http://www.kirklees.nhs.uk/fileadmin/documents/About_Us/KPCT_Strategic_Plan_web.pdf_lowres by NHS Kirklees

Ambitions for a Healthy Kirklees

Five year Strategic Plan 2008 - 2013

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Contents Section 1

Foreword by the Chairman and Chief Executive Executive Summary

9 11

Section 2

Vision and Values

2.1

NHS Kirklees

2.2

Vision 2.2.1 2.2.2 2.2.3 2.2.4

12 12 13 13 14

2.3 Section 3

Medium to Long Term Changes How These Changes Address Local Health Needs Joint Strategic Needs Assessment Investment Plans

PCT Values

Context 3.1 Public Expectations and Political Drivers

15 15

3.2

Population, Demographics, Health Needs and Clinical Quality 3.2.1 System Alignment - Partnerships and Shared Goals 3.2.2 Comprehensive Area Assessment (CAA) 3.2.3 Safeguarding Children and Vulnerable Adults 3.2.4 Community Engagement 3.2.5 Health Challenges 3.2.6 Reducing Health Inequalities 3.2.7 Locality Working 3.2.8 Improving Access

16 18 20 20 20 21 21 22 24

3.3

Insights from Service Users, Public, Clinicians and Local Partners 3.3.1 Service User and Public Engagement 3.3.2 Clinical Engagement and Leadership

25 25 26

3.4

Existing Targets and Local and National Health Priorities 3.4.1 Local Priorities 3.4.2 National Priorities – NHS Next Stage Review – Healthy Ambitions 3.4.3 Business Planning

27 28 28

3.5

Provider Landscape 3.5.1 Developing the Market 3.5.2 Choice and Diversity of Service 3.5.3 Care Closer to Home

29 30 31 31

3.6

Financial Situation

3.7

Current Year’s Commissioning Activity

Section 4

Strategy

4.1

Goals

4.2

Programmes 4.2.1 Delivering our Vision 4.2.2 World Class Commissioning 4.2.3 Proposed List of Indicators 4.2.4 Rationale for Choosing Outcomes

40 40 40 41 42

4.3

Impact on Health Outcomes and Inequalities 4.3.1 Summary of Key Inequalities from our JSNA 4.3.2 Priority Programmes – focus on out of hospital care

42 42 44

4.4

Choosing Health – Programme Summaries 4.4.1 Food 4.4.2 Accident Prevention 4.4.3 Alcohol 4.4.4 Better Health at Work 4.4.5 Obesity 4.4.6 Oral Health 4.4.7 Physical Activity 4.4.8 Self Care and Expert Patient Programme 4.4.9 Sexual Health 4.4.10 Tobacco 4.4.11 Women of child bearing age 4.4.12 Social Marketing

45 47 48 49 50 50 51 52 54 55 56 57 58

4.5

Infection Control

4.6

Long Term Conditions 4.6.1 Background 4.6.2 How is this programme delivering the PCT’s goals? 4.6.3 The Long Term Conditions Pathway 4.6.4 Generic Care Pathways 4.6.5 Long Term Conditions – Programme Summaries • Primary prevention of cardiovascular disease • Stroke • Respiratory • Diabetes • Neurology • Coronary Heart Disease

60 60 60 62 62 65 65 66 67 68 69 70

4.7

Healthy Pregnancy and Maternity Services Strategy 4.7.1 Background 4.7.2 How is this programme delivering the PCT’s goals?

72 72 72

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

4.8

Children and Young People’s Strategy 4.8.1 Child Health Promotion Programme 4.8.2 Parenting Strategy 4.8.3 Teenage Pregnancy Strategy 4.8.4 Disabled Children Personalised Care 4.8.5 Emotional Health and Well-Being 4.8.6 Specialist Commissioning

75 75 76 76 76 76 77

4.9

Mental health 4.9.1 Vision for Mental Health 4.9.2 Ways of Working 4.9.3 Objectives 4.9.4 What We Have achieved 4.9.5 What We Will Achieve 4.9.6 How is this programme delivering the PCT’s goals? 4.9.7 Specialist Commissioning

78 78 78 79 79 80 80 81

4.10

Learning Disabilities 4.10.1 Vision and Values 4.10.2 What We Have Achieved 4.10.3 What We Will Achieve 4.10.4 How is this programme delivering the PCT’s goals?

82 82 82 83 84

4.11

Physical and Sensory Disability 4.11.1 Background 4.11.2 What We Have Achieved 4.11.3 What We Will Achieve 4.11.4 How is this programme delivering the PCT’s goals?

85 85 85 86 86

4.12

Drugs and Alcohol Commissioning Strategy 4.12.1 How is this programme delivering the PCT’s goals?

87 87

4.13

Primary care 4.13.1 General Medical Practice 4.13.2 Dentistry 4.13.3 Community Pharmacy 4.13.4 Optometry 4.13.5 Medicines Management 4.13.6 How is this programme delivering the PCT’s goals?

89 89 90 91 92 93 94

4.14

Urgent Care 4.14.1 Background 4.14.2 What We Have Achieved 4.14.3 What We Will Achieve 4.14.2 How is this programme delivering the PCT’s goals?

96 96 96 96 97

4.15

Planned Care Including Cancer and Palliative Care 4.15.1 Background 4.15.2 What We Have Achieved 4.15.3 What We Will Achieve 4.15.4 How is this programme delivering the PCT’s goals?

99 99 99 99 100 5

4.16

Section 5

Specialist Commissioning for Bariatric, Cancer and Cardiac Care 4.16.1 Bariatric Surgery for Morbid Obesity 4.16.2 Cancer 4.16.3 Cardiac Care 4.16.4 Renal Services

102 102 102 102 103

Delivery 5.1 Past Delivery Performance

104 104

5.2

Risk Management

104

5.3

Financial Risk 5.3.1 Mitigating Actions

105 105

5.4

In Year Monitoring

106

5.5

Commissioning Approach 5.5.1 Development of Commissioning Action Plans 5.5.2 The Health Improvement Team (HIT) approach 5.5.3 Purpose of the HIT Group 5.5.4 Objectives 5.5.5 Business Planning

107 107 108 110 110 110

5.6

Practice Based Commissioning 5.6.1 Introduction 5.6.2 Local Context 5.6.3 What Will Successful PBC Deliver? 5.6.4 Approach to the Kirklees PBC Strategic Framework

112 112 112 112 112

5.7

Workforce Planning 5.7.1 Introduction 5.7.2 Workforce Planning at NHS Kirklees 5.7.3 Achievements in 2008 5.7.4 Current Workforce Risks and Priorities 5.7.5 Evolution of Workforce Planning at NHS Kirklees 5.7.6 Conclusion

114 114 114 114 115 116 117

5.8

Communications and Engagement

118

5.9

Changes in Technology

119

5.10

Estates issues

120

5.11

Procurement Strategy

121

Section 6

Conclusion 6.1 Overall Impact Against Our Strategic Goals

123 123

Section 7

Board Approval 7.1 Declaration of Board Approval 7.2 Formal Sign Off of this Plan

125 125 125

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

List of Tables: Table 1: Kirklees Population by Age Group, 2006 and 2018 Projections Table 2: Kirklees Key Health and Well-being Issues Table 3: Locality Health Inequalities Summary – Children and Young People 2007 Table 4: Locality Health Inequalities Summary – Adults 2007 Table 5: Additional Investment 2009-10 to 2012-13 Table 6: Our Chosen World Class Commissioning Outcomes Table 7: Key Priority Areas Table A1: Table A2: Table A3: Table A4: Table A5: Table A6: Table A7:

Batley, Birstall, Birkenshaw: Population by Age Group Denby Dale and Kirkburton: Population by Age Group Dewsbury and Mirfield: Population by Age Group Huddersfield North: Population by Age Group Huddersfield South: Population by Age Group Spen Valley: Population by Age Group The Valleys: Population by Age Group

17 21 23 23 36 41 44 127 130 132 136 139 142 144

List of Figures: Figure 1: The rainbow model of well-being and health Figure 2: Local Area Agreement Priorities Figure 3: A Map of the Seven Localities of Kirklees Figure 3: The Four Tier NHS Service Model Figure 4: Generic Pathways for Long Term Conditions (LTC) Figure 5: Primary Medical Care Expenditure 2007 / 2008 total expenditure (excluding premises) per patient (weighted population) Figure 6: The Kirklees Strategic Commissioning Process

109

Figure A1: Figure A2: Figure A3: Figure A4: Figure A5: Figure A6: Figure A7: Figure A8:

A Map of the Seven Localities of Kirklees Batley, Birstall, Birkenshaw: Locality Providers Denby Dale and Kirkburton: Locality Providers Dewsbury and Mirfield: Locality Providers Huddersfield North: Locality Providers Huddersfield South: Locality Providers Spen Valley: Locality Providers The Valleys: Locality Providers

126 129 131 134 137 140 143 145

Appendices Appendix 1 The Kirklees Localities – Profiles and Priorities for the Future

126 126

Appendix2

Approach to the Kirklees PBC Strategic Framework – detailed action plan

147

Appendix3

Glossary of abbreviations

149

18 19 22 32 64 89

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Section 1

Foreword by the Chairman and Chief Executive Welcome to our five year strategic plan – ‘Ambitions for a Healthy Kirklees’ Kirklees Primary Care Trust – also known as NHS Kirklees – is the leader of the local NHS. We are responsible for improving the health of our population, reducing health inequalities, and ensuring that health services are in place to meet the needs of local people. This plan sets out our aims for the coming five years and the actions we plan to take to improve the health and well-being of all the people in Kirklees. In taking forward our plans, we are driven by the following goals: • To place the person at the centre of everything we do; • To improve health and reduce health inequalities; • To improve quality and promote safety; • To promote choice and accessibility; • To work well in partnership with communities, individuals and their families, staff and organisations; • To promote local sensitivity through effective commissioning; • To promote strong clinical leadership; • To drive service re-design and innovation;

• To be a visibly credible organisation, operating to the highest standards. We are committed to partnership working as we recognise that this is the only way to achieve real success for Kirklees. In particular, we have a strong relationship with Kirklees Council, including a Joint Director of Public Health. This partnership is helping us focus our attention on making improvements in health and reducing the health inequalities that exist across Kirklees. Kirklees is an interesting and diverse area. Many of the people living within our boundaries identify closely with the locality in which they live, rather than with Kirklees as a whole. Together with the Council, we recognise this by working in partnership in the seven distinct localities that make up the borough of Kirklees. This plan sets out details of the actions we plan to take at locality level, as well as those focused on Kirklees as a whole. We know that there are health inequalities avoidable gaps in health outcomes experienced by different groups of people within Kirklees. A strong feature of this plan is our commitment to narrow these gaps. Over the next few years, this will mean a stronger targeting of resources to ensure that everyone has access to the opportunities and services they need, to improve equality of outcomes. We have also published supporting plans covering finance, workforce, organisational development and communications. These plans should be regarded as an initial statement of how we expect services to evolve over the next few years. They demonstrate our recognition of the need to evolve and respond to our communities, technological changes, clinical advances and

external factors. Therefore, this five year strategic plan will be subject to ongoing review and updated as needed to reflect changes both within Kirklees and externally.

Rob Napier Chairman

Mike Potts Chief Executive, NHS Kirklees

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Executive Summary This five year strategic plan has been produced by NHS Kirklees, the PCT which serves the population of Kirklees in West Yorkshire. It sets out our ambitions for improving the health and well-being of the people of Kirklees up to 2013/14 and ensuring better delivery of health care services. This plan looks forward over the next five years. It sets out a vision for the future local delivery of NHS services and is founded on the recognition that the NHS is a system rather than an organisation. This means that we must work closely with local partners and stakeholders to deliver accessible, safe and high quality services across the area. Our commitment to these partnership principles underpins this plan. This plan clearly explains the actions we will take to improve local health outcomes and reduce the health inequalities as identified in the local Joint Strategic Needs Assessment (JSNA)1 jointly published by NHS Kirklees and Kirklees Council. It sets out our early priorities for investment and service development and describes how we will make planned changes. It is supported by our medium term financial plan, our organisational development plan and by this and subsequent years’ annual operating plans. It also sets out:

• our approach to implementing national priorities and existing commitments; • a service baseline for each locality, with gaps identified and priorities made clear; • an overarching framework to guide our commissioning strategy for primary, community and secondary care; • strategic direction for decisions on investment in people, IT and the estate. The PCT Board advised by the Professional Executive Committee have played a central role in the development of this plan which was officially endorsed by the Board at their meeting on the 29th October 2008. The plan will be reviewed annually as part of the business planning process to ensure it reflects changes in national or local priorities, progress in implementation, resource availability and disposition and other relevant developments or changes. In this way, the plan will continue to guide future decisions on investment, commissioning and prioritisation. The Board will establish a dedicated sub-committee to oversee the implementation and ongoing review of this Strategic Plan. This plan is for the information of our key partner and stakeholder organisations. We will also produce a summary version for local people.

• the areas where we will need to work closely with partners if we are to achieve our joint objectives for improved health and well-being in Kirklees;

The Kirklees Joint Strategic Needs Assessment (JSNA) Report and Summary Document published jointly by Kirklees PCT and Kirklees Council on 27 February 2008. 1

Section 2

2.2

Vision and Values

Working together to achieve the best health and wellbeing for all the people of Kirklees

2.1 NHS Kirklees Kirklees PCT was established in October 2006 from the three former PCTs in Huddersfield and North Kirklees. We are the custodians of the National Health Service in Kirklees and this is reflected in our name - ‘NHS Kirklees’. We have the same boundaries as Kirklees Council and we both organise our work across the same seven localities. We serve a population of some 400,000 people which is expected to grow by a further 33,000 by 20182. We are responsible for improving the health and well-being of local people and making sure that NHS services are in place to meet their needs. We commission services from others, including GPs, dentists, pharmacists, optometrists, voluntary organisations and local and specialist hospitals. We are accountable for ensuring that these services are accessible, high quality and safe.

Vision

Our vision will ensure that NHS Kirklees works together – individually, and with our partners - to achieve this vision. 2.2.1 Medium to Long Term Changes Over the period covered by this plan (and beyond) we want to achieve changes which further our goals. We have a shared ambition with Kirklees Council and other partners that by 2020 Kirklees will: • be recognised in West Yorkshire and beyond as an area of major success; • have a strong economy supported by an attractive, high quality environment, offering the best of rural and urban living; • place a high value on creativity and learning; • comprise communities who are proud of their past, but enjoy diversity, are outward looking and face the future with optimism; • be a safe, healthy and supportive place to live and work for both young and old people, with a clear commitment that all should share in this success.

ONS 2006-based population forecasts (whereas the Kirklees Joint Strategic Needs Assessment, published in February 2008, uses ONS 2004-based forecasts).

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

2.2.2 How These Changes Address Local Health Needs The Kirklees Partnership, of which NHS Kirklees is a key player, recognises national and international trends that are affecting our area and describes the key challenges as being: • climate change – tackling our contribution to and planning to adapt to the impact of climate change; • ageing population and an increase in dementia; • changing economic context. In addition, key issues are emerging that are holding Kirklees back as an area. To move towards a more sustainable Kirklees and achieve the 2020 vision, we must narrow the gaps inherent in: • infant mortality and other health inequalities including a life expectancy below the national average; • educational attainment; • a low skill, low wage economy; • lack of confidence in some of our towns (particularly in North Kirklees – Dewsbury and Batley); • community relations. 2.2.3 Joint Strategic Needs Assessment In our Joint Strategic Needs Assessment (JSNA), published jointly with Kirklees Council in February 2008, we describe the future health and well-being needs of the local population. The JSNA signalled our intention to have strategic plans led by health needs. This five year strategic plan is a first step on that journey which involves

asking ourselves a number of key questions: • What are the particular issues for the specific population groups we have identified? For example, older people and young people; • What are the key health challenges our local communities will face as a result of housing, employment, income, transport, communications and climate change? • What are the key themes emerging from our existing mechanisms to give local people a ‘voice’? • What is the future shape of the population, especially in terms of age, ethnicity and migration patterns? What impact will this have on the major issues we have already identified, and will it throw up others? • How have the key issues we have identified changed over time and how will they change over the next 5/10/15 years? • What are the key challenges involved in supporting people to feel in control in relation to their health and social care issues? For example, what attitudes do different client and professional groups have to the increasing emphasis on self care? • What are the potential impacts of changes in health and social care technology and care practice? The JSNA and this plan are working to provide answers to these questions.

2.2.4 Investment Plans Realisation of our ambitions for the people of Kirklees and the pace of change will both depend significantly on the financial resources available to us in the next five years. We start from a sound position. We are in recurrent financial balance, and achieved a surplus in 2007/08. Our Medium Term Financial Plan 2008/09 – 2012/13 provides for a surplus in each of those years. Beyond that, to achieve our goal of offering high quality services to all local people we will need to target new investment on those localities and communities which are currently less well served. We shall do so transparently and will draw on the analysis which underpins this plan and similar future analysis of all local NHS services. All new investments are subject to the governance processes of the PCT. Business cases from service leads and practice based commissioners must demonstrate how their investment will meet the PCT’s objectives. They must show stakeholder engagement, have appropriate clinical engagement and demonstrate value for money. The PCT has significant value for money opportunities as demonstrated in the Better Care, Better Value indicators and many of our investments will improve efficiency as well as improving health, and reducing avoidable gaps in local health.

2.3 PCT Values Our vision is underpinned by our values. These are to: • recognise that people are at the heart of everything we do; • support people in taking responsibility for their own health and well-being; • encourage innovation and continuous improvement and celebrate the contribution made by our staff; • encourage open, clear and honest communication; • value diversity and challenge discrimination; • show understanding, dignity and respect for all our clients, partners and staff; • be accountable for the decisions we make, the work we do, the resources we use and our impact on the environment.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Section 3

Context 3.1

Public Expectations and Political Drivers Public expectations of the NHS – and indeed other public services – continue to rise. Service users and local people are increasingly active rather than passive. This is illustrated through a number of themes: • increased focus on being person centred encourages an expectation that the service user will have a much stronger role in determining how, where and by whom services are delivered; • emphasis on individual choice and the availability of comparative information to support informed decision making; • service user involvement in identifying needs and creating solutions in driving service development or to reward providers who are reinforcing and formalising the strengthened role of the service user; • the role of new technology, e.g., improving communication between service user and professional and enabling remote and/or selfmonitoring of conditions. At the very least this means planning on the basis that more services will be offered and delivered at or closer to people’s homes; more professionals will be based in the community so access is much easier. These developments are evident in Kirklees as elsewhere – e.g., the initial national GP service user survey in 2007 identified an unmet demand for access to GP services at

weekends and especially in the evening. We are ready to meet the challenges which this and other developments present. We also recognise that the period covered by this plan extends beyond established financial planning and political horizons of three and four years respectively. In addition, policy on the delivery of health services is, of course, subject to political change. These political factors make long term planning more difficult. However, there are a number of areas where there appears to be consensus, e.g.: • a shared commitment to the NHS being a publicly funded service which is free at the point of delivery; • person centred support and a greater say for individuals in planning their care; • prevention of ill health and actions to support remaining healthy, as well as prompt detection, treatment and dealing with the consequences of ill health; • supporting people to self care wherever possible; • increased individual choice (from a broad range of providers) and funding following the service user; • a greater focus on quality, safety and improved service user experience; • easy and convenient access; • separation of commissioning and provider functions in the PCT; • localisation of planning and prioritisation in PCTs, local authorities and other commissioners of services;

• plurality of provision and a degree of competition among providers; • an increasing shift towards out of hospital provision of services and care closer to home; • quality assurance through good commissioning, robust clinical governance, systematic contract and performance management and consistent, transparent and independent external regulation; • integrated, holistic and area-based performance assessment (e.g., through Comprehensive Area Assessment); • key national or local targets; and • primary and community services as the cornerstone of the wider NHS and care systems.

3.2

Population, Demographics, Health Needs and Clinical Quality Kirklees comprises both urban and rural communities with a total population of over 400,000. We have a total budget of £550 million in 2008/09 and it is imperative that we invest this, and future budgets in the years to come, wisely to reduce health inequalities and ensure high quality care is available for our population. The towns and valleys of Kirklees have their own strong and distinct identities and contain a rich and diverse mixture of cultures and faiths. This diversity, coupled with our complex links to major regional centres, creates unique opportunities and challenges for our district. Kirklees’ population is both increasing and ageing. (Table 1) By 2018, the population is predicted to increase by 33,000 (8%) - a bigger projected increase than the 25,000 (6%) growth forecast when the JSNA was first published. There are some notable variations across age groups. The projected increase ranges from 5% for the number of 0-20 year olds and 20-64 year olds, to an increase of 26% in over 65s. By 2018, one in four people will be under 20, more than one in two will be aged 20 – 64 and one in six will be aged over 65. This change in local demography will have a major impact on both service delivery and the ability of local health care organisations to attract, train and retain staff.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Table 1: Kirklees Population by Age Group, 2006 and 2018 Projections3 % change in population in age group Change in % 2007 and by age group 2018 2007 to 2018

2006 Total

2018 Total

Population Difference 2007 to 2018 (000s)

Under 20

105,000

26.2

110,400

25.4

+5,400

+5.1

-0.8

20 – 64 years

236,800

59.1

248,900

57.4

+12,100

+5.1

-1.7

65 – 84 years

51,200

12.8

64,500

14.9

+13,300

+26.0

+2.1

85 years plus

7,600

1.9

9,700

2.2

+2,100

++27.6

+0.3

400,600

100.0

433,300

100.0

+32,700

+8.2

0.0

58,800

14.7

74,200

17.1

+15,400

+26.2

+2.4

Age Group

Total All 65 and over

Overall, the numbers of births are static, but increasing among families of South Asian origin. More than one in five young people under 19 are now of South Asian origin, whilst 86% of the total population overall are white. The population is relatively stable, although there has been some immigration – e.g. Kurdish and Hungarian immigrants mainly based in Dewsbury and Polish immigrants settling in Huddersfield. Often, these immigrant populations have particularly challenging health needs (especially in the case of asylum seekers and refugees) and we need to be mindful of these needs in planning services. Kirklees has a diverse ethnic mix, with a higher proportion of our population from an ethnic minority than for England as a whole. It is difficult to be precise about specific numbers of people across ethnic groups but estimated figures in 20054 indicate that 15.5% of Kirklees’ population is from an ethnic minority, compared to the England average of 10.9%. The biggest such local populations are those with Pakistani (6.9%) or Indian (4.2%) origins.

ONS 2006-based sub-national population projections 2006-18 Source - Office for National Statistics Experimental Population Estimates by Ethnic Group for Council districts and higher administrative areas in England for 2005. 3 4

3.2.1 System Alignment - Partnerships and Shared Goals Fig. 1

We know we cannot achieve the best health and well-being for local people on our own. In the Kirklees Health and Wellbeing Inequalities Strategy, the Rainbow Model illustrates the broad range of factors that impact on an individual’s health (Fig. 1). As the model indicates, health care services make an important contribution to improved health and well-being - but other factors, not least personal behaviours, are just as important. Inequalities exist between people – both in avoidable gaps in health and in the factors that profoundly affect health. The Kirklees Partnership is crucial in tackling these inequalities as part of its aim to achieve the health and well-being of local people. We must ensure that those most at risk or in need have real equality of opportunity.

The vision for health and well-being inequalities is that people across Kirklees stay as healthy as possible by: • feeling more able to look after themselves, more in control of managing their problems and more able to make healthy choices; • being able to easily choose and access the type of opportunities and help they need, when they need it; • having opportunities for social support and being involved, so participating fully as members of their communities, as defined by them personally; • ensuring those most at risk or vulnerable have opportunities available to them to help reduce their risk or vulnerability and narrow the avoidable gaps in experience; and • having appropriate access to education, jobs, transport, housing, health care and a decent environment to live and work in.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

The contribution of NHS Kirklees focuses especially on the two themes of children and young people and healthier communities and older people, but also safer and stronger communities as well as regeneration as the PCT is a significant local employer.

We must work closely with our local partner organisations to tackle the health and wellbeing challenges facing Kirklees people and we are actively involved in the leadership and activities of the Kirklees Partnership. Kirklees Partnership themes are: • economic development and the environment; • safer and stronger communities; • children and young people; and • healthier communities and older people.

In the coming years we will build on established relationships and forge new ones to ensure that our services are of the highest quality and are integrated with or align closely with those of partner organisations. This will be particularly important in ensuring that services are tailored to meet the needs of individuals.

The Local Area Agreement (LAA) is the main vehicle by which the Partnership wil ensure delivery of local action to tackle these challenges. Fig. 2: Local Area Agreement Priorities E S AF

R ST

RONGER COMMUNI

TIES

Crime, anti social behaviour & fear of crime Reducing re-offending

Cohesive Communities

Substance misuse including drugs & alcohol

m ic a ll y S tr

CO M

Cohesive Communities

R H IE

Older people living independently

LE Healthly minds & bodies Improving the life chances of vulnerable children & young people

CHI

Mental well being

Opportunities for young people to enjoy themselves

Reduce worklessness

T AL

OP & Y O UNG PE

Dive

Young People

een

Healthy lifestyles

Education attainment & progress

Yo u ng

Maternal Health

MUNITIES & OLDE

Resident satisfaction with their local area

L DR EN

Strong community & vibrant voluntary sector - Volunteering

Increase skill levels of the working age population Combating climate change Affordable homes

Grow local businesses

Reduce waste & increase recycling

Local transport

IC D R EV E L NV I OP M ENT & T HE E

M ON

3.2.2 Comprehensive Area Assessment (CAA) The planned introduction from 2009 of Comprehensive Area Assessment (CAA) will be an important driver of change. CAA will look at the public services delivered by councils, the NHS and their partners including the private and voluntary sectors. CAA will provide assurance about how wellrun local public services are and how effectively they use public money. But it also aims to be more relevant to local people by focusing on issues that are important to their community. It is intended to: • develop a shared view about the challenges facing an area, such as crime or health challenges such as obesity; and • create a more joined up and proportionate approach to public service regulation. We therefore welcome CAA and are one of ten areas piloting the new system in 2008/09. 3.2.3 Safeguarding Children and Vulnerable Adults NHS Kirklees (NHSK) is committed to working with partner agencies to safeguard and promote the welfare of children, young people and vulnerable adults. Every person has the right to live free from abuse and neglect. This right is underpinned by the duty placed on public agencies under the Human Rights Act (1998) to intervene proportionately to protect the rights of citizens. NHS Kirklees has developed a five-year Safeguarding Strategy which covers: • statutory responsibilities; • commissioning function;

• provider function; • contracted services function; • working with other agencies. It outlines ongoing work and actions in relation to service and workforce development and details how these actions will be reviewed and monitored. This provides assurances that NHS Kirklees is meeting its statutory responsibilities, commissioning and providing services fit for purpose and achieving equality in outcomes for these vulnerable groups. This safeguarding strategy reflects our vision to work together to achieve the best health and well-being for people in Kirklees. It clearly encompasses our strategic priorities by ensuring the work programme for the next five years incorporates: • working in partnership with local people and partner agencies to promote, protect and improve health and reduce inequalities; • involving staff, service users and communities in identifying their needs; • making sure services are available and delivered safely to a high standard; • encouraging new ways of service delivery that offer choice; • ensuring services are evidence based; and • developing a learning environment. 3.2.4 Community Engagement We are committed to work closely with other partners in the locality communities. In addition, we would like to go further and offer local communities as well as individuals a greater say. We envisage the local community as being a key partner and intend to explore new ways of working with local communities. We believe that as technology enables better and more timely communication with local people and

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

service users, we will be able to engage directly with our local communities, and enable them to take responsibility for their own health and well-being. This will also allow communities a much greater and more direct say in service development. Within the timeframe of this plan we expect that such engagement will become established and replace our historic reliance on public consultations about specific proposals for changes to services, as set out in our communications and engagement strategy and plans.

3.2.6 Reducing Health Inequalities Health inequalities are health differences between people which can be changed. Change depends on the control that people felt they have over factors that prevent ill health, as well as the opportunities they feel they have to control such factors. If we are to make a difference and narrow inequalities in health, we need to:

3.2.5 Health Challenges Local people face a range of health and well-being challenges across Kirklees. These are set out in the JSNA and table 2 below summarises them.

