http://www.kirklees.nhs.uk/fileadmin/documents/publications/plans/NHSK_Strategic_Plan_Feb_10 by NHS Kirklees

Realising our Ambition

Five year Strategic Plan 2010 - 2015 Revision January 2010

Contents Section 1

Foreword by the Chairman and Chief Executive

Section 2

Introduction

2.1 2.2 2.3 2.4 Section 3

3.1

12 12 12 13 13 13 14 14 16 18 19

3.3

3.4 3.5 3.6 3.7

20 20 21 26 27 31

4.1 4.2

31 42 42 43 46 50 50 51

Strategic goals and outcomes Initiatives (programmes) to ensure delivery of strategic goals 4.2.1 Adopting a formal programme approach Strategy under multiple financial scenarios 4.3.1 Quality, Innovation, Productivity and Prevention (QIPP) 4.3.2 Cost and efficiency programmes 4.3.3 Approach 4.3.4 High priority initiatives

Delivery

5.1

5.2

Policy and planning context 3.1.1 National and regional priorities 3.1.2 Local priorities 3.1.3 NHS Next stage review â&#x20AC;&#x201C; Healthy Ambitions Demographic overview 3.2.1 Population 3.2.2 Reducing health inequalities 3.2.3 Joint Strategic Needs Assessment (JSNA) 3.2.4 Identifying future health needs in Kirklees Insights from patients, public, clinicians and local partners 3.3.1 Engagement with Practice Based Commissioning (PBC) partners 3.3.2 Clinical leadership Existing targets and local and national health priorities Provider Landscape Activity commissioned Financial Context

Strategy

4.3

Section 5

8 9 9 10 11

Context

3.2

Section 4

Vision and values Strategic Goals 2.2.1 Prioritisation criteria used to select goals Kirklees Partnership Linking the mission to the vision, goals and WCC outcomes

Delivery schedule for initiatives and achievement of critical milestones Past delivery performance 5.2.1 New investment

57 57

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

5.3

5.4 5.5

Section 6

5.2.2 Reinvestment and efficiencies Risk management 5.3.1 Financial risk 5.3.2 Mitigating actions In year monitoring 5.4.1 Board assurance and governance of programmes Organisational requirements and enablers 5.5.1 Workforce planning in NHS Kirklees 5.5.2 Performance strategy 5.5.3 Communications and engagement 5.5.4 Changes in Technology 5.5.5 Estates issues 5.5.6 Procurement strategy 5.5.7 Medicines Management and Community Pharmacy 5.5.8 Equality Impact Assessment

58 59 60 60 61 61 62 62 62 63 63 63 63 64 64

Declaration of Board Approval

6.1

6.2

Board Challenge, ownership and monitoring of strategic plan delivery Board sign off

List of Tables: Table 1: Table 2:

Kirklees key health and well-being issues High Priority investments required 2010 - 2013

16 52

List of Figures: Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8: Figure 9:

Total NHS Commissioned Expenditure (in millions) Base Case Funding Scenario Downside Funding Scenario Upside Funding Scenario Financial Impact of the PCTâ&#x20AC;&#x2122;s Strategy: Base case Scenario Delivering a 5 Year Sustainable Position Scale of Investment/Disinvestment under the different Scenarios Breakdown of investment by programme area Mapping our Delivery of Healthy Ambitions to our Programme Areas

List of Appendices: Appendix 1: Appendix 2: Appendix 3: Appendix 4: Appendix 5: Appendix 6: Appendix 7:

22 28 29 30 44 45 46 57 66

Programme Strategies 66 Workforce Planning Strategy 88 Changes in Technology 90 Community Pharmacy and Medicines Management Strategy 91 Equality Impact Assessment 94 References 107 Glossary 108 3

