CCG has planned:

• New investment in 111 mental health project, Personality Disorder Services, and CAMHS Eating Disorder Service • 24/7 crisis care for adults established via service transformational change • Joint working with Nottinghamshire Police to eradicate detentions in police cells for children and adults detained under

section 136 • Physical health CQUIN building on developments in 14/15 to improve take-up of health screening to improve health

outcomes • Delivery and continued improvement of take-up of Primary Care Psychological Therapies

There are further developments required, including:

• Improvement of the crisis care offer for children and young people • Review of care pathways across clusters 1-4

There is a dedicated mental health commissioning team and a mental health clinical lead who work closely together, engaging with key stakeholders to strengthen local services.



Identification and support for young people with mental health problems Following a comprehensive assessment of need and a CAMHS pathway review during 2014-15, working with partner CCGs, the local authority, providers and other stakeholders, a new service model will be implemented in 2015-16. This model has been approved by NNE CCG’s Clinical Cabinet. Integral to the model is:

• Effective support for universal services to improve identification of children and young people with mental health problems • The development of a ‘One CAMHS’ service with a single point of access to improve access to effective support and

reduce waiting times • Responsive rapid response and crisis care for young people

In addition, there is planned additional investment in a specialist community CAMHS Eating Disorder Service in 2015-16.

Life expectancy for people with severe mental illness A comprehensive CQUIN is in place with NHS Nottinghamshire Healthcare Trust (NHT) to improve uptake of health checks. The Healthcare Trust liaises with GPs, sharing details of patients with severe mental illness, and has agreed to undertake screening and health checks on patients who have not accessed these via their GP.

In addition a further CQUIN is in place targeting inpatients and promoting healthy living with patients. This includes smoking cessation and signposting patients to New Leaf services.

Contracts with the independent sector providers also promote health check uptake.

Going forward, NHT is exploring a roll out of an assertive implementation of zero tolerance on smoking on their hospital sites.

Access

Convenient access for everyone

Access to services - general Services commissioned by the CCG include agreed service specifications and are developed using the standard template (with clearly defined referral criteria). Specifications include a requirement to focus on minority groups. Any changes to services are accompanied by an Equality Impact Assessment to ensure there is no detrimental impact on protected groups.

Access to mental health services IAPT (Increasing access to psychological therapies) Providers of Primary Care Psychological Therapies undertake detailed analysis of access to the service by protected groups and focus their efforts on improving access.



The CCG has identified that older people under-use the service and therefore a CQUIN has been put in place to encourage providers to target this group and increase uptake. This has involved providers engaging with older people’s groups, both to raise awareness, and for services to adapt to meet their needs.

To maximise access for patients to IAPT services, leaflets have been distributed to all GP practices across the CCG. In addition, they have been distributed to local authorities and voluntary sector groups. This is supported by on-going communication with all agencies regarding timely access to services.

Translation/interpretation services for assessment and treatment stages are available across all providers. The assessment stage can be face-to-face or via the telephone, and the treatment can be through one-to-one support or group sessions, to accommodate the needs of the patient.

NNE CCG has developed a comprehensive action plan to improve referrals to IAPT services during 2015/16. This includes looking at different mechanisms to target minority groups.

The CCG also regularly uses social media to promote awareness of services.

Dementia services During 2014/15 the CCG has worked hard with its GP practices to increase the dementia diagnosis rate across the patch. To support this, the CCG has produced a comprehensive Dementia Communication Plan that has recently been shared with practices. The plan contains information about how practices can review records to identify patients who may have dementia and may be in need of a referral or support. The communication plan clearly details the different pathways available to patients, carers, and care homes if they require a diagnosis or further support. In addition the CCG has commissioned a website, www.dementiacarer.net, which enables patients to have wider access to information and service information about dementia.

During 2015/16 the CCG will continue to promote dementia diagnosis to further increase the rate achieved to ensure patients have access to appropriate services. The CCG will also ensure that GP practices continue to have the most up to date information regarding local resources to support the management of patients with dementia.

Intensive Recovery Intervention Service (IRIS) During 2015/16 NNE CCG will continue work to reduce reliance on inpatient care and strengthen community support for mental health services for older people, in line with national policy. This will be achieved through investment in and expansion of community-based services.

Working with the third sector The CCG is actively engaged with third sector organisations, e.g. MIND, to support reaching minority groups and reduce dependency on secondary care services. This engagement will inform our future commissioning decisions.

http://www.dementiacarer.net/



General practice NNE practices offer a good range of access to their patients, including early morning and late evening appointments, with one practice opening on Saturday. Good access is reflected in the Patient Survey results, which show that 77% (76% national average) of patients are fairly or very happy with the opening hours of the practices within the CCG.

Patients contacting GP practices predominantly do so via the telephone, with the remainder in person. The CCG is encouraging the use of technology by means of patients booking their appointments online and supporting practices to promote their online facilities with their patient population.

Translation and interpretation services are readily available for use within general practice and community services for making appointments and during consultations.

Within the CCG area 75% of patients feel that GP practice opening times are convenient for them, compared with the national average of 74%. The CCG encourages on-going review of access to general practice, to ensure that patients’ needs are met.