• be person centred, focusing on equality of outcomes; • involve local people in creating and delivering solutions; • develop our response to issues where we are not meeting current or future needs; • work more closely with local partners to help them meet current or future levels of need;

Table 2: Kirklees Key Health and Well-being Issues Areas where action is underway but more effective targeting is needed to address inequalities

Areas which are key issues for children and young people

heart disease & stroke

emotional well-being

diabetes

obesity

food

smoking

food

alcohol

physical activity

alcohol

Areas where our current response is under-developed to meet current or future needs Being healthy – conditions

mental-health & emotional well-being obesity pain including musculo-skeletal dementia

Personal behaviours

smoking physical activity Living and working – wider factors

housing condition and options

educational attainment

employment isolation and social networks educational attainment

• target our actions more effectively to ensure we reach those most in need; • gear up our programmes which support older people and those with long term conditions to address the challenge of a growing ageing population; • target our resources to reduce inappropriate variations in investment across our area, particularly where lower investment sits alongside poorer health outcomes; and • use our commissioning function and opportunities in the new primary care contracts to tailor services to meet the needs of the practice and locality populations. This requires two key sets of actions: 1. A culture shift across organisations, working in partnership to be person centred, involving people in identifying issues and creating solutions, focusing on those most in need. 2. The development of targeted interventions to tackle the local challenges to health and well-being inequalities that have the most significant impact, as identified by the JSNA. 3.2.7 Locality Working As explained earlier, we are increasingly planning, commissioning, managing and reviewing services at locality level. The seven localities in Kirklees are (Fig. 2): • Batley, Birstall and Birkenshaw (BBB) These comprise two sub-localities – Batley (B) and Birstall and Birkenshaw (BB) – reflecting the distinct demographic features of the two communities

• Denby Dale and Kirkburton (DDK) • Dewsbury and Mirfield (D&M) These comprise two sub-localities – Dewsbury (D) and Mirfield (M) – reflecting the distinct demographic features of the two communities • Huddersfield North (HN) • Huddersfield South (HS) • Spen (S) • The Valleys (Vall)

Fig.3: A Map of the Seven Localities of Kirklees. Batley, Birstall and Birkenshaw Spen

Dewsbury and Mirfield

Huddersfield North Huddersfield South

The Valleys

Denby Dale and Kirkburton

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Table 3: Locality Health Inequalities Summary – Children and Young People 2007 Issues Infant deaths Rotten teeth – 5year olds+ Mums smoking at birth 14 year olds Physically inactive Smoking weekly Happy to smoke* Alcohol weekly* Drink alone Using drugs Teenage conceptions Had sex Felt miserable Felt angry Poor relationships – school staff Unhappy with self Do not have someone to talk to Bullied past 2 months Not 5 GCSEs grade C+

DDK

Spen

Vall

Spen

Vall

Shaded boxes show where a locality is significantly worse than the Kirklees average * Of those who smoked or drank + Decayed, missing or filled average number of teeth

Table 4: Locality Health Inequalities Summary – Adults 2007 Indicator Being Healthy Role functioning Pain problems Depression, anxiety, nervous illness Cancer registration breast Heart disease aged under 65 Heart, stroke deaths aged under 75 High blood pressure Stroke Asthma Diabetes Obesity Cancer deaths aged under 75 Deaths all causes 15-64 Personal Behaviours Smoking Alcohol excess Males Alcohol excess Females Enough physical activity Living and working Low income Housing - overcrowding

DDK

Shaded boxes show where a locality is significantly worse than the Kirklees average 23

Appendix one gives a full breakdown of the health issues by locality, and describes actions being taken to address them. 3.2.8 Improving Access We aim to offer Kirklees people responsive, prompt and convenient access to services (including weekends and evenings). This means we need to ensure that there is sufficient service capacity locally and that providers are organising and managing themselves to deliver services which are sensitive to their service users’ needs and preferences. This includes reversing the inverse care law, i.e. where those most in need experience weaker services. To achieve this, we want to ensure that: • People have the opportunity to access their GP practice during evenings and weekends for routine care and have access to effective care out of hours (overnight, weekends and public holidays). - Some initiatives have begun already, such as procurements of new GP led health centres, commissioning of additional dental services, investment in mental health, and extended GP opening hours with the majority of local practices now offering some additional access. • Urgent care needs can be met away from hospital settings where appropriate, with the service tailored to reflect local needs and factors such as geography and travelling times. - We will be working with partners and local service providers to review urgent care provision and agree a strategy for the future. This work will begin in late 2008.

• The services we commission meet national standards such as 18 weeks from referral to treatment, maximum four hour wait in A&E and GP appointments within 48 hours. When resources and capacity allow, we will seek to exceed these national standards. Where necessary, we will address shortfalls in performance.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

3.3

Insights from Service Users, Public, Clinicians and Local Partners

3.3.1 Service User and Public Engagement As part of World Class Commissioning we are committed to increasing service user and public engagement and greater clinical involvement throughout the commissioning process. Increased clinical and service user input, combined with a more accurate assessment of long term local requirements, ensures services are more closely designed to meet evolving service user needs and provide a good experience of the NHS in Kirklees. We will therefore engage actively with local people. We already speak regularly to local people about their health and the sort of services and support they need. We have also started, through a social marketing approach, to help local people have healthier personal behaviours. Examples of this include: • working with groups of people in our localities to develop locality plans; • public consultations on major changes to services, e.g., Looking to the Future (2005/06 and continuing); • public consultations on more local changes to services, e.g., on the future of Liversedge and Slaithwaite Health Centres (early 2007); • urgent care consultation (spring 2007);

monitor quality and accessibility. The findings identify needs, show whether services are up to standard and if individuals are experiencing a good level of care; • creation of an Expert Patient Support Group to encourage better health through peer support; • establishment of a Readers’ Panel to ensure that our public information leaflets are easy to read and understand; • consultation on the introduction of GP led health centres; • a diabetes survey to obtain feedback for action on the care and support which local people with diabetes receive; • Patient Public Involvement Forum/ LINks; • Specific focussed consultations within communities whether issue or sociodemographic specific; • The local Overview and Scrutiny Committee. The communications plan reflects and addresses issues arising from our continuing service user and public involvement work. It will also raise new concerns which will require further public engagement and discussion with partner organisations before crystallising into firm service development commitments. We will ensure that this happens.

• service user surveys – whether organised nationally or locally by ourselves or by providers. We work with practices on a regular basis to

In planning services for the future, we will work closely with our local hospital trusts to ensure that our service users have access to the range of services they need, and that services are easily accessible, safe and of high quality. People should only attend hospital if the care they need cannot be safely provided in a community setting or in their own home. In all cases we will work closely with local communities when we need to review existing services, or are considering proposals for service reconfiguration or investment.

We are already embedding clinical leadership into our commissioning processes. For example, we have: • appointed clinical leads in some of our health priority areas, e.g., mental health, long term conditions and musculo-skeletal services;

3.3.2 Clinical Engagement and Leadership Local clinicians have a key role in assessing local needs and shaping priorities. Their professional experience of delivering care, combined with their understanding of service users’ needs, will be crucial to designing high-quality, personalised health and care services. In Kirklees, we are fortunate in having a number of clinicians already engaged in commissioning – e.g. as members of the Professional Executive Committee (PEC), through practice based commissioning (PBC), and as clinical leaders in their own specialist areas. The PEC plays a key role in ensuring the Board receives appropriate clinical advice and support in undertaking its statutory responsibilities. The involvement of clinicians through Practice Based Commissioning is also vital to our success. Practice based commissioners, working closely with NHS Kirklees and other clinicians, will lead the work in shaping clinical outcomes. They will also play a key supporting role in assessing local needs for the practice and locality populations, helping to decide local priorities, and designing care.

We are committed to working in partnership with our local clinicians and to supporting their development, in a way that will help drive innovative commissioning. As a result, we will see new service models and providers, promoting greater choice, centred on the needs of the individual within an environment where innovation thrives and where safety and assured quality are pre-requisites.

• demonstrated our commitment to PBC by putting in place the management capacity to support its development and actively promoting joint working between PBC and NHS Kirklees. Wideranging programmes are being addressed through our Health Improvement Teams and this commitment is reflected in the positive results reported in successive PBC surveys5. These show that most practices are supportive and are actively engaged; • approved a number of proposals for service re-design developed by PBC teams, e.g. the introduction of consultant-led specialist outreach clinics in practice, and new models of care for people with diabetes; and • ensured clinicians are involved in tendering exercises, e.g., for GP out of hours services, the new GP led health centres and intermediate care bed provision.

DH quarterly practice surveys- wave 4 survey published by DH on 4 August 2008

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Through the NHS Next Stage Review, GPs and other clinicians from Kirklees contributed to all those work streams in a process managed across Yorkshire and the Humber. A priority for the future is to facilitate the involvement of PBC in our locality working. This approach will further strengthen relationships with key local partners, particularly Kirklees Council, and ensure better links between different aspects of care so that overall care solutions are more personalised and effective. To secure best alignment of local systems we have considered seeking closer convergence between our local PBC structures and the seven localities. In doing so we recognise that PBC consortia are founded in relationships between practices as well as reflecting the local geography and links with the community. We would not want to put these relationships at risk. In addition, we must also acknowledge that practice populations are not always drawn from the population of the locality in which the practice is located. Therefore, we believe that trying to force closer alignment could put at risk the development of PBC and offer fewer benefits than is initially apparent. We shall therefore support PBC in evolving organically, while at the same time supporting the active engagement of PBC in locality working.

3.4

Existing Targets and Local and National Health Priorities It is crucial that our strategy and goals reflect and respond to the opportunities and direction of national policy and reform. The priorities for the NHS and direction for the next three-year planning cycle are set out in the annual NHS Operating Framework, in which the emphasis is on shifting from central direction-setting to local priority setting in partnership with local people and communities. The Kirklees Local Area Agreement (LAA) was held up as good practice by the Yorkshire and Humber Government Office, and building on the strength of the partnership working, was agreed ahead of national deadlines. Our strategy reflects the commitment to this approach. NHS Kirklees has already put structures in place to improve health and access to the most appropriate services of the local population. Health Improvement Teams have been established as part of the Commissioning and Business Planning Framework with clinical leadership. Current local performance challenges include hospital and community acquired infections, long waiters for inpatient care at tertiary providers, mental health targets, and access to A&E. Investment in terms of resource, workforce planning and organisational development over the next five years will support the delivery of the strategic plan and delivery of the national and local priorities. Our choice of outcomes for world class commissioning reflects the above. These, together with our existing priorities, e.g., Vital Signs for the LAA, form the basis of our future performance regime.

3.4.1 Local Priorities The outcomes identified through a process of consultation as part of world class commissioning have been chosen in line with local priorities as set out in the JSNA. In the majority of cases Kirklees is an outlier for each of the chosen measures. The local health priorities of Kirklees are directly linked to the chosen outcomes and in line with both NHS Kirklees’ vision and the ‘areas of care’ from the NHS Next Stage Review. The delivery of the national and local priorities will support the achievement of our goals not only in terms of outcomes but also in terms of ways of working. Through strong clinical leadership and focus on the priorities and performance challenges, NHS Kirklees will be able to commission effectively to improve health and reduce inequalities. 3.4.2 National Priorities : NHS Next Stage Review - Healthy Ambitions The results of the national NHS Next Stage Review (NSR) were published in June 2008. The final report of Lord Darzi’s review High Quality Care for All, builds on earlier national statements of policy, in particular Our Health Our Care Our Say: a new direction for community services (2006), Choosing Health (2005) which stretch back to The NHS Plan, published in 2000. The NSR sets out a vision to provide people with good quality social care and NHS services in the communities where they live. The NSR report sets out plans that build on progress and how innovation and creativity of staff can further improve services. The report commits the Government to change driven by empowering staff at a local level not through top-down targets.

The NSR report is accompanied by publication in early July 2008 of the NHS Next Stage Review - Our vision for primary and community care. This sets out the Government’s intended direction for primary and community care in England, where essential standards are ensured and excellence is rewarded. It focuses on personal and responsive health care providing integrated care based around the person, not just their individual symptoms or care needs. In the Yorkshire and Humber area Healthy Ambitions was published by the Strategic Health Authority (SHA) at the same time as the national reports. This document provides an invaluable benchmark against which to check our own local vision and plans. Healthy Ambitions also stresses the importance of strong primary care to the overall health care system. A strong primary care system leads to lower overall costs, better prescribing, better individual outcomes and higher service user satisfaction. The existing practice registered list based model is central to delivery but must be accompanied by intelligent commissioning of primary care services, supported by use of good quality clinical and public health data. Taken together, Healthy Ambitions, the national reports and the broader factors discussed earlier provide a reasonable and sound basis on which to build our local vision for services and to plan ahead. Indeed, as we explain below, the direction for the future of health and health care in Yorkshire and the Humber as set out by Healthy Ambitions chimes well with our own existing vision and we are already addressing many of the priorities which it identifies. Examples include the LAA which has set key targets in a number of these

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

areas including the promotion of breastfeeding and reducing obesity. Significant progress is also being made on specialist community and mental health services. The information and ambitions set out in this plan establish a clear set of goals for NHS Kirklees and our partners, which in turn sets the direction of travel for investment and service delivery. It also provides a benchmark against which to consider proposals and plans in the interim. The ambition is to build on existing successes and to continue to drive improvements in local health and to reduce inequalities (by the effective targeting of investment) between different Kirklees communities and localities. These will be further developed progressively in successive business and operational plans over the period. 3.4.3 Business Planning Delivery of national and local targets is supported by our Commissioning and Business Planning Framework. The framework ensures that key clinical areas have clinical leadership from clinicians across primary and secondary care, with priorities for investment established through a robust business case assessment and accreditation process.

3.5 Provider Landscape Kirklees people receive hospital services largely from two main providers â&#x20AC;&#x201C; the Calderdale and Huddersfield NHS Foundation Trust (CHFT) and the Mid Yorkshire Hospitals NHS Trust (MYHT). The South West Yorkshire Mental Health Trust (SWYMHT) provides most of our mental health services. Ambulance services are provided by Yorkshire Ambulance Services (YAS). Community services are provided by Kirklees Community Health Care Services, which operates under the organisation of NHS Kirklees. CHFT has hospitals in both Halifax and Huddersfield, and the MYHT has hospitals in Dewsbury, Wakefield and Pontefract. Hospital services are also commissioned from a wide range of other trusts, including Bradford, Leeds and Sheffield. People needing referral to hospital by their GP can choose which hospital they would like to attend. A small number choose to travel further afield. This may grow in coming years as people become more familiar with the choices which are now available to them. Looking To The Future (LTTF) the integrated service strategy linking primary and secondary care launched in June 2005 and currently being implemented has the explicit aim of providing as much care as possible closer to peopleâ&#x20AC;&#x2122;s homes, wherever this is safe and practical, and to provide high quality, specialist services in our hospitals. In short we want to make sure that local people are offered the right care, by the right people, in the right place at the right time. For North Kirklees, we are similarly currently working with Mid Yorkshire Hospitals NHS Trust to review service provision across their

hospital sites and to explore what services they can deliver in community settings such as our new health centres in North Kirklees. World class commissioning requires us to demonstrate separation in terms of governance arrangements between the commissioning and providing parts of the organisation. This ensures the provider part of the organisation is treated the same as any other provider even though the Board of NHS Kirklees remains accountable for both functions. Primary care services are provided by 74 GP practices, 59 dental practices, 90 pharmacists and 42 optometrists. Out of hours services are currently provided by Local Care Direct under a contract which runs until March 2009. Since 2008, NHS Kirklees has been working with the four other West Yorkshire PCTs to apply a county-wide collaborative approach to the re-design and procurement of urgent care services. As a result of our work with our main local providers, we envisage considerably more services being delivered out of hospital over the next five to ten years than is currently the case. 3.5.1 Developing the Market It is our responsibility as a strong commissioning organisation to ensure that we understand what services we need to commission and who is best placed to provide them. We will work with existing service providers to re-design and improve services where we know this will be in the best interests of individuals. We will also assess service gaps in terms of availability or quality and identify clear strategies to address these, using effective procurement to bring new providers into Kirklees. Such

new providers may include â&#x20AC;&#x2DC;traditionalâ&#x20AC;&#x2122; NHS service providers as well as the independent sector, voluntary or not for profit organisations and others. As we move towards more person centred services, bringing care closer to our communities , we have the opportunity to increase choice for our population and improve equity of provision, dependent on need. Traditionally, care has been delivered in primary and secondary care settings across traditional care pathways. These were based on medical models, with a limited number of tier two services and gaps in integration and coordination of pathways. This has resulted in duplication of services and confusion for service users. Standards set by National Service Frameworks have identified gaps in provision, particularly at the end of life and in the provision of self care support. Working with the Council we have improved provision significantly to support self care, particularly for those with long term conditions. The redesign of services will focus on person centred care and individually determined outcomes. The challenge will be to open the market to a range of providers who will add value and choice to the system. The strengthening of quality standards in contracts and the performance management of these standards will enhance the reputation of the NHS, giving the public confidence that services are of the highest quality.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

3.5.2 Choice and Diversity of Service NHS Kirklees is committed to make better use of the potential of other service providers to work alongside and complement traditional service providers. We need to ensure that we commission effectively and identify areas where people do not receive an appropriate service for their needs. In some areas, we may not have the range of service providers we need and we need to use the levers available to us to increase choice and diversity. Examples of this include: • Working more closely with the third sector - Offering organisations such as social enterprises and voluntary organisations the opportunity to provide services and working closer with them to facilitate a level playing field between them and other existing or potential NHS or commercial providers. • Extending the role of the community pharmacist - Community pharmacies are usually located in the heart of communities and are visited frequently. We believe there is great potential for their more effective use to support the prevention of ill health and self care, as well as reducing inappropriate A&E attendance and unnecessary hospital admissions.

• Extending the role of the optometrist - There are similar opportunities, to enhance the role of local optometrists and reduce the need for people to visit hospital in relation to certain conditions, e.g., diabetes. 3.5.3 Care Closer to Home One of our goals is to ensure that services are delivered as close to people’s homes as possible. The underlying principle supporting this goal is that only those services which cannot be provided effectively and safely within a community location should be provided within an acute hospital setting. Future service provision will be shaped around the four tier service model (Fig. 3) which we have adopted and developed. This balances the aspiration to provide services as close as possible to where people live and the continuing imperatives to secure value for money, clinical effectiveness and assured quality.

• Improving oral health - As part of the new contract for dentists from April 2006, the transfer to PCTs of the responsibility for commissioning primary care dental services gives them the opportunity to develop services in a more strategic manner, commissioning dental services where they are most needed and where they will lead to improvements in oral health. 31

Fig. 4: The Four Tier NHS Service Model

Ca r lf Se

Outpatients, Rehabilitation and Therapy, Surgery, Day Case Management, Community Team Base, Partner Organisations

iou

Extended Primary Care Centre

Diagnostics,

av eh yB lth

Community Hospital

a He

Acute

Core Primary Care Services GPs, Dentists, etc…

This model envisages four levels or tiers of health care service: • • • •

Acute and specialist care Community hospitals Extended primary care services Core primary care

Level 1 - Acute and specialist care Our main acute providers are CHFT, MYHT, and SWYMHT, with people also travelling to hospitals such as Leeds and Sheffield. It is likely that the increased focus on individual choice will result in people travelling to different hospitals, travelling even further afield or using private hospitals as NHS service users.. Through the mechanism of our contracts with acute providers, we will focus on securing high quality services that meet the standards which people tell us are most important to them when they stay in hospital, e.g.: • waiting times and choice of appointment time; • cleanliness and a high priority on

infection control; • good clinical outcomes and a continued focus on best practice; • personal attention with good communication between service users, their carers and clinicians; and • privacy and dignity. In addition, we will work with our main acute providers to plan how hospital services should be most appropriately configured in future. Some of this work has already been done. In June 2005 the PCT (specifically two of the three predecessor PCTS – Huddersfield Central and South) in partnership with Calderdale PCT and CHFT jointly launched the plans for an integrated service strategy which aimed to deliver as much care as possible closer to people’s homes, wherever this is safe and practical, and to provide high quality, specialist services in our hospitals. As a result, some hospital services such as paediatric inpatients, specialist obstetrics and planned surgery have been re-configured across the Calderdale and Huddersfield hospital sites,

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

and a range of new community based services such as community matrons have been introduced. We are now working with MYHT and partners in Wakefield District PCT to review the configuration of services across the three hospital sites in Dewsbury, Pontefract and Wakefield. This work will consider the most appropriate configuration for a range of hospital services in the future and we will consult with the public on options in early 2009. As with the Calderdale and Huddersfield programme, an important aspect of this work will be commissioning community based services that avoid unnecessary admissions to hospital, or increase the numbers of services that can be delivered in community settings such as Dewsbury Health Centre. We will also ensure that we have in place effective commissioning arrangements for specialised services provided in specialist centres to catchment populations of more than one million people. The underlying aim of the arrangements for commissioning specialised services is to ensure fair access to effective, high quality clinical services across our area. User numbers for such services are small and a critical mass of service users is needed in treatment centres to: • achieve the best outcomes and maintain clinical competence; • sustain the level of training of specialist staff; • ensure cost effectiveness in provision; and • make the best use of scarce resources. Although these services are required by far fewer people than those provided in primary care and local hospitals, they do account for around 10% of total PCT

expenditure. To ensure that these services are commissioned effectively, we will continue to commission in partnership with the other PCTs in Yorkshire and the Humber through the Specialist Commissioning Group (SCG) structure. The SCG brings together all PCTs in Yorkshire and the Humber to enable us to make collective decisions on the review, planning, procurement and performance monitoring of specialised services, as well as any other service where an integrated commissioning response/action is beneficial. Current priority areas include: • • • • •

Obesity surgery Cancer reform Cardiac services Children’s services Long term conditions – renal services, neurological conditions; and • Mental health

Further detail about specific commissioning intentions for each of these areas can be found in section 4. Level 2 - Community hospitals If we are to deliver care safely out of hospital, it is vital that we have facilities that are fit for purpose. We believe that a population of the size of Kirklees could support around three larger community sites, from which a range of services could be provided. Our view is that these three key sites are: • Dewsbury Health Centre, Dewsbury • Holme Valley Memorial Hospital, Holmfirth • Princess Royal Community Hospital, Huddersfield Town Centre (this site is owned by the CHFT)

The services that could be delivered from these sites include: • outpatients; • rehabilitation and therapy; • intermediate care (including beds where appropriate); • diagnostics; • minor/day case surgery; • community nursing bases; • sexual health; • primary care mental health services; and • services for people with alcohol problems. Not all services would need to be available from all three community hospital sites – we need to commission them appropriately to ensure they are most effective. We will work with local people and health and social care professionals to plan the most appropriate configuration of services across these sites, taking into account population need, critical mass, and service interdependencies. The strategy is supported by an award from the Department of Health of Community Hospital Funding of £6.63m (out of a total of £13.79m awarded jointly to Kirklees and Calderdale PCTs) capital investment over the period 2008/09 – 2011/12). These resources have enabled NHS Kirklees (and Calderdale PCT) to take forward with confidence a broader range of schemes, thereby providing a significant boost to the overall programme. Level 3 - Extended primary care services These are services beyond those offered by all practices – core primary care or level 4 services – which may be offered by some (but not all) practices or by other local providers (e.g. KCHS). Where practices offer such a service or services, the service(s)

will be typically offered to a wider population than just the people registered with that practice, usually on referral. These services will include most of those offered by community hospitals (e.g. podiatry and therapeutic services) but an individual provider may well offer only one or two such services. Level 4 - Core primary care These are services provided by the traditional NHS primary care contractor professions which people can expect their GP, dentist, pharmacist or optician to provide as NHS services. For example, people can expect access to a GP (or nurse) from 8-30am to 6-30pm Monday to Friday, usually through an appointment (and urgent attention in an emergency). The doctor (or nurse practitioner) will also issue prescriptions, offer advice and support in living with a long term condition or refer the person to a specialist doctor, if necessary. The family doctor will also visit people at their homes to provide these services, if appropriate. Outside these hours, the practice will facilitate access to the local out of hours service. In addition, many practices are now extending their opening hours by offering appointments in the evening or at weekends. Generally, these services are offered to people who are registered with the practice, but practices will also provide such services to people who are in the Kirklees area temporarily or to anyone in an emergency. Many local practices do, of course, offer a greater range of services (e.g. a range of vaccinations and immunisations or level 3 services, as above). In some cases, practices

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

offer these services to a population wider than its own registered list by referral from another practice under a contract with NHS Kirklees. Similarly, under their NHS contracts, pharmacists dispense NHS prescriptions written by GPs or nurse prescribers, and may also offer a range of other services (e.g. minor ailments schemes) under a local contract with NHS Kirklees.

3.6 Financial Situation When the PCT was established in October 2006 it inherited a recurrent deficit and an accumulated debt of £6.2m. Actions initiated by the predecessor PCTs and continued by Kirklees PCT, achieved a balanced financial position in 2006/07 (surplus £900k). During 2007/08, the accumulated deficit was repaid whilst delivering a surplus of £4.4m. This surplus was brought forward into 2008/09. Due to its success in turning a recurrent and legacy deficit from its predecessor organisations into a recurrent surplus with no historic debt, the PCT accumulated, at its maximum in 2007/08, a Strategic Investment Fund (SIF) of £19.8m. During 2008/09, the PCT Board agreed to play a full part in an agreement between the Yorkshire and Humber Strategic Health Authority (SHA), Mid Yorkshire Hospitals NHS Trust, Wakefield District PCT and ourselves to provide a solution to the accumulated deficit of MYHT. The PCT has committed £11m of its SIF over the next three years to help provide a sound financial base for one of its major health care providers. In 2008/09, the PCT plans to deliver a surplus of £2.8m (i.e. ½% of its revenue allocation). Additionally the PCT has agreed with the SHA to achieve a control total of £17.4m. The control total is the outturn for the year plus the sum remaining on deposit with the SHA in the SIF. The PCT’s overall financial target this year is therefore £2.8m surplus with £14.6m remaining in the SIF. To achieve the SIF balance, the PCT is spending £5.2m of the SIF this year, £3.3m of which is the first contribution to the MYHT solution.

Current forecasts show that the PCT is on target to deliver the required surplus and control total.

Table 5: Additional Investment 2009-10 to 2012-13 Funds Available

Looking forward, the PCT will begin 2009/10 with a recurrent budget surplus. The PCT’s resources in future years include prudent assumptions of recurrent growth in line with guidance from the SHA, the phasing of withdrawals from the SIF and the non recurrent surpluses made available in the year following achievement to fund a contingency budget to help manage risk. The PCT believes that this contingency budget and the level of surplus planned provide sufficient financial risk mitigation. The current economic turbulence and the uncertainty of the effect of a new tariff based on HRG4 have the potential to have a significant effect on our resources and costs. However, these are impossible to quantify at this stage and could have beneficial or adverse effects. Providing resources for these risks could potentially leave the organisation unable to spend enough to meet its control total and therefore these risks are noted but not provided for. Table 5 below shows the additional investment that we expect to receive over the next four years from 2009-10 and the assumptions on the use of these.

£000

Growth funding- rec

107,600

SIF funding returned

14,600

Non recurrent surpluses

13,800

Efficiency plans

18,000

Total

Use of Resources

154,000

£000

Inflation

69,000

Investment in secondary care

27,000

Initiatives -priority areas

36,000

Contingency – risk reserve

12,000

Additional surplus

2,300

Corporate services

7,700

Total

154,000

The investments planned in secondary care and the priority areas are described in detail in section 3 and section 4 of the plan. The Board accepts that some of those investments will be disproportionately targeted across the different localities and other communities as the PCT aims to reduce health inequalities.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

3.7

Current Year’s Commissioning Activity In 2008/09 we have commissioned sufficient activity to meet our projected demand, including delivery of the 18 week target. Monitoring actual demand against plan is at a relatively early stage and there are a range of issues that we are investigating in partnership with providers but which are not conclusive at this stage. These include:

• •

•

• •

• An increase in outpatient activity at both main providers. • Under trading on elective activity against plan. • Non-elective activity. • At one main provider, whilst activity is relatively stable, costs have increased suggesting either changed case-mix or a counting and coding change having been implemented. • At our other main provider, we are seeing an overtrade, particularly relating to long-stay service users. • In general, our providers are advising that they are seeing an increase in referrals. We are working with them to understand whether this will translate to a genuine increase in demand for outpatient, inpatient and day case activity. • There are indications of increased costs relating to non-PBR activity.

• • • • •

PbR activity costs are based on the average prices at CHFT and MYHT. The baseline used is 2007-08. The 2008-09 activity plan is used as a baseline and adjustments made for current forecast overtrades for the two main providers. Adjustment is included for change in policy for non elective activity, i.e. removal of threshold. Adjustment for non recurrent activity from plans i.e. 18 weeks. Identified developments and growth, e.g. Lucentis for macular degeneration Growth applied using ONS statistics. Efficiency programme – activity impact, i.e. long term conditions. A&E and WIC – population growth only applied. Dental activity – population growth applied to 2008-09 forecast. SCG – activity not included in the activity plan but costed in the financial plan and included in section 1.2 – other non HRG expenditure.

In summary, the PCT’s current planning assumptions (as described above) include further investment of £27m being spent on secondary care over the next four years.

The following baseline assumptions were made to support the development of the activity levels commissioned: • SUS was used as data source for Payment by Results (PbR) activity. • Modelling has been based on HRG V3.5. It is recognised that there will be shifts in both activity and costs once HRG V4 is introduced. For Non

Section 4

Strategy 4.1 Goals To achieve our vision, we are driven by clearly defined goals. These goals have been reviewed and now reflect both the key national drivers and our local priorities. For these reasons, our goals form a ‘golden thread’ running through our plans, and will underpin our approach to our priority health programmes. Our goals are to: • place the person at the centre of everything we do; • improve health and reduce health inequalities; • improve quality and promote safety; • promote choice and accessibility; • work well in partnership with communities, individuals and their families, staff and organisations; • promote local sensitivity through effective commissioning; • promote strong clinical leadership to drive service re-design and innovation; • be a visibly credible organisation, operating to the highest standards.