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Section 1

Foreword by the Chairman and Chief Executive Welcome to ‘Realising our Ambition’ – our strategic plan for the period 2010 – 2015. This is our second strategic plan. Since last year we have made strong progress, and for the year 2008/09 achieved a rating of ‘good’ from the Care Quality Commission for quality of services, compared with a rating of ‘fair’ in the previous year. We also performed strongly in our World Class Commissioning assessment and are committed to maintaining these high standards in the coming years. We are proud of our achievements so far and can demonstrate how we have delivered against the aspirations set out in last year’s plan. We have commissioned a range of new services to respond to the needs of our population for example: • An adult weight management service; • A range of services to address the growing problem of alcohol misuse, ranging from brief interventions in primary care to an alcohol treatment service for those requiring more specialist interventions; • Services to support people with long term conditions, including the introduction of a new primary care based system that will enable us to identify those people most at risk of worsening health in the future • Further developments in telehealth and telecare will revolutionise the ability to deliver services and support to people in their own homes.

In addition to these new services, considerable attention has been given to reviewing and improving existing services that we commission, for example, services for people with respiratory conditions and mental health services for children and young people. However, there still remains more to do and moving forward, from this year onwards we face significant challenges, particularly around achieving financial balance whilst maintaining ever more stringent performance standards. This will be achieved through our approach to improving productivity with the QIPP agenda. Our vision and values remain the same, as does our commitment to targeting the health inequalities we know exist in Kirklees. However, in common with other PCTs, our financial position has changed and it is now even more important for us to spend our money wisely and work collaboratively with others to maximise our efforts . To this end, we will be focussing on the four strategic priorities set out in Section Four of this plan and prioritising our investments accordingly. These challenges face not just the NHS, but the wider public sector. In Kirklees, we have strong relationships with our key partners such as Kirklees Council and local clinicians, and we remain committed to strong partnership working to ensure we deliver on our collective vision for Kirklees. We will continue to lead the contribution of the NHS in this work.

Most importantly, we value the feedback we receive from local people and will continue to improve their experience of service by driving up service quality and commissioning services that deliver the best outcomes. The involvement of local people in our work over the past year has been extremely valuable and something we want to build on and strengthen in the coming year.

Rob Napier Chairman

Mike Potts Chief Executive NHS Kirklees

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Section 2

Realising our Ambition – the 5 year strategic plan Our 5 year strategic plan combines all the elements of work that we undertake into one concise document. The work which we undertake is derived from the needs of the Kirklees community in conjunction with the strategic needs of our partners and stakeholders. The plan is supported and driven by a number of factors as set out below:

Vision and Values within this document

Our Vision and Values

Joint Strategic Needs Assessment Comprehensive Area Assessment Needs of our population Local Area Agreement Yorkshire and Humber “Delivering Healthy Ambitions”

Our Strategic Goals and Programme Objectives

Programme Delivery Strategies Local Operating Plan Organisational Development Plan

Delivering the Strategy and Plans

Medium Term Financial Plan Workforce Development Plan

Estates Strategy Communications and engagement

Supporting activities

Information management and technology

• Be accountable for the decisions we make, the work we do, the resources we use and our impact on the environment.

Section 2

Introduction NHS Kirklees was established in 2006 from 3 former PCTs in Huddersfield and North Kirklees. We have the same boundaries as Kirklees Council and organise our work across the same 7 localities. Working on a geographical basis, we are together with our partners, using the context of Place to tackle the particular issues of that area, where needs are identified for that locality from the JSNA and local intelligence as well as for other communities of interest e.g. those with certain disease, disability or at risk of significant ill health. Directors and senior PCT staff are members of the leadership groups within these areas.

2.1

Our vision and values

“Working together to achieve the best health and well-being for all the people of Kirklees” • 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; and

We are responsible for improving the health and well being of local people and making sure that 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. 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 of 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).

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

2.2

Strategic Goals

GOAL 1

Improve health outcomes for children and young people, working in partnership to improve life chances and safeguard children.