Improving access is a key component of the CCG’s Primary Care Strategy for 2015/16. During 2014/15 the CCG implemented a GP same day/urgent care pilot as part of the Prime Minister’s Challenge Fund. This aims to improve access to general practice, improve patient experience, reduce hospital admissions, and ‘free-up’ GP time to focus on case management of people with long-term conditions. This model will be reviewed, developed, and refined during 2015/16 to ensure maximum possible benefit for patients needing to access GP practices for primary care services.

The CCG recognises the importance of improved access and efficient practice operations to manage increasing demand. To support this, NNE has offered a number of opportunities for practices to consider alternative ways of working, including, for example, Productive General Practice. Initiatives that support ‘best practice’ and promote efficient and lean ways of working are shared. These initiatives are supported by Protected Learning Time events and specific training. For example, training has been provided around telephone triage and minor illnesses. During 2015/16 the CCG will continue to encourage the development of systems, processes, and pathways that will ensure effective and efficient working and improve access for patients.

Community services All services commissioned by the CCG are supported by robust service specifications and equality impact assessments. Providers are required to conform to their legal responsibilities, and submit regular quality returns to the CCG.

Patient and public involvement (PPI) The CCG uses a variety of methods for engaging with patients and the public on service development. These include practice participation groups, local events, surveys, focus groups, linking with local voluntary groups, and a database of patients and public. The CCG has a People’s Council which has delegated authority for ensuring that the patient and public involvement carried out is relevant and proportional. At a general practice level, practice participation groups are involved in actively



monitoring patient surveys and developing action plans.

Plans to improve early diagnosis for cancer and to track one-year cancer survival rates The CCG has identified a number of priorities around early diagnosis for cancer, which support implementation of the cancer action plan. The CCG is working collaboratively across the south planning unit to address early diagnosis as part of the Nottinghamshire Cancer Network and the East Midlands Cancer Network

During 2015/16 the MacMillan electronic cancer decision support tool (eCDS) will be implemented in general practice. In addition, the CCG will maintain its on-going commitment to up-skilling primary care work force through the following:

• Support for Protected Learning Time training session focused on cancer • Investment secured for cancer training for registrars and GPs • Training needs of GPs to be included as part of the Nottingham University Hospitals NHS Trust (NUH) Survivorship

Programme

The CCG will continue to implement strategies to increase the number of people with a diagnosis of cancer referred through the Two Week Wait (2WW) pathway, through active engagement by the CCG’s clinical lead for cancer to promote best practice and use of 2WW referral forms and patient leaflets.

The CCG will also support the National Awareness and Early Diagnosis Initiative (NAEDI), and will:

• promote the national ‘Be Clear on Cancer’ campaigns • liaise with public health colleagues to promote publicity and evaluation materials to NNE CCG practices.

In addition, the CCG will:

• publicise national screening uptake data to NNE CCG practices to inform targeted work with practices and future education requirements

• implement learning from the basal cell carcinoma (BCC) community triage training clinic, to reduce inappropriate referrals to secondary care

• improve management of patients with cancer of unknown primary (CUP) – scoping of pathway to be undertaken.

Local implementation of the Map of Medicine will support earlier diagnosis through pathways to support diagnosis and access to relevant referral forms.

Plans to track one year cancer survival rates - NNE CCG cancer outcomes dashboard Across healthcare in England, national statistics currently establish overall measures of survival for local populations. As these are tracked annually, it is not possible to monitor progress throughout the year. However a local cancer outcomes dashboard to monitor the CCG’s performance (data extracted from Cancer Commissioning Toolkit) has been developed and is updated



monthly. This will be further refined and reviewed in 2015/16 to inform future commissioning decisions.

Meeting the NHS Constitution standards

Access to treatment All NNE CCG plans are developed on the principle of successfully delivering the rights of patients as laid out in the NHS Constitution. The CCG will continue to offer a range of choices for patients, and in so doing will deliver excellent waiting times for elective care.

For elective services, demand will be managed by reducing unwarranted variation between GP practices in respect of first outpatient appointment referrals, by maximising clinical leadership, using GP leads for 15 specialties, and utilising clinical education sessions. The CCG will localise services to improve patient experience and streamline pathways for patients by using referral protocols and self-management.

In doing so, and working collaboratively with other local CCGs, NNE will flex the elective capacity across the system in order to fulfil the continued challenge of meeting the demands on the urgent care system, manifesting itself in the 4-hour A&E target and ambulance response times.

Cancer standards, whilst challenging, will continue to be closely managed in order to maintain those currently being delivered and improve areas which are marginally below the required performance.

For all services, detailed demand projections have been carried out jointly with acute providers in order to arrive at a shared understanding of the underlying level of contracted activity. This will be refined over forthcoming weeks to take into account the impact of non-recurrent work (for example to reflect the additional winter resilience beds and reductions in elective RTT incomplete pathways) and the application of QIPP and pathway changes planned for 2015/16.

The CCG aims to maintain its excellent performance against other NHS Constitution guarantees during 2015/16.

In relation to busy periods for urgent care During 2015/16, at times of extreme pressure the urgent care system will continue to strive to ensure appropriate access to treatment as outlined in the NHS constitution rights and pledges. This will involve the following:

• The development of improved access to GPs. This includes improved triage for GP appointments, extended hours opening, review of referrals to ensure appropriate provision of care, and the improved quality of GP services.

