the doncaster health and social care - microsoft · 2019-12-06 · delivery plans contents 4 the...

The Doncaster Health and Social Care Appendix 1

Commissioning Strategy Delivery Plans 2019-2021

Contents 2

Starting Well - Strategic Delivery Plan 4

Living Well - Strategic Delivery Plan 10

Ageing Well - Strategic Delivery Plan 35

Ageing Well - Operational Delivery Plan 39

Learning Disability - Operational Delivery Plan 15

Primary Care - Operational Delivery Plan 17

Adult (all age) Mental Health - Operational Delivery Plan 21

Urgent Care - Operational Delivery Plan 25

Planned Care - Operational Delivery Plan 29

Cancer - Operational Delivery Plan 32

Medicines Management - Operational Delivery Plan 43

The Doncaster Health and Social Care Commissioning Strategy 2019-2021 - Appendix 1 Doncaster Council and NHS Doncaster Clinical Commissioning Group

Delivery Plans Contents 3


Starting Well



STARTING WELL (Children & Maternity) - Strategic Delivery Plan: 2019-21

VISION: To be the most child friendly Borough in the country

Key Programmes of Work Feeding into the Vision

Catalyst Ref Key Milestones Outcome(s) the Action will Deliver

Due By Owned by: (org/person)

Low Level interventions based in neighbourhoods

1.1 To evaluate Thrive and Roots of Empathy programmes to check efficacy and if they should be rolled out across the Borough. Both programmes support wellbeing

QO2, Q05, AM5, AM6, AM7, AM8, AM9, AM28 & FE1

30.04.19 Paul Thorpe

1.2 To develop the new concept of collaboratives and if they fit into the wider discussions around area based assets and area based commissioning



1.3 To implement the new concept of Collaboratives QO2, Q05, AM5, AM6, AM7, AM8, AM9, AM28 & FE1


1.4 Agree on the non-pay costs for the service to give an understanding of total financial envelope to commission the service for Childrens Community Nursing

AM23 & AM24 30.05.19 Kate Featherstone- Bennett

1.5 Develop new service specification with a focus on out of hospital care, in particular for those with previously avoidable admissions for Childrens Community Nursing

AM23 & AM24 30.06.19 Kate Featherstone- Bennett

1.6 Implement new service for Childrens Community Nursing AM23 & AM24 31.10.19 Kate Featherstone- Bennett

Co-ordinated access to services when needed

2.1 Work with colleagues to explore the concept of more area based commissioning and how this fits in with a more community asset based approach, i.e. Doncaster Growing Together Local.

QO4, QO6, AM11 & AM12 31.08.19 Lee Golze/ Sarah Holmes

2.2 Oversee the implementation of the local provider's Place Plan & Transformation plan as part of the South Yorkshire and Bassetlaw Integrated Care System: Local Maternity System

QO1, AM1, AM2, AM3 & AM4 31.03.21 Andrea Ibbeson/ Fiona Feris

2.3 Oversee provider service improvement development with a specific focus on Antenatal care & pathways and intrapatum care delivery

QO1, AM1, AM2, AM3 & AM4 31.03.21 Andrea Ibbeson/ Fiona Feris

2.4 Implement the Local Transformation Plan to secure sustainable improvements in children and young people's emotional wellbeing and mental health


31.03.20 Emily Reseigh

2.5 Achieve the 4 week access standards as part of the trailblazer pilot QO2, Q05, AM5, AM6, AM7, AM8, AM9, AM28 & FE1


2.6 New (trailblazer) mental health support teams to provide face to face support for 2,000 children and young people











2.7 Develop a campaign around children's emotional wellbeing and mental health, that showcases progress to date and what the service offer is, i.e. where to go for support.


31.08.19 Young Advisors

2.8 Review imagination library and develop options paper on new offer to support reading opportunities for young children

AM21 30.05.19 Angela Harrington

2.9 Provide strategic commissioning support to the development of a school improvement strategy AM20, AM21 & AM22 31.10.20 Kerry North

2.10 Commission a new school for children with autism so fewer children are placed out of area for this type of educational need

AM20, AM21, AM22 31.10.20 Angela Harrington

2.11 Work with the Department for Education to commissioning services to develop life skills for young people, that will equip them for later life

AM20, AM21, AM22 31.10.20 Kerry North

2.12 Review how Doncaster Children's Trust and Council can collaborate on commissioning and procurement, sharing resources, knowledge and skills where possible, whilst maintaining organisational independence

QO8 & QO9 31.03.20 Lee Golze and Rob Moore

2.13 Doncaster Children's Trusst to work with the Council to explore efficiencies from new governance arrangements (ALMO) - e.g. insurance, transport

QO8 & QO9 31.12.19 Anna White/ Laura Sims/ DC

2.14 Children's Trust to investigate Residential WRF collaboration with Leeds and other Local Authorities QO8 & QO9 31.07.19 Leeds Local Authority

2.15 Children's Trust to Review of Matrix agency MSP contract (£10m over 3 years), expires Dec 2019. Procurement process to begin April 2019 - using ESPO MSTAR3 framework

QO8 & QO9 31.12.19 Anna White/ Laura Sims

2.16 Childrens Trust to implement an IFA engagement event QO8 & QO9 31.05.19 Anna White/ Laura Sims

2.17 Effective delivery of Healthy Child Programme 5-19; delivery of Health and Wellbeing clinics in schools; delivery of National Child Measurement Programme; completion of individual and school health plans

AM29, AM30 31.03.20 Carrie Wardle

2.18 Uptake of chlamydia screening programme; ensuring care planned interventions resulting in managed agreed positive exits; increase uptake of Long Acting Referable Contraceptive in under 19 population

AM32 31.03.20 Carrie Wardle

2.19 Improved outcomes for the Transforming Care cohort, reduction in admissions to Tier IV, embedding the Care, Education and Treatment Review (CETR) process to align with other statutory functions, decrease in the number of Care, Education and Treatment Reviews (CETR's) held

AM7, AM13,QO9 31.03.20 Carrie Wardle

2.20 Completion of 5 mandated Healthy Child programme checks and reviews; increased breastfeeding rates at 6-8 weeks; increase CO verified 4 week quits for pregnant smokers

AM31 31.03.20 Carrie Wardle









2.21 Business case to be considered at Joint Commissioning Management Board, exploring possibilities of piloting a new way of working

QO1, AM1, AM2, AM3 & AM4

30.05.19 Lee Golze

2.22 Implement commissioning responsibilities for Starting Well, 1001 Days QO1, AM1, AM2, AM3 & AM4

31.12.19 Lee Golze

2.23 Business case to be considered at Joint Commissioning Management Board for Starting Well, first 1001 days AM19 30.05.19 Lee Golze

2.24 Implement commissioning responsibilities for starting well and vulnerable adolescents AM19 31.12.19 Lee Golze

2.25 Create a team of young commissioners to support young people's voice Q04 31.08.19 Dean Mangham

2.26 Develop new service specifications for therapy services including setting new outcome indicator AM21 31.03.20 Fiona Feris

2.27 To commission good or better child care provisions AM28 31.03.20 Angela Harrington

Holistic delivery of care and support

3.1 To implement the three agreed test areas of integrated commissioning; a) Vulnerable adolescents placed out of area, b) the first 1,001 days and a new way of working, c) Children with additional needs

QO4, QO6, AM11 & AM12 31.12.19 Lee Golze/ Sarah Holmes

3.2 To evaluate the test areas of integrated commissioning QO4, QO6, AM11 & AM12 31.03.20 Lee Golze/ Sarah Holmes

3.3 Oversee the implementation of the provider Maternity action plan to ensure improvements in quality of care QO1, AM1, AM2, AM3 & AM4

31.07.19 Andrea Ibbeson/ Fiona Feris

3.4 Commission services around school improvement at both primary and secondary to support improvements in attendance and attainment.

AM20 & AM21 31.10.19 Angela Harrington

Responsive & Accessible Care in Crisis

4.1 Develop a business case for an enhanced community mental health provision across the Integrated Care System footprint, with the aim of reducing the number of acute in-patient admissions


31.07.19 Lee Golze

Person Centered support for complex needs

5.1 To standardise the approach for dynamic risk registers across the transforming care partnership footprint, so that all children and young people get the same offer

QO7, AM13, AM14, AM15 & AM16

30.05.19 Andrea Ibbeson

5.2 Commission a new care and treatment review resource to ensure community options are considered prior to admission

QO7, AM13, AM14, AM15 & AM16

30.05.19 Kate Featherstone- Bennett

5.3 Relaunch the children's commissioning steering group in relation to Transforming Care QO7, AM13, AM14, AM15 & AM16

30.04.19 Kate Featherstone- Bennett








Person Centered support for complex needs

5.4 Reduce the waiting times for Autism pathway AM16 31.03.20 Emily Reseigh

5.5 Reduce the waiting times for Attention Deficit/Hyperactivity Disorder (ADHD) pathway AM16 31.03.20 Emily Reseigh

5.6 Develop a future placements strategy with recommendations that is aligned to the vision as keeping as many children and young people at how, or as close to home

AM19 31.03.19 Lee Golze

5.7 Implement recommendations from future placement strategy AM19 31.03.20 Lee Golze

5.8 Explore pooled budget arrangements for Future Placements AM19 30.05.19 Lee Golze

5.9 Support the development of a new alternative education offer to ensure all children and young people get fair access to learning

AM20 31.12.19 Angela Harrington

5.10 Implement the recommendations from the self-evaluation framework that supports the vision of providing the best support possible to children and young people with additional needs

AM13, AM14, AM16 & AM22

30.07.19 Angela Harrington & Emily Reseigh

5.11 Development of joint commissioning inline with the code of practice, across health, education and social care for special eduction needs

AM13, AM14, AM16 & AM22

31.03.20 Angela Harrington & Emily Reseigh

5.12 To commission services within the scope of the areas of opportunity to improve education and social mobility AM22, AM25 & QO10 31.03.20 Claire Hughes

5.13 Commission timely initial health assessments for Looked After Children AM17 31.10.19 Kate Featherstone- Bennett



To Deliver the following Outcomes for Starting Well

Ref: Quality Outcomes

QO1 Reduction in Stillbirths, Maternal mortality, neonatal mortality and serious brain injury by 50% for 2025

QO2 There will be 0 suicides for Children and Young People in Doncaster

QO3 Each acute general children’s service provides a consultant paediatrician-led rapid-access service so that any child or young person referred for this service can be seen within 24 hours of the referral being made

QO4 Ensuring children and young people have a positive experience of care

QO5 Sustainable improvements in emotional wellbeing and mental health through the increased access to at least 34% of Children and Young People with a diagnosable Mental Health Condition receive treatment, 95% of children and young people receive treatment within 4 weeks of referral and 2000 children and young people receive a face to face interventions as a result of the trailblazer project

QO6 Improving Waiting Times for Urgent and Routine Referrals for Children and Young People's Eating Disorder Services

QO7 Reducing and preventing Children with a learning disability, autism or both being admitted to a tier IV inpatients service

QO8 Reduction in the Rate of Children in Need per 10,000 population (PM34)

QO9 Reduction in the Rate of Children in Care per 10,000 population (PM33)

QO10 Increase social mobility inline with the areas of opportunity


Ref: Activity Measures

AM1 A higher proportion (35%) of expectant mother will have continuity of care via a consistent midwife by March 2020

AM2 There will be fewer babies born by emergency Caesarean (15.2% by March 2020)

AM3 Reduction of proportion of women Smoking At Time Of Delivery by 5% with the aim of obtaining the 11% standard by 2022

AM4 Increase the proportion of women with Normal (include all registerable spontaneous vaginal births) births to 60.9% by March 2020

AM5 Reduction of 5% in the number of Children and Young People admitted non-electively to General Hospital with Mental Health related illness compared to 2018-19 baseline

AM6 Reduction of 3% in the number of People admitted to General Hospital related to self-harm compared to 2018-19 baseline

AM7 There will be 5 or fewer Children and Young People being admitted to Tier IV services for 2019-20

AM8 Reduction of 10% in the number of Children and Young People presenting in crisis (Urgent and Emergency Cases) by March 2020

AM9 Reduction of 5% in the number Children and Young People presenting at AE with Mental Health related illness

AM10 Increase the number of Successful calls into Paediatrics from Primary Care via Consultant Connect



AM11 95% of Urgent referrals for Children and Young People are seen within one week by March 2020

AM12 95% of Routine referrals for Children and Young People are seen within four week by March 2020

AM13 All children and Young People with a learning disability, autism or both get a community Care, Education and Treatment Review (CETR) to consider other options before they are admitted to a tier IV inpatients service

AM14 90% of children and young people with a learning disability, autism or both admitted to a tier IV inpatients service have either had a pre-admission CETR or a CETR within 3 months of admission.