GOAL 4

GOAL 3

Raise male and female life expectancy at birth so that it is not significantly below the national average in any part of Kirklees

GOAL 2

The strategic goals for NHS Kirklees are:

Target individuals and populations to tackle health and well being inequalities, focusing on the priority issues identified locally. Provide advice, support and care to these individuals, families and communities, in the form of high quality targeted interventions known to work, to increase the control they have over their own health and wellbeing.

Empower those people in Kirklees with a long term condition to exercise control over their own lives and be central to the decision making about their own care, so preventing problems arising or worsening and enabling them to independently manage their own health and well being.

2.2.1 Prioritisation criteria used to select goals In selecting our strategic goals, NHS Kirklees have addressed those areas of health needs across our community where our focus needs to be strongest, and where we need to demonstrate not only improved health outcomes for those localities where this is currently the poorest, but also in raising the quality of the services which we commission and achieving real value for money in everything we do. The goals represent a life-cycle approach, starting with life expectancy, through childhood, health inequalities, and people

with long term conditions. Each of our goals has been mapped against real and measurable targets as defined in our World Class Commissioning Outcome Aspirations, and against a variety of other outcome measures and targets such as Vital Signs, LAA outcomes etc. (See Section 4 for full analysis). A process of consultation has taken place over the summer months, with all our key stakeholders, including our Board, Senior Management Team, Programme Leads, and our partners in Practice Based Commissioning (PBC), to ensure that our 9

new Goals were representative of our community and also to ensure that our initiatives, and outcomes, can be mapped against them.

2.3 The Kirklees Partnership Our wider work with the Kirklees Partnership has enabled the delivery of a joint Sustainable Community Strategy which covers the period 2009 – 2012. This sets out the strategic direction and long term vision for Kirklees. It is a strategy to promote the social, economic and environmental well-being of the area. The overarching vision for this strategy is: “By 2020 Kirklees is recognised in West Yorkshire and beyond as an area of major success. Its strong economy is supported by an attractive, high quality environment, offering the best of rural and urban living. Creativity and learning are highly valued. Communities are proud of their past, but enjoy diversity, are outward looking and face the future with optimism. Both young and old find it a safe, healthy and supportive place, where there is clear commitment that all should share in this success”. Within the strategy, the “Picture of Kirklees” identifies the priorities we need to focus on to be able to close these gaps, which fall into 5 themes: • • • • •

Educational attainment Low skills and low wage economy Infant mortality and health inequalities Low confidence in some of our towns Community relations.

As a major partner in the Kirklees Partnership, the NHS Kirklees Five Year Strategic Plan must be closely aligned to the Kirklees Partnership Strategy. There is a 10

particular focus on narrowing the avoidable gaps for local communities, with nine priorities. Of these, four are identical with our own World Class Commissioning Outcome aspirations and our strategic programmes, i.e.: • Reduce the rate of teenage pregnancy; • Reduce the prevalence of smoking, particularly in children and young adults; • Address the issues related to alcohol, with respect to screening and support and reducing the rate of alcohol related admissions; • Reduce obesity and improve local healthy diets and increase physical activity, particularly in children. The Local Area Agreement focuses partnership working on those priorities which matter most to Kirklees and the Partnership. These are grouped into the four themes of partnership working: • Children and Young People • Safer Stronger Communities • Healthier Communities and Older People • Economic Development and the environment Thus, there are direct links again between the strategic goals identified in this Plan and the priorities within the LAA. Joint commissioning strategies are also in place for Mental Health, Learning Disabilities, Older People and Long Term Conditions. Total Place is a new way of partnership working that makes sense for users / residents. NHS Kirklees is committed to this approach. The 2009 Comprehensive Area Agreement updated on the strength of local partnership working.

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

2.4

Linking the mission to the vision, goals and outcomes Mission By 2020 Kirklees is recognised in West Yorkshire and beyond as an area of major success. Kirklees Partnership

Mission Vision Working together to achieve the best health and well-being for all the people of Kirklees NHS Kirklees

WCC Outcome aspirations over the next five years

Goals

Vision

Raise male and female life expectancy at birth so that it is not significantly below the national average in any part of Kirklees

Improve health outcomes for children and young people, working in partnership to improve life chances and safeguard children.