Place the person at the centre of everything we do By: • engaging with people to help them understand and take responsibility for their own health • supporting people to feel in control of managing their problems and able to make healthier choices of personal behaviours • providing people with personal choice in accessing help and interventions as ‘close to home’ as feasible • commissioning services which are based on, and responsive to, the person’s needs and preferences, so focus on outcomes • involving local people in creating and delivering solutions Improve health and reduce health inequalities By: • achieving the best possible health outcomes within available resources • commissioning services that encompass prevention, detection, treatment and the consequences of ill health • achieving equality of outcomes through targeting resources to follow needs and so reducing gaps in services and support, i.e. reverse the inverse care law Improve quality and promote safety By: • commissioning services that are delivered safely and to the highest standards and are evidence based around clinical and cost effectiveness • encouraging new and innovative ways of delivering services that are sensitive to the diverse needs of our community, demonstrate improvements in quality and are

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

delivered in an environment that staff and local people can be proud of • developing a learning environment that promotes continuous professional development, motivates people to achieve their full potential and aids recruitment and retention of high calibre staff Promote choice and accessibility By: • providing people with a choice of a range of services and interventions and ensure that services are accessible, with the principle of ‘closer to home’ being applied as far as possible.

Be a visibly credible organisation, operating to the highest standards By: • achieving the highest standards of probity and accountability, managing risk and maintaining effective governance arrangements to make sure that the organisation is run efficiently within available resources and in a way that inspires public confidence Throughout our plan we will say more about what these goals mean to us and the difference they will make to the people of Kirklees.

Work well in partnership with communities, individuals and their families, staff and organisations By: • achieving real involvement of local people, especially users, staff and our local community in identifying their needs, agreeing priorities for commissioning , creating solutions and taking action Promote local sensitivity through effective commissioning By: • setting outcomes and actions that reflect local needs and priorities • acting at the right level, e.g., locally or regionally, depending on the issue or outcome desired. Promote strong clinical leadership to drive service re-design and innovation By: • having the skills and capacity to enable effective clinical leadership and engagement in all relevant aspects of the commissioning process

4.2

Programmes

4.2.1 Delivering our Vision We are working with local partners, stakeholders and our own staff to put in place a range of programmes designed to align the local NHS and related systems to deliver the goals described above. These programmes are supported by a range of underpinning strategies for the key delivery mechanisms e.g. the workforce planning framework. Progress and outcomes will be managed, monitored and reviewed using a new performance management framework which we are developing. All our programmes of work link to Healthy Ambitions. Each programme has specific priorities for actions which include: • a better system with fewer journeys for service users, carers and families; • healthier personal behaviours – with a halt in the rise of obesity; • halving the number of children admitted to hospital with asthma; • mental health services available without waiting;

4.2.2 World Class Commissioning If our vision is to be realised, robust and appropriate delivery mechanisms are essential. World Class Commissioning (WCC) is now the key vehicle for delivering an NHS fit for the 21st century. This applies to primary and community services as much as it does to acute services. WCC is designed to enable the NHS to meet the changing needs of the population and deliver a service which is clinicallydriven, service user-centred and responsive to local needs. This requires us to develop a more strategic, long term and community focused approach to commissioning services, where we and other local commissioners work together with health and care professionals to deliver improved local health outcomes. WCC is central to achieving the vision of a health and care system which is fair, person centred, effective and safe.

• saving 600 premature deaths every year with better stroke care; and

Consistent with WCC we are placing greater emphasis on assessing local needs (e.g. through the JSNA), and prioritising investments to deliver long term improvements in health outcomes through the locality based planning approach). These changes are pivotal in addressing local health inequalities. WCC also supports the shift from treatment and diagnosis to prevention and the promotion of well-being.

• doubling the number of people able to choose to die at home rather than hospital.

Under WCC, we are required to choose a number of health outcomes against which our performance will be assessed in future

• halving the number of preventable admissions from diabetes; • highly experienced staff making decisions at the front door of every hospital;

Healthy Ambitions also sets out a regional primary care vision which is intended to reflect the real strengths of the UK primary care model as well as some of the challenges. It emphasises that the strengths of the model have become lost in the continuing debate about access.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

years. We have worked closely with our key partners, in particular Kirklees Council, to identify outcomes and related indicators which both reflect our local health challenges and strategic priorities and are within our ability to influence and change. 4.2.3 Proposed List of Indicators Table 6: Our Chosen World Class Commissioning Outcomes Health Area

Metric No

Metric Health Inequalities Life Expectancy

Metric Definition Average IMD (deprivation index) score Life expectancy at time of birth, in Years Actual percentage of women known to be smokers at the time of delivery

Birth

Smoking during Pregnancy

Staying Healthy

Smoking quitters

Rate per 100,000 population aged 16 and over

Acute

Stroke admissions given a brain scan within 24 hours

Percentage of people admitted with a stroke given a brain scan within 24 hours

Mental health

Alcohol harm

Long term conditions

CHD controlled BP

Other

Childhood Obesity

Other

Emotional health of children

Other

People with LTC supported

Rate of hospital admissions per 100,000 for alcohol related harm Percentage of people with Coronary Heart Disease in whom the last BP reading was 150/90 or less in the past 15 months Percentage of obesity among primary school age children in Year 6 Baseline to be established through national Tellus Survey in Summer 2008. Targets will be set for 09/10 People with LTC supported to be independent and in control of their condition, definition to be confirmed by central government

Comment Mandatory for all PCTs Mandatory for all PCTs Large impact on infant deaths, low birth weight, Kirklees bottom 10% Very high levels in certain localities In LAA Largest impact on health, lot to do esp in women In the LAA (NIS 123) Bottom 25% of performance BUT small nos, limited impact Rapidly rising levels of excess drinking locally, worse than regionally High impact, incl cerebrovascular disease

In LAA (NIS 56) Large impact In LAA (NIS 50) Large impact

In LAA (NIS 124) VSC11 (but not nominated to DH/HCC) Large impact

4.2.4 Rationale for Choosing Outcomes The following were used to guide our thinking: • what issues have the biggest impact locally across Kirklees at a population rather than an individual level both in size and severity? • what issues are most changeable and within our ability to change? • what issues have the most scope for change? For example, issues that need considerable development, or where Kirklees is performing poorly for that indicator. • a focus on outcomes rather than process measures as a proxy, where feasible. • selecting outcomes from as many of the eight different categories as possible. • the reliability of the underlying data, i.e. accurate definition, completeness of numerator and denominator in rates, or proposed methods of collecting them. We avoided the following indicators: • those with very small numbers. For significant issues we looked for indicators which have a major impact. For example, infant mortality is not proposed as it is a very small number, but smoking at birth is an outcome that is significantly linked to such deaths. • those that measure an extreme of the underlying issue, e.g., suicide as an indicator for mental ill health. • those that the PCT is already being performance managed on. • those that are ambiguous in their definition, e.g., self-reported experiences of service users and carers that could refer to a variety of issues such as clinical care, hotel services, or communication. 42

4.3

Impact on Health Outcomes and Inequalities

4.3.1 Summary of the key inequalities from the JSNA Using the rainbow model (Fig. 1) as a framework will aid the understanding of factors that affect health and well-being. There are four main groups of priorities to tackle to reduce health and well-being inequalities and these are reflected in the Kirklees LAA: • • • •

living and working conditions family and community networks personal behaviours biological changes including long term conditions

To impact on the above health and wellbeing inequality priorities requires a comprehensive and coherent overview of the contributing factors. We have developed high level programmes of work to achieve this in Kirklees in relation to biological factors and personal behaviours. The Council has the lead role in ‘family and community networks’ and ‘living and working conditions’, with various partners working with local communities. The Kirklees priorities are shown below: Living and working conditions Living and working conditions include: • education, including adult learning and skill development • work type – availability, accessibility and working conditions • levels of income – adequacy of income and access to financial advice and support • housing - suitability, affordability and access

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

• environment - safety and quality of the built and natural environment and the public realm Family and community networks are significant in affecting the health and wellbeing of an individual. They frame the behaviours and the degree of support available when problems arise, e.g., disease or conditions that affect heath. There are three main foci: • supporting people in tackling the social and wider consequences of diseases and conditions • improving social cohesion especially in those communities that have fewer personal resources. This includes processes to help people develop skills to acquire and deploy resources collectively and more effectively. This includes family or community support, social capital, tackling isolation, social exclusion, anti-social behaviour and crime. • promoting participation and inclusion, community engagement and enabling citizens Personal behaviours – “Choosing Health”. Personal behaviours have a direct effect on health and well-being. The role of the NHS is to work with individuals, the council and partners to create opportunities for people to adopt healthier behaviours in a range of settings. A particular focus for Kirklees is girls and women of child bearing age (WoCBA), as well as issues relating to: • • • •

Personal behaviours are now the cause of much ill health and disease in our society. Tobacco, food and physical inactivity are now recognised as the most significant factors affecting our health, with substance misuse also increasingly challenging. The ability of an individual to cope with their circumstances varies widely depending on the range of resources they have. These resources depend on the factors shown in the Rainbow model of health and wellbeing which include the local opportunities available to help a healthy choice. Biological changes Biological changes, e.g., a disease or condition that affects health, are largely tackled clinically by the NHS in their detection and management. These include: Long term conditions, especially: • • • • • •

pain heart disease and stroke diabetes obesity respiratory emotional well-being - depression and anxiety, dementia • disabilities

tobacco food physical activity alcohol

4.3.2 Priority Programmes â&#x20AC;&#x201C; focus on out of hospital care These programmes are all aimed at improving the health of local people and reducing health inequalities. Given our local demography, we have a particular focus on long term conditions with specific priorities relating to older people and vulnerable adults. These programmes match closely with the priorities identified in Healthy Ambitions and other national strategies. The detail of what each programme will achieve is set out later in this document. Table 7: Key Priority Areas NHS Kirklees

Healthy Ambitions:

Choosing Health (including food, alcohol, tobacco control, sexual health, obesity, oral health)

Obesity

Infection control Long term conditions (including stroke, coronary heart disease, diabetes, respiratory conditions, self care, therapy, rehab and intermediate care, older people)

Stroke

Partnership commissioning (including Maternity services, Children and Young People, Learning Disability (Adults), Mental Health (Adults), Physical Disability (Adults), substance misuse)

Mental health

Primary care

Tackling variations in primary care

Urgent care Planned care/18 weeks (including cancer, palliative care (end of life care), diagnostics)

End of life care

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

4.4

Choosing Health - Programme Summaries

How are the Choosing Health programmes delivering the PCT Goals? There are many opportunities in our society to adopt unhealthy personal behaviours such as diet and physical inactivity, as well as alcohol abuse and unsafe sex. Local opportunities vary with healthier opportunities often being least available to those that most need them. For example, there are many housing estates with no healthy food outlets, but many selling takeaways and processed food. In addition, the healthier option tends to be government-led, and is often discounted by people. The white paper Choosing Health was a significant step up in the pace of tackling these issues nationally. Locally, this has resulted in significant investment and the engagement of local people and a wide range of partners in tackling these issues.. The main programmes in Choosing Health are summarised below. All these programmes follow the golden thread of NHS Kirklees’ goals. The focus of all the programmes is on supporting people to change their behaviours and choose healthier options. However, we recognise that this will require a massive shift in culture across both the public and commercial sectors.

Social marketing provides insights about target communities which can then be used to design interventions that will enable them to change attitudes and behaviour. This includes involving them in creating and delivering their own solutions. Organisational redesign focuses on being person centred, and tackling inequalities. Key questions are: • can the interventions enable the user to take control and have real choice? • what are the outcomes? What difference is being made and for whom? • is it clear who is most at risk or in need of a specific health challenge? Are they getting the right support at the right time? • are resources focusing on those most in need? Is the inverse care law vanishing? • are local people involved? What do those most at risk feel they can do about changing behaviour and what do they think would be helpful? What can they do to help themselves? Where can they get useful help? • are we thinking laterally? Who else can help significantly and needs to be involved?

A key action is ensuring that the public sector provides consistent healthy choice messages and backs this up by offering employees such choices in the workplace.

The Choosing Health Programmes have a clear programme management structure which enables a real focus on outcomes and lateral thinking to ensure key links are made, including working with the right people. This also ensures probity and governance and supports being credible as an organisation.

Enabling people to make healthier choices means using interventions that are relevant for them. Social marketing and organisational redesign are two crucial elements.

The JSNA shows that a number of population groups have inequalities resulting from their personal behaviours, including women of child bearing age; those with long term conditions, especially 45

those with heart disease, diabetes and pain; and those living in certain geographical areas. The Choosing Health Programmes can focus on these groups and tailor behavioural change interventions to their needs. As can be seen, the starting point for these programmes is increasingly social marketing insight combined with a systematic review of needs from local intelligence and evidence reviews from elsewhere. However, this can represent significant challenges in partnership working, as those who should be closely involved, including partners, front line staff and the public, may not be focused on these issues. We need to respond by gaining an understanding of the motivation of key players and using all available opportunities to promote engagement and support for the Choosing Health Programmes. In designing care pathways and interventions, there is a balance to be struck between delivering high quality interventions and enabling as many people as possible to take action. This is being achieved, e.g., via a tiered system of interventions, especially in respect of behavioural change. This involves brief training to get people motivated to change, followed by modules of increasing skills and competencies to help people make change. These programmes are accredited, ensuring quality and safety. Much emphasis is placed on simple interventions that involve the target groups and get them started on the path of healthy behaviours. For example, the Expert Patient Programme for people with long term conditions, is successful in helping participants feel more in control of their condition. Accessibility to opportunities is crucial,

especially for those most at risk. This again requires the insights provided by social marketing to be really clear about what might work where and for whom. Commissioning may require very local partnerships below locality level (e.g., the cooking skills programme); regional action (e.g., reducing tobacco smuggling); or Kirklees-wide action (e.g., self care for people with long term conditions). This tailored response requires local sensitivity though effective commissioning, and clear skills and capacity in local public health leadership to drive and support service redesign. The health and well-being inequality framework outlined above underpins this, especially by bringing diverse partners together on a common issue. For example, a cooking skills programme in Batley can combine a range of local issues relating to ill health, disease, educational attainment, isolation, intergenerational links and improved community cohesion, local food resourcing, local businesses and town centre regeneration.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

4.4.1 Food Outcomes • Adopting healthy eating behaviours in terms of what people eat and how they eat e.g. family environments, dining areas. • Making healthy choices of food more accessible. • Increasing breastfeeding rates. Related Indicators: • Number of frontline workers receiving brief Intervention training – food module. • Percentage of Year 9 pupils who eat breakfast (YPHS 2007) • Proportion of adults eating five or more portions fruit/ vegetables per day (CLIK survey 2008) • 65% of schools achieving National Healthy Schools status by Dec 08 (inc. food strand) • Number of food outlets with Healthy Choice Award and number with Gold HCA. Annual Target - 400 • Prevalence of breastfeeding at 6-8 weeks after birth. (DH Vital signs prevalence rate - 43%)

• Baby friendly Initiative accreditation • Breastfeeding peer support education networks and centres of excellence. Children & Young People: • Interactive, family based healthy lifestyle initiatives. • Refer to NIHCE guidance on child and maternal nutrition • Healthy Start Scheme Key localities: Birstall, Batley & Birkenshaw, Spen, Dewsbury, Huddersfield North.

Evidence based action required to deliver programme across Kirklees: Adults: • Healthy lifestyles programmes targeting low income groups. • Community healthy cooking scheme • Improving local access to healthy options; incentives for local food outlets. • Healthy Start scheme - improve access to fruit, vegetables and vitamin supplements. • Evidence based activity in line with NIHCE guidance on child and maternal nutrition. 47

4.4.2

Accident Prevention

Outcomes • Reduction in the number of home accidents in the population aged 0-5 and aged 75+ which require medical treatment or assessment. • Reduction in the number of Kirklees residents who are killed or seriously injured as a result of a road traffic crash as vehicle occupants or pedestrians • Reduction in the number of persons who die or are seriously injured as a result of an unintended event. Related Indicators: • A&E Attendances • Hospital Admissions • Morbidity/serious injuries • Deaths Evidence based action required to deliver programme across Kirklees: Adults: • Multi-faceted intervention prevention – programmes based on risk factor assessment and tailored intervention • Smoke detector programmes (leading to injury reduction and behaviour change) • Seat belt education campaigns (leading to behaviour change) • Encouraging the use of automatic transmission cars for older people (in advance of cognitive decline) • Designing signals and road markings for the more limited capabilities of older drivers. • Encouraging eye tests, advice on tiredness, alcohol and medicines home assessment and surveillance can reduce falls in frail older people. • Calcium and Vitamin D supplements

can reduce fractures in older people and result in reduced bone loss. • Physical activity can be protective against hip fracture. Hip protectors can substantially reduce hip fractures in older people in nursing homes Children & Young People: • 20 mph zones (leading to injury reduction and behaviour change) • Cycle helmet education campaigns (leading to behaviour change) and cycle helmet legislation (leading to behaviour change) • Child restraint loan schemes (leading to behaviour change) and child restraint legislation (leading to behaviour change) • Poisoning – child resistant packaging (leading to injury reduction) • Window bars (leading to behaviour change) • Education aimed at parents about hazard reduction and pedestrian injuries (leading to behaviour change) Key localities: Adults: Dewsbury; Birstall, Batley & Birkenshaw, The Valleys, Denby Dale Kirkburton, Huddersfield North, Huddersfield South Children & Young People: Birstall, Batley & Birkenshaw, Huddersfield North, Dewsbury, Spen, Huddersfield South

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

4.4.3

Alcohol

Outcomes • Improve people’s awareness of safe levels of alcohol consumption • Reduce alcohol-related attendances at A&E • Improve earlier identification of alcohol-related health problems. • Improve the availability of and access to relevant and effective treatments for alcohol misuse • Reduce alcohol use in those aged under 18s • Focus on women of child-bearing age to ensure they do not drink during pregnancy Related Indicators: • Number of women of child bearing age who are hazardous drinkers. • Number of GP practices signed up to the screening & brief intervention Local Enhanced Service (LES) • Number of GP practice staff trained to deliver Step 2 alcohol screening & extended brief intervention • Number of frontline staff trained to deliver Step 1 or Step 2 alcohol screening & brief advice

appropriate targeted campaigns or interventions. • Targeted work with the university, in conjunction with relevant partners and students, to identify ways to promote sensible drinking and harm minimisation messages. Children & Young People: • Targeted work with schools and colleges, in conjunction with relevant partners and young people, to identify ways to promote sensible drinking. • With partners, ensure the development and delivery of appropriate training to those working with children and young people to offer simple alcohol advice and/or extended brief interventions. • Ensure links with local licensing teams, PubWatch, Responsible Retailer, Best Bar None, and Challenge 21 schemes around underage sales and responsible sales. Key localities: Adults: Males- Batley, Mirfield. Females DDK, Huddersfield South & Spen. Children & Young People: Huddersfield North & Spen.

Evidence based action required to deliver programme across Kirklees: Adults: • Engagement with primary care & PBC to encourage sign up to the screening and brief Intervention Local Enhanced Service. • Increase numbers of frontline staff able to offer simple alcohol advice, and/or extended alcohol brief interventions. • Work with partners to promote sensible drinking messages and other

4.4.4

Better Health at Work

Outcomes • To provide an occupational health, safety and return to work support service to businesses, and improve the quality and accessibility of this service. • Support and maintain the health of the working population. • To provide a service for individuals with work related health conditions. • To improve knowledge and skills of workers and support them to deal with work related health issues. • To engage with large local employers to develop employee health and wellbeing programmes Related Indicators: • Number of businesses engaged. • LAA 173 • Monitor number of referrals • GP and health professional referrals • Deliver health and safety training courses • Number of employers engaged and number of employees involved Evidence based action required to deliver programme across Kirklees: Adults: • Businesses with active health and safety arrangements • Reduce flows on to Incapacity Benefit from employment • Health Adviser presence in a number of GP surgeries • Support to local employers Key localities: Birstall, Batley and Birkenshaw, Dewsbury and Spen.

4.4.5

Obesity

Outcomes • Increase in weight management service provision. • Increase in uptake of weight management services. • 5-10% weight loss of those attending weight management services. • Increase in percentage of adults with a BMI recorded by their GP in the last 15 months. • Increase in the response rate of Reception and Year 6 pupils with height/weight recorded for the National Recording Programme. Related Indicators: • 2007/08 BMI recording LES (LES and BMI recording indicator under review) Evidence based action required to deliver programme across Kirklees: Adults: Currently using the ODS (Organisational Development Service) Model to review and redesign obesity/weight management services across Kirklees. This involves identifying the needs of the population and the services required to meet their needs. These services will need to be compliant with the NIHCE (CG43) guidance, including: • Helping people assess their weight and decide on a realistic healthy target weight • Focusing on long term lifestyle changes rather than a short-term, quick-fix approach • Being multi-component, addressing both diet and activity, and offering a variety of approaches • Using a balanced, healthy-eating approach

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

• Recommending regular physical activity (particularly activities that can be part of daily life, such as brisk walking and gardening) and offering practical, safe advice about being more active • Including some behaviour change techniques, such as keeping a diary and advice on how to cope with ‘lapses’ and ‘high-risk’ situations In addition the services will need to address the psycho-social determinants of weight gain and obesity. . Children & Young People: As with adults regarding the ODS process and the NIHCE guidance. In addition, services need to be family focused, recognising that the wider family is a significant determinant in a child’s weight gain. Good practice is necessary throughout early years provision. Schools to provide environments that encourage and enable healthy eating and physical activity, but also identify and deal appropriately with obese children. Key localities: Birstal, Batley and Birkenshaw, Dewsbury, Spen and Huddersfield North.

4.4.6

Oral Health

Outcomes • To improve people’s knowledge, and skills and influence behaviour change by supporting them to make informed choices that will improve their dental health and have a positive impact on their general health. • To reduce the prevalence of dental caries, tooth loss, dental trauma and oral cancer in the child and adult population. • To improve access to timely and good quality dental services. • Consistency of oral health messages to the public from relevant front line workers. Related Indicators: • Improvement in tooth decay levels for children • Year on year increase in the number of people accessing primary dental care services. • Number of public health programmes which include oral health messages as part of a common risk factor approach to health and oral health. Evidence based action required to deliver programme across Kirklees: Adults: • Training staff in oral health care of clients in residential accommodation. • Brief intervention training for dental teams on smoking cessation and alcohol misuse. • Training/guidelines on the use of mouth guards for contact sports. • Commission ready access to dental care for those people who don’t normally see a dentist. • Review provision of services and

interface between primary and secondary dental care. • Partners to raise level of awareness of the importance of good oral health to general health and well-being. Children & Young People: • Brushing for Life programme for new born children through Health Visitors to continue. • Brushing is Fun programme in targeted early years provision to be extended. • Promote application of fluoride varnish in young children’s teeth by dental practitioners. • Dental impact of Healthy Schools initiatives to be highlighted. Key localities: Birstall, Batley and Birkenshaw, Huddersfield North.

4.4.7

Physical Activity

Outcomes • To increase knowledge and awareness of the key messages about physical activity to enable people to make choices that will improve their health. • To understand the barriers to participation in physical activity among target populations. • Target populations can access a range of physical activity opportunities. • To provide motivation and support to target populations who wish to increase their levels of physical activity. • Increased profile of physical activity. Related Indicators: • Percentage of sedentary adults • Percentage of adults taking part in 30 minutes or more of active recreation on at least three days of the week • Percentage of 11- 15 year olds taking part in the recommended level of physical activity, i.e. one hour daily • Number of children and young people on specialist programmes. • Percentage of children and young people participating in two hours of PE and sport/activity per week. Evidence based action required to deliver programme across Kirklees: Adults: • Brief intervention/advice to be given by a clincian, supported by written material to individuals followed by referral to The Physical Activity and Leisure Scheme (PALS). • Promotion of moderate intensity physical activity (typically walking) to inactive populations. • Activities designed specifically for adults aged over 50.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

• Interventions using behavioural or cognitive approaches with both group and home based activity programmes (older adults). • Organisation-wide multi-component programmes to encourage and support employees to be physically active. • Consideration to be given in strategies, policies and plans involving change to the physical environment to ensure the potential for physical activity is maximised. • Plan and provide a comprehensive network of routes for walking, cycling and using other modes of transport involving physical activity. • During building design or refurbishment ensure the potential for physical activity is maximised. • Outreach work should be undertaken with potential participants, community networks and providers before a programme starts. • Activities to be available in a range of environments that are local and familiar where possible to target audience. • Build capacity where possible as part of interventions. • Recruitment of dedicated and skilled staff and volunteers that understand the needs of the groups they work with. • Connect people to more than one intervention to help them become and stay active.

• Programmes for young women should focus on building confidence. • Interactive family based lifestyle initiatives. • Appropriate designed and delivered PE curriculum. Key localities: Batley, Birstall & Birkenshaw, Dewsbury, Spen and Huddersfield North

Children & Young People: • Interventions should involve young people in the decision-making process and where possible use a non-directive approach. • Programmes should be differentiated on the grounds of gender, age and socio economic status.

4.4.8 Self Care and Expert Patient Programme Outcomes • Service users have the understanding, problem solving skills, access to self help resources, health trainers and support services to manage their conditions. • Practitioners have the required awareness and skills and can implement self care approaches with appropriate access to support services and resources. Related Indicators: • Expert Patient Programme numbers recruited and numbers completing programmes. • Health Needs Assessment for Long Term Conditions is used by professionals and data recorded on number and type of problem. • Number of attendees on cognitive behavioural approaches course and implementation in practice. • Use of self care resources in libraries monitored quarterly. • Integration of self care approaches within all Choosing Health programmes. Evidence based action required to deliver programme across Kirklees: Adults: • Ensure individuals are able to make informed choices to manage their self care needs. • Offer a range of self care options including information, skills training, Expert Patient Programme, Health Trainers, Better Health at Work and PALS. • Communicate effectively to enable

individuals to assess their needs, and develop and gain confidence to self care – Health Needs Assessment. • Support and enable individuals to access appropriate information to manage their self care needs – work with a range of professionals to communicate the self care options and utilise the self care toolkit. • Support and enable individuals to develop skills in self care and to use technology to support self care. • Advise individuals how to access support networks and participate in the planning, development and evaluation of services – Expert Patient Programme, Health Trainers and Self Care Toolkit Children & Young People: • Ensure individuals are able to make informed choices to manage their self care needs – offer a range of self care options. • Getting Sorted pilot for children and young People with asthma, Young PALS • Support and enable individuals to develop skills in self care – Getting Sorted Expert Patient Programme. • Support and enable individuals to use technology to support self care – assistive technology to support self care and self management. Key localities: Batley, Birstall & Birkenshaw, Dewsbury and Huddersfield South.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

4.4.9

Sexual Health

Outcomes • To improve people’s knowledge and skills and support them to make choices that will enhance their sexual health and wellbeing. • To reduce the prevalence of undiagnosed HIV and sexually transmitted infections (STIs) • To reduce the rate of unintended pregnancy. • To improve the quality and accessibility of sexual health services. • To maximise resources to ensure cohesive and coordinated services. Related Indicators: • Teenage conception rate. • 100% genitor-urinary medicine clinic 48 hour access. • 15% of 15 – 24 year olds screened for Chlamydia annually. Evidence based action required to deliver programme across Kirklees: Adults: • Develop a programme of campaigns to support promotion of sexual health messages to increase awareness with population around sexual health issues and services. • Modernise sexual health services to ensure tier 2 STI community provision. • Ensure long-acting reversible contraception provision in GP practices. • Commission effective GUM, HIV and services targeting specific groups such as men who have sex with men and some minority groups.

Children & Young People: • Continue to develop and evaluate relationship and sexual health courses in schools and colleges across the district to increase relationships and confidence of young people. • Increase access to sexual health services to reduce the number of teenage conceptions by the continuing accreditation of agencies via the Kirklees Young People Friendly Kite Mark Scheme. Twenty agencies to receive accreditation by April 2009 with agencies to be targeted in ‘Hot Spot’ areas. • Increase access to contraception for young people across the district by: maintaining condom distribution scheme, developing “C Card” scheme across the district. Role out of LES for LARC (Long Acting Reversible Contraception). • Increase Chlamydia screening sites across the district working with both chlamydia screening programmes. • Develop scheme to increase access to emergency hormonal contraception through school nurses. Key localities: Batley, Dewsbury and Huddersfield North.

4.4.10 Tobacco Outcomes • Achieving a reduction in the number of people smoking, particularly within identified groups. • Achieving a reduction in the number of women smoking during pregnancy, especially in Batley and Dewsbury. • Ensuring an increase in awareness of the risks of smoking and the availability of stop smoking services. • Supporting national legislation and campaigns in the pursuit of tobacco control. • An increase in the number of staff trained in raising the issue of smoking, the benefits of stopping and how to refer. Related Indicators: • 2,857 four week smoking quitters. • 1% year on year reduction in smoking during pregnancy. Evidence based action required to deliver programme across Kirklees: Adults: • A comprehensive stop smoking service comprising of group and one to one provision daytimes and evenings. • Working with Council, HM Revenue and Customs and the police and to identify ‘hot spots’ where illicit tobacco is being used/sold. • All partners to actively promote NHS stop smoking services.