AM15 The Length of Stay in Tier IV inpatient services for Children and Young People with Learning Disability, Autism or both will be reduced by 10% by March 2020

AM16 Reduction in the waiting times for patients with Autism and ADHD of 15% by March 2020

AM17 Maintain 95% standard of Looked After Children Initial Health Assessment's are completed within 21 working days throughout 2019-20

AM18 Other Looked After Children's Mental Health Outcomes to be confirmed when released by DFE

AM19 To bring back 5 Children and Young people from Out of Area Placements by March 2020

AM20 Reduction in the Number of Fixed Term Exclusions for Children and Young People (LE04)

AM21 A higher proportion of children and young people will achieve a good level of development in Early Years Foundation Stage (PM45)

AM22 A reduction in the achievement gap between disadvantaged pupils and their peers (Key Stage 2 & 4)

AM23 Reduction in the number of paediatric assessment by 3.5% by March 2020

AM24 Reduction in the number of Asthma emergency admissions by 3% by March 2020

AM25 Doncaster will see a decrease in the proportion of pupils that are classified as a persistent absentee in both Primary and Secondary Schools

AM26 Increase the proportion of pupils achieving their expected level in Year 1 Phonics

AM27 Increase the proportion of childcare and early years settings judged as good or better

AM28 Reduction of 7.5% in the number of Children and Young People being referred to Child and Adolescent Mental Health Services (CAMHS) as a specialist referral by March 2020

AM29 Increase the proportion of Children with a health weight at 5 years old

AM30 Increase the proportion of Children with a health weight at 11 years old

AM31 Increase the the prevalence of breastfeeding at 6-8 weeks after birth


Ref: Financial Efficiencies

FE1 To recognise savings on Tier IV admissions for NHS England

FE2 10% Reduction in Children and Young People's Out of Area Placements by 2020



Living Well



LIVING WELL - Strategic Delivery Plan: 2019-21

VISION: People feel supported within their community; where people do need health and care services they are coordinated and timely.





1.1 Development of Voluntary Community & Faith neighbourhood provision, with a clear support offer linked with integration of enhanced statutory provision. Expansion of jointly commissioned crisis café's into 4 Doncaster locations

QO1 31.03.20 Stephen Emmerson/ Helen Conroy/ /Griff Jones/ Mark Wakefield/ Claire Scott/ Katy Turner

1.2 Develop a social isolation alliance, to tackle all age loneliness and social isolation issues in Doncaster QO1, QO14 31.03.20 Debbie John-Lewis/ Fay Wood

1.3 Working with people with a learning disability, ensure that the recommendations from the Learning Disability strategy (currently under co-production) are considered and implemented across Doncaster, including day opportunities.

QO3, AM14 30.09.19 David Eckersley/ Mark Wakefield/ Debbie John-Lewis/ Paul Tarantiuk/ Emma Price

1.4 Embed networks as the cornerstone of integrated neighbourhood working developing closer links with stronger communities, third sector, statutory organisations and the management of GP federation contracts.

QO5, QO12 31.03.20 Carolyn Ogle/ Claire Scott

1.5 Develop and test a community based adult learning course around urgent care and self management 30.09.19 Ruth Bruce/ Karen Milner

1.6 Development and joint agency agreement of homelessness and rough sleeping strategy, including a focus on prevention.

AM10, AM15 31.03.20 Chris Marsh/AlAn Wiltshire

1.7 New contracts for young people's supported accommodation services including Doncaster Foyer and Green Gables will be awarded and mobilised

AM10, AM15 30.06.19 Sarah Sansoa/ Mark Wakefield

1.8 Domestic abuse victims contract comprising refuge, dispersed housing and outreach support will be awarded and mobilised

QO15 30.06.19 Sarah Sansoa / Mark Wakefield/ Karen Shooter


2.1 Increase access to GP Practice and extended access hubs by enabling direct booking by NHS 111 into general practices and extended access hubs. Monitor and evaluate the Doncaster GP Federation to ensure the maximisation of extended access appointments.

QO5, QO6 31.03.20 Carolyn Ogle/ Ailsa Leighton

2.2 Review the panels that oversee management and support for complex and high intensity users, working with the police to ensure one co-ordinated approach across the local system

QO1, AM1, AM4, AM8

31.03.20 Ailsa Leighton

2.3 Personal Budgets - extend coverage to include further LD population and design pathway to ensure individuals can access best health and social care dependant on need

AM1, AM13 31.03.20 David Eckersley/ Mark Wakefield/ Paul Tarantiuk/ Emma Price









2.4 Access to non life threatening urgent care will be co-ordinated between NHS 111 services and local services, enabling clinical advice to be locally delivered, tailored to local services and appointments to be directly booked as appropriate

QO8, QO9, AM2, AM3

Mobilisation from 01.04.20

Ruth Bruce

2.6 Work with the ambulance service to reduce conveyance to hospital, through timely access to local alternative services

AM4 31.03.20 Ruth Bruce

2.7 Strengthening of St Leger Single Point of Access Service and extending range of accommodation options available.

AM10, AM15 31.03.20 Chris Marsh/ Pat Hagan/ St Leger Rep

2.8 Increase the use of the Integrated Doncaster Care Record and other technologies across health and social care to enable a co-ordinated response at any point of access

QO12, AM1, AM4 31.03.20 Simon Marsh


3.1 Recognising that people with a Severe Mental Illness have poorer physical health outcomes, they will be supported with enhanced physical health screening and care planning to live well outside of statutory services by enhanced liaison between health, social and community providers.

QO10, AM5, AM6 Mobilise for 01.10.19

Stephen Emmerson/ Helen Conroy/ Griff Jones/ Mark Wakefield/ Claire Scott/ Katy Turner/ Fay Wood

3.2 Acute psychiatric liaison (both functional and organic Mental Health, and potentially alcohol/ substance misuse) will be developed to improve patient pathways by avoidance of unnecessary inpatient admission, earlier discharge from acute care, initiation of appropriate community care packages, and better patient engagement with preventative programmes

QO1, AM7, AM8 Mobilise for 31.10.19

Stephen Emmerson/ Helen Conroy/ Griff Jones

3.3 Enhance “talking therapy” services, to include bespoke approaches related to the impact of physical conditions and targeted work to increase representation and improving outcomes for BAME groups

QO1, QO11, AM1 31.03.20 Stephen Emmerson/ Helen Conroy/ Griff Jones/ Mark Wakefield/ Fay Wood

3.4 Ensure delivery of the local living with and beyond cancer strategy, to support people that have undergone cancer treatment to manage the next steps in their journey

AM9 31.03.20 Karen Leivers

3.5 Further to the Learning Disability strategy, offer greater opportunities to increase independence, providing more support at home and reducing the use of residential care

AM11, AM13 31.03.20 David Eckersley/ Mark Wakefield/ Paul Tarantiuk/ Emma Price

3.6 Develop a health community single point of access to ensure people are able to access the right services in the community, only being admitted when there is no other alternative and enhance discharge co-ordination

QO8, QO9, QO12, QO13, AM3, AM10

30.09.20 Jo Forrestall/ Ailsa Leighton/ Debs Crohn

3.7 Future commissioning arrangements for Social Prescribing will be developed to recognise how these services can be delivered within and by communities, supported by the voluntary sector

QO1 Mobilise Q1 Faye Wood/ Michele Clarke/ Claire Scott









3.8 Further strength the Complex Lives Team and its direct alignment with accommodation provision, including the development of a Doncaster Housing First model.

AM10, AM15 31.03.20 Chris Marsh/ Pat Hagan/ Mark Wakefield/ Sarah Sansoa

3.9 Increase the use of personal budgets across Doncaster, including within the Learning Disability and Mental Health populations

31.03.20 Debs Crohn/ Davis Eckersley

3.10 Enhance Early Intervention in Psychosis services, with targeted interventions for “at risk” individuals in order to prevent psychotic episodes and equip people with tools and techniques to live crisis free

QO1 Evaluation Q1 Stephen Emmerson

3.11 Develop, shape and manage the Health and Social Care market to stimulate a diverse and sustainable market capable of delivering commissioning priorities

QO5, QO12 31.03.20 Mark Wakefield/ Ailsa Leighton

3.12 Develop Physical Disability accommodation offer and wrap round care and support services QO5, QO12 31.03.20 Mark Wakefield/ Adam Goldsmith/ Charlene Welsby/ David Eckersley

3.13 Develop locally tailored Primary Care Networks to increase local delivery of services QO5 31.03.20 Carolyn Ogle

3.14 Develop the health and social care workforce (across the entire sector) to deliver living well priorities and actions

ALL In line with specific actions

Karen Milner/ Sarah Jones

3.15 Develop future commissioning arrangements for extra care housing taking account of supply, demand and affordability

QO5, AM15 30.09.19 Mark Wakefield/ Sarah Sansoa/ Charlene Welsby

Responsive and accessible care in a crisis

4.1 Review the offer for Learning Disability Respite provision, following the development of the Learning Disability strategy, with a particular focus on short term placements and all age crisis prevention services.

AM11 30.09.19 David Eckersley/ Mark Wakefield/ Debbie John-Lewis/ Paul Tarantiuk/ Emma Price/ Julia King

4.2 The urgent care model for Doncaster is under review to ensure that at the point that people need urgent care they are able to get the right service quickly and in the right place

QO8, QO9 30.09.19 Ruth Bruce

4.4 Develop and implement proposals for the front end modernisation of Mental Health Access Services, providing genuine alternatives to hospital admission and A&E presentation.

QO1, AM1, AM7, AM8

Mobilisation through to March 2020

Stephen Emmerson

4.5 Implement Suicide Prevention Year 2 Plan, contributing towards the 10% reduction required QO1 31.03.20 Helen Conroy/ Stephen Emmerson








Person centred support for people with complex needs

5.1 Development of more intensive wrap around support models bringing together accommodation, intensive key work support and rapid access to support services - including the development of a Doncaster Housing First offer,

AM1, AM7, AM10, AM15

31.03.20 Chris Marsh/ Pat Hagan/ Mark Wakefield/ Sarah Sansoa

5.2 Develop and implement targeted Government grant funded enhanced homelessness provision, including the Rapid Rehousing (Early Adopter) Programme

31.03.20 Sarah Sansoa/ Mark Wakefield/ Pat Hagan/ St Leger Rep

5.3 Work to eliminate inappropriate hospital Out of Area Placements for Doncaster residents AM12 Year 2 ICS Improvement March 2020

Stephen Emmerson

5.4 Reform the homelessness accommodation and support contract including the homeless hostels and street outreach in order to provide more strategically relevant provision informed by the wider (corporate) homelessness and rough sleeping review/strategy

AM10, AM15 31.03.20 Sarah Sansoa/ Mark Wakefield

5.5 Develop future (joint) commissioning arrangements for substance misuse accommodation and support services

AM1, AM7, AM10, AM15

31.03.20 Sarah Sansoa/ Mark Wakefield/ Helen Conroy

5.6 Ensure the successful delivery of the proactive care specification across Doncaster GP practices ensuring organisations meet requirements throughout the year and therefore identified for the most vulnerable patients in each GP Practice/ Primary Care Network

Q05, Q06 31.03.20 Carolyn Ogle



To Deliver the following Outcomes for Living Well


QO1 There will be a 10% reduction in suicides by March 2021 (from the 2016-17 level of 9)

QO2 The proportion of people in Doncaster who are overweight or obese will be reduced

QO3 100% of all adults with a learning disability will receive a timely Care and Treatment Review pre and post admission

QO4 The proportion of people in Doncaster who smoke will be reduced

QO5 Doncaster residents' quality of life will be improved and inequalities reduced

QO6 People will be more often managed in the appropriate setting

QO7 Fewer people under age 75 will die from Cancer, Cardiovascular disease and Respiratory disease

QO8 People of all ages will be able to access a range of urgent care in different settings, dependent on clinical need

QO9 Urgent care services will work smoothly and effectively across all parts of the system, at both points of access and discharge

QO10 Patient-reported outcomes from Physical healthchecks will improve for patients with a Serious Mental Illness

QO11 At least 50% of people who complete IAPT treatment should move towards recovery

QO12 Improved satisfaction of Doncaster residents with the health and care services they receive

QO13 The number of people with a Delayed Transfer of Care will be at least maintained in line with the nationally required trajectory, and reduced as far as possible

QO14 Improvement in the proportion of people who use services and carers, who report that they have as much social contact as they would like.