• Increase the male life expectancy to 78.2 and the female life expectancy to 82.3 by 2014 • Lower health inequalities for males to 9.5 and for females to 6.5 by 2014

• Improve the emotional health and wellbeing of children as measured by the Tellus survey from 72.1% to 77.3% by 2014. • Reduce the upward trend of Year 6 children who are obese. By 2014 17% of Year 6 children are measured as obese. • Reduce maternal smoking at birth by 1% year on year in those localities that are below 18% and to 18% in those localities above this figure

• Increase proportion of people who have a high risk TIA who are assessed and treated within 24 hours to 100% by 2012. • Increase the rate of smoking quitters to 823 per year for each year up to 2014, particularly in routine and manual groups • Reduce the rate of alcohol-related admissions per 100,000 population from 1,600 to 1,191

• Increase the percentage of people with CHD who have had their BP under control to 90% by 2012. • Increase the number of people with a long term condition who feel supported from 54% to 85% by 2014

See Section 4 – Strategy – for a complete mapping of all outcomes against our goals, including LAA outcomes. 11

Section 3

Context 3.1 Policy and Planning Context The work of NHS Kirklees is driven by a vast array of political, social and economic drivers. This section sets out the significant factors influencing NHS Kirklees today. In order to ensure that the needs of our population are understood, we need to; • have a good understanding of public expectations and political drivers; • have active engagement with local people; and • involve clinical leaders in assessing local needs and shaping priorities. Other key factors which drive our strategic decision making are the national and local priorities, local population demographics and needs as shown in the Joint Strategic Needs Assessment (JSNA), working with partners, the service provision and the requirements of World Class Commissioning on which further details are provided below. Our choice of outcomes for world class commissioning reflects these. These, together with our existing priorities, e.g., Vital Signs for the LAA, form the basis of our future performance regime. 3.1.1 National and Regional 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. 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 so reducing inequalities of opportunity and access. 3.1.2 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. Current local performance challenges include managing demand in secondary care and urgent care. 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. The impact of the recession has led to increased efficiency through greater collaborative working across the West Yorkshire and Yorkshire and Humber health economy, and in particular the further integration of health and social care through the CAA and Total Place pilots has

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

added to our ability to achieve excellent results within a challenged economic climate. 3.1.3 National Priorities: NHS Next Stage Review – Delivering Healthy Ambitions In the Yorkshire and Humber area “Healthy Ambitions” was published by the Strategic Health Authority (SHA) at the same time as the results of the national NHS Next Stage Review (NSR), the final report of Lord Darzi's review “High Quality Care for All”. This document provided 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. In our Strategic Plan published in March 2009, we described how taken together, Healthy Ambitions, the national reports and the broader factors provide a reasonable and sound basis on which to build our local vision for services and to plan ahead. We are already addressing many of the priorities which it identified, and have achieved much in the last 12 months. 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, innovation 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.

3.2

Demographic Overview

3.2.1 Population Kirklees comprises both urban and rural communities with a total population of nearly 425,000 (FHS 2006), of whom 1 in 4 are aged under 19 and nearly 1 in 4 aged over 65 years. By 2025, the population is predicted to increase by 7%. This is mainly in those aged over 65 years. 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 has pockets of relative deprivation for both children and older people, but is not classified as a Spearhead area i.e. in the lowest 20% of deprivation for all areas. It is however amongst the worst 50 districts for both income and employment deprivation and this has worsened since 2004, as had Educational Skills and Training and Income. In contrast, for “Barriers to Services” and “Crime” Kirklees had improved. 1 in 6 of the population are income deprived. Areas of deprivation are concentrated in and around Huddersfield Town Centre and Dewsbury in particular. Across Kirklees 27% of children aged 0 -15 years were classed as living in poverty and 21% of those aged over 65 years.