• The development of Primary Care Services at the front door of ED. This will ensure people who have a medical need which does not require an acute response are cared for by an appropriate clinician, which may avoid an acute admission.

• The development of GP access to consultant advice via a clinical navigation service. This ensures that the GP discusses the appropriate patient care with the relevant specialty consultant to provide convenient and easy access to services. This might include timely attendance at an urgent care clinic rather than a visit to ED. This also ensures decisions are made in a clear and transparent way.



• The development of care coordination models to ensure timely discharge from hospital to appropriate community or home-based services.

• The commissioning of community and home-based models of care following discharge, e.g. transfer to assess models where patients are discharged from hospital into a setting where their care needs can be fully assessed to meet their personal needs.

• The commissioning of interim models of care at discharge to ensure timely transfer of care from hospital to home during busy periods.

• The development of ‘in-reach’ models of care which involve community/primary care services working alongside acute in-patient services to review and transfer patients to more appropriate community care settings.

• Improved data collection and analysis of hospital discharge information in order to appropriately commission community-based levels of care that are based on patients’ needs.

• Full implementation of the ‘leaving hospital policy’ where health and social care staff alongside patients understand there is no longer an acute medical need which requires a stay in hospital.

• Developing appropriate 7 day services to support choose to admit and transfer to assess. • Providing on-going communications to patients, to ensure they are able to make appropriate choices about their urgent

care needs, and where these needs are best met. The CCG will build on work done to date, including use of social media. • The development of new models of care where patients are fully engaged and informed, shaped by patient comments,

complaints, and feedback.

Implementation of new mental health access standards NNE CCG is working with Nottingham City CCG (as the local lead contracting commissioner for mental health) to assess current performance against the four new mental health access standards, which are described in more detail below. A Service Development Improvement Plan will be agreed with each provider by the end of March 2015, and will detail key milestones to ensure achievement of all standards.

Standard 1: Early intervention in psychosis. More than 50% of people experiencing a first episode of psychosis will be treated with a NICE approved package within two weeks of referral. By 1st April 2016. The CCG already commissions an Early Intervention in Psychosis Service, and a preliminary review indicates that this standard is not being met. This appears primarily due to organizational issues within NHS Nottinghamshire Healthcare Trust, which are being reviewed. We are working with the provider to agree actions to improve performance. Due for sign-off in April 2015, this plan will ensure the standard is met by April 2016. It is not clear at this stage if additional funding will be required to increase capacity.



Standard 2: Improving access to psychological therapies (IAPT). 75% of people referred to the IAPT programme will be treated within 6 weeks of referral, and 95% will be treated within 18 weeks of referral. By 1st April 2016 Initial work indicates that this will be met as the CCG is already broadly achieving this target (see table below based on January to December 2014). Work is continuing with providers to ensure stop the clock practice is clear, and is in line with national guidance where there is potential ambiguity. Stretch targets will be set by April 2015, which will show gradual improvement throughout 15/16 to ensure that we achieve and maintain the target. Monthly monitoring will take place.

CCG Jan- Dec 2014 75% to receive 1st treatment in 6 weeks 95% to receive 1st treatment by 18 weeks

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

NNE 87.3% 92.2% 87% 86.8% 98.2% 98.6% 97.5% 97.8%

In the meantime, the CCG will continue to monitor actions to improve waiting times for Improving Access to Psychological Therapies, including increasing the provision of online resources, e.g. SilverCloud, an online application that helps individuals to learn techniques to overcome symptoms of low mood and anxiety. Each provider is responsible for the systematic review and sharing of exception reports relating to long waits for psychological therapies.

In addition, plans that set out the specific actions being taken by providers to improve access to these services are regularly reviewed. This includes the assessment of staff productivity levels and recruitment plans, increasing awareness of services in primary care, and the promotion of self-referral.

Standard 3: Liaison Psychiatry. By 2020 all acute trusts will have in place liaison psychiatry services for all ages appropriate to the size, acuity and speciality of the hospital. An acute liaison service - Rapid Response Liaison Psychiatry - is already in place at Nottingham University Hospitals and Sherwood Forest Hospital. This service is currently available to adults only. This service will be reviewed by the end of September 2015 to ensure that it meets the required standards. The CCG will also assess whether it is operating in the most effective way, diverting patients away from the acute trust and into mental health services where appropriate. Links have been made with the national team to understand the work under way to determine best practice and service benchmarking.

Standard 4: Eating Disorders. A national access and waiting time target will be developed for eating disorders during 2015/16. Details have yet to be published on this standard, but it is expected that it will relate to the provision of eating disorder services for children and adolescents. We have funded a community eating disorder service for children and young people, which will be



evaluated by the end of September 2015.

Quality

Response to Francis, Berwick and Winterbourne View, and plans to reduce the number of inpatients (for people with a learning disability)

The CCG’s plans reflect the key findings of a number of pivotal national reports including Francis, Berwick, Keogh, Clwyd, Hart, and Winterbourne, by recognising the role of commissioning as a tool for ensuring high quality, compassionate, and clinically-effective care.

A common theme that emerged from all of the reports was the need for the NHS to become a system devoted to continual learning and improvement of patient care, top to bottom and end to end.