QO15 The rate of domestic abuse incidents reported to the police, per 1,000 population will be reduced



AM8 There will be a 5% reduction in admissions into the Section 136 suite in 2019-20

AM9 The number of Cancer patients who have a holistic needs assessment will increase

AM10 There will be fewer households in temporary accommodation (per thousand households) awaiting settled accommodation

AM11 There will be more learning disability respite places offered

AM12 There will be a reduction in inappropriate out of area placement bed days due to capacity to 350 days by March 2020

AM13 There will be more people with a personal budget or in receipt of direct payments

AM14 At least 75% of people with a Learning Disability will receive an annual health check by March 2020

AM15 There will be a higher proportion of adults in contact with Mental health services who are living in stable and appropriate accommodation


Ref: Financial Efficiencies

FE1 Reduced secondary care expenditure for a number of specified pathways due to people being cared for in a more appropriate setting or pathway

FE2 Reduced spend in Primary Care due to addressing equity gaps in the contracts across Doncaster,such as the use of (not limited to) TELEDerm, Locally Enhanced Services and Alternative Provider Medical Service contracts

FE3 Reduced A&E attendances during 2019/20 resulting from the number of people streamed away from the ED department

FE4 Reduction in length of stay and delayed transfers of care will reduce the excess bed days total cost

FE5 Reduction in colonoscopies due to the implementation of additional Faecal calprotectin testing, and a reduction in diagnostics due to the implementation of the fecal immunochemical test

FE6 Reduction in acupuncture due to the alignment of commissioning to NICE Guidance

FE7 Reduction in prescribing spend in primary and secondary care

NB. These are the living well expected financial efficiencies from Operational Delivery Plans and therefore the specific actions to deliver them can be found in those plans.



AM1 There will be a reduction of people with a Learning Disability attending A&E by 1.25% and a reduction of people attending A&E with psychiatric conditions, and due to substance use

AM2 Greater than 50% of patients who call 111 will have clinical input and at least 40% of people that have been triaged by NHS 111 will be booked into a face to face appointment where needed

AM3 The proportion of patients who call 111 who receive an outcome of "A&E" by default (where there are no alternative services), will be reduced to less than 1% of calls triaged

AM4 Contribute to achieving a reduction in patients conveyed by ambulance to A&E, in line with the Yorkshire Ambulance Service improvement programmes for 2019-20.

AM5 At least 60% of people on Serious Mental Illness registers will receive a complete list of physical checks

AM6 People with psychosis should receive the appropriate Cardio-metabolic assessments in secondary mental health services

AM7 There will be a reduction in elective and non-elective admissions for patients with mental health conditions, and a reduction in non-elective admissions for alcohol and substance related conditions, chronic ambulatory care sensitive conditions and urgent care sensitive conditions by March 2020



LEARNING DISABILITY - Operational Delivery Plan: 2019-21

VISION: For people with learning disability and or autism to have the same rights and opportunity as anyone else to live satisfying and valued lives, and to be treated with dignity and respect. They should have a home within their community, be able to develop

and maintain relationships, and get the support they need to live healthy, safe and rewarding lives.


Programme Name Ref Key Milestones Outcome(s) the Action will Deliver


1.1 Developing the market - Developing a provider framework for Doncaster. Robust framework to hold providers to account on a standard of care across both Health and Social care.

QO1, Q02, AM2 31.10.19 Emma Price, Paul Tarantiuk and Ian Boldy

1.2 Through review process, standardise quality across all health and social care contracts to ensure most appropriate outcomes for patients.

QO2, QO3, AM1, AM5 31.03.20 Emma Price, Paul Tarantiuk and Ian Boldy

1.3 Baseline information to be produced identifying outstanding reviews of placements with subsequent measure produced.

QO1, QO2 31.07.19 Ian Boldy and David Woodcock

1.4 Personal Budgets - extend coverage to include further population of people with Learning Disabilities and design pathway to ensure individuals can access best health and social care dependant on need

AM1, AM4 31.03.19 Ian Bold and Doncaster Council lead

1.5 Learning Disability Strategy - ensure that recommendations/directions from strategy to be published in April 2019 are considered and implemented across Doncaster and reflected in ongoing Operational and Strategic Delivery Plans.

All 30.09.19 Emma Price, Paul Tarantiuk and Jayne Gilmour

1.6 Review the offer for Respite provision - short term, placements thinking specifically about all age crisis prevention services.

AM3 30.09.19 Emma Price, Paul Tarantiuk and Jayne Gilmour

1.7 Implement the Forensic Outreach and Liaison Service programme across Doncaster. 30.06.19 Emma Price, Paul Tarantiuk and Alison Wood

1.8 Remodelling of both low secure and locked rehab provision to commence following the closure of Amber beds

AM2 30.09.19 Emma Price and Paul Tarantiuk

1.9 Alignment to the Mental Health psychiatric decision unit to enable people with Learning Disabilities to utilise the assessment location.

AM1 30.06.19 Emma Price, Paul Tarantiuk and Stephen Emmerson

1.10 Understand in detail the revised Responsible Commissioner guidance for Doncaster reviewing how it will impact the current Doncaster landscape and develop new reporting measures as appropriate.

Not applicable 30.06.19 Emma Price, Paul Tarantiuk, Steve Evans, Andrew Russell and Genna Miller

1.11 Step down programme of Danes court to continue with ability to move individuals into supported/ residential care

QO2 30.09.19 Emma Price, Paul Tarantiuk, Steve Evans, Katie Rhodie



LEARNING DISABILITY - Operational Delivery Plan: 2019-21

VISION: For people with learning disability and or autism to have the same rights and opportunity as anyone else to live satisfying and valued lives, and to be treated with dignity and respect. They should have a home within their community, be able to develop

and maintain relationships, and get the support they need to live healthy, safe and rewarding lives.




Learning Disabilities Primary Care

2.1 Primary Care Direct Enhanced Service - Work with the Proactive care pillar, linking to outcomes and working with General Practice (GP) Federation.

QO2 31.03.20 Emma Price, Paul Tarantiuk and Nabeel Alsindi

2.2 Effective use of GP systems - Standardise templates across all GP platforms and work to increase consistency. Work with Information Technology to implement system specific templates across all.

QO2 31.03.20 Emma Price, Paul Tarantiuk and Gail Stones

2.3 Primary Care tests and action plans - work with GPs to increase quality/ link to evaluation of relevant actions plans for future roll out.

AM1 31.03.20 Gail Stones

Learning Disabilities National

3.1 Learning Disability Mortality Review Programme (LEDER) - Review of information and appropriate actions, working closely with CCG quality to ensure appropriate commissioning of services.

Q03 31.03.20 Emma Price, Paul Tarantiuk and Ian Boldy

3.2 Stopping the Over Medication of People (STOMP) - Review of information and appropriate actions (reduction of anti psychotics in long term placements) and confirm system to measure impact on the prescribing savings plans within Primary Care.

AM 1, AM 2 31.03.20 Emma Price, Paul Tarantiuk and Ian Boldy

To Deliver the following Outcomes


QO1 75% of people with a Learning Disability on Quality and Outcomes Framework (QOF) registers will receive an annual health check by March 2020

QO2 Placeholder, to be confirmed following completion of action: Complete outstanding reviews of placements

QO3 100% of all adults with a learning disability will receive a timely Care and Treatment Review pre and post admission



AM1 There will be a reduction of people with a Learning Disability attending A&E by 1.25% by March 2020 (reduction of 12 patients based on 2018-19 forecast)

AM2 Minimise and work to eliminate people with a Learning Disability admitted to an Assessment and Treatment Unit (ATU) reducing the number of inpatients to 4 or less by March 2020.

AM3 Increase the amount of respite places offered from baseline (sourcing data from Doncaster Council and target to be confirmed)

AM4 Increase the number of people with a Learning Disability with a personal budgets from baseline (sourcing data from Doncaster Council and target to be confirmed)

AM5 Increase the number of people with a Learning Disability in supported accommodation from baseline (sourcing data from Doncaster Council and target to be confirmed))



PRIMARY CARE - Operational Delivery Plan: 2019-21

VISION: We will ensure the resilience and long term sustainability of primary care through the development of primary care at scale. This will:• facilitate integrated working between partnership organisations at neighbourhood level, encouraging integration and collaboration;

• improve access to consistent high quality care that promotes health and wellbeing• increase the cost effective use of resources

• provide a focus for the prevention and management of long term conditions leading to improved health outcomes..




1.0

GP Practice Inequalities and Risk Management

1.1 Continue to develop an intelligence tool to support the identification of health inequalities across Doncaster GP (General Practitioner) Practice, including the facilitation of best practice, risk management and support of appropriate allocation of resilience funding.

QO1, FM2, AM4 31.03.20 Chris Empson

1.2 Continue to develop an evaluation process to enable NHS Doncaster to work collaboratively with GP Practices in understanding the variations across the geographical area and ensure improvements are made.

QO1, AM4 31.03.20 Chris Empson

1.3 Develop an online tool to support GP Practices in awareness of local services and new or revised clinical pathways.

QO1 31.03.20 Chris Empson

1.4 Identify and understand why specific GP Practices outlie in RightCare areas. QO1 31.03.20 Chris Empson

1.5 Ensure the findings of the 360 Assurance Audit on effective primary care commissioning are embedded across Doncaster.

QO7 30.09.19 Carolyn Ogle

1.6 A full review of alternative provider medical services (A-PMS) GP contracts to ensure a better equity across GP Primary Care.

FE3 30.09.19 Carolyn Ogle, Genna Miller, Adele Spence

2.0

Effective Use of Technology

2.1 Enable more patients in Doncaster to use online services to increase the ease in making appointments and ordering repeat prescriptions as well as having repeat medications dispensed directly where appropriate.

QO2 31.07.19 Wendy Lawrence, Alex Molyneux, Carolyn Ogle, Gail Stones

2.2 Enable more patients in Doncaster to electronically access their clinical record and view medical correspondence held by their GP Practice.

QO2 31.03.20 Wendy Lawrence, Gail Stones

2.3 Successfully roll out the procured online consultation tool throughout Doncaster GP Practices to enable patients to access electronic consultations.

QO2 31.03.20 Karl Roberts

2.4 Successfully roll out the TeleDERM equipment to all GP Practices in Doncaster to enable all organisations to refer to the Mole Clinic with intentions to reduce Dermatology activity in secondary care.

QO6. FE1, AM1, AM2

31.03.20 Karl Roberts

2.5 Increase access to GP Practice and extended access hubs by enabling direct booking by NHS 111 into general practices and extended access hubs.

QO2, QO6 31.03.20 Ailsa Leighton, Carolyn Ogle

2.6 Continually improve GP Practice IT infrastructure by facilitating the development and roll out of core IT schemes across Doncaster such as (but not limited to) axe the fax, Windows 10 Upgrade, NHS App deployments etc.