Kirklees has a diverse ethnic mix, with a higher proportion of our population from ethnic minorities than for England as a whole. Ethnicities present in Kirklees include those of Pakistani origin, Indian origin and African-Caribbean origin but the largest group remains of white origin. 3.2.2 Reducing Health Inequalities Health Inequalities are health differences between people which can be changed. Change depends on the control that people feel 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 the Health Inequalities gap, we need to: • Be person centred, focusing on equality of outcomes; • Involve local people in creating and delivering solutions; • Work closely with partners to ensure current needs are met and there is adequate provision for the future; • Target our actions more effectively to ensure we reach those most in need; • Establish clear programmes which support older people and those with long term conditions to address the challenge of more people living longer; • Target our resources to reduce inappropriate variations in investment across the 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 with other organisations in order to be person centred. Involving other parties in identifying issues and creating solutions, focusing on those in most 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. 3.2.3 Joint Strategic Needs Assessment (JSNA). • In our second JSNA, published jointly with Kirklees Council in June 2009, we describe the future health and well-being needs of the local population. The JSNA forms the basis for planning service development and is a key building block for the commissioning process for the next 5 to 20 years. The overall purpose of the JSNA is to identify the avoidable gaps in health and well-being for Kirklees people, i.e. inequalities that must be tackled. The JSNA uses national and local data to identify issues, together with results from local health and well being surveys of over 18 year olds, most recently carried out in 2008 and of 14 year olds, most recently carried out in 2007. This gives a richness to the routine data available and intelligence derived provides a clear locality focus of who to target to narrow inequalities.

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

This five year strategic plan is a first step on the journey which involves asking ourselves a number of key questions; • What is the future shape and distribution of the population, especially in terms of age, ethnicity and migration patterns? What impact will this changing shape have on the major issues we have already identified, and will it throw up others over the next 5/10/15 years at both district and locality levels? • What are the particular issues affecting the health and well-being of the specific population groups we have identified? These include: people with physical disabilities, people with learning disabilities including autism and people with low to moderate learning disabilities, older people, carers, women of child bearing age and parents. • What are the key differences in populations and their needs between our seven localities? Who is most at risk or in need? • How does Kirklees differ from other similar districts (based on the comparator districts for NHS care, social care and children’s services)? • What do the affected local people think about their key issues from the JSNA?: - What people think would make a difference to their emotional and physical well-being? - What they think are the root causes of their current position? - What do they think can help improve their health and what can they do?

disabilities, women of child bearing age and older people. It also looks at key conditions such as heart disease, stroke, obesity, diabetes and dementia; wider living and working factors such as employment, housing and educational attainment and personal behaviours such as smoking, alcohol, food and nutrition.

The process for developing the JSNA has enabled us to identify key issues for specific populations such as for people with

Table 1: Kirklees key health and well-being issues For adults

For children and young people

Specific vulnerable groups

Young adults (18-44), particularly women. Older people People with disabilities

People with learning disabilities

Being healthy conditions

Emotional well-being Obesity Pain including musculo-skeletal Dementia Heart disease & stroke Diabetes

Infant mortality Emotional well-being Obesity

Personal behaviours

Food and nutrition Alcohol Smoking Physical inactivity

Food Alcohol Smoking Physical inactivity Teenage pregnancies Sexual health

Living and working â&#x20AC;&#x201C; wider factors

Housing affordability and adequacy Employment and income Isolation and social networks Educational attainment and skills