Children & Young People: • Targeted work in schools identifying ways to prevent school children taking up smoking. • Promotion of smoke free homes campaign. • Working with trading standards to identify retailers that sell to under 18s. • Gathering the evidence base and future lobbying to remove all tobacco products to below the counter with no display. • Assess tobacco ‘power walls’ in local shops, map vending machines particularly those accessible to underage buyers. • Ongoing education, media and awareness of the health impacts of second hand smoke (need locally delivered training programmes to a range of staff /stakeholders). Key localities: Batley, Dewsbury, Spen and Huddersfield North

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

4.4.11 Women of Child Bearing Age (WOCBA)

Evidence based action required to deliver programme across Kirklees:

Outcomes

Children & Young People: • Additional action required in Batley, Dewsbury, Spen and Huddersfield North.

• Increased uptake of positive lifestyle choices to improve health and wellbeing of WOCBA specifically, diet, smoking, alcohol and physical activity and including the effect of emotional well-being on those choices. • Resources and activities focused on women in certain settings, e.g., children’s centres, schools, colleges, NHS frontline staff and workplaces, starting with the NHS and the Council. • Improved rates of early uptake of antenatal care to tackle health behaviours as early as possible and supporting the ‘Maternity Matters’ agenda. • Increased awareness and skills to support behavioural change in WOCBA amongst professionals and practitioners using appropriate health messages and signposting. • Ensure that WOCBA is placed as a high priority group in work stream planning with and in other relevant programmes. Related Indicators: • Reduction in smoking at delivery in Dewsbury and Batley. • Early access to maternity services. • Increased rates of breastfeeding.

Adults: • Targeted stop smoking sessions for pregnant smokers and promotion of the dangers of smoking during pregnancy. • Ensuring that the right information is being targeted to the right groups of women particularly in relation to identifying the key messages and ensuring they are in an understandable format. • To be an advocate in relevant planning systems for the health behaviours of this population group in respect of preparing to be a parent, being pregnant, being a parent and women in general. • Take a community focussed approach using existing networks and groups accessed via settings within localities. Map council-run, PCT and community based services to identify those used by WOCBA to utilise as settings. This approach harnesses the energies of the women themselves to be advocates for activity. Children & Young People: • Roll out of the Healthy Start programme. • Promotion of smoke free homes.

4.4.12 Social Marketing Outcomes • Public health programme development uses appropriate social marketing approaches. • Interventions are delivered in conjunction with: • Programme leads for specific health issues • Other staff at a variety of levels across the public, private and voluntary sector throughout Kirklees • relevant regional and national partners. • Increased understanding of social marketing and capacity and skills in social marketing. • Availability of social marketing intelligence to inform future planning and support health intelligence and needs assessments.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

4.5 Infection Control Our infection control strategy is built around our strategic goals, and can be described as follows: To place the person at the centre of everything we do • To create a safe environment for service users, visitors and health care workers. • To promote best practice through a programme of education and audit to reduce health care associated infections. • Support health care workers who are delivering services to individuals by providing them with a clear framework for managing infection prevention and control. To improve health and reduce health inequalities • Reducing health care associated infections remains a priority. • Effective root cause analysis to minimise recurrence of infections. To improve quality and promote safety • When commissioning services the PCT ensures and satisfies itself that contractors have appropriate systems in place to keep service users , staff and visitors safe from health care associated infections. Effective infection prevention and control is embedded into everyday practice and applied consistently by everyone. Minimising health care associated infections is embedded in the governance systems of the organisation to strengthen responsibility for health care associated infections.

To promote choice and accessibility • Communicating with service users and the public about health care associated infections in the health economy and to ensure the information meets the needs of the local population. To work well in partnership with communities, individual users and their families, staff, and organisations • The Infection Prevention and Control Strategy empowers all staff to follow good practice. A commitment that everyone in the organisation including independent contractors and commissioned services understands their role in preventing infections. To promote local sensitivity through effective commissioning • To ensure that infection prevention is an integral part of delivering care. To promote strong clinical leadership to drive service re design and innovation • To change behaviour through consistent leadership at every level and ensure accountability for infection prevention and control is explicit. To be a visibly credible organisation, operating to the highest standards • Infection prevention and control is central to the delivery of safe and cost effective health care. Outcomes • Reduce the number of avoidable health care acquired infections to zero across Kirklees

4.6

Long Term Conditions (LTC)

4.6.1 Background In Kirklees, over 200,000 people are living with a long term condition. People with long term conditions account for 80% of GP consultations and 36% of overall bed day usage. Existing approaches to long term conditions were challenged in the framework, An NHS and Social Care Model for improving care for people with long term conditions. This framework identified the imperative to treat people earlier and closer to home, whilst allowing individuals to take control over their lives. The strategy produced by Yorkshire and Humber, Healthy Ambitions, puts person centred care and support to enable people to self care at the heart of service reform. Care planning will be led by the individual in partnership with professionals, supported by high quality information. This will radically shift the focus of the long term conditions pathway, moving away from a predominantly medical model, to a greater focus on prevention and self care, supporting people to achieve self determined outcomes. This approach demands a cultural and behavioural change which will challenge the health and social care sector and will require strong professional leadership and partnership working across all sectors. Quality improvement will need to be consistent across all sectors and organisations. Barriers to integration must be challenged. It is important to recognise that whole scale system change involves some degree of risk; real innovation will be needed and not simple tinkering at the edges of existing services.

System change will be aligned to quality improvement, engaging clinicians, service users , communities and managers. Decision making will be devolved as close as possible to service users, allowing maximum flexibility at a local level as outlined in High Quality Care for All. Much of the focus to date has been on developing out of hospital and specialist services in community settings, but access to these services and the choices available are not equitable. To address the widening gap in health inequalities we will need to focus resources where they are most needed and where prevalence rates are increasing significantly against local and national averages. 4.6.2 How is this programme delivering the PCT’s goals? Place the person at the centre of everything we do An informed person who knows when to self care and when to seek clinical support can control their LTC much more effectively. Consistent with Healthy Ambitions in Kirklees, we have learned from the Year of Care Pilot the importance of person centred care planning. This means individuals: • set their own goals supported by high quality information; • take personal responsibility for their own health; and • are the expert for the management of their condition. The aim is for everyone with a LTC to have a management strategy, supported by and developed in partnership with a clinician. We will build on the developments achieved through the quality and outcome

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

framework and primary care knowledge of individuals to improve continuity of care and care coordination for people with long term conditions. Improve health and reduce inequalities The JSNA highlights the increased incidence of LTC and recent Health Care Commission (HCC) reports show that people with LTC in our most deprived wards are diagnosed later than those in more affluent areas. Addressing health inequalities requires investment to focus on improving services in those areas where choice is limited and traditional services are having little impact. Promote choice and accessibility We will use techniques such as social marketing to commission services appropriate to the needs of the local population. For example, we plan to use social marketing techniques in Dewsbury to encourage people at risk of diabetes to access screening programmes. Each of the LTC programmes has identified areas of inequality and actions required to meet the needs of local communities. Working with localities we will provide services that are appropriate to individual communities matching approach to need and improving access. To improve quality and promote safety We need to offer choice and services designed to meet the needs of service users who are more informed and active in the management of their condition. This will result in the commissioning of services from a range of service providers, some of whom are not traditional health care providers. As commissioner we need to set rigorous quality standards and embed these in our contracts. Quality standards and service user safety indicators will be monitored. In LTC we will work with our partners in the

Council to ensure consistent standards which will include the need for a competency based workforce. Working with Higher Education Institutions we will commission programmes that will meet the needs of the new pathways. Work well in partnership with communities, individuals and their families, staff and organisations. Partnership and consultation underpin our approach to the LTC strategy. The LTC board includes representatives from NHS Kirklees, the Council, the voluntary sector, Acute Trusts and PBC consortia. Clinical leadership is embedded in the structure with clinical leads for all the HITs. Widespread consultation with users is fundamental to our work. This is an ongoing process, with stakeholder summits used to check the direction of travel and revalidate the pathway. The generic care pathway consultation, the route to a solution approach to the redesign of intermediate care services and the Year of Care user focus groups ,demonstrate the commitment of the LTC partnership board to involve users in service redesign and commissioning of pathways. A key principle of the Kirklees strategy for LTC care will require a closer co-operation between specialists and primary care teams. Specialists can pass on their knowledge to primary care staff and care can be â&#x20AC;&#x153;sharedâ&#x20AC;? between primary and secondary care. Effective partnership with all appropriate agencies is vital for improving LTC care locally; integration and care that is responsive to local needs has resulted in demonstrably improved outcomes for the individual and their carers.

The common assessment framework and integrated record systems will support and enable these changes but we will need to drive them. To underpin the changes we need robust measurement systems which are benchmarked and published to support informed choice. 4.6.3 The Long Term Conditions Pathway (Fig. 5) Stroke, respiratory conditions, diabetes, pain, heart disease, neurological conditions and mental health are all long term conditions, sharing the same risk factors. Co-morbidities are common – 26% of people with LTCs have three or more conditions and conditions can affect each other. For instance, people with diabetes are three times as likely to suffer from depression as those without diabetes. The two conditions are inter-related. The focus of Choosing Health is to prevent people developing a long term condition. Any pathway must start with this ambition and offer opportunities for people to improve their health and wellbeing. Self care will be embedded at every stage of the pathway to maximise the potential of each individual to maintain their social interactions and stay healthy. We will develop specialist elements of the pathway in line with the standards set out in the disease specific National Service Frameworks, concentrating on bringing services closer to home and developing hospital services that offer rapid access to assessment ,diagnostics and treatment, particularly for those who have suffered or are at high risk of suffering a stroke . Using the pathway we can identify gaps in the services we commission and at each element of the pathway link service

development and redesign with the financial plan. 4.6.4 Generic Care Pathways All conditions have a generic and specialist component and the generic care pathway in Kirklees sets out the options across the pathway for service users and carers. Our plans include: • Commission and implementation of a risk stratification tool to identify people with LTCs and ensure they are receiving the appropriate level of care, support and services with a view to reducing hospital referral or admission. • Extension of the community matron and case manager workforce by 50% and integration of this workforce alongside other generic practitioners such as GPs, Practice Nurses and District Nurses. • Development of primary care services to deliver enhanced services for people with LTCs. • Introduction of a 24 hour generic health and social care workforce for the support of individuals and carers. • Commission expansion of the single point of contact health and social care service. • Development of telehealth and telecare scheme and the introduction of assistive technology for people with LTCs to improve opportunities for self care, supported early discharge and admission avoidance. • Commission community discharge coordinators to reach into the acute

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

trusts to facilitate safe and appropriate discharge. â&#x20AC;˘ Self care programmes integral to respiratory and pain pathways. Wide range of resources available to public via libraries across Kirklees. â&#x20AC;˘ Year of Care pilot in four practices and person centred care planning introduced. â&#x20AC;˘ Redesign of intermediate care services to reduce the admissions and length of stay for people who need nursing and therapy support but do not require acute hospital care. Following a comprehensive review we are committed to: i. redesign of the care pathway. Proposals are currently (October 2008) out to consultation; ii. reduce duplication of services and the number of handoffs; iii. improve access to intermediate care beds and extend access of these beds to community matrons and specialist nurses and allied health professionals; and iv. implement a redesigned falls service.

Raise awareness via education of risk factors

ASSESS RISK FOR LTC

EARLY IDENTIFICATION

FOUNDATION LEVEL

Fig. 5: Generic Pathways for Long Term Conditions (LTC)

• Target general population and those who have behavioural/disease risk factors • Support people to alter personal behaviour to reduce risk factors PERSON HAS LTC DIAGNOSED

What level for initial treatment?

Individual health and social care needs assessment

LEVEL 1

Person has care planned and monitored by identified Key worker/Care manager from e.g. Primary Health Care, Social Care, Voluntary Sector PERSON DELIVERS OWN CARE

Person’s clinical need can be met within Level 1

Person’s clinical need can not be met within Level 1. Individual health and social care needs assessment

Scheduled Care Single Point of Access

Unscheduled Care Out of Hours Service

Individual health and social care needs assessment

LEVEL 2a and 2b

LEVEL 1

Level 2a

LEVEL 2

Level 2b

Person has care planned and managed by identified key worker/Care Manager.

Person has care planned and managed by identified key worker/Care Manager plus specialist input Care delivered and monitored by generalist +/- specialist input

Care delivered and monitored by generalist.

Person’s needs can not be met within Level 2. Individual health and social care needs assessment

Scheduled Care Single Point of Access

Person requires End of Life care

Unscheduled Care Out of Hours Service

Person referred to Community Matron or Case Manager LTC

LEVEL 3

Person requires acute assessment in secondary care Individual health and social care needs assessment Person has care planned and managed by a specialist (e.g GPsi, Disease Specific CNS, Palliative Care) and monitored with Community Matron OR Care planned, monitored, managed and delivered by generalists (Generic Care Worker, District Nurse, Intermediate Care, Respite Services) or Community Matron. Person’s clinical need improves and can be met within Level 2 KEY WORKER/CARE MANAGER: The person who is responsible for the coordination of an individual’s health or social care.

GENERALIST: A person who has generalist skills in health or social care management e.g. GP, Practice Nurse, Social Worker, District Nurse.

Person requires further and ongoing assessment in secondary care SPECIALIST: A person who can provide specialist assessment or management opinion working collaboratively with the generalist e.g. Palliative Care, Specialist Consultant, Specialist Nurse.

LEVEL 3

Person requires End of Life care COMMUNITY MATRON OR CASE MANAGER LTC: coordinate management of complex health or social needs, diagnosis, treatment or crisis alongside other members of the primary or secondary care health or social care teams.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

4.6.5 Long Term Conditions – Programme Summaries Primary Prevention of Cardiovascular Disease Outcomes • To substantially reduce mortality rates from heart disease, stroke and related diseases by at least 40% in people under 75, with a 40% reduction in the inequalities gap between the fifth of areas with the worst health and the population as a whole • To reduce premature morbidity and mortality in the most deprived communities • To reduce non-elective admissions for cardiovascular conditions. • To increase the number of people identified ‘at risk’ of developing Cardiovascular Disease (CHD, diabetes, stroke and chronic kidney disease) across Kirklees • To increase the number of people identified ‘at risk’ from the most deprived communities • To ensure all cardiovascular disease programme areas work in partnership to achieve these outcomes Related Indicators: • Implement the national policy ‘Putting Prevention First’ by: • To develop ‘at risk’ registers within primary care • To offer those identified ‘at risk’ a personalized education package to enable them to reduce their risk factors e.g. healthier lifestyles and treatment. • To increase the number of the target population who have been risk assessed • To increase the number of the

target population who have been assessed and identified as being at increased risk of developing cardiovascular disease, prescribed appropriate medication to reduce their risk • To increase in the number of referrals to appropriate mainstream services, e.g. stop smoking services Evidence based action required to deliver programme across Kirklees: • To develop a GP Local Enhanced Scheme to support practices in the identification and management of people who are at risk of developing cardiovascular disease • Commission an outreach service which targets those hard to reach groups in the most deprived communities • To ensure effective marketing which will encourage individuals to attend opportunities for risk assessment • Work in partnership with Choosing Health programmes in Kirklees to ensure appropriate services are commissioned to support individuals to make changes in personal behaviours to reduce their risk of Cardiovascular disease. Key Localities: All localities with concentrated effort in more deprived areas

Stroke Outcomes • Members of the public and health and care staff are able to recognise and identify the main symptoms of stroke and how it needs to be treated as an emergency. • Immediate referral for appropriately urgent specialist assessment and investigation for all who present with a stroke or transient ischaemic attacks including access to appropriate and timely follow up. • All individuals with stroke are immediately transferred to the hospital hyper-acute stroke service. • People who have had a stroke and their carers have access to high quality rehabilitation and receive support from stroke skilled services as soon as possible after they have had a stroke, available in hospital, immediately after transfer from hospital and for as long as they need it. • All individuals with stroke have prompt access to an acute stroke unit and spend the majority of their time at hospital in a stroke unit with high quality stroke specialist care. • Appropriately qualified clinicians are available to address respiratory, swallowing, dietary and communication issues. • People who have had a stroke and their carers are enabled to live a full life in the community. • People who are not likely to survive due to their stroke receive care at the end of life which takes account of their needs and choices and is delivered by a workforce with appropriate skills and experience in all care settings.

Related indicators: • Access is available to a hyper-acute stroke service that provides access to 24 hour brain imaging, consultant stroke specialist and thrombolysis if appropriate. • Brain imaging is available within 60 minutes of request including out of hours. • Those with high risk of full stroke are assessed within 24 hours. • Those with lower risk of full stroke but are presenting with TIA are assessed within seven days. • Adherence to national and local guidelines for the management of stroke and related risk factors including cholesterol, diabetes, obesity, hypertension and overall action is taken to reduce overall vascular risk. People who have had a stroke spend 90% of their time in hospital in a stroke unit. Evidence based action required to deliver programme across Kirklees: • A comprehensive specialist rehabilitation programme delivered by practitioners with specialist skills in stroke rehabilitation and comprising of an individualised exercise programme and education sessions which are integrated with the Expert Patient Programme and starts during admission to the stroke unit and continues after discharge in primary care. • All partners to actively promote specialist stroke rehabilitation, ensure effective marketing (internal/external) and signposting to clients. • A comprehensive early supported discharge service for people with stroke.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

• Prompt primary care assessment for risk factors associated with stroke. • Prompt primary care assessment and appropriate referral for all individuals who have had TIA. • Identified key worker and case management for all people who have suffered a stroke, their families and carers. • Commission services to support hyperacute management of stroke. • Develop and commission specialist services to support and address respiratory, swallowing, dietary and communication issues. • Comprehensive rollout of Gold Standards framework and Liverpool care pathway within all care settings throughout Kirklees. • Incorporate care planning into routine care of people at risk or with stroke.

Respiratory Outcomes • Achieving a reduction in the numbers of people admitted to hospital due to respiratory disorders. • Achieving a reduction in the length of stay for people admitted to hospital with Chronic Obstructive Pulmonary Disease. • Ensuring an increase in awareness of the risks of smoking and the availability of stop smoking services. • Ensuring an awareness of the risk factors for exacerbation of respiratory disease. • Ensuring an awareness of sleep disorders and risk factors for sleep disordered breathing. • Supporting people to self manage their respiratory disease. • An increase in the number of staff trained in managing respiratory disease in primary care and making appropriate referrals to specialist services, e.g oxygen, sleep disorders. • An increased level of self-efficacy and quality of life in people with respiratory disorders. Related indicators: • Reduced emergency admissions due to asthma and COPD. • Reduced length of stay for COPD. • Reduced crisis calls due to condition exacerbation. • Reduced A&E visits and YAS callouts due to respiratory disorders. • Adherence to national and local prescribing guidelines including oxygen therapy.

Evidence based action required to deliver programme across Kirklees:

Diabetes Outcomes

• A comprehensive pulmonary rehabilitation programme comprising of an individualised exercise programme and education sessions which is integrated with the Expert Patient Programme. • All partners to actively promote pulmonary rehabilitation, ensure effective marketing (internal/external) and signposting to clients. • A comprehensive early supported discharge service for people with COPD. • Primary care specialist assessment for oxygen and nebulised therapy. • Primary care specialist sleep service for diagnosis and treatment of respiratory sleep related disorder. Key localities: Batley, Dewsbury, Spen and Huddersfield North

• Achieving a reduction in the number of people admitted to hospital due to diabetes or complication related to diabetes. • Increased number of people whose diabetes is diagnosed and managed in primary care. • Ensuring an awareness of the risk factors for developing diabetes. • Ensuring an awareness of the screening programmes available for people with diabetes to identify early signs of complications related to diabetes. • Supporting people to self manage their diabetes with an associated increased level of self-efficacy and quality of life. • An increase in the number of staff trained in managing diabetes in primary care and making appropriate referrals to specialist services. • A reduction in the number of complications related to poor diabetes control being managed in primary care. Related indicators: • Reduced emergency admissions due to diabetes or complications related to diabetes. • Reduced GP crisis calls due to hyperglycaemia or hypoglycaemia. • Reduced A&E visits and YAS callouts due to hyperglycaemia or hypoglycaemia. • Adherence to national and local guidelines for the management of diabetes including: 1. Increased uptake of retinal screening 2. Increased uptake and access to

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

appropriate foot screening 3. Increased uptake and access to service user and carer education programmes. • Reduced inappropriate referral to secondary care based specialist services. Evidence based action required to deliver programme across Kirklees: • A comprehensive service user education programme which has clear links to primary and secondary care and the Expert Patient Programme. • All partners to actively promote service user education, ensure effective marketing (internal/external) and signposting to clients. • A comprehensive foot screening programme for all people with diabetes. • Primary care diabetes service redesign including specifications which have care planning as an integral part of service user review. Key localities: Huddersfield North, Batley and Dewsbury

Neurology Outcomes We will deliver the quality requirements set out in the Natinoal service Framework for Long term Conditions (DH 2005). The intial focus will be on: • All people with neurological conditions will be supported to self care and have access to high quality information to enable them to make decisions appropriate to their needs. • To develop an end of life care pathway for people with neurological conditions working with appropriate voluntary sectory partners, e.g. Parkinsons Society, MS Society. Related indicators: • Achievement of 18 week targets for neurological conditions. • Joint involvement of PCTs, social care and service user. Representatives in all relevant projects and initiatives. • Reduced incidence of hospitalisation for neurological conditions. • Implementation of well evaluated selfmanagement programmes. • Standardised and quality assessed provision for home care and community services related to neurological conditions. • Role of Neurological Alliance established within local service provision. • Improved service user feedback. Evidence based action required to deliver programme across Kirklees: • Ensuring sufficient capacity is available to sustain the achievement of national waiting time targets. • Establishing a common approach to

the use of existing and new disease modifying therapies for people with multiple sclerosis. Reviewing the provision of rehabilitation services for people with neurological conditions. • Reviewing the provision of services for people with epilepsy. Key localities All localities: • Training GPs and other non-specialist clinicians re. awareness and appropriate management of M.E. • Link with Leeds Neurology Team to review current referral practice. • Appropriate provision of acute rehabilitation for people with post acute head injury within both.

Coronary Heart Disease Outcomes • To reduce mortality rate from heart disease in people aged under 75, particularly those communities with the worst health and deprivation indicators • To reduce the size and severity of Coronary Heart Disease in the Kirklees population • To reduce the number of people with Coronary Heart Disease who smoke • To support individuals with established Coronary Heart Disease and their carers to self care and minimize the impact on their long-term health • To ensure equitable access to assessment and treatment options for those experiencing coronary symptoms and events to minimize the impact on long-term health • To reduce the number of people admitted to hospital with heart disease in the Kirklees population • To ensure appropriate systems are in place to offer risk assessments to the close family members of people who have suffered sudden cardiac death • To develop specialist services and pathways to meet the needs of those with confirmed or suspected heart failure Related Indicators • To ensure equitable and evidence based multidisciplinary programmes of secondary prevention and cardiac rehabilitation are available to individuals who have experienced a cardiac event • To achieve the 2 week wait standard for access to Rapid Access Chest Pain Clinics • To deliver a 10% increase per year in

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

•

the proportion of people suffering a heart attack who receive Thrombolysis within 60 minutes of calling for professional help To update practice based registers so that patients with Coronary Heart Disease continue to receive appropriate advice and treatment in line with National Service Framework standards To ensure practice based registers and systematic regimes, including appropriate advice on diet, physical activity and smoking, also cover the majority of patients at high risk of Coronary Heart Disease, particularly those with diabetes and a BMI greater than 30 To adhere to national and local guidelines for the management of Coronary Heart Disease and related risk factors, and action is taken to reduce overall risk Improve the management of patients with heart failure in line with NIHCE Clinical Guidance

failure • Commission services which identify close family members at risk of those suffering sudden cardiac death

Evidence based action required to deliver programme across Kirklees • Commission a comprehensive evidence based equitable programme of cardiac rehabilitation delivered by practitioners with specialist skills in cardiac rehabilitation • Continue to commission specialist stop smoking services which will enable those with established Coronary Heart Disease to access support for stopping smoking • Prompt primary care assessment and appropriate referral for all individuals who experience chest pain • Develop and implement an evidence based pathway and related services for the management of people with heart

4.7

Healthy Pregnancy and Maternity Services Strategy

4.7.1 Background According to “Maternity Matters” (DH, April 2007), the priority for modern maternity services is to provide a choice of safe, high quality maternity care for all women and their partners. This is to enable pregnancy and birth to be as safe and satisfying as possible for both mother and baby and to support new parents to have a confident start to family life. Delivering Healthy Ambitions in Yorkshire and Humber makes key recommendations for effective delivery of a maternity and newborn pathway, including: • improving outcomes for more vulnerable and disadvantaged families; • the reduction in working hours of doctors as a result of the European Working Time Directive; and • demographic and lifestyle changes. At the same time, the principle should be that pregnancy and birth are normal life events supported by midwives, with services delivered in community settings as far as possible during the antenatal period. The purpose of the Healthy Pregnancy Strategy is to define a shared vision for pregnancy care in Kirklees that will deliver the government’s vision, meet the needs of women and their infants and ensure better health outcomes for all. During development of the North Kirklees Annual Health Report for 2005, the local rates for infant deaths raised some immediate concerns. This resulted in the topic becoming a major priority for investigation by the Primary Care Trust and the Local Public Service Boards for Adults &

Healthy Communities and for Children & Young People, as well as MYHT. It should be recognised that infant deaths will occur within the population, but locally the rates vary widely across all Kirklees localities, with two localities being over double the national rate and four localities having an upward trend, three of which are in north Kirklees. A Maternity Matters event was held which focused on Kirklees with the anticipation of achieving strategic alignment with Calderdale and Wakefield PCTs. This would be beneficial to services where women cross boundaries i.e. Wakefield women delivering in Dewsbury and women from Huddersfield delivering in Calderdale. It is acknowledged that a significant amount of work has previously been undertaken to inform the reconfiguration of services around Maternity Care and the Integrated Service Strategy, and that this will have an impact on the acute provider services for The Mid Yorkshire Hospitals NHS Trust and Calderdale and Huddersfield NHS Foundation Trust. 4.7.2 How is this programme delivering the PCT’s goals? To place the person at the centre of everything we do Women have told us that on finding out they are pregnant there is a lack of clear information about what to do, confusion that health messages keep changing and therefore a tendency to ignore or discount all messages. Their main support and advice comes from family and friends (or ‘no-one’), not from professionals. There are also no clear messages about early booking into midwifery services.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

The Healthy Pregnancy Strategy will place women and families at the centre of their pregnancy journey by listening and supporting them to identify and address their needs across health and social care. This will include enabling women to support each other through peer groups in a range of settings familiar and comfortable to women themselves. To improve health and reduce health inequalities The north Kirklees infant deaths report identified a number of key priorities if action to reduce inequalities is to be effective. These priorities include health related behaviour of women of child bearing age including drinking alcohol before and during pregnancy, smoking before and during pregnancy and lack of appropriate nutrition and physical activity. (See WOCBA programme, section 4.4.11.) The Strategy aims to address these issues by ensuring women have access to effective support to make sustainable lifestyle changes relevant to the context of their lives and those of their families. The Strategy will ensure women and families are supported around their pregnancy and clinical needs, their health and lifestyle needs and their wider social needs including income, housing, domestic violence and substance misuse. To improve quality and promote safety Professionals delivering maternity care tell us that the booking appointment system is experienced as highly pressurised; that they are overwhelmed with paperwork to the detriment of engaging with women; and that there is no additional time for appointments with interpreters or link workers. There is insufficient time to discuss key health behaviour issues (smoking, diet, etc) as well as social issues impacting on

health including housing, poverty and domestic violence, which women see as more of a priority than healthy behaviour changes. The Healthy Pregnancy Strategy includes development and implementation of Care Pathways for pregnancy. These indicate that where additional or complex needs have been identified, additional support will be accessed through a multi-agency response. Women and families will be supported by family support workers, working alongside peer groups, who will help identify and address the range of needs for each family. Peer support will encourage and facilitate early booking into midwifery services and ensure that women have their health and social needs assessed early in pregnancy to improve outcomes. To promote choice and accessibility Maternity Matters promotes choice for women and families about how to access services as well as the type of ante and post-natal care and place of birth. Women have told us that initial contact with the service feels overwhelming and often feel overloaded with information. Women with particular needs feel unsupported and there is a lack of time to ask about what they want to know. Overall, women do not experience services as supportive. The Healthy Pregnancy Strategy aims to ensure services are configured and organised to provide direct access to a midwife, ability to book as early as at six weeks of pregnancy, choice of how to access maternity care (directly, through GP, through Childrenâ&#x20AC;&#x2122;s Centres) and choice of type of antenatal care.