QO7 31.03.20 Wendy Lawrence, Gail Stones










3.0

Enhanced Services

3.1 Update and improve all Doncaster GP and Pharmacy local enhanced services by implementing robust monitoring and collections processes as well as clear and detailed specifications.

QO1, QO2, QO6, FE4 30.06.19 Adele Spence, Carolyn Ogle

3.2 Ensure the successful delivery of the Proactive care specification across Doncaster GP Practices, ensuring organisations meet the requirements throughout the year and therefore identify the most venerable patients in each GP Practice/Primary Care Network.

QO2, QO3, QO5, QO6, AM5, AM6

31.03.20 Carolyn Ogle

3.3 Increase the appropriate use of secondary care by analysing nine key local enhanced services to ensure activity is delivered in the correct clinical setting.

Q02, QO5, QO6, FE4 30.09.19 Chris Empson

3.4 Support the delivery of the planned care revised eye care specifications to optimise the use of community and secondary care ophthalmology services.

QO5, QO6 31.03.20 Karen Leivers, Adele Spence, Carolyn Ogle

3.5 Ensure there is no duplication with existing services and the new Quality Outcomes Framework (QOF) domains for prescribing safety and end of life care.

Q04, QO8, QO9, AM4 31.03.20 Jo Forrestall, Alex Molyneux, Stephen Emmerson

3.6 Ensure better value for money through a realignment of Direct Access Pathology GP consumables. FM1 31.03.20 Carolyn Ogle, Adele Spence, Genna Miller

4.0

Implementation of the Primary Care Strategy

4.1 Develop a Doncaster Cardio Vascular Disease (CVD) prevention programme as the annual clinical priority for population health management.

QO7 30.06.19 Carolyn Ogle. Healthwatch

4.2 Primary Care will be provided with Primary Care data analytics for population segment and risk stratification according to the national data sets.

QO1 31.03.20 Nabeel Alsindi, Victor Joseph, Jon Briggs

4.3 Identify opportunities to increase the role of community pharmacy as the front door for primary care, support the further improvement of oral health care in Doncaster and engagement with optometrists through the local optical committee (LOC).

QO2, QO6 31.03.20 Carolyn Ogle, Local Pharmacy Council, Public Heal, Karen Leivers

4.4 Development of a Primary Care focused estates implementation plan to enable the Clinical Commissioning Group to make informative and robust decisions regarding Primary Care estates and support access to relevant sources of capital funding.

QO7 30.06.19 Carolyn Ogle, Tracy Wyatt, John Lawson

4.5 Ensure all practices are engaged in primary care networks and delivering the Network Contract Direct Enhanced Services.

QO1, QO2 July 2019 Carolyn Ogle, Primary Care Doncaster










4.0

Implementation of the Primary Care Strategy

4.6 Develop locally tailored Primary Care Networks to increase local delivery of services and invest £1.50 recurrently in the development and sustainability of Primary Care Networks (plus additional £1 per head in 19/20) to move Doncaster towards level 3 on the maturity matrix.

QO7 31.03.20 Carolyn Ogle, Primary Care Doncaster

4.7 Embed networks as the cornerstone of integrated neighbourhood working developing closer links with stronger communities, third sector, statutory organisations and the management of GP Federation contracts.

QO5, FE2, QO7 31.03.20 Carolyn Ogle, Cath Doman

4.8 Expand and develop the primary care workforce to ensure effective future sustainability and resilience. QO7 31.03.20 Carolyn Ogle, Primary Care Doncaster

5.0

Appropriate Access

5.1 Ensure the appropriate use of Primary Care appointments by supporting and developing Care Navigation to sign post patients to more appropriate services.


5.2 Monitor, evaluate and support GP Practices in the use of Consultant Connect to ensure the appropriate use of appointments in secondary care.

QO6, AM1 31.03.20 Karen Leivers, Carolyn Ogle

5.3 Continue to ensure referrals from Primary Care to Secondary Care are appropriate and relevant by supporting key agendas as described by the Planned Care Delivery Plan.

QO6, AM1, AM2, AM3

31.03.20 Karen Leivers, Carolyn Ogle

5.4 Monitor, evaluate and support GP Practices in understanding the workforce and appointment utilisation to create more capacity in GP Primary Care by implementing the Apex and Insight software applications.

QO2, Q07 30.06.19 Carolyn Ogle, Primary Care Doncaster

5.5 Monitor and evaluate the Doncaster GP Federation to ensure the maximisation of extended access appointments.

Q02, Q06 31.03.20 Anthony Fitzgerald, Carolyn Ogle, Chris Empson

5.6 Ensure continual availability of GP Practice services by ensuring core hours access requirements are understood and met by all GP Practices in Doncaster.




To Deliver the following Outcomes for Ageing Well


QO1 Reduce the health inequalities for Doncaster patients in Primary Care by March 2020. There are multiple indicators for this outcome.

QO2 Improve patient health outcomes by increasing access to Doncaster Primary Care e.g. extended access, online, better use of estates etc.. There are multiple indicators for this outcome.

QO3 Maintain or improve the volume of patients in Doncaster who receive personalised care (baseline's tbc) through personalised care plans and personalised budgets. There are multiple indicators for this outcome.

QO4 Improve the overall patient experience and quality of Primary Care from 2016-17 GP Patient Survey. There are multiple indicators for this outcome.

QO5 Increase Care closer to home by closer and more effective joint working between Primary Care and Community Care. There are multiple indicators for this outcome.

QO6 More patients are managed in the appropriate setting by the effective use of consultant connect, care navigation and TeleDERM. There are multiple indicators for this outcome.

QO7 Ensure continual improvement of GP Practice while ensuring a safe, sustainable and resilient Primary Care. There are multiple indicators for this outcome.

*QO8 "At least 67% of patients with Dementia will be diagnosed in line with the national standard in 2019-20 (Improvement Assessment Framework 126a). *Activity Measure taken from the Mental Health Operational Delivery Plan. Associated actions can also be found in the Mental Health Operational Delivery Plan.

*QO9 There will be an increase in Dementia patients whose care plan has been reviewed in primary care in the last 12 months (Improvement Assessment Framework 126b) to 80% by March 2020. * Activity Measure taken from the Mental Health Operational Delivery Plan. Associated actions can also be found in the Mental Health Operational Delivery Plan.

*QO10 75% of people with a Learning Disability on Quality and Outcomes Framework (QOF) registers will receive an annual health check by March 2020. * Activity Measure taken from the Learning Disabilities Operational Delivery Plan. Associated actions can also be found in the Learning Disabilities Operational Delivery Plan.


Ref: Financial Savings/QIPP

FE1 Reduction of Dermatology first outpatient appointments by using the TeleDERM service to diagnose moles and lesions. A potential saving of £57,306.50

FE2 A reduction of Dermatology first outpatient appointments by re-directing patients through a triage service (Street Lane). A potential saving of £160,426.00

FE3 A review of A-PMS contracts to ensure equity across all GP contracts. A potential saving of £32,251.00

FE4 Increase in the uptake by GP Practice of five local enhanced services (Ring Pessary - Fit/Change, Endometrial Biopsy, IUCD Insertion, Removal of Cervical Polyps, Colposcopy). A potential saving of £10,112.33

FE5 To identify further financial savings from in year schemes, ensuring a saving of approximately £39,904.17 (excludes cost pressures).

*FE6 Reduction in referrals. * Financial savings taken from the Planned Care Operational Delivery Plan. Associated actions can also be found in the Planned Care Operational Delivery Plan.

*FE7 Ophthalmology Community Procurement. * Financial savings taken from the Planned Care Operational Delivery Plan. Associated actions can also be found in the Planned Care Operational Delivery Plan.

*FE8 Calprotectin * Financial savings taken from the Planned Care Operational Delivery Plan. Associated actions can also be found in the Planned Care Operational Delivery Plan.



*AM1 Fewer patients (%) will be discharged at first appointment (with no diagnostic investigation) from 2018-19 baseline (60%) by March 2020. * Activity measure taken from the Planned Care Operational Delivery Plan. Associated actions can also be found in the Planned Care Operational Delivery Plan.

*AM2 Less patients are referred to secondary care for Dermatology through the Increase of the use of telederm in primary care. This will support the ongoing management of the patient and have a positive impact on waiting times, by reducing the need for a referral into secondary care. * Activity measure taken from the Planned Care Operational Delivery Plan. Associated actions can also be found in the Planned Care Operational Delivery Plan.

*AM3 There will be fewer inappropriate referrals and procedures undertaken by implementing commissioning for outcomes (CFO) policy and Evidence based interventions (EBI) to ensure a consistent approach across South Yorkshire & Bassetlaw. * Activity measure taken from the Planned Care Operational Delivery Plan. Associated actions can also be found in the Planned Care Operational Delivery Plan.

*AM4 At least 60% of patients on Serious Mental Illness registers will receive a complete list of physical checks (IAF 123g) * Activity measure taken from the Mental Health Operational Delivery Plan. Associated actions can also be found in the Mental Health Operational Delivery Plan.

*AM5 There will be a reduction in A&E attendances for patients aged 65 and over per 1000 population, including those from care homes. * Activity measure taken from the Ageing Well Strategic Delivery Plan. Associated actions can also be found in the Ageing Well Strategic Delivery Plan.

*AM6 There will be a reduction in non elective admissions for patients aged 65 and over per 1000 population, including those from care homes. * Activity measure taken from the Ageing Well Strategic Delivery Plan. Associated actions can also be found in the Ageing Well Strategic Delivery Plan.



ADULT (ALL AGE) MENTAL HEALTH - Operational Delivery Plan: 2019-21

VISION: Mental Health Services will develop to improve service accessibility and quality at the time of need, promote better integrated and holistic care within a range of delivery settings that include the persons own home, and focus on reducing the

relatively poorer mortality and physical healthcare outcomes for a person diagnosed with a mental illness.




Functional Mental Health - MH Crisis, Access & Inpatient Care

1.1 Implement Mental Health Front End Modernisation proposals - accessibility & resilience Q02, Q03, Q04, QO5, AM1, AM2, AM3, FS2

Commence Q1 2019

Stephen Emmerson

1.2 Serenity Integrated Mentoring (SIM model) mobilisation & evaluation of need / behavioural change for frequent attenders

Q05, AM1 31.03.20 Dan Thorpe, Stephen Emmerson, Helen Conroy

1.3 Development of Alternative Places of Safety / Safe Haven Q02, Q03 ,Q04, QO5,AM2, AM3, FS2

31.03.20 Stephen Emmerson

1.4 Single Gatekept access to Home Treatment / Inpatient & intermediate bed admission, with purposeful defined admission outcomes and transition between care settings

Q02, Q03, Q04, QO5 31.03.20 Stephen Emmerson

1.5 Implement adult functional acute psychiatric liaison and aligned targets with CORE 24, including alcohol / substance misuse liaison

Q02, AM2, AM3, FS2 31.03.20 Stephen Emmerson, Helen Conroy

1.6 Development of Voluntary Community & Faith neighbourhood provision, with a clear support offer linked with integration of enhanced statutory provision. Expansion of jointly commissioned crisis cafés into 4 Doncaster locations

Q02 31.03.20 Stephen Emmerson, Helen Conroy, Fay Wood

1.7 Reduced reliance / impact on acute physical care including emergency, elective and non-elective systems, and reduced reliance on Mental Health inpatient care

Q03, Q04, QO5, AM1, AM2


Functional Mental Health - Primary & Secondary Community MH

2.1 Implement Severe Mental Illness Physical Healthcare & Psychosis Recovery Pathway proposals Q06, AM4, AM5 30.09.19 Stephen Emmerson

2.2 Improving Access to Psychological Therapies(IAPT) Core (low level intervention and promotion of self help) - incremental prevalence trajectory - expanding reach and demographic representation

Q01, Q02, AM6, AM7, AM8


2.3 IAPT Long Term Condition (low level intervention and promotion of self-help) - continue mobilisation and evaluation of effectiveness and financial efficiencies, identify the case for inclusion of further physical Long Term Condition cohorts

Q01, Q02, AM1, AM2, AM6, AM7, AM8, AM9


2.4 Early Intervention in Psychosis (EIP) - evaluation of first year - including a review of demand and capacity and outcome impact of the extended intervention set

Q02,AM10 30.09.19 Stephen Emmerson









Dementia 3.1 Refresh of plans to raise awareness of dementia across Doncaster, educate workforce, reduce stigma, and ensure care and access to care appropriately consider the needs of a person diagnosed with dementia.