Educational attainment Personal unhappiness and social networks Safeguarding

Looking to the longer term there are two significant threats: â&#x20AC;˘ What we eat and how active we are â&#x20AC;˘ Climate change The key health and well-being issues identified within the JSNA have an important role in developing our programme objectives. Our planning is evolving to incorporate the priorities identified and this is now reflected in specific programmes and objectives. 3.2.4 Identifying Future Health Needs in Kirklees Intelligent commissioning requires a supporting information infrastructure that can inform evidence based decision making and actionable recommendations. One of the keys to preventing unplanned and avoidable use of secondary care services is identifying those patients who are most likely to experience deterioration 16

in their condition so that proactive interventions can be undertaken to reduce this risk. This requires both a strong predictive model and a segmentation approach that focuses the intensity of care management resources in a way that is proportionate to risk and need Many primary care practitioners can intuitively identify some of the higher risk patients who are most visible in primary care, either because they struggle to persist with treatment, are reluctant to engage with face-to-face services or, perhaps, are frequent users of primary care, accident & emergency or out-of-hours care. However, even the most seasoned clinicians may be unable to identify those patients who will become frequent users of secondary care but are currently less visible in primary care. These emerging risk patients can be most effectively identified through the use of risk stratification tools.

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Predictive modelling provides the most accurate and comprehensive approach to risk stratification. This method systematically assesses the entire population, identifying patients along the continuum of risk, which will enable each practice or cluster to target interventions based on individual patient’s risk and to tailor these interventions to deliver the right amount of support at the right time. NHS Kirklees’ Long Term Conditions (LTC) programme will: 1. Increase and embed into our local health and social care community an effective, systematic approach to the care and management of patients with Long Term Conditions • Development of generic care pathway for management of LTCs • Development of care pathways for all the individual LTC programmes • Development of patient reference groups to support patient and public involvement in care pathway development • Commissioning of single point of access for health and social care services 2. Reduce the reliance on secondary care services and increase the provision of care in a primary, community or home environment • Commissioning of predictive risk tool to identify people at risk of admissions due to LTCs • Increased provision of community matrons and case managers for complex case management • Increased support and management of housebound patients with LTCs through District Nursing service

3.Meet the individual requirements of people with long term conditions through improved high quality personalised care which offers increased choice and services commissioned to meet the needs as determined by the individual • Facilitate the opportunity and contribution of stakeholders including the service users to the development of personalised care planning • Identify any training or education needs of health or social care professionals to introduce and develop personalised care planning • Identify any training or education needs of service users for successful implementation of personalised care planning • Develop benefit realisation framework including patient specific outcomes e.g. Quality of Life, patient reported outcome measures, patient reported experience measures and service user and carer satisfaction • Link disease specific indicators to a risk stratification tool 4. Support more people with a long term condition to be independent and in control of their condition • Implementation of access to Expert Patient Programme for all patients • Develop and implement structured LTC patient education programmes • Set up self help groups/peer groups for patients and carers • Develop a local model for the implementation of Health Trainers in LTC management • Develop a training programme for health and social care staff in facilitating self care and behaviour change skills

• Availability of access to appropriate resources 5. Promote an increased workforce which is responsive to the needs of people with LTCs • Training needs analysis - assessment of capability of workforce • Assessment of capacity of workforce to develop LTC pathways • Commission training packages to meet needs of developing workforce • Development of blue print for LTC workforce development

3.3

Insights from patients, public, clinicians and local partners 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 these activities include: • Social Marketing approach to help support healthy personal behaviours of women before, during and after birth looking specifically at behaviours relating to Food, Physical Activity, Alcohol and Smoking

• Social Marketing approach to halt the rise in obesity on 16-24 year olds • Involvement of local target audience in developing new stop smoking groups and associated marketing materials using a social marketing approach • Involvement of both non service and service users (adults and young people) and clinicians in setting up weight management services for both adults and young people • Planned projects (if you want them) • Alcohol: Developing a social marketing approach to target specific target audiences grouped according to age, location but also motivation. The overarching behavioural goals will be to: - increase awareness around drinking levels - take people from precontemplation to contemplation • Regional collaborative • Involving people with long term pain in redesigning care • Involving young people with ADHD and their parents / carers in redesigning the ADHD pathway this included conducting interviews, discussion groups, questionnaires and establishing two service user reference groups, one for the young people and one for the parents / carers. • The regular triennial and biennial surveys of adults and 14 year olds on health and well being • Working with groups of people in our localities to develop locality plans • Taking a Camper Van to a number of events being held in Kirklees over the summer to film members of the public giving their views on NHS Kirklees • Developing a database of members of the public that have expressed an interest in being involved in the work of NHS Kirklees