The need for strong clinical leadership and clear understanding of fundamental standards and measures of quality, promotion of transparency and candour, support for compassionate care, focus on outcomes, working collaboratively with partners and, above all, listening to the voice of the patient and frontline clinicians, is key to the success of bringing about the required change in culture.

The following paragraphs outline the CCG’s approach to addressing these requirements:

Understanding fundamental standards and measures of quality and focus on outcomes is being achieved through the development of Quality Schedules and CQUIN schemes that utilise national best practice to identify effective measures of quality, facilitate benchmarking, set aspirational improvement targets, identify, analyse, and address variation and support the development of a learning culture.

Transparency and candour is being addressed through consistent implementation of Being Open policies and continuing to foster an open culture through values based recruitment, induction, training and appraisal based on the 6Cs of compassion in practice.

The voice of the patient/ citizen is actively sought through ensuring robust feedback mechanisms, the continuing development and influence of patient participation groups and triangulation of patient experience data including complaints, survey results and the Friends and Family test.

Frontline clinicians’ views will be actively sought through survey results, focus groups, and the Friends and Family Test, and staff will be supported to raise concerns by the application of whistleblowing policies.

The CCG is a leader and active participant in the South Nottinghamshire Transformation programme, which aims to reshape the health and social care system with the patient/citizen at the centre. This requires collaboration with partners to remove organisational barriers and to encourage different sectors to work together seamlessly in the pursuit of a common vision:

‘Creating a sustainable, high quality health and social care system for everyone through new ways of working together, improving communication and using our resources better.’



The CCG will continue to ensure that people with a learning disability receive appropriate and regular assessment and are cared for in the most appropriate setting, and will look to commission services that enable them to remain in their community and close to friends and family.

Winterbourne/Transforming Care A cross-agency Project Board is in place and will continue during 2015/16. Regular meetings take place to monitor progress and focus on any blockages. This group reports to the Integrated Commissioning Group which is a sub-group of the Health and Wellbeing Board. All individual care reviews have taken place and plans are in place to monitor progress towards discharge. A patient tracker is reviewed at each meeting; this details key milestones and is RAG rated. The Local Authority has secured additional funding for developing additional local accommodation.

The CCG currently has only one patient with a learning disability receiving care in a hospital setting.

There are several key risks to securing discharge:

• Recruiting care staff in supported living projects. Whilst the caring profession is being promoted locally, and an enhanced financial premium is offered via the supported living plus scheme, recruitment continues to be a challenge.

• Patients detained under Ministry of Justice (MoJ) restrictions. Local teams identify that individuals are ready for discharge but the MoJ does not approve a move.

• Housing. Providing housing in the area patients and their carers want is a challenge. Individuals frequently require a bespoke new build provision that can take time to establish.

• Deprivation of Liberty Safeguards. Many of the patients will need authorisation from the Court of Protection as a recent judgement lowered the threshold. Obtaining an authorisation is lengthy and costly. Currently we are placing patients first rather than waiting for approval as this could take in excess of 12 months.

Patient safety Understanding and measuring harm to patients, and plans to support the development of capacity and capability in patient safety improvement The CCG will continue to work with providers to ensure that quality schedules and CQUIN schemes promote the development of comprehensive patient safety indicators, including the measurement of the nature and level of harm that can occur in healthcare services. We will develop quality dashboards that facilitate the triangulation of both process and outcome measures across the range of quality indicators including patient safety, experience, and clinical effectiveness/outcomes. We will use a range of safety data including safety thermometer, incident reporting, claims, and complaints to facilitate benchmarking, and peer review to support the identification and sharing of best practice.

The CCG will work with the Patient Safety Collaborative to reduce harm in nursing and residential care from pressure damage, by rolling out the successful ‘React to Red’ campaign, and to work with this sector to develop quality dashboards to support monitoring and assurance.



Reporting of harm, particularly in primary care The CCG will use recognised tools to measure organisational safety culture and maturity, e.g. Manchester Patient Safety Assessment Framework (MaPSAF) and the NPSA Seven Steps to Patient Safety, to identify areas for improvement and facilitate the development of strategies to improve reporting rates, learning from incidents, and development of a maturing safety culture.

The CCG will also work with the Patient Safety Collaborative to develop and deliver root cause analysis training for clinicians to further improve learning from incidents and the ability to identify and implement harm reduction strategies. This will also include training in human factors in healthcare, which will increase staff understanding of how and why things go wrong and what action can be taken to prevent recurrence.

The CCG will continue to develop robust methods of feedback, particularly in primary care, to facilitate learning from incidents and encourage increased reporting by demonstrating the positive impact that this can have on improvement.

The CCG will ensure that mechanisms for staff and patients/carers to raise concerns about the quality or safety of services are accessible and effective, ensuring that appropriate action is taken in response to concerns, and that this intelligence is triangulated with other sources of information to provide a comprehensive picture of the quality of services being delivered.

Tackling sepsis and acute kidney injury The CCG is developing CQUIN schemes with its providers to ensure that evidence-based practice and training is delivered with the aim of ensuring that consistent assessment and treatment is delivered, enabling early recognition of acute kidney injury and sepsis facilitating prompt rescue and improved outcomes.