Q09, Q10 31.03.20 Louise Robson, Stephen Emmerson

3.2 Ensure continual improvement in diagnosis rate, increase level and quality of care planning within primary care, and undertake deep dive review of referral / interface between primary care and secondary mental health.

Q09, Q010 31.03.20 Stephen Emmerson

3.3 Ensure the urgent and emergency pathway for patients with Dementia aligns with the intermediate care program to develop out of hospital care and ensure purposeful and appropriate admission for people with dementia.

AM13, AM14 31.03.20 Stephen Emmerson, Jo Forrestal

3.4 Develop post diagnostic services through the Integrated Care Partnership approach Q08, QO10 31.03.20 Stephen Emmerson, Kate Anderson-Bratt

3.5 Prepare for Referral to Treatment target reduction - 10 week to 6 week by 2020/21 AM12 20.06.20 Stephen Emmerson

Place Partnership 4.1 Better Mental Health (Adult) Doncaster Improvement Plan - Following Health & Wellbeing Board endorsement, regularly review progress and multi-agency collaboration opportunities.

ALL 31.03.20 Stephen Emmerson, Helen Conroy, Julia King, Lisa Swainston, Jo Carver Provision - RDaSH, Aspire, Adult Social Care

4.2 Suicide Prevention - Year 2 Plan contribute to 10% reduction target Q02,AM6,AM7,AM8 31.03.20 Helen Conroy, Stephen Emmerson

4.3 Social Prescribing - mobilisation of newly procured service Q02 30.06.19 Fay Wood, Stephen Emmerson









South Yorkshire & Bassetlaw Integrated Care System

5.1 Integrated Care System (ICS) priorities - planning session to confirm 5 March 2019 - Perinatal Mental Health, Children & Young People Crisis Pathway, Suicide Prevention, Autistic Spectrum Condition, Employment Individual Placement Support, Out of Area Placement (capacity), Out of Area Placement (specialist), Adult Crisis Pathway, Learning Disability Transforming Care Partnership, Mental Health Investment Strategy, Workforce of which, Doncaster CCG Adult Mental Health lead:

Various ICS MH & LD workstream

5.2 Out of Area Placement (adult acute Mental Health capacity (not specialist placement) - delivery against the ICS improvement trajectory to virtually eliminate out of area inpatient placement

AM11 31.03.21 Stephen Emmerson

5.3 Mental Health Crisis ICS - develop multi-agency protocols and interface with acute & Mental Health care system (with context / transparency into each Place offer)






QO1 At least 50% of people who complete Improving Access to Psychological Therapies (IAPT) treatment should move towards recovery (IAF 123a)

QO2 There will be a 10% reduction in suicides by March 2021 against the 2016-17 level of 9.6

QO3 There will be a 5% reduction in admissions to mental health inpatient beds - Brodsworth, Cusworth, Windermere and Coniston wards - linked to mobilisation of new crisis pathway so will be reviewed in year.

QO4 There will be an increase in the number of referrals to Home Treatment service from the 18-19 outturn of 680 (based on M10) As QO3 - linked to mobilisation of crisis pathway.

QO5 Crisis Resolution and Home Treatment services should be able to meet core functions (IAF 123e))

QO6 Improved patient- reported outcomes from Physical health checks for patients on the Serious Mental Illness (SMI) register through successful patient engagement. Threshold currently being developed through the Contract.

QO7 Providers will be expected to maintain an optimised level of performance under the Data Quality Maturity Index (IAF 123i)) Rotherham, Doncaster & South Humber NHS Foundation Trust (RDaSH) current performance 94.2% (Q3)

QO8 Fewer people with a diagnosis of Dementia will be admitted into a care home - DC collect data, in the process of obtaining baseline

QO9 At least 67% of people with Dementia will be diagnosed in line with the national standard in 19-20 (IAF 126a)

QO10 There will be an increase in people with Dementia whose careplan has been reviewed in primary care in the last 12 months (IAF 126b) to 80% by March 2020

QO11 There will be a reduction in carers of people with Dementia requiring episodes of emergency respite - DC collect data, in the process of obtaining baseline

QO12 Improved patient outcomes will be delivered by the Dementia Accountable Care Partnership as evidenced by "we" statements - Data to start being collected Q2 2019-20



FS1 Increase baseline spend on Mental Health Services by 6.3% on 2018-19 expenditure and continue to deliver the MH Investment Standard (IAF 123i)

FS2 Reduce the amount of S136s expenditure by £3000

FS3 DEMENTIA POSITION - being sourced through finance colleagues



AM1 There will be a reduction in A&E attendances for patients with psychiatric conditions from the 2018-19 outturn of 1333 by March 2020 (based on M10)

AM2 There will be a reduction in elective and non-elective admissions for patients with mental health conditions by March 2020 from the 2018-19 outturn of Electives 5996, Non-electives 5769, Readmissions 2932 & Average Length Of Stay elective 2 days, non-elective 4 days. Plus a subset of this data for alcohol and substance misuse will be defined and measured in the same way

AM3 There will be a 5% reduction in admissions into the Section 136 suite in 19-20, compared to 18-19 baseline of 312; giving a reduction to 297.

AM4 At least 60% of people on Serious Mental Illness registers will receive a complete list of physical checks (IAF 123g)

AM5 People with psychosis should receive the appropriate Cardio-metabolic assessments in secondary mental health services (evidenced by annual CQUIN audit carried out by Royal College of Psychiatrists) (IAF 123h) .Threshold will be developed in-year

AM6 The number of individuals entering IAPT treatment as a proportion of people with anxiety or depression should be increased to 19.75% by March 2020 (IAF 123b) 5.5% in Q4

AM7 At least 75% of people entering into IAPT treatment do so within 6 weeks of referral

AM8 At least 95% of people entering into IAPT treatment do so within 18 weeks of referral

AM9 There will be more people with long term conditions accessing IAPT services. Numbers taking up service will be monitored in year in order to develop a baseline & future outcome measure

AM10 At least 56% of people aged 14-65 experiencing their first episode of psychosis will start treatment within two weeks (IAF 19)

AM11 There will be a reduction in inappropriate out of area placement bed days due to capacity to 350 days by March 2020 (ICS trajectory). (IAF 123f)

AM12 People referred with suspected Dementia will have an initial assessment within 8 weeks, April to December 2019 and 6 weeks January - March 2020

AM13 There will be a reduction in non elective admissions for people with Dementia by March 2020 against 2018-19

AM14 There will be a reduction in re-admissions for people with Dementia by March 2020 against 2018-19



URGENT CARE - Operational Delivery Plan: 2019-21

VISION: People feel supported to manage within their communities and link with a range of sectors, including the voluntary and faith sectors. Where people do reach out to the statutory sector health and social care services will be co-ordinated, duplication reduced and people

will be able to navigate to the services that they need.




A&E attendance and admission avoidance

1.1 Work across the Integrated Urgent Care system to ensure alignment, to deliver:

• 50% calls receiving clinical consultation via NHS 111 and local clinical assessment, advice & treatment

• Access via 111 only

• Up to date and accurate Directory Of Service (DOS) with Accident & Emergency (A&E) default for less than 1% of pathways

• Increase in direct booking to Urgent Treatment Centres, and development of direct booking to extended access hubs

• Electronic prescribing

QO4, QO5, AM1, AM2 30.04.19 Ailsa Leighton

Emma Serfozo

Carolyn Ogle

Tracey Edwards

1.2 Work with the lead commissioner for ambulance services and local Yorkshire Ambulance Service (YAS) lead to ensure that YAS:

• Develop and implement plans to increase the number of ambulance response diversionary pathways

• Work with Doncaster & Bassetlaw Teaching Hospitals Foundation Trust (DBTHFT) to reduce handover waits over 30 minutes to zero

QO1, QO2, AM3 30.04.19 Emma Serfozo

Lesley Hammond

1.3 Deliver the Urgent Care Area of Opportunity, ensuring that people receive the right response, tailored to their clinical need, efficiently delivered and driven locally. In this first instance this will be directed towards the following cohorts:

20-35 year olds

40-59 year olds

65+ where a mental health need has been identified at presentation

The Area of Opportunity will focus on:

• the development of intelligence around demand, capacity and patient flow

• the development of the Doncaster urgent care future state, ensuring that services are procured and mobilised in readiness for October 2020

• the development of the urgent care workforce for the future the development and implementation of a robust communications strategy, building on the findings of #System Perfect “The Prequel”

QO4, QO5, QO6, AM4, FS1

31.10.20 Ruth Bruce









Managing patient flow

2.1 Following the clinical standards review implement the new standards, ensuring timely assessment, treatment and patient flow, for patients attending A&E / admitted acutely

QO3, AM4, FS1 31.10.19 DBTHFT (once developed)

2.2 Deliver the national ambition to reduce long stay patients in the acute hospital by 40% (against 2017/18 baseline) in order to reduce patient harm and bed occupancy through:

• Increasing the number of acute admissions discharged on the day of attendance Same Day Emergency Care (SDEC) to 33%

• Delivering a clinical frailty assessment within 30 minutes of arrival

• Focussing on reducing the number of patients with lengths of stay over 7 and 14 days

QO7, AM5, AM6, FS3 31.03.20 30.09.19 for SDEC

DBTHFT Ailsa Leighton

2.3 Ensure that the number of delayed transfers of care do not increase and work towards ”exemplary” status against all elements of the High Impact Change model for Delayed Transfers Of Care (DTOC), in a way that is aligned with the Doncaster urgent care system:

• Early discharge planning

• Systems to monitor patient flow

• Multi-disciplinary discharge team

• Home first/ Discharge to assess

• 7 day services

• Trusted assessors

• Focus on Choice

• Enhancing care in care homes

QO8, FS2 31.03.20 DBTHFT

Ailsa Leighton

DBTHFT

RDASH

All urgent care system



Karen Tooley/ RDASH









Managing patient flow

2.4 Develop and implement a community based Single Point Access (SPA) in Doncaster, building on the Integrated Discharge Team and Rapid Response approaches already in place to deliver:

• Single point of access for patients moving to and from acute and community services

• Facilitate admission avoidance and early supported discharge

• Co-ordinate the most appropriate care pathway for each patient

Also refer to operational delivery plan for Intermediate Care

QO4, QO5, QO7, QO8, AM2, AM6, FS2, FS3

National requirement by 2023

Ailsa Leighton, Jo Forrestall

2.5 Continue to manage the urgent care system, ensuring that:

• Robust Winter / Bank Holiday and escalation plans are developed and maintained, including further System Perfect opportunities

• The local escalation approach is reviewed in light of the National Guidance, the Escalation Management System (EMS) and further table top exercises undertaken

• The implications of the Integrated Care Systems (ICS) Acute Hospital Services Review are taken into account as decisions are made across the patch; to include Urgent and Emergency Care, Stroke, Gastroenterology and Endoscopy, Maternity and Care of the Acutely Ill Child

All In year

As required

Emma Serfozo





QO1 Increase in the number of people contacting 999 receiving a more timely response, to meet the national standards for 999 response times by March 2020

QO2 Improve patient experience and timely treatment by reducing ambulance handover times to eliminate handovers over 30 mins in line with the national standard

QO3 A higher proportion of people attending A&E are treated, admitted or discharged from A&E within 4 hours, improving to the national standard by March 2020

QO4 Patients of all ages will be able to access a range of urgent care in different settings, dependent on clinical need

QO5 Urgent care services will work smoothly and effectively across all parts of the system, at both points of access and discharge

QO6 The growth in patients using urgent care services will not be above the level expected for demographic factors in 2019-20

QO7 Improve patient experience by reducing their length of stay in hospital

QO8 Incidence of patients with a Delayed Transfer of Care is maintained in line with national required trajectory throughout 2019-20



FS1 Reduced A&E attendance cost of during 2019-20 (compared to 2018-19 forecast) resulting from the number of people streamed away from the ED department

FS2 Reduction in delayed transfers of care will reduce the excess bed days total cost; methodology to calculate needs to be confirmed

FS3 Reduction in length of stay will reduce the excess bed days total cost; the methodology to calculate needs to be confirmed



AM1 Greater than 50% of patients who call 111 to have clinical input and 40% of people that have been triaged by NHS 111 will be booked into a face to face appointment where needed, in line with national standards

AM2 Reduce the proportion of the patients who call 111 who receive an outcome of "A&E" by default, where there are no alternative services, to less than 1% of calls triaged, in line with the national standard

AM3 Contribute to achieving a reduction in patients conveyed by ambulance to A&E, in line with the YAS improvement programmes for 2019-20. Target to be agreed with YAS.