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

• Developing a newsletter to let the public know how they can get involved and what has happened as a result of them being involved • Public consultations on major changes to services, e.g., Mid Yorkshire Service Strategy (MYSS), Looking to the Future (2005/06 and continuing) • Service user surveys – whether organised nationally or locally by ourselves or by providers. We work with practices on a regular basis to 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 • Reference groups of service users established for all Long Term Conditions Health Improvement Teams (HITs) • Establishment of a joint Readers’ Panel with Kirklees Council, to ensure that our public information leaflets are easy to read and understand • Consultation on the introduction of GP led health centres, this includes members of the public being involved in the selection of the new providers e.g. patient reps have been / are involved in Dewsbury Health Centre, Victoria Medical Practice • A diabetes survey to obtain feedback for action on the care and support which local people with diabetes receive • LINks; (which replaced the PPI Forums) • Specific focussed consultations within communities whether issue or sociodemographic specific; and • 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. 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. This is increasingly making use of the social marketing experience we have already gained. 3.3.1 Engagement with Practice Based Commissioning (PBC) partners GP practices are consulted in various ways. These include through the monthly Commissioning College, plenary meetings which are attended by members of each of the commissioning consortia and the regular consortium executive meetings. Practices have been consulted about the plan priorities and about the specific development areas within each of the service areas. Findings are captured through meeting minutes and through reports produced during focus groups. Plans for future consultation, as required, for example consultation on specific major service configuration.

GP practices have been consulted about the major service reconfiguration for Mid Yorkshire Trust. This has and will continue to take place through the Commissioning College, through the consortium plenary meetings and through practice protected time events. A description of local access to and use of services by key population segments, particularly highlighting inequalities Each Practice Based Commissioning group, whether consortium or stand alone practice produces an annual commissioning plan which uses both the JSNA and local “on the ground” knowledge to identify priorities. The PBC local incentive scheme is used to identify services where access by populations is different for example the use of A and E services. PBC partners have been involved in strategic financial planning, including the identification of efficiency settings. 3.3.2 Clinical 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, 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.

3.4

Existing targets and local and national health priorities All targets, whether they be Vital Signs, Care Quality Commission targets, Local Area Agreement priorities or World Class Commissioning outcomes are reported against on a monthly basis. These reports are used to make management decisions on actions required to manage risk and improve performance. Sustainable improvements have been seen in the achievement of mental health targets. Action planning and investment in partnership with our local provider has delivered targets ahead of local timescales, albeit later than national requirements. The current areas of greatest risk include ambulance response times, cancer, stroke, smoking at the time of delivery in the Dewsbury & Batley areas, chlamydia and teenage conceptions. All of these targets are integral to the programme plans aligned to the priorities and strategy of NHS Kirklees. Part of the challenge is delivery of new or extended targets such as cancer and stroke where new pathways are necessary to provide high quality care. These also need to be underpinned by data flows in line with national definitions of what should and shouldn’t be reported. This work is

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

being developed as part of the programme planning framework, led by the Health Improvement Teams. Strong partnership working underpins the children and young peopleâ&#x20AC;&#x2122;s agenda looking at teenage conceptions / sexual health, Chlamydia screening, infant mortality and smoking at delivery for mothers. Again programme plans are in place to deliver sustainable improvements as well as more immediate actions to drive improvement in performance. NHS Kirklees also continues to work with the Yorkshire Ambulance Service, both at operational level and more formally through the contracts. Regular meetings are held with operational people, including colleagues from the acute sector, to look at practical and quick solutions to issues hindering performance achievement. The full levers included in the contract, hosted by NHS Bradford & Airedale, are also being explored to maximise performance achievement for the population of Kirklees.