Compliance with the sepsis care bundle, early warning score monitoring, and national acute kidney injury algorithm will be measured and triangulated with outcome data, e.g. mortality and unexpected admissions to intensive care.

The CCG will also facilitate primary care-facing communication campaigns/education focused on the recognition, diagnosis, and treatment of sepsis using protected learning time sessions to promote maximum uptake.

Plans to improve antibiotic prescribing Joint guidelines for antimicrobial prescribing have been developed across primary and secondary care. These guidelines have been ratified by the Nottinghamshire Area Prescribing Committee and have been implemented across the CCG and secondary care organisations: http://www.sample1.notts-his.nhs.uk/attachments/article/3/antimicrobial%20guidelines.pdf The prescribing of antibiotics within practices will continue to monitored on a quarterly basis during 2015/16. The following data

http://www.sample1.notts-his.nhs.uk/attachments/article/3/antimicrobial%20guidelines.pdf



is analysed:

1. Total volume of antibiotics prescribed 2. Volume of cephalasporins prescribed 3. Volume of quinolones prescribed 4. Volume of co-amoxiclav prescribed

Practices where excessive prescribing has occurred are contacted and their prescribing audited. These practices can then be supported through the medicines management team to review their prescribing where appropriate.

Patient harm (Prescribing) Regular audits of compliance with prescribing guidelines are undertaken in secondary care, and variances are discussed and addressed through the regional infection prevention and control committee and quality scrutiny panels.

The Medicines Management Team strategy focuses on good quality prescribing and patient safety. Medication-related adverse events are an important source of patient morbidity, and many cases can be prevented by high-quality prescribing and medicines management.

During 2015/16 the CCG’s Prescribing Team will continue to monitor and implement the Royal College of General Practitioners’ (RCGP) indicators that are rated as valid for assessing the prescribing safety of individual GPs. The CCG Prescribing Team will also support the roll-out of pharmacist-led information technology intervention for medication errors (PINCER trial) across all practices. This intervention has been shown to substantially reduce the frequency of a range of clinically important prescription and medication monitoring errors.

In addition, the CCG has plans to employ a care home pharmacist who will focus on the quality of prescribing and medicines management within care homes. This pharmacist will review patient medication in conjunction with GPs to ensure good quality and safe prescribing for this group of frail elderly patients.

Patient experience Reducing poor experience of inpatient care and general practice The CCG will continue to triangulate a wide range of patient experience data (e.g. complaint themes and numbers, survey findings, Friends and Family Test results, referrals to the Ombudsman) with other sources of feedback (e.g. from focus groups, patient participation groups, quality visits) to establish baselines and set measurable ambitions to reduce poor experience of inpatient care and poor experience in general practice.

In particular, the CCG will set targets to achieve the following measurable ambitions:

• An increase in the response rates to patient surveys (in particular Friends and Family Test in low response areas such as ED and Maternity)



• An increase in the percentage of patients stating that they are likely or extremely likely to recommend a service to their friends and family

• A reduction in the number of complaints referred to the ombudsman that are upheld • An improvement in the timeliness of complaint handling and complainant satisfaction with the process and outcome

The CCG does not plan to set reduction targets for the receipt of complaints as this would go against the desire in some areas to increase receipt of patient feedback. The CCG will, however, set ambitions to reduce complaints of a certain nature, if appropriate following analysis of data, e.g. attitude related complaints.

For NNE CCG the overall experience and rating recorded within the NHS Survey shows that patients’ experience is considered good to very good, reporting with an average of 87%, which is above the national average. This is a great achievement; however, the CCG acknowledges that it is important to constantly improve the care and experience that patients receive within primary care.

NNE CCG’s Primary Care Strategy emphasises delivery against the following outcomes:

• Improved patient experience • Patients and their carers feeling supported to manage their own health • Patients better informed when making decisions about their health and treatment options • Improved access

To deliver the strategy, during 2015/16 the CCG will continue to:

• actively encourage practices to feedback their patients’ experiences within primary, community, and secondary care, to inform the development of pathways and services

• enable practices to record information onto the locally-developed management information system, eHealthScope, or report to the CCG, to inform learning and improvements to processes or services

• encourage Patient Participation Groups and the People’s Council to monitor and review patient satisfaction.

The Care Quality Commission (CQC) has commenced their GP practice inspections across the CCG. The CCG is working with the CQC Public Engagement Team to ensure that patients are appropriately informed and given an opportunity to comment on the services provided by the practice prior to inspection. The outcomes of inspections are shared nationally, and, locally, the CCG will use the information and feedback from the practices to support learning and development, and to disseminate areas of best practice.

Quality of care experienced by vulnerable groups of patients During 2015/16 the CCG will continue to:

• monitor compliance with the Public Sector Equality Duty through the EDS2 along with the development of quality



schedules and monitoring via Quality Scrutiny Panels and Equality and Diversity Forum • monitor data capture against the nine protected characteristics and examine how this is used to identify potential quality

issues and identify strategies for improving quality of care • develop and deliver patient engagement activities with a particular focus on hard to reach/seldom-heard groups using the

feedback from these activities to inform the planning and monitoring of services • continue to work in partnership with local authority colleagues to develop, implement, and monitor quality assurance

frameworks in nursing and residential care, supporting providers to continually improve.

A focus in 2015/16 will be the development of monitoring frameworks for home care services.