AM4 Patients who attend A&E with a primary care need or who can be streamed to an alternative department will improve to deliver an average of 16% streamed away from the main Emergency Department (ED) throughout 2019-20

AM5 Increase the number of appropriate patients receiving a clinical frailty assessment within 30 minutes of arrival. Baseline and standard to be set in year.

AM6 Patients' length of stay to be reduced by 40% in line with the nationally required ambition, and a reduction in the number of patients with lengths of stay over 7 and 14 days; without increasing readmissions.



PLANNED CARE - Operational Delivery Plan: 2019-21

VISION: Patients will access appropriate community or hospital services or receive advice and guidance dependent on need. Patients have access to all specialities aligned to constitution at the “right time in the right place”, dependent on need.

This is achieved by reducing inappropriate referrals into secondary care, providing an alternative approach for follow-up pathways, aligned to all areas of focus to the SYB ICS Elective and Diagnostic objectives where appropriate for 2019-21.




General 1.1 Overall review of contract and activity numbers for planned care 2019-20 FS1, 31.03.19 Karen Leivers

1.2 Monitoring adherence to DBTH/DCCG Model Access Policy 2018 (refresh 2019) Q02, Q03 31.03.19 Karen Leivers Emma Challans

1.3 Engagement and Communication of Planned Care Workstreams via DCCG forward planner 30.04.19 Karen Leivers

Pathway Redesign to Support Transforming Outpatients

1.1 Work with ECDC to monitor pilot phase and move into BAU across 100 day project work. 3 new areas 18/19 Fibromyalgia, Ophthalmology & Spinal. To monitor existing and focus on new pathway improvement areas, i.e.. MSK, cardiovascular and respiratory

Q02, Q03, Q04, Q07 FS5, FS7, FS8

30.09.19 Karen Leivers Claire Jenkinson

1.2 Monitor implementation of revised Community services within Ophthalmology; Children's post-vision Screening, OHP monitoring, stable Glaucoma, Cataract referral and F/U and MECS

Q02, FS7, FS8 31.10.19 Karen Leivers

1.3 Support the implementation of a Doncaster community Dermatology Service via the Provider Alliance, to build on the existing telederm service.

Q03, AM4, FS5 30.04.19 Karen Leivers Emma Challans

1.4 Reducing follow-up encompassing patient initiated follow-up and alternatives to conventional face to face follow-up.

AM2, AM3, FS4, FS7 31.03.20 Sarah Lever Claire Jenkinson

Commissioning for Outcomes (CFO) / Evidence based Interventions (EBI)

2.1 Continuous monitoring against BAU for phase 1 and 2, including annual audit as agreed AM5, FS2, FS3 30.04.19 Karen Leivers Karen Mcalpine

2.2 Implement all Category I and II interventions into contract, aligning existing CFO into new NHS E EBI.

AM5, FS2, FS3 31.03.19 Karen Leivers Karen Mcalpine

2.3 Ongoing Clinical engagement and learning- Primary and Secondary Care Q05, FS1, FS2, FS3 31.03.20 Karen Leivers Karen Mcalpine



PLANNED CARE - Operational Delivery Plan: 2019-21

VISION: Patients will access appropriate community or hospital services or receive advice and guidance dependent on need. Patients have access to all specialities aligned to constitution at the “right time in the right place”, dependent on need.

This is achieved by reducing inappropriate referrals into secondary care, providing an alternative approach for follow-up pathways, aligned to all areas of focus to the SYB ICS Elective and Diagnostic objectives where appropriate for 2019-21.




Improvement in Primary Care Information and Referral Management

3.1 Monitor Phase 3 Consultant Connect Implementation (Advice and Guidance) and communication between GPs and Consultants

AM6, AM7 Q06, Q08 31.03.19 Karen Leivers

3.2 Baseline Q4 outcomes- Improvement upon to support future commissioning model FS4 30.09.19 Karen Leivers

3.3 Monitor impact of changes to LES agreements in primary care, against secondary care activity and focus on strengthening inter-practice referral. The areas of focus are; IUCD, ring pessary, endometrial biopsy, colposcopy, steroid Injection into joint, punch biopsy into skin and cervical polyps

FS4 31.03.20 Karen Leivers

3.3 Link into care navigation programme working with Primary care to ensure services are suitable to accept referrals

Q05, Q08, AM7 30.09.19 Karen Leivers

3.4 DCCG to regularly inform primary care of provider waiting times for both inpatient and outpatient treatment across all providers.


3.5 Support the implementation of Faecal Immunochemical Testing for symptomatic patients through 2018/19 in line with the Yorkshire and Humber roll out.

FS6, FS8 30.09.19 Karen Leivers

Patient Engagement, Choice and Shared Decision Making

4.1 Missed appointments Monito the implementation of the missed appointment objectives. To support a reduction in patient DNA and patient and hospital cancellations

AM1, AM2 31.03.20 Karen Leivers

4.2 Participate in eRS optimisation with NHS digital and all local stakeholders. Q01 30.06.19 Karen Leivers





QO1 Patient choice is increased by eRS utilisation, with 96% of patients receiving a hospital appointment from Primary care.

QO2 As at March 2020 there will be less people on the waiting list than there were March 2018.

QO3 92% of people referred onto a Referral to Treatment (RTT) pathway will be treated within 18 weeks. Reducing patients waiting times and improving patient experience.

QO4 No patient will wait more than 52 weeks for treatment, to ensure the patient receives the best outcome.

QO5 Patients are more often managed in the appropriate setting. Therefore there will be an increase in call volume to Consultant Connect in 2019-20 compared to the baseline of March 2019 (TBC) and there will be an appropriate level of patients referred to secondary care.

QO6 Patient experience will be improved via 100 day rapid improvement testing captured by qualitative feedback.

QO7 No more than 1% of patients should wait six weeks or more for a diagnostic test, as this may impact on the waiting times and outcomes for the patient.

QO8 More patients will reach the correct specialty the "first time", and will more often follow a clear pathway with reduced inappropriate appointments. (reduce inappropriate referrals, further monitoring of the 100 day work in year)



FS1 Planned Care QIPP 2019-20 £2,291,141

FS2 National and Local Evidence Based Interventions phase 1, CFO £336,261

FS3 National and Local Evidence Based Interventions phase 2, CFO £1,352,420

FS4 Reduction in referrals £94,400

FS5 Accupuncture £124,788

FS6 Cancer FIT testing- reduction in diagnostics £157,839

FS7 Opthalmology Community procurement £129,757

FS8 Calprotectin £95,676



AM1 More patients will attend their outpatient appointment, therefore reducing the Did not attend (DNA) rate towards the national average of Qtr 3 (8.73%) by March 2020

AM2 Fewer patients (%) will be discharged at first appointment (with no diagnostic investigation) from 2018/19 baseline (60%) by March 2020.

AM3 Fewer patients will have inappropriate follow ups, with a reduction of 20% of outpatient follow up appointments by implementing the "Follow up Strategy" by March 2020

AM4 Less patients are referred to secondary care for Dermatology through the Increase of the use of telederm in primary care. This will support the ongoing management of the patient and have a positive impact on waiting times, by reducing the need for a referral into secondary care. This will be monitored by using March 2019 referrals as a baseline.

AM5 There will be fewer inappropriate referrals and procedures undertaken by implementing commissioning for outcomes (CFO) policy and Evidence based interventions (EBI) to ensure a consistent approach across SY&B. The baseline will be based on the 2018/19 outturn.

AM6 To maintain the current connection rate for consultant connect from the 2018/19 target of 75% throughout 2019-20.

AM7 Patients who have been waiting over 6 months for treatment, will be offered an alternative provider. We are not in a position to set a target.



CANCER - Operational Delivery Plan: 2019-21

VISION: In line with the National Strategy the aim is to improve the care, treatment and support for all patients diagnosed with cancer.


Programme Name

Ref Key Milestones Outcome(s) the Action will Deliver


Prevention 1.1 Work closely with Doncaster Local Authority Public Health, Rotherham Doncaster and Sheffield Hospitals, Public Health England Screening and Immunisations and system partners on prevention and awareness including smoking cessation, and linking to hard to reach groups via health Ambassadors.

AM02 31.03.20 Karen Leivers, Louise Robson, Jo O'Marr, Sarah Archer

1.2 Continue to monitor impact on Be Clear on Cancer campaign recruiting community champions to share messages of awareness raising with the population

AM02 31.03.20 Karen Leivers Jo O'Marr

Early Diagnosis 2.1 Support Increase in provision of straight to test (direct access diagnostic) pathways in line with High Value Pathways work South Yorkshire, Bassetlaw and North Derbyshire (SYB&ND) Cancer Alliance and review innovative diagnostic solutions to increase capacity to meet demand including - Vague Symptoms implementation.


2.2 Support GP Education via TARGET sessions annually including Significant Event Analysis feedback AM03 28.02.20 David Crichton

2.3 Pilot and implement Straight to Test Colonoscopy (High Value Pathway) AM03-06 30.09.19 Karen Leivers, DBTHFT

2.4 Support the implementation of Faecal Immunochemical Testing for symptomatic patients through 2018/19 in line with the Yorkshire and Humber roll out.

AM03-06 30.09.19 Karen Leivers

2.5 Support the implementation of the one-stop Prostate clinic following pilot period (Timed Pathway, HVP) AM03-06 30.06.19 Karen Leivers, DBTHFT

2.6 Review of roll out of a breath test which will assess a patient's lung cancer risk, high risk patients will then be given an immediate low dose computerized tomography (CT) scan.


Treatment 3.1 Timed pathways - Providers will implement and deliver the following pathways in line with national planning guidance; Prostate Lung, Lower Gastrointestinal

AM03 30.06.19 Karen Leivers, DBTHFT

3.2 Improve efficiency and effectiveness of cancer pathways at place level and into Tertiary Centre via IPT, through analysis and benchmarking of breaches and Cancer Waiting Times data. Continue to undertake analysis of day 38 breaches and root cause analysis of cancer breaches (62 and 104)


3.3 Aim to achieve National Cancer Waiting Times Target Referral to Treatment 62 days, incorporating the monitoring of agreements between providers across SYBND Cancer Alliance to balance supply and demand more effectively


3.4 Achieve Diagnosis or Discharge by Day 28 – in line with national planning guidance by March 2020 (with shadow monitoring up to March 2020)


3.5a Monitor and support implementation of an improved diagnostic pathway within Gynaecology including same day diagnostics




CANCER - Operational Delivery Plan: 2019-21

VISION: In line with the National Strategy the aim is to improve the care, treatment and support for all patients diagnosed with cancer.




Treatment 3.6 Monitor and support implementation of an improved diagnostic pathway within Skin including same day treatment


3.7 Continue to improve upon latest recorded staging figures, including all patients staged and noting stages documented at stages one and two (links to Improvement and Assessment Framework measure)


3.8 Review and possible implementation of genomic testing to all people with cancer whom will be of clinical benefit (NHS England).