The Strategy aims to ensure choice of place of birth, including: • a home birth; • birth in a local facility, including a hospital under the care of a midwife; • birth in a hospital supported by a local maternity care team including midwives, anaesthetists and consultant obstetricians (for some women this will be the safest option); and • choice of place of post-natal care. To work well in partnership with communities, individuals and their families, staff and organisations Maternity Matters requires that local commissioners of services ensure that a full range of partner organisations are engaged appropriately in the design and delivery of pregnancy care services. This includes women themselves, families and communities in ensuring that appropriate support is in place. Women have told us that parent craft classes are either not known about, not accessible or experienced as very disappointing. Women who have additional needs feel excluded from the ‘nice’ parts of the service and there is a mixed picture regarding opportunities to discuss and plan for birth. There are very strong feelings about breast feeding, including feeling judged about a decision not to breastfeed. The Healthy Pregnancy Strategy aims to ensure that women are fully engaged in the development of information and are supported to inform commissioners and providers how services can best be provided to meet their needs.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

4.8

Children and Young People’s Strategy

The main principles of our work are: • To focus on the needs of children and young people • To be guided by their views and those of their families • To work across statutory and voluntary services to deliver services that meet needs and are evidence based • To focus on early intervention and prevention. To this end we have developed a prioritised work programme which incorporates the National Strategic Framework (NSF) and national directives. The findings of the JSNA are summed up below and these findings feature throughout our work programme. The top five priorities from the JSNA are: • • • • •

Food Alcohol use Emotional well-being Educational attainment and Those with disabilities

To meet the needs of Kirklees’ children and young people we have ensured a close fit between the Children and Young People’s Plan (CYPP) and the Local Area Agreement (LAA) for Kirklees. We acknowledge that we need new ways of working together and are committed to actively pursuing the further development of integrated children’s services.

4.8.1 Child Health Promotion Programme Priority – Focus on early intervention and prevention. The promotion of health, wellbeing and prevention of disease at an early stage, whilst ensuring appropriate intensive intervention to the family and child at an early age, to develop the family’s optimum potential for the future. The National Policy context is embedded in the Children’s NSF (2004) and building on this, the Child Health Promotion Programme (2008) provides a powerful case for radical change to improve outcomes for children and their families. Action - The PCT is on target to deliver the child health promotion programme across all seven localities. A key component is the integration of service delivery across children’s centres, general practice and health visiting. The delivery of an agreed specification for health visiting ( which is currently commencing consultation) and the integration of service delivery across localities will ensure that core service delivery meets national recommendations whilst promoting the focus on each of the seven localities’ specific health needs. (See Tables 3 and 4). Key Outcomes – Support for parents meeting their identified need, universal core programme, plus programmes and services to meet different levels of need and risk being delivered and monitored.

We have set up a clinical network for children and maternity care working with the acute trust to address issues with regards to the delivery of services and the strategic direction of services across Kirklees with a focus on secondary care.

4.8.2 Parenting Strategy Priority - Focus on the needs of children and young people, be guided by their views and those of their families, focus on early intervention and prevention. Action - There is progress being made with the delivery and implementation of a parenting strategy across Kirklees with business cases being developed to ensure implementation. Co-ordination and clarity of support and where it is available and how to access needs to be further clarified and commissioned in a coordinated way.

4.8.4 Disabled Children Personalised Care Priority – Ensure access to effective and appropriate services for disabled children. Children and young people have selfdirected support and individualised budgets and are actively involved in decision making and shaping services for them. Action – to implement ‘Aiming High for Disabled Children’ and ‘Standard 8 NSF’. The HIT team will assess the current service and complete a Self Assessment Matrix. A framework will be developed for selfdirected support and individual budgets.

Key outcomes – Support for parents to meet their identified needs, improving attainment at key stages and a reduction in the number of looked after children

Key outcomes – Families/carers have access to a variety of support options and are fully informed about what is available

4.8.3 Teenage Pregnancy Strategy

4.8.5 Emotional Health and Well-being

Priority – Implementation of effective teenage pregnancy strategy, to develop and implement Sexual Health Programme

Priority – to improve emotional health and well-being for children and young people.

Action - There is an effective Teenage Pregnancy Strategy both agreed and implemented and the sexual health programme contributes to the Teenage Pregnancy strategic objectives. Other key strategies, especially Alcohol and Drug, Food, Obesity, and Emotional Well-being have clear priorities for children and young people to have access to appropriately young friendly services that effectively address their needs. Key Outcomes – Reduction in unwanted/unplanned teenage conceptions, better access to more effective services, improved self-esteem, better relationships.

Action – To implement a comprehensive Emotional Health and Well-being Strategy. To deliver a timely, integrated, high quality multi-disciplinary mental health service. This would ensure effective assessment, treatment and support for children, young people and their families. We are making significant progress in a number of areas, namely child and adolescent mental health and the proactive commissioning of services across all the tiers currently meets the four proxy indicators for 2008/9. Key Outcomes – Improve self-esteem, increase resilience to stressors, improve self efficacy, better relationships, improved emotional literacy, less bullying, increased/improved assertiveness and better access to more effective Mental Health Services.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

4.8.6 Specialist Commissioning Our strategic priorities for specialist commissioning for children’s services are: • Agreeing a service specification and procuring a Yorkshire and Humber wide paediatric and neonatal intensive care transport service. • Undertaking a capacity and demand analysis of Neonatal Intensive Care services and designate providers of neonatology services. • Developing a national designation process for paediatric critical care. • Agreeing a service specification for high dependency care and inform the national designation process for high dependency. • Developing care pathways and services for children with HIV in line with national recommendations. • Reviewing the delivery of congenital cardiac services to children in DGH outpatient setting. • Reviewing the delivery of specialised children’s palliative care services • Child and Adolescent Mental Health Services, in particular tier 4 services and a focus on improving the mental health of children in secure settings or under Youth Offending Team supervision in Yorkshire and the Humber. • Mapping the outcome of the national interdependencies work in children’s specialised services and ensuring those services are sustainable.

4.9

Mental Health

“Services exist for the benefit of the people who use them. Service users and carers should not only be involved in shaping their care by making choices, but should be central to the provision of local services as equal partners. Service user and carer involvement must be part of everyday practice across the spectrum of mental health and social care services. Only then will service users and the public have a greater say in the way services are planned and developed, how they operate and how they can better respond to needs and expectations.” (CSCI 2005) 4.9.1 Vision for Mental Health The vision for mental health in Kirklees is designed to enable our local population to maintain and improve their mental health and well-being. For those who experience mental health distress, our intention is to obtain the highest level of self-sufficiency within their communities, through the use of valued, quality support networks and services. 4.9.2 Ways of Working Our ways of working are to: • Act with integrity in the spirit of openness and true partnership. • Encourage and empower individuals to exercise their rights to choice, respect, dignity and independence through equality, opportunity and inclusion. • Embrace the diversity of our local population to facilitate their mental well-being. • Involve and inform local people in planning and reviewing services to meet their needs. • Implement rapidly and systematically

improvements in service delivery, based on evidenced practice through effective and accountable leadership and management. • Ensure appropriate and timely access to services. • Value and accept feedback from Individuals and providers across Kirklees. • Do what we say we will. Mental Health services will be based on the recognition that it is the quality of the relationship between the individual and their social context that is important for mental health. The agreed Joint Mental Health Commissioning Strategy (2008-2011) is based on both national guidance and local needs assessment. It should be seen as a working document to guide and support future work via agreement on specific targets, measurable outcomes and dates for achievement. The strategy also contains targets designed to improve the commissioning process itself. The strategy is a formal statement of plans for securing, specifying and monitoring mental health services to reasonably meet needs. It applies to all possible optimum service solutions in relation to individuals who experience mental health problems or who may be at risk of experiencing mental health problems. It sits with joint strategic analysis work. Partnership working is central to our approach in Kirklees as we believe that it secures the best outcomes for people who experience mental health problems through the most cost-efficient use of resources. The strategy also aims to better balance services so that there is more emphasis on

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

prevention, and earlier intervention. A key aim is to reduce the need for more complex and expensive interventions and aims to secure the best outcomes as cost effectively as possible. The strategy aims to better engage with the third sector. The breadth of provision will be expanded over the three years of this strategy as more effective use of the third sector is made.

supported to address social exclusion. • The partnership work underway will be further developed to deliver better outcomes and economies of scale. The health and social well-being of people who live in Kirklees is a high priority. • The highest standards of performance will be expected.

During the lifetime of this strategy, we aim to create supportive environments, promote protective factors for individuals, reduce the impact of risk, and so improve well-being. This means that we will be aware of the interaction between the emotional, physical, and social aspects of people’s lives. The strategy will also provide a sound framework for specialist mental health service provision.

4.9.4 What We Have Achieved The PCT has developed expertise in developing and commissioning services to meet the needs of our diverse and discrete communities. We have established a history of strong partnership working and a good reputation for service user involvement and public engagement.

4.9.3 Objectives • There will be emphasis on the promotion of independence and protection of vulnerable people. We will work on reducing reliance on institutional care by creating more suitable service solutions and packages of care for people in the community. • There will be an emphasis on prevention and well-being. • There will be a real focus on developing capacity in primary care. • There will be changes in directly provided services alongside work to grow the voluntary and independent sector, offering people more choice and control. • There will be an emphasis on services that are designed to promote recovery. The focus on being person centred and personalisation of public services will assist. • The development and maintenance of sustainable communities will be

Through the development and implementation of a robust database system, we have been able to analyse the significant spend by the PCT on Out of Area Treatment. The PCT is keen to repatriate service users to enable the provision of ‘care closer to home’, reduce costs, to ensure best value, ensure consistent quality and have effective case management. The PCT has commissioned four new and significant mental health services during 2008/09: • Early Intervention in Psychosis • Primary Care Mental Health Services • Section 136 of the Mental Health Act (1983) • Psychiatric Intensive Care Unit. Also in partnership, we have newly commissioned a range of services with third sector providers: • Employment service • Self help • Arts

• • • • •

Physical activity Advice and support Gender specific Carers Advocacy

4.9.5 What We Will Achieve The next phase of the PCT’s strategic development is to build upon achievement to date; to strengthen and enhance the PCT’s position in line with its Vision, Values and Goals, providing a platform for the future which will see the PCT occupying a strong position, confident of meeting the needs of the population served in a proactive, creative and confident way. We will continue to build on our opportunities to repatriate Out of Area Treatments (OATs), explore opportunities through policy change, e.g., NHS Next Stage Review, build on developing IT infrastructure to improve business efficiencies, including refined demand and capacity modelling and influence the national agenda and for Payments by Results (PbR). To secure this position the PCT will focus on the following strategic priorities: • Ensure existing robust commissioning and contracting relationships are maintained with providers, influence the mental health market through enhancing relationships. • Develop the PCT’s regional and national reputation to support the development of a currency and classification system for mental health, in addition to supporting service redesign and modernisation. • Establish a clear PCT profile to support and enhance the PCT’s reputation within the market and support relationships with key stakeholders. • Through an analysis of the market,

explore opportunities to enhance contestability and plurality in the market. • To continue to foster strong relationships with partners and local communities. In addition, there are a number of new service developments which the PCT intends to pursue for 2009/10. The anticipated commissioning budget required is £943k. Active negotiations are taking place to secure: • Services for Adults with Deficit and Hyperactivity Disorder (ADHD). • Community Eating Disorder services (initial projected efficiencies have been identified to commission this service from Out of Area Treatments) • Expanded Dual Diagnosis Service • Redesigned specialist psychology services – to achieve 18 week referral to treatment targets The PCT has identified and set out its commissioning intentions for further developments to improve service delivery from 2010 to 2012/13. The anticipated commissioning budget required is £744k. 4.9.6 How is this programme delivering the PCT’s goals? To place the person at the centre of everything we do To work well in partnership with communities, individuals and their families, staff and organisations The Mental Health Partnership Board (MHPB) which incorporates the function of the NSF, Local Implementation Group LIT as the key local stakeholder group, (including, service users, carers, statutory and third sector organisations alongside commissioners) for mental health services

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

will take the lead in implementing, reviewing and updating this Joint Commissioning Strategy. To improve health and reduce health inequalities To promote choice and accessibility The development of pathways of care in Mental Services are based on care pathway design. This ensures that the key significant steps in the pathway are understood by the service users as well as the clinicians, however there is always flexibility within the pathway to allow for service user choice and clinician decision making. We continue to work closely with all stakeholders, both locally and across the region, on specialist commissioning, to understand commissioning decisions and give a clear direction for planning mental health services so that the people of Kirklees are not disadvantaged. To improve quality and promote safety Building in quality, to existing contracts with providers is important and these are monitored regularly. Key Performance Indicators (KPIs) will be used to ensure that quality is continually built on. Within statutory service contracts we have included both penalty and incentive schedules. Within third sector contracts we have developed outcome measurements utilising the ‘outcome star’. To promote local sensitivity through effective commissioning To promote strong clinical leadership to drive service re-design and innovation. The Mental Health Partnership Board and the Mental Health Health Improvement Team have clinical representation, including GPs, nurses and allied health professionals. We have used clinicians extensively from existing services, through PBC consortia and from other specialist providers to enable us

to design and commission mental health services. Individual pathways have clinical leaders and we have held a variety of session with clinicians from primary and secondary care to work jointly to develop pathways of care To be a visibly credible organisation, operating to the highest standards NHS Kirklees has worked closely with all of its stakeholders and partners in ensuring care is delivered at a high standard, particularly through innovation and pathway redesign. The PCT has played a key role in leading on redesigning specialist psychology pathways to achieve the 18 week standard and has been recognised regionally for this work. The PCT has a close working relationship with the Yorkshire and Humber Mental Health Commissioning Network. 4.9.7 Specialist Commissioning of Mental Health All PCTs in Yorkshire and the Humber are committed to working together to commission specialised mental health services, and we have a well established forum taking this forward. Areas of priority are: • The development of services for individuals with a personality disorder. • Low secure inpatient services, including services required for people with a learning disability. • Service user involvement. • Specialist mental health services such as gender identity and Children & Adolescent Mental Health Services Tier 4.

4.10

Learning Disabilities

4.10.1 Vision and Values The vision for Learning Disabilities in Kirklees is to empower and enable individuals with learning disabilities to lead a full and, as far as possible, ordinary life as part of the community with the same hopes and aspirations as everybody else. The vision is based on four main principles which mirror the DH document published in 2001, Valuing People: A New Strategy for Learning Disability for the 21st Century of: • • • •

Choice Inclusion Legal and civil rights Independence

Having a learning disability is not a need in itself. People have needs based on individual circumstances, often determined by social, financial and health factors. People with learning disabilities have needs that are the same as the rest of the population, but they may need more support to achieve their goals. People want to reach their potential as human beings, live as independently as possible and have a full and active role in the community. This involves making lifestyle choices, working and making other valued contributions in the community. Everybody in Kirklees is an equal citizen and has a contribution to make to the community. The aim of the vision is to set out the main areas we need to focus on to enable people with a learning disability to maximise their potential and achieve their aspirations. We also need to ensure that we include everyone as part of the vision regardless of their personal situation. We conducted three public consultations for people with learning disabilities and carers.

The feedback was analysed and incorporated in the development of the vision and commissioning strategy. Consultation is an ongoing process; we need to constantly check that the changes we make are the right ones. The Learning Disability Partnership Board has a strategic role to play and is committed to ensuring the vision is implemented. This will be achieved through working in partnership with key partners. The PCT has the lead responsibility for ensuring that a commissioning strategy is developed and implemented for both mainstream and specialist health services. As commissioners we are required to ensure that we can fulfil our statutory obligations to commission appropriate, quality learning disability services that meet the required and future needs of this vulnerable care group within Kirklees. It is inevitable that there will be a significant impact on both primary care and specialist services. 4.10.2 What We Have Achieved The PCT has developed expertise in developing and commissioning services to meet the needs of our diverse and discrete communities. We have established a history of strong partnership working and a good reputation for service user involvement and public engagement. We have worked with both our main specialist health service provider and main social care provider to improve performance in learning disability services. Our action plans and service provision are fully integrated and show that we consider the delivery of learning disability services as a whole system pathway through a variety of services in primary and secondary care.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Our current and planned service models, identified within the learning disability commissioning strategy, are consistent with the recently published national guidance and recommendations; (Valuing People: A New Strategy for Learning Disability for the 21st Century (2001), Commissioning Specialist Adult Learning Disability Health Services; Good Practice Guidance (DH November 2007), Good Practice in Learning Disability Nursing (DH December 2007), Health care for all (DH July 2008) and Valuing People Now: From Progress to Transformation (2008).

innovative approaches to service redesign and modernisation. • Establish a clear PCT profile to support and enhance the PCT’s reputation within the market and support relationships with key stakeholders. • Through an analysis of the market explore opportunities to enhance contestability and plurality in the market, actively promoting competition from NHS and non NHS providers. • Continue to foster strong relationships with partners and local communities.

Prior to developing the approved learning disability commissioning strategy, we completed a benchmarking exercise of both our current primary care and specialist health service provision. This information has been utilised to provide robust commissioning intentions for appropriate, quality learning disability services that meet the required and future needs of this community of people within Kirklees.

We will continue to build on our opportunities to repatriate Out of Area Treatments (OATs) and explore opportunities through policy change, e.g., Commissioning Specialist Adult Learning Disability Health Services; Good Practice Guidance (DH November 2007), Good Practice in Learning Disability Nursing (DH December 2007) and Health Care for All (DH July 2008).

4.10.3 What We Will Achieve The next phase of the PCT’s strategic development is to build upon achievement to date; to strengthen and enhance the PCT’s position in line with its Vision, Values and Goals, providing a platform for the future which will see the PCT occupying a strong position, confident of meeting the needs of the population served in a proactive, creative and confident way.

The PCT intends to pursue specialist learning disability pathway redesign for 2009/10. The anticipated commissioning budget required to achieve this to a quality benchmarked standard is £370k. The PCT has identified and set out its commissioning intentions to further develop and improve service delivery from 2010 to 2012/13. The anticipated commissioning budget required is £960k.

To secure this position the PCT will focus on the following strategic priorities: • Ensure existing robust commissioning and contracting relationships are maintained with providers and influence the learning disability market through enhancing relationships. • Develop the PCT’s regional and national reputation to support 83

4.10.4 How is this programme delivering the PCTâ&#x20AC;&#x2122;s goals? To place the person at the centre of everything we do To work well in partnership with communities, individual users and their families, staff, and organisations Social Marketing has been a new approach in getting to the root of understanding what the population of Kirklees want and need and their frustrations in current service provision. We consistently consult through established, robust involvement networks and the Learning Disability Partnership Board on current and future services and how these are integrated with wider NHS and social care services. Feedback is invaluable in understanding what we need to commission, but also as a baseline to measure whether the improvements we are making will address the needs of service users. To improve health and reduce health inequalities To promote choice and accessibility Learning Disability services are often part of a more complex pathway of care that needs to be fully integrated. How and where individuals receive their care is factored into the planning of learning disability services. Improved health is measured on outcomes and it will be these that direct our commissioning and development of services. Where care is delivered is also important. Through the information in the JSNA and understanding of localities that have traditionally worse health outcomes, we have been able to increase and direct our focus. We continue to work closely with all stakeholders, both locally and across the region, on specialist commissioning, to understand commissioning decisions and give a clear direction for planning learning disability services so that the people of

Kirklees are not disadvantaged. To improve quality and promote safety Building in quality to existing contracts with providers is important and these are monitored regularly. Key Performance Indicators (KPIs) will be used to ensure that quality is continually built on. The action plans for our main specialist learning disability, e.g., focus on quality improvements with individuals receiving care in a timely way in the correct setting from an appropriate clinician. To promote local sensitivity through effective commissioning To promote strong clinical leadership to drive service re-design and innovation. Wider changes to secondary care provision have been consulted on in localities as well as with specific groups of people in strategic reviews of secondary care. This was done in partnership with our NHS provider colleagues. The PCT has been recognised as using good techniques for clinical leadership and involvement in redesign work and pathway development. Our Learning Disability Partnership Board and HIT have clinical leadership. To be a visibly credible organisation, operating to the highest standards. NHS Kirklees has worked closely with all of its stakeholders and partners in ensuring care is delivered at a high standard, particularly through innovation and pathway redesign. We work with our other commissioning colleagues at all levels to ensure that our design principles and approach to commissioning is fully integrated with our partners. The PCT has a close working relationship with the Yorkshire and Humber Learning Disability Commissioning Network.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

4.11

Physical and Sensory Disability

4.11.1 Background Patterns of physical and sensory impairment (PSI) prevalence are complex and diverse. Eighteen per cent of people over 16 years have at least one dimension of disability (equating to over 50,000 people in Kirklees) as defined by the Health Survey for England. Eighteen per cent of people over 18 years need help with at least one task of daily living which is over 50,000 people in Kirklees. A larger number of people with a range of long term conditions will come into contact with NHS Kirklees services, some of whom are jointly cared for by KC Services. The conditions which affect a lot of people aged 18 to 64 years old are visual impairments and hearing impairments, including profound hearing impairments.. The conditions which affect small numbers of people aged 18 to 64 years old but have a huge impact on them and services are conditions such as cerebral palsy, acquired brain injury, multiple sclerosis, spinal injury, Parkinson’s disease, motor neurone disease, Huntington’s disease and dual sensory loss. There is no evidence to suggest dramatic increases in the number of people with physical and sensory impairments in future years for the 16-64 age group. However, later onset conditions such as Parkinson’s disease, sensory Impairment, arthritis and musculo-skeletal conditions will rise as the population aged 45 and over rises. Disabilities linked to conditions such as diabetes and obesity are set to increase as levels of diabetes and obesity increase.

and sensory impairments into employment is critical to enabling people to remain independent. There are few accommodation options for people with more profound disabilities. Supported living and extra care housing options need to be better developed for people with more profound disabilities. Some of the pressures include: • a lack of supported living choices for disabled adults and families with disabled members; increasing costs for residential and nursing home placements; • a growing demand for complex and costly home-based care and support packages; • the need to deliver value for money in care provision whilst maintaining high quality standards and excellent outcomes for service users; • the need to develop individual care planning to meet the demands of the ageing population; and • a growing number of people with a long term condition (LTC). 4.11.2 What We Have Achieved We have had a strong focus on Neurological conditions and LTC. We have introduced LTC management as a holistic approach for the care of individuals. We believe that independence should be maximised wherever possible and that individuals should be in control of their own decisions. We have worked closely with our partners, and together with new community staff, have focused on case management which has improved care for our service users.

Research has suggested that only half of people with complex impairments remain in their jobs. Supporting people with physical 85

4.11.3 What We Will Achieve We will further improve our approach to LTC (see section 4.6) and introduce new pathways of care for service users with physical and sensory impairment. We will focus on improving services for people with hearing and sight impairment. With partners, we will commission services that improve access and outcomes for people with long term disabilities or who have particular conditions such as stroke and other neurological conditions. We will develop a single point of access with our partners so that the health and social care system is more easily navigated by service users and their carers. We will build on our approach to service user involvement and ensure this is fully integrated into how we design and commission services.

To promote choice and accessibility We will work with KC to further develop telehealth services to support people with long term conditions in their own home. We will also introduce generic LTC care workers that will allow service users greater choice and access to a range of services as well as the support required to ensure their continued independence.

4.11.4 How is this programme delivering the PCTâ&#x20AC;&#x2122;s goals?

To promote local sensitivity through effective commissioning Improve social and health care outcomes for people who have a stroke and their carers through commissioning services and ensuring delivery of services where people need them. Continue to develop the range of equipment available to people with visual impairment

To place the person at the centre of everything we do Partnership working with the Council (KC) is integral to the development of services, but our partnership working will not stop there. We will work with service users, service user groups and carers to design and commission service to meet our service usersâ&#x20AC;&#x2122; needs. We will use our patient partnership boards and social marketing to achieve this. To improve health and reduce health inequalities We will further develop the Community Matron Service that will be based where the need is and use our JSNA to reinforce this. To improve quality and promote safety Continue to work with PCT partners on delivering the quality requirements in the Long Term Conditions National Service Framework, the Stroke Strategy and Our Health Our Care Our Say recommendations. 86

To work well in partnership with communities, individuals and their families, staff and organisations Further develop Expert Patient Programmes for people with a Long Term Condition (LTC), involve service users and their families and carers as well as partner organisations so that there is a collective joint approach to well-being.

To promote strong clinical leadership to drive service re-design and innovation Develop pathways of care for people with a LTC that are comprehensive and inclusive. Review and redesign diabetes services and respiratory services with partners in secondary and social care.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

4.12

Drugs and Alcohol Commissioning Strategy

Kirklees Drug and Alcohol Action Team (DAAT), based within NHS Kirklees, continues to commission treatment services for drug users and is leading, in partnership with Public Health, the development of the alcohol treatment system. Some very challenging drug misuse targets have been met and we have doubled retention and programme completion whilst bringing waiting times down from 13 weeks to one week. Over 2,000 people were treated for drug misuse in 2007/08 and service user surveys show high service satisfaction rates. The impact of these interventions has been less crime and improved health and social functioning (NTA, 2007). Despite this, there is more to do. Delivering Healthy Ambitions in Yorkshire and the Humber (2008) recommends that brief interventions are ‘industrialised’, i.e. training for front line staff are made widely available as well as services for dependent drinkers are further developed. The tiered approach recommended was developed in 2007 and we are committed to delivering clearly identifiable and separate drug and alcohol services. Improvements to the evidence base and tools such as world class commissioning (2008) provide the means to make genuine strides in further tackling drug and alcohol misuse in Kirklees, and coupled with the findings from the JSNA (2007) we will target resources in the areas of greatest need. The underlying theme behind the strategy is to enable service users to break with the dependence on problematic use of substances and associated ill health and social exclusion.

4.12.1 How is this programme delivering the PCT’s goals? Development of a person centred approach We will commission services that are personalised and responsive to individual needs. We have successfully attracted drug users into services by a harm reduction approach that has resulted in large numbers of people on methadone maintenance. This is the ‘carrot’ into services. However, it is now time to develop more potential pathways out of treatment, including offering a wider range of interventions and better access to mental health support, good housing, employment and training. The Treatment Outcome Profile will tell us which service are most effective, and coupled with service user feedback we will be able to better direct resources to more popular services and introduce wider choices into the system. As recommended in Staying Healthy (Healthy Ambitions), we will commission and deliver alcohol services separately from drug services. Improving health at the heart of our treatment system Over half of people with drug and alcohol problems also have significant mental or physical health problems. We will develop a preventative approach based on overall service user well-being, including improved access to mental health, blood borne virus and counselling services. We will ensure that newly released prisoners receive appropriate harm reduction information to prevent relapse and/or overdose. Better access to services and reduced inequalities We will continue to develop and review pathways into and out of treatment, particularly for offenders and other hard to reach groups. We will widen access by

ensuring the further development of primary care based services across Kirklees for both drug and alcohol users. This will enable people to access services closer to home as well as ensuring that people with lower care needs are managed in primary care, not specialist provision. Consistency of provision across Kirklees localities will reduce health inequalities and deliver a responsive and more personal service. Quality to be enshrined in the commissioning process, including clinical effectiveness We will continue, through contract management to drive service improvement and meet national and local targets. This includes implementation of the Treatment Outcome Profile and evaluation of the findings. We will ensure all service users have an appropriate care plan and health care assessment and keep waiting times within target by commissioning open access services, as well as continued engagement with National Treatment Agency and Health Care Commission improvement programmes, including delivering the improvements determined necessary through the quarterly review and inspection programme. Kirklees was the first DAAT in the country to implement Standards for Better Health across commissioned services and we will continue to implement new guidance from NIHCE and the NTA. In particular, we will ensure the new prescribing guidance is fully implemented. Commissioners and clinical leads will ensure that they provide leadership and support for implementation of new guidance and audit of the existing treatment system Choice for service users and care closer to home Our service user led initiatives continue to be recognised nationally and we will ensure the input of service users and carers

through peer education, organised groups and advocacy, is entrenched in both service planning and delivery. We are committed to improving service user choice and a further means of delivering this will be to make better use of other service providers to complement traditional service providers. We will be tendering alcohol treatment services over the period in question and will review our Integrated Drug Treatment System to ensure it remains fit for purpose and can deliver the broader approach, encompassing harm reduction, maintenance and abstinence based treatments as the evidence base suggests. We are commissioning more locality based services via primary care both to increase initial service user choice whilst also ensuring speedier entry and exit in the treatment system. Locality based services will also enable us to develop services that reflect local needs and deliver a more flexible approach in the system. This may enable a more flexible approach to service planning and differential, needs-led outcomes in different localities. Partnership to deliver collaborative advantage It is essential that commissioners and providers are contributing towards larger strategic goals for Kirklees such as those contained in the LAA 2008-2010. Continuing to build strong partnerships is a key cornerstone of the approach to drugs and alcohol and we will use the levers outlined in World Class Commissioning to deliver integrated and well managed services that add collaborative advantage locally. This added value will increase the chances of meeting targets outlined in the LAA as well as aligned targets around mental/physical health, offending and community safety.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Fig. 5. Primary Medical Care Expenditure 2007 / 2008 total expenditure (excluding premises) per patient (weighted population) 15.0% Primary Medical Care Expenditure 2007/08 total expenditure per patient (weighted population)

10.5% 10.0%

4.9% 5.0%

7.7%

0.8%

Spen

Background Healthy Ambitions stresses the importance of strong primary care (ie GPs, dentists, pharmacists and optometrists) to the overall health care system, and this is a major priority for NHS Kirklees. A strong primary care system leads to better outcomes and higher satisfaction for service users. The existing practice registered list based model is central to delivery but must be accompanied by intelligent commissioning of primary care services, supported by use of good quality clinical and public health data.

Our priority for primary care is to tackle existing variations; whether in quality of service, levels of investment and capacity, accessibility or clinical outcomes.