Demonstrating improvements from FFT complaints and other feedback The CCG will monitor progress against the measurable patient experience ambitions identified above and will continue to work with providers to monitor the changes that are made in response to patient feedback, developing and maintaining service improvement logs and ‘You said, we did’ feedback.

Meeting patients’ rights as detailed in the NHS Constitution During 2015/16 the CCG will continue to monitor compliance with the NHS Constitution patient rights and commitments through contract management and quality schedules. This will include:

• monitoring access and waiting times (including plans through the Prime Minister’s Challenge Fund to increase access to GP services)

• ensuring that providers have appropriate consent policies in place and methods of monitoring adherence • ensuring that providers are able to demonstrate patient involvement in decision making where they have the capacity to do

so and that where this may not be the case that best interest decisions are made • assuring provider compliance with the Hygiene Code, provision of a clean, safe environment • monitoring implementation of best practice including NICE • assuring that providers have accessible and effective complaints and redress policies and procedures in place and there is

evidence of learning from patient feedback • ensuring that providers learn from adverse events, comply with the Duty of Candour and use this learning to continually

improve safety and services • monitoring compliance with single sex accommodation standards • ensuring that the public has access to the availability of local services and that these are commissioned to meet the local

population needs • in 2015/16 the CCG will be employing a Personal Health Budgets (PHB) Project Lead to ensure that where appropriate

PHBs are offered enabling increased patient choice and empowerment.



Meeting the Caldicott Review recommendations relevant to patient experience The CCG will continue to monitor compliance against the Caldicott2 recommendations using the Information Governance Toolkit as a framework for assessment. We will continue to participate in the Nottinghamshire wide Records Information Group which will ensure that the duty to share in the best interests of clinical care are promoted by the development of policies, procedures, processes and training that support the Caldicott recommendations.

In 2015/16 the CCG will implement year 2 of an Information Sharing CQUIN which focusses on the practical application of information sharing agreements to improve handovers in clinical care, with a particular focus on end of life and comprehensive geriatric assessment.

The CCG will continue to roll out the Medical Interoperability Gateway (MIG) to connect GP records across the NHS, which will support the move to more federated models of practice, and in particular access to GP services in the out of hours period in line with the Prime Minister’s Challenge Fund and new models of working proposed in the Five Year Forward View.

Compassion in practice

Compassion in Practice in local provider plans The CCG will continue to monitor delivery against the Compassion in Practice implementation plans and Dignity Challenge via Quality Schedules and Quality Scrutiny Panels.

Roll-out of the 6Cs across all staff The 6Cs are being incorporated into recruitment practices (recruiting for attitude), induction programmes, training, supervision, and appraisal processes.

Staff satisfaction Factors affecting staff satisfaction and how staff satisfaction locally benchmarks against other areas The CCG carried out a bespoke staff survey annually, prior to becoming a statutory body. The survey provided feedback on the factors affecting CCG staff satisfaction and areas for development. The survey utilised relevant elements from the NHS staff survey in order to provide management with benchmarking information.

The 2014 NNE CCG Staff Survey results were largely positive across all sections including organisational culture and structure, own work, personal development, health and wellbeing, communication, working environment, and interaction with manager and senior leaders. Staff responded particularly positively when describing their relationship with both their manager and senior leadership. Staff understand NNE CCG’s role in the local health economy, how their input contributes to the organisation’s performance, and feel they can use their initiative in their work. The greatest positive is that most respondents described



themselves as interested in their work, with a majority enjoying coming to work, and all recommended NNE CCG as a place to work.

The CCG will work with providers and partners (e.g. Health Education East Midlands) to develop an in-depth understanding of the factors affecting staff satisfaction in our locality and the link between this and patient satisfaction by triangulating staff feedback information (e.g. results from cultural barometer surveys, staff Friends and Family Test, national and local surveys, feedback from student placements, quality visits, and workforce indicators) with a view to implementing strategies that support recruitment and retention of a motivated, compassionate and skilled workforce.

A particular focus in 2015/16 will be ensuring that the workforce has the capacity and capability to work in the future NHS landscape and is able to support the need for transformation. Organisational readiness for implementation of the new nurse revalidation process will be assured.

Impact of staff experience on patient experience The CCG will continue to triangulate a wide range of staff and patient experience data (e.g. complaint themes and numbers, survey findings, Friends and Family Test results, referrals to the ombudsman) with other sources of feedback (e.g. from focus groups, student placements, patient participation groups, quality visits) to establish baselines and set measurable ambitions to improve staff experience in order to improve patient experience.

In particular, we will set targets to achieve the following measurable ambitions:

• Increase in response rates to staff surveys (in particular Friends and Family Test) • Improving percentage of staff stating that they are likely or extremely likely to recommend their organisation to their friends

and family as a place to receive care and as an employer • Improving workforce indicators, e.g. reduced sickness, reduced turnover/ vacancies, increased fill rates • Improvements in cultural barometer findings

Seven day services The national planning guidance for 2015/16 requires acute providers to agree improvement plans with commissioners which include a focus on seven day service provision, i.e. making progress on at least five of the ten nationally defined clinical standards.