AM07 DBTH, NHS England

Living With and Beyond Cancer

4.1 Commission and implement Living With and Beyond Cancer Recovery package including electronic holistic needs assessment and care plan, electronic treatment summaries shared with patients and GP and Cancer care review by GP of diagnosis for 100% applicable patients. Also to review lifestyle advice given after treatment to support secondary prevention.

QO04 31.03.20 Karen Leivers, DBTHFT

4.2 Ensure all prostate and colorectal cancer patients have access to stratified follow up pathways of care. Also work with Doncaster and Bassetlaw Teaching Hospitals Foundation Trust and Primary Care to develop ambitions and framework for access to services for patients with re-occurrence.




QO1 Improve to 62% of patients with cancer diagnosed at Stage 1 or 2, from the 2016 baseline of 48%

QO2 Improve to 75% of patients with cancer reaching 1 year survival by March 2020

QO3 Reduction in the 1 year survival deficit in older people (75+) to meet the overall 1 year survival achievement

QO4 Improve the number of Cancer patients who have a holistic needs assessment - baseline and target to be set in year following further implementation

QO5 Quality of Life Metric - Awaiting national publication



AM01 Smoking prevalence to be less than 13% by 2020 and 5% by 2025

AM02 Retain above England average for uptake against all three National Screening Programmes (Cervical, Bowel and Breast Screening)

AM03 Work towards achievement of National Cancer Waiting Times Standards through 2019-20



AM04 Patients will receive a diagnosis of cancer, or cancer ruled out by day 28 following referral - to be shadow monitored from April 2019. Followed by working towards achievement against the national standard once published.

AM05 Improve the proportion of patients being transferred for treatment by day 38 from referral by March 2020 (contributes to achievement of treatment within 62 Days)

AM06 Minimise and work to eliminate any patient waiting more than 104 days for treatment (of those on a 62 Day Waiting Time Pathway)

AM07 Improve the proportion of patients diagnosed with cancer who have a stage recorded in their Cancer Outcomes and Services Dataset record to 90% by March 2020 and work towards 95% for March 2021

AM08 Reduction in the number of patients who go on to be diagnosed with Cancer following an Emergency Admission from 24% in 2017-18 to 22% by March 2020

AM09 Every patient with cancer to have access to a recovery package by 2020

AM010 Patients feel they have sufficient access to a Cancer Nurse Specialist or key worker

AM011 All eligible patients to be on a risk stratified follow up pathway, in place for the 3 common cancers by 2020.



Ageing Well



AGEING WELL - Strategic Delivery Plan: 2019-21

VISION: Doncaster ageing population will receive person-centred, flexible, integrated care and support in their own “home”, that aims to maximise their health and independence.





1.1 Refresh of the Doncaster Dementia Action Plan and continue to raise awareness and reduce stigma across Doncaster.

QO1, QO2 31.03.20 Rosemary Leek/Stephen Emmerson

1.2 Further embed falls risk assessment documentation with core offer, across all providers and align ongoing developments in line with the wider prevention agenda.

AM1, AM2 31.08.19 Jo Forrestall/Rosemary Leek

1.3 Raise public awareness of the importance of the last year of life across Doncaster, including awareness of dying, death loss and bereavement and improving conversations.

QO7 31.03.20 Public Health

1.4 Increase uptake in direct payment and utilisation of Personal Health Budgets 31.03.20 Debs Crohn

1.5 Ensure that all services adopt an asset based approach and promotion of self management and support QO4, QO5, QO6, AM1, AM2, AM3 31.03.20 Fay Wood

1.6 Explore the future delivery of contracts and consideration of other local priorities to establish provision that meets the requirements of commissioners.

31.03.20 Jo Forrestall

1.7 Develop commissioning intentions for day opportunities and ensuring links to Your Life Doncaster and neighbourhood developments.

QO3, QO4, QO5, AM8 31.03.20 Rosemary Leek

1.8 Development of an ageing well prevention agenda to include but not limited to social isolation, loneliness, improving vaccination and screening uptake, falls prevention, self management and increased use in technology, (further prevention aligned to the NHS Long Term Plan ( LTP)).

QO3, QO4, QO5, QO6, AM1, AM2, AM3, AM4, AM9

31.03.20 Public Health

1.9 Improve recognition of and support for carers AM4, AM5, AM6, AM7, AM8 Angela Waite


Cross refer to 2.1, 2.4, 2.5, 2.7 within the Living Well Strategic Delivery Plan









3.1 Continue to embed previously agreed community model with wider care stakeholders of the neighbourhood model for community based multi-professional teams in partnership with mental health and social care teams in line with Doncaster Place plan and emerging Primary Care Networks.

QO1, QO3, QO4, QO5, QO6


3.2 Holistic Elderly Care planning to include but not limited to identification of, robust co-ordinated management and crisis response. With a focus on admission avoidance and proactive advanced care planning.

QO3, QO4, QO5, AM1, AM2, AM3, AM4, AM9, AM10

31.03.21 Jo Forrestall Debs Crohn

3.3 Explore the opportunities of a joint community therapy offer in particular Occupational therapy to provide practical support to empower people to facilitate recovery and overcome barriers preventing them from doing the activities to increase people's independence.

QO3, QO4, QO5, QO6 30.09.20 David Eckersley/ Jo Forrestall

3.4 Intermediate out of hospital pathways will be improved for people diagnosed with dementia. In particular, dementia patients with an urgent physical presentation will be supported by better integration of the intermediate and care home Mental Health liaison offers

QO1, QO3, QO4, AM1 31.03.20 Stephen Emmerson/ Fay Wood

3.5 Post Diagnostic Dementia Support (including Admiral Nursing) will be refined by an Accountable Care Partnership Approach to better focus available resource, improve access and service capacity, and better integration with the broader care system.

QO3, QO4, AM9, AM10 31.03.20 Stephen Emmerson / Kate Anderson-Bratt

3.6 Ensure that as local primary care strategy develops that the requirements for our Ageing population are addressed along with ensuring that General Practice is a key part of the neighbourhood approach to delivering holistic care

Q03, QO4, QO7, QO8 30.04.19 Carolyn Ogle / Jo Forrestall

3.7 Deliver the Community Care & Support at Home (CCaSH) action plan. Test the Trusted Reviewer model with the CCaSH Strategic Lead Provider’s trusting them to flex packages of care dependent on changing levels of need and identifying other resources within the community to support the persons independence.

QO3, QO4, QO5, QO6, AM1, AM2, AM3, AM4, AM8

31.03.20 Rosemary Leek

3.8 Ensure continued suitable provision of community equipment is available to support the "Home First" approach and align these changes across the system.

QO3, QO4, QO5, QO6, AM8

31.08.19 Rosemary Leek/Adele Spence

3.9 Review of CCaSH Contract and begin planning for the future commissioning of Domiciliary Care QO3, QO4, QO5, QO6 31.03.20 Rosemary Leek

3.10 Development of a new Care Home action plan and a robust market position statement 31.03.20 Rosemary Leek / Jo Watkinson

3.11 Continue to explore opportunities and risks around joint contracting for Care Homes 31.12.19 Rosemary Leek / Jo Watkinson

3.12 Evaluate Extension of Community Led Outcomes (ECHO) and financial impacts of training and consider utilisation across a wide range across all independent sector provision.

31.12.19 Karen Tooley / Kate Anderson-Bratt








Responsive and accessible care in a crisis

4.1 Ensure Admission and discharge processes into Acute hospitals are efficient and seamless ensuring a 'home first' approach for continuous care with robust direct pathways and signposting to alternative where appropriate.


31.03.20 Debs Crohn / Jo Forrestall

4.2 Continue to work with providers to implement the specified Intermediate Care service model. QO3, QO4, QO5, QO6, AM2, AM3, AM4, AM5, AM6, AM7, AM8, AM9, AM10

31.03.20 Kate Anderson-Bratt/ Jo Forrestall

4.3 Focus on maximising independence, health and well being, tailoring care and support to build on individual strengths and local community assets and ensuring that the intermediate care offer is the best it can be when people need it

QO3, QO4, QO5, QO6, AM1-AM10

31.03.20 Kate Anderson-Bratt/ Jo Forrestall

4.4 Ensure the urgent and emergency pathway for people with Dementia aligns with intermediate care program to develop out of hospitals care and purpose admission for people with dementia that have a physical presentation.

Mental Health Plan AM12 31.03.20 Jo Forrestall / Stephen Emmerson

Person centred support for people with complex needs

5.1 Influence and improve management of palliative care patients and increase Advance care planning by ensuring links with all stakeholders.

QO7,QO8 31.03.20 Jo Forrestall / Stephen Emmerson

5.2 Ensure the urgent and emergency pathway for people with Dementia aligns with intermediate care program to develop out of hospitals care and purpose admission for people with dementia that have a physical presentation.

Mental Health Plan AM13,AM14,FS6

31.03.20 Jo Forrestall / Stephen Emmerson





QO1 There will be an increase in people with Dementia whose care plan has been reviewed in primary care in the last 12 months to 80%(IAF 126b)


QO3 People aged 65 and over will report an improvement in their functioning and quality of life following the episode of care in the Intermediate Care patient outcomes tool (to be finalised in 2019-20). Baseline to be developed in 2019-20

QO4 More people aged 65 and over will report that they would be likely to recommend community services to friends and family. Baseline to be developed in 2019-20

QO5 There will be an Increase in people aged 65 and over being discharged to their usual place of residence in 2019-20 from 18-19 baseline 92% acute, 68% Intermediate Care

QO6 There will be an Increase in the percentage of people aged 65 and over still at home 91 days after discharge from hospital into reablement/rehabilitation services Adult Social Care Outcomes Framework (ASCOF) 2(b)) from baseline of 82%

QO7 There will be a reduction in the percentage of people who died and had 3 or more emergency admissions in the 90 days prior to death(IAF 105c) Baseline of 7.05% in 2017

QO8 The percentage of people recorded on the end of life pathway as dying in their preferred place of death will increase in 2019 from 2018-19 baseline of 92.6% - this baseline may be reviewed in year as reporting from other services comes on line



AM1 There will be a 5%reduction in people aged 65 and over attending A&E, including those from care homes from 2018-19 baseline of 27,415. Care homes baseline to be developed during 2019-20

AM2 There will be a reduction in people aged 65 and over being admitted to hosptial as an emergency, including those from care homes from 2018-19 baseline of 16,479. Care homes baseline to be developed during 2019-20

AM3 The average length of stay in hospital for people aged 65 and over will be maintained or reduced compared to 2018-19 outturn of 10 days (excluding 0 and 1 day length of stay)

AM4 There will be fewer delayed discharges of care for people aged 65 and over from Windermere and Coniston wards from the 2018-19 baseline of 1026 days

AM5 People aged 65 and over requiring a crisis response will receive it within 2 hours - to set a baseline during 2019-20

AM6 People aged 65 and over requiring an urgent response will receive it within 4 hours - to set a baseline during 2019-20

AM7 People aged 65 and over requiring Intermediate Care Services will have a service in place within 48hrs - to set a baseline during 2019-20

AM8 Fewer people aged 65 and over will be re-admitted to an acute hospital as an emergency within 30 days from 2018-19 baseline

AM9 Fewer people aged 65 and over per 100,000 population will be permanently admitted to residential care. From 2018-19 baseline

AM10 Fewer people aged 65 and over per 100,000 population will be permanently admitted to long term care. From 2018-19 baseline



AGEING WELL - Operational Delivery Plan: 2019-21





Dementia

1.1 Refresh of the Doncaster Dementia Together Action Plan and continue to raise awareness and reduce stigma across Doncaster.

Q01, Q02 31.03.20 Louise Robson

1.2 Ensure continual improvement in diagnosis rate, increase level and quality of care planning within primary care, and undertake deep dive on referral / interface between primary care and secondary mental health.

Q01, Q02 31.03.20 Stephen Emmerson

1.3 Ensure the urgent and emergency pathway for patients with Dementia/Delerium aligns with the intermediate care program to develop out of hospital care and ensure purposeful and appropriate admission for people with dementia.