Huddersfield North

Primary Care

Dewsbury & Mirfield

4.13

-10.0%

-8.5%

Total Kirklees

-4.6%

The Valleys

-2.3%

Huddersfield South

-5.0%

Denby Dale & Kirkburton

We will use the flexibilities and opportunities available to us - e.g., new primary care contracts - to develop local strategies for commissioning and delivering local services. We will also take the opportunity to tailor services to meet the needs of our differing communities and localities and increasingly we will plan services at locality level where this is appropriate to the service concerned.

Batley Birstall & Birkenshaw

0.0%

The immediate challenge is to ensure that core services are accessible to all our local people and that everyone is offered assured high quality services. The current position across Kirklees is generally good, but there are variations and we need to take action now â&#x20AC;&#x201C; e.g. through targeted investment and systematic performance management â&#x20AC;&#x201C; to ensure high quality services are available to all Kirklees people. 4.13.1 General Medical Practice General practices have a critical role as part of primary care. The practice will act as the navigator and co-ordinator of the care service users receive; it will focus on health and health care; and it will work in partnership with service users to ensure they are involved in determining how care is delivered for themselves and their communities.

It is important that everyone can register with a GP practice and can readily access a GP or nurse when they need to. When registering, people should also have a choice of practice. Capacity – the number of GPs and nurses – is key to delivering these ambitions. At present, we have a relatively low number of GPs for our population. In July 2008, we had 57 GPs per 100,000 weighted population, whereas the England average was 61.86. There is some evidence that this capacity shortfall is being addressed by skill mix or innovative use of non GP capacity – we have 30.6 practice nurses per 100,000 weighted population compared with the England average of 29.26. But this nursing workforce will not compensate fully for the relatively low GP capacity. Our aim is to increase GP numbers towards the England average. In doing so, we want to target the new investment and capacity in those areas with fewest GPs for their populations. There is evidence that GPs (and other practitioners) tend to practise in the areas in which they train. Accredited training practices are therefore important if we are to attract and retain young doctors and ‘grow our own’ medical workforce. We aim to increase the number of training practices in Kirklees.

4.13.2 Dentistry The Oral Health Strategy for Kirklees (200811) commits us to a wide range of actions and to working closely with partner organisations and stakeholders to improve dental services and the oral health of the local population. In line with this strategy, our priorities include: • Making the best use of our new powers and flexibilities to commission services locally. Our aim is to reduce existing inequities of access; tailor services to the health needs of people in the differing localities; and support year-on-year increases in the number of Kirklees people seen by a dentist. • Exploring further water fluoridation for our population and, if appropriate, participate in consultation activities. The process established nationally for exploring fluoridation means that this work is likely to continue beyond 2011. • Developing local protocols, care pathways, clinical networks and dentists with a special interest in appropriate specialties to improve linkages between services and provide service users with a seamless and easy route into regular NHS primary dental care. Where necessary, providing more specialist services, in particular: • Orthodontistry • Restorative services • People with special care needs • Oral surgery • Developing choice for service users in dentistry so that individuals may make

These figures are based on September 2006 workforce census and 2005 weighted population, as used by DH in the Equitable Access project.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

an informed decision about where best to access primary dental care and, if necessary, hospital dental care. • Exploring and exploiting more fully the potential for dental practitioners to contribute more to the key factors for oral health such as diet, sources of fluoride and smoking. 4.13.3 Community Pharmacy The 2008 White Paper ‘Pharmacy in England – Building on Strengths – delivering the future’ proposes a broader role for pharmacists – moving from purely dispensing ‘clinical care’ to being commissioned on the range and quality of services they deliver and being rewarded for health outcomes. Key programmes are identified within the White Paper which highlight the potential for community pharmacies, e.g., long term conditions support, promoting health and healthy behaviours, improving service user and medication safety and the development of minor ailment schemes. We already have examples of new services being delivered by community pharmacists, e.g., services to support smoking cessation, and the introduction of a new sexual health service to include pregnancy testing, condom distribution, emergency hormone contraception (EHC) and chlamydia screening. Other developments will also be supported by improvements in technology. For example, the Electronic Prescription Service (EPS) will streamline the prescribing and dispensing process by enabling individuals to go directly to their pharmacy where medicines will be ready for collection or delivery.

The challenge for us is to ensure that access to new services is equitable, according to need, ie that they are available in the more deprived areas as well as other parts of our area, and that service users have choice and an assured quality service. We are addressing these challenges and opportunities through a new strategy for community pharmacies which is in development. Central to the strategy is the importance placed upon community pharmacies because they are at the heart of our communities and are easily accessible over extended hours without the need for an appointment. Also central, is the need to build additional capacity in primary care for the future. We intend to build on the strengths of community pharmacies, and to move away from the culture of ‘volume’ as a means of recompense, towards one based on the quality and range of services provided. Key areas for development have been identified. Our strategy aims to ensure that pharmacies will: • be promoted and used as healthy living centres; • provide minor ailments schemes; • become more involved in the management of long term conditions; • actively contribute to improving medicines and service user safety; and • be more involved in screening and monitoring of medical conditions such as heart disease, hypertension and obesity management.

All these ambitions can be realised by using the skills of the pharmacy workforce more appropriately. But is important to note that pharmacies and their staff cannot do all this alone. To gain maximum benefit for service users, they must work in partnership with other health professionals in the delivery of health care. To assist with the delivery of this strategy, and other related strategies for primary care services, it is important that appropriate capacity is built into any future system of health care provision in the community. To support this, and the key developments identified, we need to ensure that we have a pharmacy workforce that is both competent, and fit for purpose. With this in mind, we will support the development of the pharmacy workforce, through development of pharmacists with a special interest. We will also develop clear and robust standards of accreditation for any services that are commissioned and ensure these commissioned services are designed to meet the needs of our local population. We will also work with pharmacies to improve access to medicines and service user safety in respect to medicines. 4.13.4 Optometry Similarly, we now have real opportunities to enhance the range of services delivered by optometrists. We will seize these opportunities and in doing will reduce the number of visits people need to make to hospital. Earlier detection will also lead to improved outcomes. Examples of the opportunities we now have include: • glaucoma referral refinement service – this is already in place; • supporting care for people with

diabetes – where we have already commissioned a commercial provider to offer diabetic retinopathy screening; • management of cataract referrals to ensure that only those requiring surgery are referred to hospital; • support to people at risk of falling – including advice on the best type of spectacles, frames, lighting etc; • working with optometrists to consider their role in the service pathway for age-related macular degeneration (ARMD) especially now that NIHCE has endorsed NHS use of effective new medication; • treatment of minor anterior eye conditions e.g., dry eye, and red eye such as conjunctivitis; • smoking cessation - smoking is a causative factor in cataract formation and macular eye disease; • the possibility of improving provision of low vision aids (magnifiers etc) to people with vision impairment. Existing provision is patchy and could be improved; • encouraging children to have regular sight tests through their local optometrist. This should offer a long term improvement in eye health as children grow into adulthood recognising the need for regular eye examinations. We are currently working with local optometrists and other clinicians to prioritise these developments and the redesign of eye care services is an important area for the coming year.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

4.13.5 Medicines Management Medicines are integral to 21st Century healthcare, with medicines being the most frequently used medical intervention / treatment nationally. Pharmacy and medicines management are common threads throughout all the recent NHS reforms and documents, with regulatory and contractual frameworks having been developed and implemented to underpin the strategic direction for pharmacy and medicines management services.

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Medicines constitute approximately 20% of the total NHS budget, it is therefore crucial to ensure the continued promotion of costeffective and evidence based management of medicines by Health and Social Care professionals, patients and carers to maximise the health benefits medicines can provide.

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The following are a summary of the key areas for development that are documented within the Medicines Management and Non-medical Prescribing Strategies:

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• • Medicines Commissioning – The existing arrangements for commissioning medicines, including High Cost drugs, Non-NIHCE / NonTariff drugs will be reviewed and strengthened through the use of World Class Commissioning competencies and frameworks. Performance measures will be included within all contractual agreements. • Personalised Medicines Management – With the move towards holistic care closer to home, the increasing age of the population and the increasing number of patients with Long Term conditions, the number and complexity of medicines

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regimes is increasing. It is therefore critical for the future patient care to maximise health benefits medicines afford through personalised medicines management. The PCT will build upon existing medicines management services to embed personalised Medicines Management into front line services. World Class Commissioning – medicines and medicines management will be embedded in all aspects of commissioning arrangements. Medicines Management training and education – The PCT will develop and / or commission a range of training and education packages designed to meet the needs of patients and staff to ensure we have a confident and competent workforce across health and social care, including the private sector. Non-medical prescribing – the PCT will further develop the role of nonmedical prescribers to support the shift of care into the community. Medicines Safety – The PCT will develop and implement a programme of measures to enhance the safe use of medicines locally. Medicines Governance – will be assured through review and continuous improvement of existing processes. Long Term Conditions and Intermediate Care - The PCT will further develop Medicines Management Support to patients as part of the Intermediate Tier and Long Term Conditions management services.

4.13.6 How is this programme delivering the PCT’s goals? Our focus on reducing variations in primary care will address many of our goals, but the following are particularly relevant: To place the person at the centre of everything we do Primary care offers a number of opportunities to extend the range of services available close to people’s homes. We want to harness these opportunities over the next three to five years and respond to what local people tell us when planning service provision. We are working to a service model that will allow us to define the core services that should be available to everyone in primary care, and then those which are more appropriately delivered at either locality level or above. Within these arrangements, we will explore possibilities to co-locate services where this is beneficial to the people who use them. To improve health and reduce health inequalities In parallel with our development work, we need to ensure that existing variations are addressed and that all people in Kirklees can access high quality services relevant to their needs. Some of these actions will require investment and we are already addressing this in some areas. For example, we are commissioning a new GP led health centre in Dewsbury – this area was selected in recognition of existing high GP list sizes in the area. This centre will offer appointments between the hours of 8am and 8pm seven days a week. Likewise, we are investing in additional dental activity, again targeting this in the areas of Dewsbury, Batley, Birstall and Birkenshaw where there were high

numbers of people on the dental waiting list. We plan to assess the impact of the new GP and dental capacity being introduced into Dewsbury and Batley, and then consider what further services may need to be commissioned to reduce any remaining variations. To improve quality and promote safety Commissioning new services such as GPs and Dentists is only part of the solution to reducing variations in primary care. We also need to ensure that existing services, plus any new services commissioned, deliver services that are safe and of high quality. Our Clinical Governance and Quality Framework (2008 – 20012) is key to this. This framework sets out our arrangements for quality and clinical governance and we will be working with independent contractors (and others) to develop our own quality matrix, as a means of reviewing and risk assessing the services we commission. In addition, we are mindful of planned national changes to NHS regulatory frameworks which will impact on us during the lifetime of this plan. We will work closely with independent contractors and other providers to understand and implement these changes. To promote choice and accessibility Service users tell us they want to be able to access primary care services easily and outside traditional working hours for both routine and urgent care. For this reason, we have responded quickly to the national drive to extend GP opening hours, with a significant number of Kirklees practices offering appointments at evenings or weekends by October 2008. We will continue to review the extended hours

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

offered by practices to ensure they reflect service usersâ&#x20AC;&#x2122; preferences as reflected in surveys. In addition, we will review the usage of the new 8am â&#x20AC;&#x201C; 8pm centre in Dewsbury and assess if this is a model that could also be commissioned for other parts of Kirklees. We also believe it is important for people to feel they can exercise choice in selecting their provider of primary care services, in the way that we are starting to see when people are referred to secondary care. Ideally, we would like people to have a choice of at least two practices within a reasonable travel time by foot or public transport. This may require modification in rural areas where travel times are invariably longer and the population is insufficient to support more than one local practice.

4.14

Urgent Care

4.14.1 Background Urgent care is care that is not planned in advance. This care is delivered in a variety of settings and by a variety of clinicians. GPs, Yorkshire Ambulance Service (YAS), Accident & Emergency Departments (A&E), Out of Hours (OoH) services amongst others all play a part in delivery of urgent care services for the people of Kirklees. The vision of a single point of access and a fully integrated, seamless urgent care pathway was described by Sir George Alberti in his paper Transforming Emergency Care in England (October 2004) “improvements in A&E were not enough …. a comprehensive modernisation of the whole system was needed”. Additionally, Dr David Colin-Thome, in the same paper, stated that “by far, the largest numbers of emergency and urgent contacts by patients occur in primary care. For too long this has been considered in isolation from both the Emergency Departments in acute hospitals and ambulance services. We are now committed to whole system working”. We work closely with our providers of urgent care services in order to ensure that high quality standards of care are delivered. With our main providers, we have clear action plans to develop and improve service delivery. We have also set out commissioning intensions in order to develop urgent care services by improved integration of OoHs, YAS, GP equitable access services and A&E. Urgent care centres will be developed on our main A&E sites. We have made a commitment to invest a minimum of £400k in setting up urgent care centres, over the next four years.

The delivery of urgent care will shift in some instances from secondary to primary care. For example, through the provision of equitable access centres and improvements in OoH services which will mean individuals do not attend A&E. The work of the Urgent Care Health Improvement Team is directed by service user and public feedback, ‘Healthy Ambitions’, National policy as described above, and our own PCT goals and outcomes. 4.14.2 What We Have Achieved We have worked with both of our acute providers at MYHT and CHFT to improve performance in urgent care services. Our action plans are fully integrated and show that we consider the delivery of urgent care service as not just A&E but the whole pathway through a variety of services in primary and secondary care. For example, we expect our intermediate care teams to work with and visit the main hospital sites to ensure that discharge happens in a timely way and that delays are minimised. We have integrated GP services into A&E departments. We have achieved a marked improvement in our YAS performance through joint action planning. We have developed a full and comprehensive service specification for urgent care that will deliver improvement over the next three to five years. 4.14.3 What We Will Achieve We will achieve a fully integrated urgent care service for the people of Kirklees. This will mean that service users will know where to receive their care and from whom. We will integrate a new ‘Access and Assessment’ service for West Yorkshire that will provide consistent information for our service users and a central point for their urgent care needs to be addressed.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Services that work to deliver urgent care will be fully integrated. This includes OoHs services, A&E departments and ambulances services. These services will also work in tandem with GPs, secondary care and social care services. We will develop Urgent Care Centres to provide a breadth of high quality and accessible care for individuals as intended by NHS Kirklees and outlined in â&#x20AC;&#x2DC;Delivering Healthy Ambitions in Yorkshire and Humberâ&#x20AC;&#x2122;. We will measure our success against the concerns and aspirations expressed by people in our consultation exercise. We will continue to work with our communities and partners to improve the quality and accessibility of urgent care services and reduce inequities of care by continued social marketing and seeking feedback about our services. We will know when we have been successful when outcome measures have been attained and KPIs are consistently high.

4.14.4 How is this programme delivering the PCTâ&#x20AC;&#x2122;s goals? To place the person at the centre of everything we do Prior to the redesign process and subsequent tendering of OoH services, we conducted a public consultation. Below are the key aspirations which emerged and which are now integral to our urgent care specification. In addition, we used social marketing to deepen our understanding of what the people of Kirklees really need and what we can commission accordingly. Integral to the urgent care specification are the themes from this: 1. My voice as a service user or carer is clearly heard and acted upon 2. I know how to access services if I have an urgent need 3. If I have an urgent need I can access care quickly and simply 4. My safety is paramount to everyone who cares for me 5. I can rely on getting the right care (including support for self care), 6. Whenever I need it and whoever I am 7. The care I received meets my needs appropriately, taking account of the urgency and value for money To improve health and reduce health inequalities Urgent care is often part of a more complex pathway of care that needs to be integrated. LTC care pathways, so how and where service users receive their care is factored into planning of urgent care services. Improved health is measured on outcomes and it will be these that direct our commissioning and development of services. Where care is delivered is also important. Through the information in the JSNA and understanding of localities that have traditionally worse health outcomes

we have been able to increase and direct our focus, e.g. the development of a centre in Dewsbury to improve access to clinical services. To improve quality and promote safety Building in quality to existing contracts with providers is important and these are monitored regularly. KPIs will be used to ensure that quality is continually built on. The action plans for our main provider A&E departments, e.g., focus on quality improvements with individuals receiving care in a timely way in the correct setting from an appropriate clinician. To promote choice and accessibility Service users told us that they want to know how to access urgent care services when they need it. To this end we have developed a specification for an access and assessment service that is being commissioned. This is a single telephone number that people can call to receive sign posting to the most relevant urgent care service. This works in a similar way to NHS Direct and is integrated with it. The added benefit to service users is that it is fully integrated into local GP and OoH services. Given the best information available and understanding the need to deliver care where it is safe, service users can choose to receive their care from a GP, OoH service or in secondary care. To work well in partnership with communities, individuals and their families, staff and organisations Social Marketing is a new approach in getting to the root of understanding what people want and need and their frustrations in current service provision. We asked a range of individuals and groups their thoughts on urgent care services as well as how these are integrated with wider NHS and social care services. Their feedback is

invaluable in understanding what we need to commission but also as a baseline to measure whether the improvements we are making will address their needs and anxieties. To promote local sensitivity through effective commissioning Wider changes to secondary care provision have been consulted on in localities as well as with specific groups of people in strategic reviews of secondary care. This was done in partnership with our NHS provider colleagues.

To promote strong clinical leadership to drive service re-design and innovation We aim to ensure that our Urgent Care HIT has clinical representation, including GPs, nurses and allied health professionals. We have used clinicians extensively and particularly through PBC consortia to enable us to design and commission urgent care services. Clinicians are fully integrated into the procurement process for OoH and wider urgent care services. To be a visibly credible organisation, operating to the highest standards We work with our other PCT colleagues at all levels to ensure that our design principles and approach to commissioning is fully integrated with our neighbours. We play a key and active role in achieving this.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

4.15

Planned Care Including Cancer and Palliative Care

4.15.1 Background Planned care is the care of people with conditions where services can be planned for e.g. surgical intervention following diagnosis. For many years, one of the biggest concerns, both locally and nationally, has been how long people need to wait for treatment. Over the past few years we have worked towards delivering the 18 week standard. People should wait no longer than 18 weeks from GP referral to definitive treatment. This has meant improvement in several ways including greater efficiencies in service delivery; more procedures commissioned; changes to the way clinicians work through pathway reform; and improvements to our information systems to record and report progress. All of these improvements have required understanding and joint working to ensure services are commissioned to meet the standard. To meet the challenge of sustaining this standard, the PCT has made a recurrent commitment of £200k to support pathway and service redesign to ensure service users receive care in the correct setting by the correct clinician and at the correct time. Similarly, cancer services have been improved overall, including for specific types of cancer. The Cancer Reform Strategy will bring further enhancements to the delivery of cancer services. Palliative care is integral to this and these two services go hand in hand.

Palliative care is end of life care where symptoms are managed to improve the quality of life. There have been big changes in palliative care, e.g., the steps taken to ensure there is consistency and equity in how end of life care is delivered. In addition palliative care is not provided only for people with cancer, but is also increasingly provided for people with a variety of long term and terminal conditions. The PCT has made a commitment of £500k per year to support cancer reform and £400k to support establishing and delivering palliative care and end of life care services. 4.15.2 What We Have Achieved Clinical engagement in pathway redesign for planned care and cancer care has been a significant achievement for the PCT. Not only through its planning structure and design but partnership working with provider colleagues and PBC. We have commissioned services and worked with providers to ensure that the 18 week standard has been met. We have achieved national standards in cancer care and continue to improve these. Palliative care has been integrated into new pathways for long term conditions and the Gold Standard for end of life care has been adopted in some of our nursing homes. 4.15.3 What We Will Achieve The future for delivery of planned care will involve providing care and services closer to people’s homes. Where possible, elements of the pathway will be commissioned from primary care providers. Individuals will be given greater choice and inequalities of care through the use of clear pathways adopted by all, will be significantly reduced.

For cancer care, we will implement the changes required in the cancer reform strategy. This will allow individuals to receive their care in a timely fashion and have a say in how their care is delivered. Palliative care services will be improved. End of life care will be available for everyone with long term terminal conditions. Individuals and their families will be at the core of how care is commissioned and delivered. 4.15.4 How is this programme delivering the PCTâ&#x20AC;&#x2122;s goals? To place the person at the centre of everything we do People have told us through local and national surveys that they want fast and convenient services. We have sought to involve service users in pathway redesign to ensure that their needs are met and that the services we commission will be safe, fast, convenient, of high quality and able to deliver expected outcomes. Service users have been involved in a number of pathway redesign projects. Service users have said that for some conditions, gynaecology e.g., they may not want to see their male GP and always choose the secondary care option. We listened to these concerns and developed specific primary care gynaecology services to ensure the individualâ&#x20AC;&#x2122;s dignity is respected and health concerns can be more openly discussed by service users. Such a focus is particularly important when considering race and culture. To improve health and reduce health inequalities We work closely with or partners to ensure that the services they want to develop are those that we will commission and that they

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meet the needs of our service users as understood through the JSNA e.g.. The development of pathways of care for planned care as well as in cancer services and palliative care. This ensures that the key significant steps in the pathway are understood by the individual as well as the clinicians. However, the pathway is flexible to allow for service user choice and clinician decision making. We will continue to work closely with the PCT and providers across the region to understand commissioning decisions and give a clear direction for planning cancer services to ensure the people of Kirklees are not disadvantaged. To improve quality and promote safety Existing pathways and those currently in development are predicated on safety. We work closely with our partners and clinicians to ensure that this is the case. In addition, the PCTâ&#x20AC;&#x2122;s governance processes also provide checks and balances to ensure safety. Using and measuring clinical outcomes and improved health will be a major step in how we monitor pathways as well as the length of time the individual waits. This will apply to both cancer and non-cancer pathways. Quality boards have been introduced with our providers and quality measures built into our contracts. To promote choice and accessibility Service users have a choice of providers for the vast majority of planned care. This is being increased through additional providers, especially in the primary care setting. For example, new services for people suffering from musculoskeletal conditions in primary care mean that service users have greater choice of provider and care is delivered closer to home.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

To work well in partnership with communities, individuals and their families, staff and organisations We have a strong history of working with our partners in developing new pathways of care, particularly to support 18 weeks. This approach needs to be more fully integrated into communities, individuals and their families. In cancer services, partnership working is already well-developed, with the PCT working with a variety of service user groups to understand their needs and commission accordingly. Likewise with palliative care, service user groups and organisations play a key role in influencing commissioning decisions. To promote local sensitivity through effective commissioning PBC consortia have played a vital role in supporting pathway development and are able to provide insights into local requirements. We work in partnership with them to ensure services are commissioned appropriately. The delivery of hospice services commissioned by the PCT is a good example of how we decide where and how care is delivered for a specific pathway of care in specific communities. The investments in palliative care will support this further.

structures through HITs, the PEC and PBC all have clinical leadership as the strong cross cutting theme. To be a visibly credible organisation, operating to the highest standards NHS Kirklees has worked closely with all of its stakeholders and partners to ensure care is delivered at a high standard, particularly through innovation and pathway redesign. The PCT has played a key role in leading on delivering the 18 week standard and has been recognised regionally for this work. In cancer care, the PCT actively participates in local implementation teams across both MYHT and CHFT. In addition, the PCT has a close working relationship with the Yorkshire Cancer Network.

To promote strong clinical leadership to drive service re-design and innovation NHS Kirklees has been recognised as using good techniques for clinical leadership, involvement in re-design work and pathway development. Our HIT has clinical leadership, individual pathways have clinical leaders and we have held a variety of sessions with clinicians form primary and secondary care to jointly develop pathways of care. Similarly, in cancer and palliative care we have strong involvement from our clinicians who provide the leadership expected. The design of our planning

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4.16

Specialist Commissioning for Bariatric Surgery, Cancer and Cardiac Care

4.16.1 Bariatric Surgery for morbid obesity Bariatric surgery will be commissioned via the Specialist Commissioning Group from April 2009 and work is already underway to ensure this is done effectively. Priority actions are: • To develop a service model which reflects the need for a consistent interface between secondary and tertiary services. • To review the demand and capacity for obesity surgery in the context of NIHCE recommendations and identified national and/or best practice international standards. • In conjunction with national processes, prepare for the designation of service providers in 09/10. • To develop and agree a common commissioning policy and service specification for obesity surgery. 4.16.2 Cancer Expert advice on the commissioning of cancer services is provided through three cancer networks operating in Yorkshire and the Humber – Humber and Yorkshire Coast, North Trent and Yorkshire. Each network will have its own specific local priorities, with the following strategic intentions being common to all: • The co-ordination and implementation of the recommendations outlined in the Cancer Reform strategy (DH 2007). This includes working with PCTs to achieve the required world

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class commissioning of cancer services. • The development of consistent approaches to the management of the rarer cancers across the three cancer networks • The development and implementation of action plans to achieve national evidenced based best practice. • The cancer networks will work as enablers for the Y&H SCG to participate in the National Peer Review process, supporting the provider development to ensure that the specialist cancer services are achieving the required national standard, as well as to support Locality Group development. • Networks will support the recommendations in the Lord Darzi review, and the regional Delivering Healthy Ambitions in Yorkshire and Humber plan so they work with commissioners to ensure cancer services adopt national and local policy. 4.16.3 Cardiac Care We also have three specialist cardiac networks across Yorkshire and the Humber. The strategic priorities for cardiac services across these areas are; • The development of services for acute coronary syndrome and stable angina, in particular the development of primary angioplasty and elective angioplasty services. • The development of heart failure services in line with NIHCE technology appraisals.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

• Addressing the requirements of the NSF for CHD (chapter 8) on Arrhythmia and sudden cardiac death. • The development of cardiac surgery services in Leeds and Sheffield. • The improvement of services for adults with congenital heart condition who are now seeing significant improvements in life expectancy. 4.16.4 Renal Services With the other PCTs in Yorkshire & Humber, our priority areas for the specialised commissioning of renal services are: • Developing a Yorkshire and Humber wide strategy for the planning and delivery of renal services across the whole spectrum of care for the next ten years, from risk checks, prevention, early detection and diagnosis in primary care to end stage renal failure in specialist centres and end of life care. • Ensuring sufficient capacity for dialysis and end stage renal failure services are planned and procured. • Ensuring investment plans are fully developed and implemented to increase the number of live donor transplants over the next three years at Leeds Teaching Hospitals Trust. Overseeing the mobilisation and integration of the Independent Sector Wave 2 dialysis facilities into local renal service provision.

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Section 5

Delivery 5.1 Past Delivery Performance Kirklees PCT was rated as ‘Fair’ for quality of services by the Health Care Commission on 2006/07 and 2007/08 performance. This successful achievement, during a period of significant organisational change, was fundamentally supported by the organisational ownership and understanding of performance. Through a number of organisation structural changes, performance has been maintained with NHS Kirklees using this legacy to support continued improvement and sustainability. Where performance challenges exist, these will be addressed as outlined in section 3 of the Strategy. The positive past delivery of performance against national priorities is a strong enabler in allowing Kirklees to take forward the new challenges set by Delivering Healthy Ambitions in Yorkshire and Humber and the NHS Next Stage Review.

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5.2 Risk Management Our approach to risk management is based on an integrated approach to the assessment and management of risk. To enable this approach, the PCT has procured the Performance Accelerator System which is a software application that supports PCT performance management across a range of PCT activity. This starts with the Board Assurance Framework based on the PCT’s strategic objectives. This identifies the potential risks that could affect the PCT’s ability to deliver these objectives. Additionally, all items within the system have a risk tab attached to them, where risk controls and mitigating action can be quantified. Specific directorate risks can also be added to the system. The PCT has started to use this software system in 2008 and further staff training and cultural change are needed to embed this way of working across the PCT. Risks associated with specific plans are identified in this document, but this is not yet systematic throughout the organisation.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

5.3 Financial Risk The PCT recognises that its ability to deliver its strategic priorities heavily depends on its ability to identify and manage financial risk and respond to unforeseen events. The significant financial risks are identified below: • A continuation of increased referrals and increased inpatient activity in acute secondary care that is not checked by demand management initiatives. • Acute trusts improve PbR coding, resulting in additional costs with no commensurate increase in activity. • Practice based commissioners have several plans which require investment and aim to reduce activity in secondary care, therefore demand may increase to fill the feed up surplus capacity. • The community hospitals programme is not deliverable due to the unavailability of strategic capital. • The efficiency schemes do not deliver, in particular the long term conditions programme which plans to reduce admissions and length of stay to the value of £4.5m. • Prescribing includes an efficiency target of 3% each year and although this is felt reasonable, prescribing is volatile and sometimes unpredictable. • The Mid Yorkshire Service Strategy cannot be delivered within PbR tariff over the longer term, a non-recurrent cost is assumed in the plan • NIHCE approves more expensive drugs than those currently in the planning assumptions.

5.3.1 Mitigating Actions Whilst there are many risks, there are also opportunities which the PCT can pursue: • There is scope to reduce length of stay in acute trusts at a greater pace which will result in more efficient use of capacity and a reduction in excess bed day costs. The Better Care Better Value indicators show continued savings opportunities for the health economy that are not fully reflected in this financial plan. • This plan includes the financial costs of initiatives. Less well developed in the plan are the savings in secondary care that should result from many of the initiatives. The above risks, which could increase PCT financial commitments over and above those already planned, would threaten the availability of resources required for the achievement of the PCT’s objectives. In recognition of this, the PCT is planning to hold a ½% contingency each year and is planning for an increasing surplus. This means it should have sufficient resource to manage most financial risks over the medium term. Overall, the Board believes that although the scale of the financial impact of some of the risks is large, it is manageable if anticipated and corrective action taken promptly. As the PCT has planned for at least a ½% surplus and a ½% contingency each year, the Board assesses financial risk at green.