The East Midlands Clinical Senate has recently published a report confirming the case for change for seven day services locally. This report highlights that, overall, NUH is performing better than the East Midlands average on seven day provision; however, eight of the ten standards are RAG rated red (below 50% performance) or amber (below 70% performance) for the Trust. The NUH specialties reported as having the greatest challenge in delivering the standards are general surgery, oncology, therapy, and urology.

Of the three standards rated red for NUH, two relate to the wider health and social community: standard 7 focuses on



psychiatric liaison, with the national planning guidance confirming the opportunity for improvement through invest to save (savings from reduced repeat attendees and four-hour breaches can be as high as £4 for every £1 invested), together with a £30m targeted investment that will be made available in 2015/16; and standard 9 – transfer to primary, community and social care: the local BCF plans already aim to address this gap.

The five standards rated amber for NUH are all confirmed as suited to an ‘operational’ response, i.e. an internal trust/site improvement endeavour.

The planning guidance states that improvement should be achieved within the resources available and confirms that the tariff for 2015/16 does not include specific additional resource for seven day working. The East Midlands report suggests the total investment needed, based on indicative costs submitted by half the acute providers, ranges from 0.8%–4.4% of turnover. However, the report acknowledges that the costs identified by these providers are broad, with more detailed assessment needed; in addition, there is a need for a cost/benefit analysis to be undertaken as there are examples emerging throughout the country where implementation has been either self-financing or generated savings.

The report confirms that most trusts recognise that to meet the costs of 7 day provision and the funding shortfall, more collaboration and risk-sharing will be needed between providers, commissioners, and other parties, and proposes that alternative funding sources/contractual arrangements will need to be found, including the potential use of marginal rate of emergency tariff (MRET) and reform of emergency and urgent care (UEC) payments.

Safeguarding Protecting vulnerable adults The CCG will meet the accountability and assurance framework requirements by:

• Training staff to recognise and report safeguarding issues. This includes CCG protected learning time sessions for GPs and practice nurses. We will also provide training sessions for CCG staff.

• Having clear lines of accountability for safeguarding with the CCGs, with a lead director (Chief Nurse) and a Safeguarding Committee that reports directly to the Governing Bodies.

• Participating in the operation of local safeguarding boards. The new Care Act duties regarding adult safeguarding are in place.

• Ensuring effective arrangements for information-sharing through our Nottinghamshire Multi-Agency Safeguarding Hub (MASH), membership of Multi-Agency Public Protection board and case conferences (MAPPA). Participation in the adult safeguarding Serious Case Review Sub-Committee for Nottinghamshire.

• Ensuring we have designated doctors and nurses for safeguarding children and for looked-after children, and a designated paediatrician for unexpected deaths in childhood.

• Ensuring we have a safeguarding adults lead and a lead for the Mental Capacity Act, supported by the relevant policies and training.

• Undertaking visits to organisations to assess their safeguarding procedures and continuing to use a Self-Assessment



Framework with organisations across Nottinghamshire.

Support for quality improvement in application of the Mental Capacity Act In response to the Care Act requirements, The CCG is recruiting a Head of Quality and Adult Safeguarding who will fulfil the statutory role of Designated Safeguarding Adults Manager (DSAM). The CCG officers who are responsible for safeguarding have undertaken training on the appropriate use of the Mental Capacity Act (MCA).

Following a successful bid for NHSE funding, the CCG is currently rolling out training in the MCA and application of Deprivation of Liberty Safeguards to clinicians in primary care. This includes the implementation of an app, e-learning, and facilitated workshops aimed at improving understanding and compliance with the Act.

During 2015/16, the newly appointed DSAM will undertake a formal review of commissioner and provider application of the Mental Capacity Act. Further action plans will then be developed in response to the findings.

Meeting the standards in the PREVENT agenda PREVENT is an element of the government’s anti-terrorism strategy. It aims to prevent people from being drawn into extremism or extremist activities. Nottinghamshire is not deemed a high-risk area. NHS England has produced a competency framework, ranging from general awareness to higher levels of specific training.

The safeguarding policy and training needs analysis is now being updated in light of the latest guidance to ensure that appropriate levels of awareness and training are developed and delivered for each staff group. Training capacity will be developed in 2015/16 to increase the number of accredited PREVENT trainers to improve resilience to deliver the training within the agreed timescales (WRAP should be completed within 12 months of starting in a role requiring this level of training. Organisations should achieve 90% compliance within 3 years).

The training will be supplemented with a communications strategy to ensure that all staff are aware of how referrals should be made in the event of concerns being identified.

The Safeguarding Adults Assurance Framework will be used to measure CCG and provider compliance with the standards This will include monitoring requirements to have an Executive Lead, Operational Leads, access to accredited trainers, a PREVENT policy, clear referral processes and completion of awareness raising and full WRAP3 training as determined by the training needs analysis.

Compliance with the requirements will be monitored by the Adult Safeguarding Committee (a joint committee of the five Nottinghamshire CCGs). The Committee will be responsible for identifying and mitigating risks associated with meeting the standards in the prevent agenda. Training figures and referral activity will be reported to NHS England via monthly returns.

The CCG’s Director of Nursing and Quality will act as the Executive Lead for PREVENT.