Mental Health Plan AM13, AM14, FS6

31.03.20 Stephen Emmerson Jo Forrestall

1.4 Develop post diagnostic services through the Accountable Care Partnership approach improve access and service capacity, and better integration with the broader care system.

Q03, QO4, AM9, AM10 31.03.20 Stephen Emmerson Kate Anderson Bratt

1.5 Prepare for Referral to Treatment target reduction - 10 week to 6 week by 2020/21 Mental Health Plan, AM12 20.06.20 Stephen Emmerson

Care Homes 2.1 Following Case Notes Review develop Core and Advanced care tool, format & scoring thresholds and operational application. Use the findings to develop Multi Disciplinary Team (MDT) approaches linked to the wider Ageing Well agenda

As per 4.2 30.12.19 Karen Tooley

2.2 Develop the learning from the case note review, report key findings & identify next steps 30.12.19 Karen Tooley

2.3 Workforce development & training:

• Pilot and evaluate Extension of Community Led Outcomes (ECHO) learning platform and financial impacts of training and consider utilisation across a wide range across all independent sector provision.

• Develop and Implement Post Registration Nurse Training and then monitor ongoing programme

• Develop and Implement HCA training and induction programme, to include Supporting & Maximising Independence (SAMI)

• Develop and implement a Medicines Policy for Care providers and scope training requirement

QO7, QO8

30.12.19

31.03.20

31.03.20

30.09.19

Karen Tooley

2.4 Test proof of concept of SystmOne usage within Care Homes, evaluate and identify next steps. Enable care homes access to NHS Net Emails

QO1, QO7 30.09.19 Karen Tooley








Care Homes 2.5 Develop key principles from "Red Bag" programme in line with trusted assessor model and implement a Doncaster approach to support admission and discharge

AM3 31.07.19 Karen Tooley

2.6 Develop mechanisms to manage performance, issues and risks in nursing home 31.03.19 Ian Boldy Karen Tooley

2.7 Develop contract, including specification and quality measures Explore contracting options for Discharge to Assess beds

30.09.19 Jo Watkinson Kate Anderson Bratt

Intermediate Care

3.1 Continue to work with providers to implement the specified service model and monitor progress via Gateway framework. With specific emphasis on further integration of services by jointly appointed singularly managed, multi- skilled workforce

Q03, Q04, QO5, Q06, AM1, AM2, AM3, AM4, AM5, AM6, AM7, AM8, AM9, AM10

31.03.20 Jo Forrestall Kate Anderson Bratt

3.1.1 Simplifying Access- further development of triage and implementation of trusted assessor role to facilitate access to Beds via community Single Point of Access (SPA)


3.1.2 Homefirst-Deliver the response as a single, integrated pathway offering a greater range of more responsive home based support . To include increased step up support


3.1.3 Bed base- Continue to redesign & redirect resources to the HomeFirst service. 31.03.19 Jo Forrestall

3.2 Undertake a service wide approach to utilisation of technology to support individuals and hospital avoidance Q03, Q04, QO5, AM1, AM2, AM8


Community & End of Life

4.1 Continue to embed previously agreed community model with wider care stakeholders of the neighbourhood model for community based multi-professional teams in partnership with mental health and social care teams in line with Doncaster Place plan and emerging Primary Care Networks

Q01, Q03, QO4, QO5, QO6 31.03.20 Jo Forrestall

4.2 Holistic Elderly Care planning to include but not limited to identification of, robust co-ordinated management and crisis response. With a focus on admission avoidance and proactive advanced care planning.

QO3, QO4, QO6, AM1, AM2, AM3, AM4, AM9, AM10


4.3 Review existing provision and specification of Community Geriatrician and specify future requirements aligned to the whole of the Ageing well agenda

QO3, QO5 31.03.20 Jo Forrestall

4.4 In partnership with finance and contract colleagues continue the review of services included within the acute block contract, with specific focus on Dietetics, Speech and Language (SALT) and Physiotherapy









Community & End of Life

4.5 Explore the opportunites of a joint community therapy offer in particular Occupational therapy to provide practical support to empower people to facilitate recovery and overcome barriers preventing them from doing the activites to increase people's independence.

QO3, QO4, QO5 30.09.20 David Eckersley

4.6 Working with Provider Alliance implement the specified integrated Wound care pathway across Doncaster 30.09.19 Jo Forrestall

4.7 Ensure that as local primary care strategy develops that the requirements for our Ageing population are addressed along with ensuring that General Practice is a key part of the neighbourhood approach to delivering holistic care

QO5, QO6 30.04.19 Carolyn Ogle Jo Forrestall

4.8 Ensure that admission and discharge processes into the Acute Hospitals are efficient and seamless ensuring a "Home First" approach with robust direct pathways and signposting to alternative support where appropriate.


31.08.19 Jo Forrestall Debs Crohn

4.9 Ensure Continued suitable provision of community equipment is available to support the "Home First" approach and align these changes across the system.

QO5, QO6, AM8 31.08.19 Rosemary Leek

4.10 Falls- Further embed falls risk assessment across all providers. Respecify the elements of the Specialist falls service within Intermediate Care and clearly identify requirements for strength and balance element

AM1, AM2 31.08.19 Jo Forrestall Rosemary Leek

4.11 Raise public awareness of the importance of the last year of life across Doncaster, including awareness of dying, death, loss and bereavement and improving conversations.

QO8 31.03.20 Jo Forrestall

4.12 Influence and improve primary care management of palliative care patients aligned to changes to Primary Care Quality and Outcomes Framework (QOF) and increase Advanced Care Planning to improve end of life care


4.13 Following evaluation of community palliative care provision move to one access point for patients requiring support for palliative or end of life care with Community Single Point of Access (SPA) and Rapid Response and Enhanced Support respond to a patient in their last 72 hours of life


4.14 Continue to support all providers with the implementation of Recommended Summary Plan for Emergency Care & Treatment ReSPECT and monitor compliance and to work with community providers to explore which clinical roles are able to independently complete the ReSPECT form.






QO1 There will be an increase in people with Dementia whose care plan has been reviewed in primary care in the last 12 months to 80%(IAF 126b)


QO3 People aged 65 and over will report an improvement in their functioning and quality of life following the episode of care in the Intermediate Care patient outcomes tool (to be finalised in 2019-20). Baseline to be developed in 2019-20

QO4 More people aged 65 and over will report that they would be likely to recommend community services to friends and family. Baseline to be developed in 2019-20

QO5 There will be an Increase in people aged 65 and over being discharged to their usual place of residence in 2019-20 from 2018-19 baseline 92% acute, 68% Intermediate Care

QO6 There will be an Increase in the percentage of people aged 65 and over still at home 91 days after discharge from hospital into reablement/rehabilitation services (ASCOF 2(b) from baseline of 82%

QO7 There will be a reduction in the percentage of people who died and had 3 or more emergency admissions in the 90 days prior to death(IAF 105c) Baseline of 7.05% in 2017

QO8 The percentage of people recorded on the end of life pathway as dying in their preferred place of death will increase in 2019-20 -RDaSH 18-19 baseline 92.6% - this baseline may be reviewed in year as reporting from other services comes on line



AM1 There will be a 5%reduction in people aged 65 and over attending A&E, including those from care homes from 2018-19 baseline of 27,415. Care homes baseline to be developed during 2019-20

AM2 There will be a reduction in people aged 65 and over being admitted to hospital as an emergency, including those from care homes from 2018-19 baseline of 16,479. Care homes baseline to be developed during 2019-20

AM3 The average length of stay in hospital for people aged 65 and over will be maintained or reduced compared to 2018-19 outturn of 10 days (excluding 0 and 1 day length of stay)

AM4 There will be fewer delayed discharges of care for people aged 65 and over from Windermere and Coniston wards from the 2018-19 baseline of 1026 days

AM5 People aged 65 and over requiring a crisis response will receive it within 2 hours - to set a baseline during 2019-20

AM6 People aged 65 and over requiring an urgent response will receive it within 4 hours - to set a baseline during 2019-20

AM7 People aged 65 and over requiring Intermediate Care Services will have a service in place within 48 hrs - to set a baseline during 2019-20

AM8 Fewer people aged 65 and over will be re-admitted to an acute hospital as an emergency within 30 days from 2018-19 baseline

AM9 Fewer people aged 65 and over per 100,000 population will be permanently admitted to residential care. From 2018-19 baseline

AM10 Fewer people aged 65 and over per 100,000 population will be permanently admitted to long term care. From 2018-19 baseline



MEDICINES MANAGEMENT - Operational Delivery Plan: 2019-21

Medicines Management will support GP practices to deliver quality cost effective prescribing via its in-practice support team and at Clinical Commissioning Group (CCG) level.


Programme Name

Ref Key Milestones Outcome(s) the Action will Deliver


Finance and efficiency

1.1 Encourage safe prescribing that adheres to local formulary and appropriate cost savings through Optimise Rx system maintenance and usage, medication switches, deprescribing in Primary Care.

FS1, FS2, FS3, FS4, QO1 31.03.20 Alex Molyneux

National Guidance

2.1 Encourage patient self-care by restricting prescribing for self care, self limiting conditions and vitamins and minerals

AM1, FS5 30.12.19 Alex Molyneux

2.2 Deprescribing of drugs that have been deemed to have a limited clinical value from the NHS England approved list.

QO2 30.12.19 Alex Molyneux

2.3 Contribute towards the national agenda of reducing resistance to antibiotics through the quality care premium using Optimise Rx and quality premium dashboard

QO3 31.03.19 Alex Molyneux

Patient engagement

3.1 Empower patients to take more responsibility and control over their own medications and reduce waste by reviewing 3rd party ordering of prescriptions.

AM2 30.12.19 Jo Sanderson

3.2 Carry out polypharmacy reviews for vulnerable patients who are receiving over 15 repeat medications to improve quality of patients life and reduce waste on unnecessary medications.

AM3 31.03.20 V-Lin Cheong

3.3 Review patients with Chronic Obstructive Pulmonary Disease (COPD) to contribute to a reduction in exacerbations and hospital admissions.

AM4 31.03.20 Alex Molyneux

Links to other Delivery Plans

LD - 3.2 Stopping the Over Medication of People (STOMP) - Review of information and appropriate actions (reduction of anti psychotics in long term placements) and confirm system to measure impact on the prescribing savings plans within Primary Care.

AM1 & AM2 - Learning Disabilities Delivery Plan

31.03.20 Emma Price, Ian Boldy & Paul Tarantiuk

PC 2.1 Enable more patients in Doncaster to use online services to increase the ease in making appointments and ordering repeat prescriptions as well as having repeat medications dispensed directly where appropriate.

QO2 - Primary Care Delivery Plan

31.07.19 Wendy Lawrence & Carolyn Ogle

The accountability for this delivery plan sits specifically with NHS Doncaster CCG.





QO1 Optimise Rx Best Practice acceptance messages to reach average of 15% for the full financial year

QO2 Reduce the number of items prescribed in the list of drugs with limited clinical value to within 20% of the national average

QO3 To achieve the Antibiotic quality premium target - 30% reduction (or greater) in the number of Trimethoprim items prescribed to patients aged 70 years or greater on baseline data (June15-May16)



AM1 Reduce the number of items of Over the Counter medications that have been prescribed in Primary Care by 20% per quarter on average

AM2 80% of practices to be signed up to the new ordering process of prescriptions.

AM3 Reduce the number of people who are prescribed 15 medications or more by 50%

AM4 100% of practices offered the review service for patients with COPD with a target of 50% of practices to received reviews by 31st March 2020.



FS1 Achieve at least £2.2m for the medicines management Quality, Innovation, Productivity and Prevention (QIPP) plan with the aim to reach for the target of £3.3m

FS2 QIPP Savings made though Optimise Rx system - Target £180k

FS3 QIPP Savings to be made through switches- Local and Integrated Care Systems - Target £1.4m

FS4 QIPP Savings to be made through deprescribing of medications - Target £695k

FS5 QIPP Savings to be made thorough restriction of prescribing medications that are available over the counter - Target £900k

the doncaster health and social care - microsoft · 2019-12-06 · delivery plans contents 4 the...

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