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5.4 In year monitoring NHS Kirklees has robust systems in place for performance managing key national targets such as Vital Signs and Health Care Commission performance rating targets. These systems are built on the principle of strong accountability and ownership throughout the organisation, including the Trust Board. Routine reporting to various key forums of the PCT ensure that management decisions are taken and acted on to ensure delivery and achievement. The Finance and Performance Committee, sub-committee of the Trust Board, has a key role to play in the delivery of the operating plan and targets. It makes recommendations to the Board on investment decisions resulting from strategic and practice based commissioning business cases for delivery of priorities as well as monitoring progress. The previously mentioned integrated software solution supports the organisation in the transparent performance management of national and local targets and priorities. The performance monitoring framework ensures that performance against Vital Signs, relevant national indicators, Local Area Agreement, existing commitments and other key targets is managed in an informed and considered way. The Operating Plan 2008/09 has informed the individual and/or directorate business plans. The actions and requirements of the Operating Plan 2008/09 have been included in individual directorâ&#x20AC;&#x2122;s objectives for delivery through their teams. There will be a clear cascade of these from director to individualâ&#x20AC;&#x2122;s objectives. Through this clear cascade of priorities and targets it is expected that there will be increased accountability and ownership from staff

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across the entire organisation. Health Improvement Teams, in partnership with PBC colleagues, regularly report on progress of new initiatives via our Business and Financial Planning Committee, a subgroup of our Finance and Performance Committee. All new initiatives are first discussed at the B&FPC, with associated efficiency savings, intended outcomes and performance measures, to ensure strategic fit and effective governance.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

5.5 Commissioning Approach Planning within the NHS is becoming driven by service users, carers, commissioners and staff, rather than national targets and topdown performance management. This is focused on finding ways in which to improve services and develop good practice via outcomes and their associated indicators, not inputs or processes. The outcomes and indicators can be combined with other information, such as the JSNA, productivity data, programme budgeting, and other best practice guidance. This is used to identify the local health priorities that require review to commission appropriate service by the PCT, working with the Council, practice based commissioning units and representatives of the population. To achieve this there needs to be a framework within which: • The PCT has a clear understanding of the health priority areas it is focusing on. • There is an identified lead for each of these areas who is the first point of contact to others, and this lead person is supported by, and works with, others from elsewhere in the organisation. Organisational leads are responsible for bringing together the teams of people needed to address their areas of responsibility. • There is an explicit statement from the PCT about the requirements on these leads/teams, and what they need to do and by when to inform the organisation’s annual planning process. • There is clear accountability within the PCT for the work of these leads/teams.

5.5.1 Development of Commissioning Action Plans Each of our HITs is responsible for tackling a health priority through the creation of a clear commissioning plan. HITs also performance manages its plan and is responsible for its implementation and ongoing activity. They: • Follow the planning process to identify the most appropriate means of meeting the health needs of that priority, including potential inequalities whether geographical or other groups, and national priorities/frameworks. • Recommend the most appropriate services to be commissioned to address these needs. • Engage others in their work from the outset, in particular, practice based commissioners, clinical leads, voluntary sector and local people. • Produce prioritised and costed service development needs within each plan that address the identified health inequalities. • Ensure that appropriate dialogue is taking place with other HITs on areas of mutual interest, e.g., a Cardiac HIT would liaise with a tobacco control HIT to ensure that service provision and development needs were being addressed. The collective costed, prioritised requirements from the HITs is then assessed against overall priorities and resource limits to produce the PCT’s health development programme and associated financial plans for a period of time.

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5.5.2 The Health Improvement Team (HIT) Approach Each HIT adopts a common approach to programme management: • There is a common process of planning. See Fig. 6. • Each works to a time-limited deadline to ensure that a) there is focus on achieving its deliverables; b) the overall requirements of the PCT can be assessed together, e.g., for the annual Vital Signs (LDP) process. • There is one lead person for each HIT, so ensuring one overall view is maintained. This person acts as PCT lead on their improvement area, and is the first point of contact for external agencies such as the SHA. • Each lead reviews current forums and networks to assess whether or not they are fit for purpose. • Each HIT has membership from the relevant core directorates and links to others as required, e.g., public health colleagues on health needs assessment, Patient Care and Professions on clinical governance and audit etc. • Where relevant, HITs also have dedicated input from a primary care clinical lead who can act as a clinical champion for their area and facilitate joint working between the PCT and PBC.

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Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Fig. 6: Strategic commissioning process.

1. Strategic Needs Assessment Health priorities across Kirklees incl. inequalities Each has HIT group for planning into

Choosing Health HITs

Infection control HIT

Clinical / Expert

PBC Providers Joint Commissioning PPI

Long term conditions HITs

Urgent care HITs

Local Information - people - providers - commissioners

18 Weeks HITs

Partnership commissioning HITs

Role of HITs 2. Planning what should be done

Locality priorities planning

3. Identify gaps including ÂŁ, workforce, IM&T

4. Design services / commissioning plans for investment / disinvestment / reallocation of resources

Final commissioning overall plan for Kirklees

Providers PBC Joint Commissioning

5. Performance management of commissioning plans

PBC Joint Commissioning

6. Readjust levels and type of activity

Locality plans

7. Reassess need and restart process

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The main driver of this planning framework is to enable the PCT to plan and commission effectively. However, in a number of areas, plans are developed in partnership with the Council, and performance monitored via the LAA. Wherever possible, health-related targets in the LAA should map directly to targets the PCT already recognises and is working on. The existence of the LPSBs means that for some PCT leads, they will be required to provide performance updates to both the PCT Board and the relevant LPSB. 5.5.3 Purpose of the HIT Group: • Develop a strategy for integrated working with strategic partners across health and well being. • Promote the strategy to all relevant staff, clinical and non-clinical throughout Kirklees and facilitate opportunities for all key stakeholders to contribute to the strategy. • Develop opportunities to identify the public of Kirklees who are at risk or affected in any disease group, and ensure they receive appropriate and timely health and social care by developing a joint Council and PCT philosophy of integrated working. • Ensure the PCT goals are embedded in the strategy, to achieve clear improvement in local health. 5.5.4 Objectives • To maximise the opportunities for integrated ways of working between the NHS and other partner organisations, building on the health and wellbeing strategy. • To develop and manage any working groups tasked with individual actions, including setting aims, objectives and timescales. • To ensure appropriate stakeholders are fully engaged and involved in the

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development or redesign of service provision, e.g. service users, community nurses, GPs. • To identify the resource implications of service development or redesign alongside practice based commissioners and make recommendations to the relevant groups. • To identify any risks associated with service development or redesign and make recommendations to relevant professional groups. • To identify any training or education needs for service development or redesign and make recommendations to the relevant groups. 5.5.5 Business Planning During 2008, the HITs and practice based commissioners have submitted a number of business proposals for approval for additional financial investment, at a total revenue cost for 2008/09 of £9M. The evaluation process considered the following issues during assessment of the cases for funding: • The difference between cases to support commissioning additional services, as opposed to provision. • The need to ensure strategic ‘fit’ against the PCT’s priorities and objectives, including the JSNA, and also national policy, including the NHS Operating Framework published in Dec 07 and access targets as well as PCT goals and priorities, mapping to Standards for Better Health. • The clear dependencies between many of the cases which must be considered collectively (e.g., long term conditions) • Many of the cases have significant cost savings and the net financial

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

effect therefore must be considered as part of the assessment process â&#x20AC;˘ Many of the cases are to support pressured pathways (18 weeks) and these have automatically been recommended for consideration by PEC and the Board, given the priority to support our local trusts to meet these targets. Schemes should demonstrate our goals, as well as champion innovation in service change and promote continuing professional development and staff motivation.

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5.6

Practice Based Commissioning

5.6.1 Introduction The Kirklees Practice Based Commissioning (PBC) Strategic Framework has been produced to enable the successful future development of PBC throughout Kirklees. Taking as a starting point relevant key national guidance and best practice, the aim is to ensure strong PBC as an integral component of one system of commissioning. The effective development of PBC will contribute significantly to the PCT and its constituent practices becoming world class commissioners. 5.6.2 Local Context Within Kirklees, the configuration of PBC has evolved over time, resulting in a configuration of some 61 practices in four consortia, and 12 practices standing alone.

and transformational change”. Within Delivering Healthy Ambitions in Yorkshire and the Humber, it is emphasised that “clinical leadership and engagement is recognised as an essential and legitimate component of the commissioning process”. 5.6.4 Approach to the Kirklees PBC Strategic Framework This framework has been developed through identifying 11 themes or areas of work and, for each theme, assessing: • What DH guidance and/or national best practice examples say • Strategic objective – what is the aim for each theme? • What has happened in Kirklees to date? • What needs to happen next? The eleven themes identified are:

This configuration has been determined by the practices who decided whether they wished to work as part of a consortium and if so which consortium, or whether they wished to work on a stand-alone basis. This freedom of choice in configuration has resulted in greater engagement by practices than an imposed configuration would have done. However, it does not match the model of seven localities, shown below, that operates across Kirklees for much of health and social care. This is an issue which joint planning and PBC will need to recognise. 5.6.3 What Will Successful PBC Deliver? World Class Commissioning links PBC to many of the 11 competencies. In particular, competence 4, collaboration with clinicians, identifies “continuous and meaningful engagement of all clinicians to inform strategy and drive quality, service design and resource utilisation” and continues “PBC is the key methodology for this and should be maximised to drive innovative

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1. Strengthening PBC and enabling one system of commissioning 2. Practice engagement and communication 3. PBC Commissioning plans and business cases 4. Finance 5. Performance and information 6. Contracts 7. Public health 8. Service user and public involvement 9. Medicines management 10. Accountability and governance 11. Performance management of PBC The framework is underpinned by a detailed action plan that is tightly performance managed. This can be found in appendix two. This Practice Based Commissioning Strategic Framework has been developed to set the future course for PBC in Kirklees, by

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

following a direction that has the commitment of all stakeholders. The implementation of this framework will ensure that PBC has a lead role, as a key partner with a strong identity, in one system of commissioning. Through this, PBC will make a crucial contribution to world class commissioning in Kirklees. Please see Appendix 2 for the PBC Strategic Framework.

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5.7

Workforce Planning

5.7.1 Introduction A skilled, motivated workforce is critical to the delivery of our strategic goals, and to our Delivering Healthy Ambitions in Yorkshire and Humber and world class commissioning agendas. The changing demographic profile and health needs of our local population mean that NHS Kirklees must take a lead role in workforce planning across the local health economy. This paper describes the approach NHS Kirklees has taken to workforce planning to date and its plans and aspirations for the future. The paper also highlights several of the key identified risks in the Kirklees health care workforce. Full details of all identified risks and accompanying mitigating actions are contained in the Workforce Risk Assessments submitted to the Workforce & Education Directorate of the SHA in late September 2008. 5.7.2 Workforce Planning at NHS Kirklees The long term aim of our workforce planning activity is to integrate workforce planning with standard financial and business planning processes so that we can attract and retain a motivated workforce with the right skills and competencies to meet the health needs of the populations of Kirklees’ seven localities. In April 2008, the NHS Kirklees Board approved a workforce planning framework for the organisation that aims to fulfil the requirements of paragraph 3.32 of the 2008/2009 NHS Operating Framework and achieve the aim described above. The framework is based on the four pillars described in the NHS Plan (2002). It takes

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an holistic approach to workforce planning, using the organisation’s goal to be an Employer of Choice as the bedrock for all accompanying plans and actions. The framework recognises that the organisation’s approach to workforce planning is evolving, and will continue to evolve over coming months and years. 5.7.3 Achievements in 2008 This year, NHS Kirklees has started with the important fundamentals of workforce planning, focusing on: • Improving workforce information in order to monitor and inform people management practices and plans: The NHS Kirklees Workforce Scorecard, introduced in September 2008, represents a major step in this process. The Workforce Scorecard will enable the organisation to more effectively monitor and improve key elements related to the workforce, including sickness, turnover, agency spend and staff well-being. • Engaging with partner organisations: In line with NHS Kirklees’ strategic goals and Delivering Healthy Ambitions in Yorkshire and Humber, the organisation is building workforce planning partnerships with its key partner and provider organisations, including Kirklees Council, SWYMHT and CHFT. • Improving workforce planning capacity and understanding across the organisation: Information and consultation sessions at Board, Director and Assistant Director meetings and NHS Kirklees Community Health Services workforce sub group meetings have been crucial in raising the profile of workforce

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

planning. Further training sessions are planned before the end of 2008, focusing in particular on operational managers in the provider arm of the PCT. Organisation Development Services (ODS) have been commissioned to provide facilitator training on their SHA-preferred Population Centric™ model before the end of 2008, in order to increase the capacity of NHS Kirklees to carry out workforce planning. • Initiating discrete workforce planning projects: Several projects are underway or in development at NHS Kirklees. The projects are based on the Organisation Development Services (ODS) Population Centric™ model, and are carried out with the full engagement of the staff and partner organisations affected. The projects include: - a major ‘Health in Schools’ service redesign initiative, jointly with local education partners - a small workforce visioning project with a community occupational therapy team - a major project under development in the pre-school Kirklees Community Health Services team, in partnership with the Council, - a significant project planned to review the district nursing workforce in Kirklees • Carrying out workforce risk assessments: NHS Kirklees has taken steps to ensure that it has carried out risk assessments of the local health care workforce, including its own commissioning and provider workforces. It has also carried out; workforce risk assessments in

partnership with its major provider acute trusts, ambulance trust and mental health trust. Identified risks have been mitigated where possible and further action has been planned. 5.7.4 Current Workforce Risks and Priorities Through carrying out workforce risk assessments internally and with partners, NHS Kirklees has identified a series of workforce risks and mitigating actions across its local health economy. Full details are contained in the risk assessments themselves, which will be submitted to the SHA under separate cover; however several of the headline risks are outlined below for illustrative purposes. In addition, work has been carried out with finance colleagues to ensure that our workforce projections reflect the risks and plans identified to date. • Changes in personal support ratio: The Yorkshire Futures study (September 2006) on population projections indicates that the Personal Support Ratio in Kirklees, will decrease significantly between now and 2030 (PSR is the number of the population in the working ages divided by the number in the older ages). This means that by 2030 there will be only 3.08 people of working age to support each person over 65 compared to 4.5 in 2005. NHS Kirklees will need to develop and grow its workforce to deal effectively with the increased longevity of its population. It is likely that it will have to attract employees from sections of its local community that are traditionally economically inactive.

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• World class commissioning competencies: NHS Kirklees aims to become a world class commissioning organisation and as a priority is taking steps to equip its workforce to deliver the world class commissioning agenda and improve its performance against the required competencies. A comprehensive training needs analysis of both PCT employees and PBC partners is underway, following which a training plan will be developed

5.7.5 The Evolution of Workforce Planning at NHS Kirklees It is anticipated that during the coming months and years, further work will take place to improve workforce planning capacity and capability within NHS Kirklees; embed workforce planning into standard business and financial planning processes; and continue to develop joint workforce planning approaches with partner organisations. Specific action planned includes:

• New and extended skills: Delivering Healthy Ambitions in Yorkshire and Humber and work such as 18 Weeks and the Care Closer to Home agenda will require the development of new and extended skills in our health economy workforce. Health improvement skills in primary care and specialist skills in areas such as orthopaedics and radiotherapy are examples of skills areas identified as being in increased demand.

• Health economy dialogue: In line with its intention to be the leader of workforce planning in the local health economy, NHS Kirklees has planned a major health economy workforce planning event in partnership with Wakefield District PCT. The event is scheduled for 21 November 2009 and will bring together partner organisations with a view to developing further shared understanding of workforce requirements and furthering joint projects. Facilitators have been secured from Organisation Development Services (ODS) and the Strategic Health Authority to lead the event.

• Medical recruitment: Medical recruitment in secondary care has been particularly challenging during 2008/2009, with few suitably qualified applicants emerging for advertised posts at all levels, including junior doctor rotations. At CHFT a range of actions have been taken to allow 95% - 100% compliance with European Working Time Directive requirements in 2009. • Age profiles: With significant numbers of community nursing staff approaching retirement, discrete workforce planning projects are scheduled at NHS Kirklees to ensure that succession planning and opportunities for innovative ways of working are fully explored.

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• Improving the workforce planning capacity of commissioners: It is anticipated that the event described above will further NHS Kirklees’ and its partners’ understanding of the commissioner’s role in workforce planning. Subsequently it will be possible to arrange development for key commissioning staff, in particular the Health Improvement Team leads, so they can identify required workforce planning and development activity in partnership with providers.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

â&#x20AC;˘ Integrating workforce planning: NHS Kirklees will continue to work towards its long term goal of integrating workforce planning with its standard business and financial planning processes. Specifically, work will take place within the Business & Financial Planning Committee, to ensure that workforce considerations become embedded into standard procedures. â&#x20AC;˘ Building workforce information expertise: NHS Kirklees has approved the recruitment of a workforce analyst, who will play a key role in collating planned workforce expansion and development information as well as leading the continuing improvement of workforce and management information provided to the organisation. 5.7.6 Conclusion NHS Kirklees recognises that 2008 is the beginning of a journey to improve workforce planning in the local health economy for the long term benefit of its local population. There is further work to be done before workforce planning is fully integrated with the organisationâ&#x20AC;&#x2122;s standard business processes, and the workforce planning relationship between commissioner and provider is still evolving. However, NHS Kirklees is making positive steps in the right direction and will continue to do so. For further detail please see the Organisational Development Plan.

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5.8

Communications and Engagement Communications needs to be service user focused and centred, so that individuals have the information they need to make informed choices about their care and are able to influence the development of services. We will also seek out ways to work with our partners, such as Kirklees Council, on new social marketing techniques to proactively influence and effect changes in peopleâ&#x20AC;&#x2122;s behaviours on public health issues and health choices. A joint Marketing Board now oversees campaigns and social marketing across the PCT and Council. NHS Kirklees is committed to actively involving and working in partnership with the public and service users to design, review, monitor and deliver quality services to meet their needs. NHS Kirklees has a number of key service change priorities which will continue to benefit from service user, carer and public involvement and engagement ,as well as formal consultation processes. We are working to develop a number of key messages for our different stakeholders. For further detail please see the Communications Plan.

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5.9 Changes in Technology We will continue to deploy the Connecting for Health (CfH) sponsored solutions. By the end of 2008 we will have completed the deployment of the TPP SystmOne solution to our Provider Services arm. We will continue to upgrade and refresh the IT equipment in our GP practices and to support their use of a GP Systems of Choice (GPSoC) level 2 clinical system, as a minimum. Many of our GP practices are already based upon TPP SystmOne and others will follow. Therefore, our ability to deploy a virtual full service user record will increase. In parallel with this, we expect the national rollout of the Summary Care Record (SCR) to continue. This will enable increased safety and effectiveness of care, as information is able to flow around the system. This is, of course, always going to be subject to individual choice (for their information to be included) and to appropriate governance. We will continue to support the deployment of the Electronic Prescribing Service (EPS) to our community pharmacists.

network websites, such as Facebook, and comparison websites, such as TripAdvisor, we will face an increasing demand from our service users, citizens and staff to interact and share knowledge. We will therefore need to invest in the provision of opinion based sites (such as Patient Opinion) and to further develop our internet and intranet presence to meet this demand. This will include the provision of personal health websites such as HealthSpace. In addition, we expect that further developments in telehealth and telecare will revolutionise the ability to deliver services and support to people in their own homes. The focus will be on high quality information, supported self care and self management using the latest advances in assistive technology. Working with partners in the Council, we intend to combine our resources and systems to use telehealth and telecare to support vulnerable people in their own homes. In this way we will offer real time access to support for users and carers 24 hours a day.

The planned investment level in CfH solutions is estimated to be ÂŁ250K per annum over each of the next five years. In support of commissioning, we are expecting to use a data warehouse to enable the planning of services and activity levels to be managed effectively. We would anticipate that this will be done collaboratively with other PCTs within Yorkshire and Humber. We have also developed a joint warehouse of health data and information with the Council. Our biggest challenge will be with the provision of information to our service users and the public. With the advent of social

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5.10 Estates Issues The provision of high quality services requires premises and equipment which are fit for purpose. Our overarching strategy on facilities may be summarised as being to secure premises which are: • • • •

in the right place; in the right condition; of the right type; and able to respond to future service needs.

The existing estate falls some way short of this ambition. • Our direct estate holding comprises some 30 buildings containing some 20,000 sqm of space. These are occupied either as freeholders, leaseholders or under license via a PFI contract. The buildings range in condition and suitability from excellent to poor. • In addition, the 74 GP practices occupy some 92 further buildings. Again these range in condition and suitability from excellent to poor. Management of the estate in part reflects the formerly separate PCTs. • In the north, the estate holding is predominantly part of the PFI scheme with North Kirklees Facilities Ltd. (10000sqm). Under the 2004 Project Agreement, NKFL are required to provide a fully maintained and compliant building for thirty years. The remainder of the estate of five buildings is in good to excellent condition. Estates services to the non PFI buildings are provided by Mid Yorkshire NHS Trust under a service level agreement and by individual landlords.

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There are 31 GP practices (102 GPs) operating from 41 premises in the north. Of these, 12 operate from NHS Kirklees owned/leased premises leaving 19 premises owned or leased by GPs. Their condition is variable. • In the south there is a mix of freehold and leasehold premises including premises partially occupied by NHS Kirklees but owned by CHFT. Estates services to the majority of buildings are provided by CHFT under a service level agreement and by individual landlords. Ad hoc arrangements are in place for those building not covered by these arrangements. There are 43 GP practices (136 GPs) operating from 51 premises within the south. Of these, seven practices operate from NHS Kirklees owned/leased premises leaving 44 premises owned or leased by GPs. NHS Kirklees also has leasehold occupancy rights in 20 GP premises and other sites for community staff for which it pays a rent and a proportion of running costs. The condition of all these premises is variable. Our objectives in managing the overall estate are to: • support easy and convenient access to buildings and services by service users, staff and others; • support delivery of the highest quality services to local people; • comply with statutory requirements; • deliver best value for money; and • support delivery of this Five Year Strategic Plan.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

5.11 Procurement Strategy Procurement is a whole life-cycle process of acquisition of goods, works and services. It starts with identification of need and ends with the end of a contract or the end of useful life of an asset, including performance management. Good care of service users depends on the required services, equipment and materials being available to the right standards, at the right time, in the right place and at the right price and this can be delivered through strong procurement. The PCT makes a clear distinction between the process of determining commissioning need, and that of deciding on the appropriate provider. The procurement process starts with the identified need (although the requirements for robust procurement also influence definition of commissioning need, e.g. in producing service specifications that are fit for purpose). The overall procurement process includes not only the ‘buying’ process, but also a separate stage of accreditation to ensure that all contracted providers can and do meet the required standards, and ongoing contract management throughout the life of the contract to ensure standards are met and outcomes are achieved. The most relevant world class commissioning competencies are: • (C7) Effectively stimulate the market to meet demand and secure required clinical and health and well-being outcomes • (C9) Secure procurement skills that ensure robust and viable contracts

Way forward The principles of an NHS Kirklees Procurement Policy and Procedure have been agreed. Our policy is that NHS Kirklees will comply with legal and policy requirements in its approach to tendering of clinical and non-clinical procurements. The objectives are to: • Show how we will meet statutory procurement requirements. • Set out the transparent process by which we will determine whether Part B services are to be formally tendered. • Contribute to achieving WCC competency around secure procurement skills. • Enable early determination of whether and how services are to be opened to the market, to facilitate open and fair discussion with existing and potential providers. We will have confirmed our approach to procurement by November 2008, and the following points will be addressed: • For non-Part B procurements we will follow EU rules and PCT SOs/SFIs. • For Part B procurements we are exploring the use of the “any willing provider” (AWP) model as our preferred approach. If the AWP model is not appropriate, the PCT will make a documented decision on whether a formal procurement is desirable on the grounds of demonstrating best value, market testing, maintaining competitive tension and complying with the procurement rules. In addition, the following governance arrangements are proposed:

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• Any large (estimated value above £500k), novel, contentious or repercussive tenders will require a procurement strategy to be agreed with the Board. • Any contracts for new or significantly changed services, or with an estimated value above £139k, which are not suitable for AWP provision and where it is proposed not to tender, will require Board approval and will be reported to the SHA. The procurement policy/procedure document will also set out how the PCT will comply with the key principles of good procurement and procurement strategy. It will be ratified by the end of 2008.

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Section 6

Conclusion 6.1

Overall Impact Against Our Strategic Goals This plan sets out our ambitions for the services we offer to the people of Kirklees. It establishes a direction of travel for the next five years, sets objectives for our services and explains how we intend to deliver them. It should be read in conjunction with our: • Organisational Development Plan • Communications and Engagement Strategy • Finance Plan • Operating Plan • Joint Strategic Needs Assessment When considered together, this suite of documents provides a clear picture of the key health issues in Kirklees and our strategic goals and objectives. Our goals are central to all our planning activities and form the basis for ongoing strategic development in partnership with all our stakeholders. Our service users are at the very centre of this. To help us raise our game, meet the competencies described in world class commissioning and other local and national systems reform and redesign, our goals are our guiding principles and a consistent means of measuring success throughout the entire system.

We know that service user choice is an issue in some areas, and new investment will include a real increase in primary medical care capacity in the Dewsbury, Huddersfield North and Spen areas to bring the localities closer to the Kirklees and England averages. At the same time, and as in other areas, we need to ensure that services are delivered in premises that are fit for purpose, limit the scope for clinical isolation and ensure continuity of services as existing single handed GPs retire or leave. All this will ensure that we provide people with a choice of services and interventions, and that services are accessible, with the principle of ‘closer to home’ being applied as far as possible. Our commissioning strategies aim to deliver whole scale systems redesign in critical areas such as Long Term Conditions, Mental Health, Children and Young People and supporting planned and urgent care commissioning with our partners in secondary care. These strategies describe improvements in quality and service user safety, by commissioning services which are delivered safely and to the highest standards, and which are evidence based around clinical and cost effectiveness. Genuine partnership working with our stakeholders, in primary, secondary, tertiary care and with Kirklees Council will require setting outcomes which truly reflect local needs and priorities.

Planned improvements in quality, health outcomes and inequalities can be measured against the benchmarks we have set ourselves through our “Choosing Health Programmes”, which demonstrate a very clear understanding of the challenges we face, and where our efforts must be focused to meet the needs of our population. 123

Effective commissioning will: â&#x20AC;˘ ensure that changes in demand and activity can be planned for and managed effectively without adversely affecting our performance, â&#x20AC;˘ ensure that we continue to meet and exceed our targets, â&#x20AC;˘ allow us to help our partner organisations, particularly those in secondary care, meet their own targets thus enabling whole system improvements. Our investments over the period of this plan have been agreed by the Board to deliver our objectives in our priority areas. These priority areas were guided by our goals. The financial plan over this planning period is both affordable and prudent. It makes use of non-recurrent resources to initiate service changes and provides a contingency for risk. We will deliver all our financial objectives whilst investing for health and well-being. The involvement of our clinical leads and champions, both at a strategic level on our Board and PEC, and also within systems redesign with our Health Improvement Teams, will fulfil our ambition to promote strong clinical leadership to drive service change and innovation. Finally, we aspire to be the best that we can: a world class commissioner of health care and a visibly credible organisation, operating to the highest possible standards and meeting the needs of our local population, and minimising avoidable gaps in health between local people.

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Section 7

Board Approval 7.1 Declaration of Board Approval The Board has been involved in the development of the plan in a number of different ways. Board members are also members of sub committees and other groups, so members have been able to see the development of strategies and ideas from the bottom up as well taking the strategic lead through Board briefing workshops and formal Board discussion. The Board has set out through its approval of the business planning framework, scheme of delegation and practice based commissioning systems and processes the way the PCT will develop its plans.

7.2 Formal Sign Off of this Plan The Board closes the cycle by formal agreement of all plans developed as part of the World Class Commissioning assessment process at a public Board meeting on 29th October 2008. These plans are thus submitted for assessment under the World Class Commissioning Framework.

Rob Napier Chairman

The Professional Executive Committee (PEC) has been a key player in developing clinical pathways through the clinical leadership role of PEC members and service strategy providing advice to the Board on the plans. The links with the council through the Local Public Service Boards on which PCT Board members sit has also enable Board members to make sure that partnership working is a key theme within the plans.

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Appendix 1

The Kirklees Localities â&#x20AC;&#x201C; Profiles and Priorities for the Future This section sets out a brief profile of the population of each locality, the key health challenges which those populations face, a description of the existing services which we offer and our priorities for future investment in services.