Innovation

Research and innovation

Support to research The CCG is a member of the East Midlands Clinical Research Network and is aware of its statutory responsibilities in this area, and, for example, together with partner CCGs in Nottinghamshire, has a process for considering and approving extra treatment costs (ETCs). Throughout 2015/16 the CCG will continue to support research, in particular looking at opportunities to develop research capacity and capability in primary care.

The Academic Health Science Networks The CCG and the local health community are actively engaged in and benefitting from the work of the Academic Health Science Network. The South Nottinghamshire Unit of Planning is represented on the AHSN Board by the Chief Officer of NHS Rushcliffe CCG. The benefits range from the development of evidence-based stroke early supported discharge and community rehabilitation teams through to the Patient Safety Collaborative.

During 2014, the South Notts Unit of Planning requested the East Midlands Academic Health Science Network produce an evidence-based review of the characteristics of three internationally renowned systems of care (Jonkoping, Sweden; Canterbury, New Zealand; and Alzira/Valencia, Spain). The findings in the resultant report will inform the development of new models of care in the local area over the course of 2015/16.

Innovation The CCG:

• Has access to the research and development activities of the range of NIHR infrastructure organisations within the East Midlands Biomedical Research Units in Nottingham and Leicester, Clinical Trials Units, the Clinical Research Network, and CLAHRC.

• Is a member of the EMAHSN, which offers opportunities to adopt and spread research outcomes and evidence-based practice: the translation of research and proven innovation into practice at pace and scale. Membership also enhances networking opportunities and work in partnership across the health economy to create solutions to healthcare challenges.

• Works proactively with CLAHRC EM - to support the reduction of clinical variation in public health and chronic disease across patient population.

• Is strengthening compliance with evidence-based practice through greater adherence to NICE Technology Appraisals. • Has a named organisational contact working in partnership with the EM PSC to identify priorities to address key patient

safety challenges. • Is actively involved in AHSN/CLAHRC research and innovation projects to improve clinical and cost effectiveness in

service delivery.



• Has further developed information systems to facilitate sharing of innovative ideas and service improvements. • Will look to increase capacity and capability for research and innovation, e.g. supporting PhD students, accessing short

courses offered by CLAHRC EM, e.g. introduction to statistics, implementing change, evaluation skills etc. • Promotes a working environment and culture where innovation and experimentation are encouraged and supported. • Works proactively with EMLA/HEEM to develop its workforce (including its GP practice workforce) in order to support

innovation. • Encourages providers to ‘innovate’ through the Quality Contract/CQUIN Schedule. • Is exploring opportunities to use technology to support patients to manage their own care.

Delivering Value

Financial resilience; delivering value for money for taxpayers and patients and procurement

Meeting the business rules on financial plans The CCG sets a budget in the context of a longer-term financial strategy. The financial strategy of the CCG is in line with national and local planning guidance and assumptions, and is in line with the commissioning strategy of investment in the integration of community/primary care, e.g. Better Care Fund and reduced acute spend and additional investment in Mental Health services in terms of parity of esteem.

The CCG’s five-year Financial Plan details how it will deliver financial balance recurrently without the use of unplanned non-recurrent funding. Non-recurrent resources available are analysed and monitored on a separate schedule to ensure they are funding non-recurrent schemes.

The CCG is planning to deliver a recurrent surplus of 1% each year in line with planning guidance. In addition to the recurrent surplus of 1%, the CCG is holding a 1% recurrent Transformational Reserve which will be used on a non-recurrent basis, and is therefore planning to have a recurrent underlying surplus of 2%.

The CCG also holds a 0.5% non-recurrent contingency in 2015/16 and is planning to remain within their running cost allocation in 2015/16.

Clear and credible plans The CCG has an annual QIPP target in line with the CCG’s financial strategy. The CCG’s identification of QIPP schemes is on-going throughout the year based on reviewing benchmarking information, redesigning services, reviewing other local QIPP plans, etc. It is currently looking specifically at further benchmarking in respect of practice variations.

The CCG produces a number of performance and benchmarking reports on a regular basis. For the CCG this includes a comprehensive performance management report presented to Governing Body and Clinical Cabinet, which includes benchmarking. The CCG’s Finance and QIPP meeting also receives a monthly practice comparison report showing activity and



cost levels, as well as standardised referrals and admission rates for all contract points of delivery. Individual practices receive weekly fast-track information on activity levels, monthly comparison reports, and reports specific to GP-level referral reports for their individual practices.

The South Nottinghamshire CCGs are looking at comparative information on costs and performance in terms of the formulation of plans, with a lead CCG identified for each piece of work, i.e. Nottingham North East CCG – Thresholds, Rushcliffe CCG – Benchmarking, Nottingham West CCG – Clinical Variation and Community Services, CCG Prescribing Team/Area Prescribing team – Prescribing.

Links between service plans, financial and activity plans The CCG’s financial strategy reflects the commissioning and service plans of the CCG. The CCG ensures that all decisions on service plan changes reflect activity and finance changes as signed off by a member of the senior finance team.

In addition, all QIPP plans are worked through in terms of the effect on both activity and finance, which is then fed through both the finance and activity plans and subsequently through the contracting process.

For the main acute contract there is a joint ‘Commissioning Working Party’ that is building the activity plan together, with input from Directorates at NUHT and QIPP leads from the CCG. The output of this will therefore result in a jointly agreed activity plan (as well as money).