Fig. A1: A Map of the Seven Localities of Kirklees Batley, Birstall and Birkenshaw Spen

Huddersfield South

The Valleys

Much of the material here is drawn from the JSNA. This is also informed by the development a set of locality plans led by Kirklees Council in partnership with key stakeholders, including NHS Kirklees. As those plans develop, we will review our service priorities for each locality to ensure consistency and to support continued and enhanced partnership working. In this Five Year Strategic Plan, we have set out our priority health initiatives for the next few years. For some of these initiatives, e.g., long term conditions and the Choosing Health Programmes â&#x20AC;&#x201C; we have also identified where locality specific action is required. See sections 4.4 and 4.6. For much more detail, please refer to our JSNA.

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Dewsbury and Mirfield

Huddersfield North

Denby Dale and Kirkburton

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Batley, Birstall and Birkenshaw This locality lies in the north east of the Kirklees area. Table A1 shows the age profile for the locality. Table A1: Batley, Birstall and Birkenshaw: Population by Age Group (Mid–Year Estimate 2005) Age Group

Under 20

20 - 64 Years

65 - 84 Years

85 Years plus

Total

All 65 and over

Number

14,920

30,100

6,040

780

51,840

6,820

% of locality

28.8

58.1

11.7

1.5

100.0

13.2

Kirklees %7

26.2

59.2

12.7

1.9

100.00

14.6

N.B. This presentation hides differences between the populations of Batley and of Birstall and Birkenshaw. For this reason the locality is often sub-divided further, as here, into its two major communities of Batley and of Birstall and Birkenshaw.

Batley Population profile The town of Batley has a particularly young profile when compared with the population of Kirklees, with 28% of the population aged under 19 in 2006. Around 12% of the population are aged over 65. Within Batley 32% of the population in 2006 were of South Asian origin. Life expectancy Life expectancy at birth for males in Batley is similar to the Kirklees rate, which in turn is similar to the national rate of 76.6 years. In contrast, life expectancy of females at birth is below the Kirklees rate, which in turn is slightly below the national rate. Overall life expectancy in Batley is 78.5 years and nationally is 80.9 years. Life expectancy at 65 for both men and women in the locality is less than that of Kirklees and for women in particular is two years less than the national rate. Priority health issues The JSNA identified Batley as experiencing much worse health than Kirklees overall and identifies a number of health inequalities. Issues of particular concern include: Children and young people: • nearly twice the national rate of deaths in infants aged under a year and linked to this, one in eight babies were born with a low birth weight; • maternal behaviours affect infant health and in Batley two in five women of child bearing age were overweight or obese and one in three of white women were still

Note - Kirklees figures are ONS Mid-Year Estimates 2006

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smoking at the birth of their child; • five year olds have the poorest teeth across Kirklees and twice the national rate; • more 14 year olds than in the rest of Kirklees were out of control through drinking alcohol weekly or more and one in five were drinking alone; and • asthma is worse than across the rest of Kirklees and can be linked to smoking in the home. Adults: • high rates of diabetes and stroke; • behaviours that contribute to diabetes and stroke, particularly high rates of smoking and drinking alcohol in men; • suffering pain including arthritis is also an issue; and • the town is economically deprived with a lower average household income than in Kirklees as a whole and higher rates of people in receipt of benefits than anywhere else apart from Dewsbury.

Birstall and Birkenshaw Population profile In contrast to Batley, the population of Birstall and Birkenshaw has an older profile when compared to that of Kirklees and particularly when compared to that of Batley. Around 22% of the Birstall and Birkenshaw population are aged under 19 and over 15% of the population are aged over 65. Again in contrast to Batley, 11% of the population were of South Asian origin, similar to the overall Kirklees average. Life expectancy Life expectancy is very similar to the population of Batley. Life expectancy at birth for males is similar to the Kirklees and national rate (76.6 years). Life expectancy for females at birth is below the Kirklees rate which itself is slightly below the national rate. Priority health issues The JSNA identifies a number of health inequalities in Birstall and Birkenshaw. Issues of particular concern include: Children and young people: • maternal behaviours, particularly smoking at birth, although levels were closer to that of Kirklees overall; and • 14 year olds experience the highest rate of bullying in Kirklees and a high rate of those who have bullied. Adults: • overall health functioning was worse than that of Kirklees, particularly for those aged over 65; • high incidence of coronary heart disease, high blood pressure and cancer deaths in those

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Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

aged under 75; • low levels of physical activity; and • alcohol bingeing by men. Current service profile The overall locality is served by eight GP practices (with 30.1 wte GPs and one nurse practitioner delivering an average list size of 1,828 service users per practitioner), five dental practices, and 12 pharmacists.

Fig. A2: Batley, Birstall and Birkenshaw: Locality Providers

Impact on provider landscape New investment will include an increase in primary medical care capacity to bring the locality closer to the Kirklees and England averages. Likewise, we believe that residents from this locality – in particular postcode areas WF17 – have more difficulty than residents elsewhere in Kirklees (with the exception of Dewsbury) in accessing a dentist. This is based on numbers on the dental waiting list in 2008. We will review the impact of recent increases in the commissioning of dental activity and target resources in this area appropriately to ensure local needs are met.

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Denby Dale and Kirkburton This locality lies in the south-east of Kirklees. There is no significant deprivation and generally adults living in the area experience the best health of adults in Kirklees overall. But there are still a number of problems and issues in comparison to national rates. Population The locality is relatively sparsely populated and distance does inhibit access to some services. As table A2 indicates, the area has more people of working age and nearing retirement than other areas in Kirklees. Table A2: Denby Dale and Kirkburton: Population by Age Group (Mid–Year Estimate 2005) Under 20

20 - 64 Years

65 - 84 Years

85 Years plus

Total

All 65 and over

7,690

18,790

3,870

580

30,910

4,450

% of locality

24.9

60.8

12.5

1.9

100.0

14.4

Kirklees %6

26.2

59.2

12.7

1.9

100.00

14.6

Age Group Number

The locality has the lowest proportion of its population of South Asian origin, at under 1%. Life expectancy Life expectancy at birth in the locality is the highest in Kirklees but is still three years lower than the best in England. Life expectancy at 65 and at 75 is close to the Kirklees profile. Priority health issues Particular health issues include: Children and young people: • emotional wellbeing of 14 year olds; • early alcohol drinking among 14 year olds; • the highest rates in Kirklees of young people reporting feeling miserable and feeling angry; and • nearly 40% of women of child bearing age were obese or overweight, only a third were physically active enough and over a third binged alcohol in the previous week. Adults: • pain; • high blood pressure and heart disease in older people; and • high rates of pensioners living alone and older people on low incomes.

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Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Current service profile The locality is served by four GP practices (with 14.3 wte GPs and 0.5 nurse practitioners delivering an average list size of 1,787 service users per practitioner), five dental practices and five pharmacists. Fig. A3: Denby Dale and Kirkburton â&#x20AC;&#x201C; Locality providers

Impact on provider landscape Large scale change in the primary care provider landscape is not envisaged in this locality, rather we will aim to ensure continuity of service provision and ensure that facilities are up to expected standards.

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Dewsbury and Mirfield The Dewsbury and Mirfield locality lies in the east of the Kirklees area. As table A3 shows the locality population has a relatively young age profile compared to Kirklees as a whole - with a high number of children and young people and fewer older people and of working age. Table A3: Dewsbury and Mirfield: Population by Age Group (Mid–Year Estimate 2005) Age Group

Under 20

20 - 64 Years

65 - 84 Years

85 Years plus

Total

All 65 and over

Number

21,990

41,960

8,710

1,160

73,810

9,870

% of locality

29.5

56.9

11.8

1.6

100.0

13.4

Kirklees %6

26.2

59.2

12.7

1.9

100.00

14.6

Its population is the largest of the 7 localities and there is widespread deprivation. This shows in health inequalities across a range of conditions, poor personal behaviours and low living and working conditions. Overall, the locality experiences the worst health in Kirklees and this is particularly so in Dewsbury. This area is therefore often sub-divided to consider Dewsbury and Mirfield separately.

Dewsbury Population Dewsbury has 29% of people aged under 19 - the largest proportion across Kirklees. 12% are aged over 65. About 25% of the population is of South Asian origin. Life expectancy Life expectancy at birth for males is the lowest in Kirklees. Life expectancy at 65 and is lower than that of Kirklees and nationally with both men and women having a life expectancy seven years lower than the best area in England. Priority health issues Dewsbury has real health challenges: Children and young people: • babies die in their first year of life at over twice the national rate; • one in nine births are of low birth weight; • maternal behaviours are poor with high rates of obesity, one in three smoking at birth and nearly half of women of child bearing age bingeing in the last week; • tooth decay is common - which may be linked to poor diet; • 14 year olds continue to have emotional well-being issues, particularly self-esteem and isolation;

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Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

• GCSE attainment is the lowest in Kirklees as a whole; and • the highest proportion of child protection cases and second highest number of looked after children across Kirklees. Adults: • the worst rates of high blood pressure and diabetes across Kirklees; • higher rates for early death from all the major killers; • the highest rate of smoking in Kirklees; • the highest rate of females binge drinking in Kirklees; • one in five adults are obese; • the lowest achievement in Kirklees of five portions of fruit and vegetables; and • the highest rates of people claiming Income Support and Council Tax Benefit.

Mirfield Population Mirfield has an older population profile than both Dewsbury and Kirklees overall. The majority of people are of working age and heading to retirement age. The area has the lowest proportion of people aged under 19 across Kirklees and the highest proportion aged over 65, at 18%. In contrast to Dewsbury, less than 1% of the population are of South Asian origin. Life expectancy Life expectancy at birth is similar to that for Kirklees as a whole. As in Dewsbury, life expectancy at 65 and at 75 is lower than that of Kirklees and nationally with both men and women having a life expectancy seven years lower than the best area in England. Priority health issues Children in Mirfield have better health than the Kirklees profile and noticeably better than children in Dewsbury. Similarly, adults have fewer health issues than those in Dewsbury and this mirrors the Kirklees profile more closely. However: Children and young people: • Women of child bearing age are the highest in drinking over sensible limits per week and amongst the worst in bingeing in a week. Adults: • cancer registrations, particularly for breast, are higher than elsewhere in Kirklees but early death rates from the major killers, apart from suicide, are better than that of Kirklees; and • mean consumption of alcohol in males is the highest in Kirklees and three units over the recommended amount per week.

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Current service profile The locality is served by 14 GP practices (with 31.3 wte GPs and 2.2 wte nurse practitioners delivering an average list size of 2,250 service users per practitioner, nine dental practices and 21 pharmacists. Recent investments in service developments in the locality include new state-of the-art health centres in Dewsbury and Ravensthorpe. In addition, a new NHS walk-in centre (The North Kirklees NHS Walk-in Centre) was opened in 2005 at Dewsbury and District General Hospital. This centre offers nurse-led services primarily to the people of North Kirklees and offers advice and treatment in relation to minor ailments and injuries.

Fig. A4: Dewsbury and Mirfield â&#x20AC;&#x201C; Locality providers

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Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Impact on provider landscape The locality will benefit during 2009 from the new GP-led health centre in Dewsbury. This will offer medical care to local people (registered and unregistered) from 8am until 8pm each day. Once established, we will work with the service provider of this practice, and other local stakeholders, to determine what other services could usefully operate alongside this new GP service. In particular, we will focus on those services and interventions which will best address the specific needs of the people of Dewsbury, and also address the disproportionately high use of the Dewsbury A&E department for minor urgent care needs. Even with the new GP led health centre, it is likely that there may be a need for further primary medical care capacity, but we will review this before March 2010. We will explore with the local community and local providers how best to deliver any increases. The Dewsbury area is also home to a number of smaller GP practices and we will need to ensure that services are delivered in premises that are fit for purpose, limit the scope for clinical isolation and ensure continuity of services as existing single handed GPs retire (or leave). The capacity shortfalls in Dewsbury do not just relate to primary medical services, but to dentistry as well. The dental waiting list continues to grow, despite the additional investment in growth funding and Dewsbury (postcodes WF12 and WF13) is an area of high need and low provision. Historic information suggests that people in the area will not routinely travel very far for their dental treatment and this could be further compromised if public transport is infrequent. One option being considered is an access type centre for dental service users in the Dewsbury area. This area is not only an area of high need but it has a high number of homeless people and asylum seekers. The high level of people who fail to return for treatment following a routine assessment suggests that to open an access service in this area would be the most cost-effective and appropriate way to deal with the high volume of service users.

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Huddersfield North The Huddersfield North locality lies at the middle of our area at the northern edge. It is predominantly urban, comprising in the main northern half of Huddersfield – but includes a semi-rural fringe to the north. The locality experiences broadly similar health to that of Kirklees overall and is the least deprived of the mainly urban localities. Population As table A4 shows, the population profile is similar to that of Kirklees with a slightly lower proportion aged 19 or under. Most are at the younger end of working age. Table A4: Huddersfield North: Population by Age Group (Mid–Year Estimate 2005) Age Group

Under 20

20 - 64 Years

65 - 84 Years

85 Years plus

Total

All 65 and over

Number

13,190

30,880

7,390

1,020

52,490

8,410

% of locality

25.1

58.8

14.1

1.9

100.0

16.0

Kirklees %

26.2

59.2

12.7

1.9

100.00

14.6

The area has the most ethnically diverse composition of all the localities in Kirklees, with nearly 14% of South Asian origin and 8% of other origin, mainly Afro Caribbean. Life expectancy Life expectancy at birth, at 65 and at 75, mirrors that of Kirklees as a whole quite closely and for those at 65 and at 75 is close to the national profile. Priority health issues The main health challenges are: Children and young people: • the numbers of 14 year olds drinking alcohol, particularly those drinking alone; • emotional well-being of 14 year olds - a third feel angry and one in four feel miserable; • relationships are also poor; and • women of child bearing age smoke less than in other parts of Kirklees but still experience higher levels of obesity or overweight and bingeing alcohol. Adults: • pain, particularly in older people; • higher rates of diabetes and high blood pressure also in older people; • although deaths from suicide are very small the area experiences nearly twice the national rate; and • less physical activity is undertaken than in most of the localities in Kirklees. Current service profile The locality is served by 17 GP practices (with 37.4 wte GPs – including six single handed

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Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

practitioners â&#x20AC;&#x201C; and 1.9 wte nurse practitioners delivering an average list size of 1,749 service users per practitioner), 16 dental practices and 16 pharmacists. There is also the Princes Royal Community Health Centre (owned by the Calderdale and Huddersfield NHS Foundation Trust) which is the base for a range of community services including community nursing service, health promotion unit, child health clinics, family planning clinics, dental clinic, genito-urinary medicine, speech and language therapy, physiotherapy, and foot health.

Fig. A5: Huddersfield North â&#x20AC;&#x201C; Locality Providers

Impact on provider landscape New investment is unlikely to include any substantial increase in primary medical care capacity. However, there are opportunities to improve the way services are delivered through relocation or expansion. We need to ensure that services are delivered in premises that are fit for purpose, limit the scope for clinical isolation and ensure continuity of services as existing single handed GPs retire (or leave). The locality has seen little development in premises in recent years and this now needs to be a

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priority. There are three particular areas of focus – the Acre Mill development; the need to improve health facilities and services in the Ashbrow/Bradley areas; and the future role of the Princess Royal Community Health Centre. The proposed redevelopment of the Acre Mill site, which we will commission, as a third party development, is expected to make a major contribution by providing the opportunity to relocate and co-locate some smaller local practices and to offer community (level 1/2 ) services to a wider population. Further work is required to scope the range of such services which could best be provided from this location and we will work in partnership with the Foundation Trust, local practices and members of the public to do this. The Princess Royal Community Health Centre (PRCHC), which is also owned by the Calderdale and Huddersfield NHS Foundation Trust, has also been identified as a key base for services in the town centre area – just outside the Huddersfield North locality. We regard this site as important to our overall strategic plan for health services in the future and with the Foundation Trust have highlighted the site as a priority for re-development under the banner of our community hospitals programme. While more work is need to define the nature of services that could be delivered from PRCHC into the future, the central nature of the site undoubtedly lends itself to services such as outpatients, ‘one stop’ clinics, advisory and support services such as those for sexual health, substance misuse, alcohol advice as well as other primary care services such as GP surgeries who may offer services at evenings and weekends as well as during the day. During the winter of 2008, we plan to begin discussions with local people and professionals on the options for the Princess Royal Community Health Centre. We will also undertake an options appraisal for establishing a new health centre in the Ashbrow/Bradley area where existing service provision is limited. This too could offer community services and accommodate GP services. It is envisaged that the Fartown Health Centre will become more of a base for community health services into the future, with primary medical care being delivered from either existing or new premises in the area.

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Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Huddersfield South This locality lies at the centre of our area and has the second largest population of the localities in Kirklees. It includes the town centre of Huddersfield and the University campus. Population Table A5 shows the age profile for the locality. It has the largest proportion of people aged 19 – 44 of the localities across Kirklees, a slightly lower proportion of people aged under 19 and a similar proportion of those aged over 65 to that of Kirklees. Table A5: Huddersfield South: Population by Age Group (Mid–Year Estimate 2005) Age Group

Under 20

20 - 64 Years

65 - 84 Years

85 Years plus

Total

All 65 and over

Number

17,180

40,670

9,680

1,300

68,850

10,980

% of locality

24.9

59.1

14.1

1.9

100.0

16.0

Kirklees %6

26.2

59.2

12.7

1.9

100.00

14.6

11% of the population are of South Asian origin and over 5% of other origin, mainly Afro Caribbean. Life expectancy Life expectancy at all stages is very close to that of Kirklees as a whole. Priority health issues The JSNA identifies the key issues as including: Children and young people: • teenagers have the second highest rate of teenage pregnancies in Kirklees and one of the highest levels of no contraception used in 14 year olds; • relationships at school are amongst the worst in Kirklees; • although those experiencing bullying is low those admitting to being a bully is the highest in Kirklees; and • maternal behaviours are poor with high levels of obesity or overweight, smoking at birth and drinking alcohol particularly bingeing. Adults: • higher rates of long term conditions particularly in older people and especially heart disease, asthma, diabetes and stroke; • people suffering pain, particularly back pain; • nearly one in four people smoke; and • binge drinking is high among both men and women. Current service profile The locality is served by 12 GP practices (with 39.6 wte GPs and 1.9 wte nurse practitioners

139

delivering an average list size of 1,796 service users per practitioner), 11 dental practices and 16 pharmacists. In addition, the Moorfields Primary Care Centre opened in 2006 at Crosland Moor. This offers primary care services to people across Kirklees and administrative support to local GPs with a special Interest (GPs who provide services in a particular specialty to individuals on referral by another GP or consultant, as well as providing traditional general practice services to the registered service users of their practice.) Mill Hill Health Centre currently houses a range of community health services serving the Dalton, Rawthorpe and Moldgreen areas.

Fig. A6: Huddersfield South â&#x20AC;&#x201C; Locality Providers

140

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Impact on provider landscape Some new investment will be required in this locality, in particular to bring premises up to standard. Equally, we are aware of areas such as Dalton where there is a lack of a GP presence and we are working with local people and service providers to address this. As part of our plans for the Dalton area we will also work with Kirklees Community Health care Services to ensure that we maximise the potential of the Mill Hill Health Centre to serve as a community services base for the people of the area. In the Crosland Moor and Thornton Lodge area we will explore options for a new health centre or centres to accommodate up to four local practices and potentially community nursing and health visitor services. In addition, we will continue to ensure that the Moorfields Centre is well equipped to deliver services in the immediate future, but will review its longer term future as part of options appraisal for the Princess Royal Community Health Centre. It is possible that some of the services provided from Moorfields may benefit more from a town centre location.

141

Spen Spen Valley is located in the northern part of Kirklees, bordering with Bradford. Many residents in the area work in Bradford. This locality most closely reflects Kirklees overall. Population As table A6 shows, the population profile for Spen mirrors that of Kirklees as a whole with slightly more people approaching retirement than in other areas. Table A6: Spen Valley: Population by Age Group (Mid–Year Estimate 2005) Age Group

Under 20

20 - 64 Years

65 - 84 Years

85 Years plus

Total

All 65 and over

Number

12,470

29,410

6,580

940

49,400

7,520

% of locality

25.2

59.5

13.3

1.9

100.0

15.2

Kirklees %6

26.2

59.2

12.7

1.9

100.00

14.6

6% of the population are of South Asian origin mainly living in the south of the locality. Life expectancy For all ages life expectancy is slightly below that of Kirklees and so slightly below that nationally, particularly for males. Priority health issues The JSNA identifies a range of health challenges: Children and young people: • 14 year olds have higher rates of smoking than elsewhere in Kirklees and a third of them are happy to continue smoking; • one of the highest locality rates of 14 year olds drinking alcohol weekly or more; • teenage pregnancies have increased and the locality has the highest rate of 14 year olds having sexual intercourse with no contraception used; • relationships with family and school staff are poor; and • maternal behaviours are poor with higher rates of obesity/overweight, and drinking alcohol over sensible limits and bingeing in particular. Adults: • pain, both back pain and arthritis are more common than in other localities, particularly in those aged under 65; and • heart attack hospital admissions are also higher than elsewhere in Kirklees. Current service profile The locality is served by nine GP practices (with 24.3 wte GPs and 2.3 wte nurse practitioners delivering an average list size of 1,840), seven dental practices and eight pharmacies. Recent service development investments include a new state-of-the-art Health Centre in Cleckheaton

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Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

(which opened in 2006), and an intermediate care facility in Liversedge (which also opened in 2006). The Cleckheaton Centre provides a range of services, including physiotherapy treatment, occupational therapy and rehabilitation, eye screening for people with diabetes, ultrasound ante-natal screening and pathology (phlebotomy). The building also provides an audiology cabin for testing hearing, consulting rooms for visiting hospital specialists, a community police officer base and two GP practices. The Eddercliffe Centre in Liversedge centre provides care for people away from hospital to support them back to health after they have experienced a health problem. Fig. A7: Spen Valley â&#x20AC;&#x201C; Locality Providers

Impact on provider landscape New investment will include a real increase in primary medical care capacity to bring the locality closer to the Kirklees and England averages. At the same time, and as in other areas, we need to ensure that services are delivered in premises that are fit for purpose, limit the scope for clinical isolation and ensure continuity of services as existing single handed GPs retire (or leave).

143

The Valleys The Valleys lies in the western part of Kirklees and geographically is the largest locality, but is very rural. Generally people living in the Valleys have better health than those in Kirklees overall. The Valleys comprises two valleys: the Colne Valley and the Holme Valley which experience slightly different health issues and priorities. Population Table A7 shows the age profile for the Valleys. The area has the largest proportion of adults of working age after Denby Dale and Kirkburton, in Kirklees. In comparison to Kirklees overall, the population under 19 is slightly lower but the population aged over 65 is similar. Table A7: The Valleys: Population by Age Group (Mid–Year Estimate 2005) Age Group

Under 20

20 - 64 Years

65 - 84 Years

85 Years plus

Total

All 65 and over

Number

17,360

41,480

8,510

1,310

66,680

9,820

% of locality

25.3

60.4

12.4

1.9

100.0

14.3

Kirklees %6

26.2

59.2

12.7

1.9

100.00

14.6

Around 1% of the population are of South Asian origin. Life expectancy Life expectancy at birth is higher than the Kirklees rate and the national rate with women experiencing the highest life expectancy at birth of all the localities. Priority health issues The JSNA identifies locality health challenges as being: Children and young people – Holme Valley: • 14 year olds drinking alcohol, at the highest rate in Kirklees; • although low, the highest rate of 14 year olds having taken illegal drugs; and • among 14 year olds the rates of feeling angry, lonely and miserable were amongst the highest across Kirklees. Children and young people – Colne Valley: • 14 year olds experiencing the highest rates of bullying across Kirklees. Adults: • unhealthy personal behaviours including obesity, smoking and alcohol use could be addressed.

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Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Current service profile The locality is served by ten GP practices (with 39.1 wte GPS and 2.4 wte nurse practitioners delivering an average list size of 1,551 service users per practitioner), seven dental practices and ten pharmacies. The Holme Valley Memorial Hospital offers acute services traditionally provided in bigger (ie district general) hospitals and inpatient intermediate care beds. The services offered at the Holme Valley Memorial site will be further expanded over the coming years. Fig. A8: The Valleys – Locality providers

Impact on Provider Landscape Substantial new investment in primary medical care capacity is not necessary – existing provision is already well above the Kirklees average and close to that for England. However, there are issues in the Colne Valley part of this locality which need addressing, in particular: • In the Colne Valley we will explore the scope to relocate the existing Golcar Clinic into new premises which could also offer more modern accommodation and facilities to a local GP practice. • In Marsden, Marsden Health Centre is a 1960s former local authority, single storey health clinic. It houses a GP practice (Dr Deacon and Partners) along with some PCT

145

services. The building is of poor quality and grossly undersized for its purpose. We have agreed with the practice the need for them to be based in new premises. Work is ongoing in terms of selecting a suitable site. • In Slaithwaite, the main centres for primary medical care and community service delivery are the Croft House practice and Slaithwaite Health Centre. The Croft House facility in particular has been identified as being unfit for purpose into the future and we will work with service providers in Slaithwaite on an options appraisal for future facilities. In addition to these developments, the locality is home to the Holme Valley Memorial Hospital in Holmfirth. This site, like the Princess Royal Community Health Centre in Huddersfield and Dewsbury Health Centre, has been identified as one of our ‘community hospitals’ – ie a facility offering a broader range of services than a typical health centre, and from which services can be offered to people beyond the boundary of the locality in which it is based. Planning for the HVMH is well underway, with work already started on the redevelopment of Hawthorne Ward. Consultation with local people and service providers is also ongoing. We will refine our plans for the HVMH service model during autumn 2008.

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Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Appendix 2

Approach to the Kirklees PBC Strategic Framework – detailed action plan The eleven themes identified are: • Strengthening PBC and enabling one system of commissioning • Practice engagement and communication • PBC Commissioning plans and business cases • Finance • Performance and Information • Contracts • Public health • Service user and public involvement • Medicines management • Accountability and governance • Performance management of PBC

Strengthening PBC and Enabling One System of Commissioning Objective To have strong PBC as an integral part of one system of commissioning for Kirklees by ensuring that the framework is effective; there is good communication; and high trust and practice skills in commissioning are supported and developed.

Practice Engagement and Communications

PBC Commissioning Plans and Business Cases Objective To ensure the development of robust commissioning plans and business cases that are based on local health needs, an agreed strategic direction for services and effective service user and public involvement. To monitor and evaluate approved business cases so that decisions on their future continuation, spread or cessation are evidence based.

Finance Objective To have devolved budgets on a fair share basis for the widest possible range of services through a methodology that is understood and agreed by practices. To implement an agreed approach to risk sharing, financial reporting and freed up resources.

Performance and Information Analysis Objective To ensure that practice based commissioners have timely access to benchmarked information in an agreed format and in which they have confidence. To support them in the use of this information to make commissioning decisions. To ensure that the whole commissioning system can benefit from sharing of information wherever this is held.

Objective To ensure that all practices across Kirklees are engaged in and have an understanding of PBC by developing an attractive and effective incentive scheme and ensuring timely communication through a range of methods, including protected learning time. 147

Contracts

Accountability and Governance

Objective To implement a system through which practice based commissioners participate fully in the development and monitoring of service specifications and quality standards for secondary, community and mental health services. To enable innovation and best value through implementing the â&#x20AC;&#x2DC;any willing provider modelâ&#x20AC;&#x2122;.

Objective To ensure that governance arrangements are supportive, proportionate and minimise delay, while ensuring public accountability, effective use of resources and clear mechanisms to mitigate against conflicts of interest.

Performance Management of PBC Public Health Objective To enable practice based commissioners to make commissioning decisions based on public health information and sensitivity to locality differences with the aim of addressing health inequalities.

Service user and Public Involvement Objective To ensure that practice based commissioning decisions, priorities, commissioning plans and business cases are informed by the views of service users and the public so that local experience, views and knowledge influence service development.

Medicines Management Objective To ensure that prescribing and medicines management is embedded as an integral part of practice based commissioning, that the impact of service redesign initiatives on prescribing and medicines management is fully understood, and that individuals get the best out of the medicines prescribed for them.

148

Objective To provide assurance, including PEC and board assurance, about the performance of PBC across Kirklees, so that there is clear evidence about the progress and effectiveness of PBC locally.

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013

Apendix 3

Glossary CHFT – Calderdale & Huddersfield Foundation Trust HIT – Health Improvement Team JSNA – Joint Strategic Needs Assessment KPI’s – Key Performance Indicators LAA – Local Area Agreement LPSB – Local Public Service Boards LTC – Long Term Conditions LTTF – Looking to the Future (para 3.3.1.) MYHT – Mid Yorks Health Trust NIHCE – National Institute of Health and Clinical Excellence NSF – National Service Framework OOH – Out of Hours Services PBC – Practice Based Commissioning PBR – Payment By Results PEC – Professional Executive Committee SCG – Specialist Commissioning Group SHA - Strategic Health Authority SWYMHT – South West Yorkshire Mental Health Trust WCC – World Class Commissioning YAS – Yorkshire Ambulance Service

149

150

Further information about the PCT can be found on the PCT’s website (www.kirklees-pct.nhs.uk) or by contacting the PCT at: Kirklees Primary Care Trust St Luke’s House Blackmoorfoot Road Crosland Moor Huddersfield HD4 5RH Tel: 01484 466000