3.5 Provider Landscape NHS Kirklees is committed to commissioning services from the providers who are best placed to deliver the needs of our patients and population. Current Position The NHS provider landscape for hospital services in Yorkshire and the Humber includes 15 acute Trusts; in addition, there are around 30 independent providers of acute medical and surgical services. NHS Kirklees contracts mainly with two acute trusts (Calderdale and Huddersfield NHS Foundation Trust and Mid Yorkshire Hospitals NHS Trust), although we also commission significant activity from Leeds Teaching Hospitals NHS Trust, Bradford

Teaching Hospitals NHS Foundation Trust, Barnsley Hospital NHS Foundation Trust, and Sheffield Teaching Hospitals NHS Foundation Trust. In addition to these local services, residents of Kirklees can receive care from over 200 acute NHS service providers across England, Scotland and Wales, either as a result of specialised care or the application of patient choice. For specialised services, it is important that patients can receive their care within reasonable travelling distances and accordingly most of our residents receive specialised care from one of the three main tertiary providers within the region, Sheffield Teaching Hospitals NHS Foundation Trust, Leeds Teaching Hospitals NHS Trust and Hull and East Yorkshire Hospitals Trust. Some residents will also travel further afield for highly specialised services (eg services for children provided by Great Ormond Street Hospital). For mental health services, NHS Kirklees contracts mainly with South West Yorkshire Partnership NHS Foundation Trust, with some specialist services being provided from a range of other organisations. Emergency ambulance services are commissioned by NHS Kirklees from Yorkshire Ambulance Service NHS Trust, which is the sole provider to the majority of PCTs in the region. NHS Kirkleesâ&#x20AC;&#x2122; current main providers of general community services are Kirklees Community Healthcare Services and Calderdale and Huddersfield NHS Foundation Trust; some services are also provided by Mid Yorkshire Hospitals NHS Trust, Kirklees Council, South West Yorkshire Partnership NHS Foundation Trust and a broad spread of other providers,

including voluntary and third sector organisations, for one or more specific services.

NHS Kirklees holds primary care contracts with 74 general practices, 59 dental practices, 88 pharmacies and 42 opticians.

NHS Kirklees has established a robust commissioner/provider relationship with Kirklees Community Healthcare Services which is governed by a formal service level agreement (based on standard community services contract) setting out clear performance and quality measures.

Out of hours services are currently provided by NHS Direct, and Local Care Direct under a new contract agreement from April 2009.

The pattern of expenditure associated with these providers is set out in Figure 1. Figure 1 Total NHS Commissioned Expenditure (in millions) 9% 0.9% 1.1% 1.4% 3.5%

37%

7.2%

7.0%

12.5%

27.4%

Calderdale & Huddersfield NHS FT - £130m Mid Yorkshire Hospitals NHS Trust - £96m South West Yorkshire Partnership FT - £44m Specialist Comissioning Group - £25m Leeds Teaching Hospitals NHS Trust - £25m Yorkshire Ambulance Service - £12m Bradford Hospitals NHS Trust - £5m Non Contracted Activity - £4m Independent Sector - £3m Other NHS - £7m KCHS - £35m

Understanding our Providers In collaboration with other PCTs and commissioning partners in Yorkshire and the Humber, we have developed a database to hold performance and financial information about providers across a range of health sectors. This database is being populated in priority order (starting with acute service providers) and helps us to understand the economics and capacity of a range of providers and consequently to identify potential capacity constraints, strengths and weaknesses of current provision, and inform market development plans linked to PCT strategy. We are already aware of particular challenges that face us and are working with local providers to address issues such as: • Recognised secondary care capacity constraints for example for some specialities such as ophthalmology and spinal surgery • The need to continue with our focus on reducing non-elective admissions and managing length of stay. In addition, we are in the relatively unusual position of having two large acute providers in our area, both of whom provide a broad range of services to significant sections of our population. This situation presents us with particular challenges, for example developing care pathways that offer equitable and high quality services to all parts of our patch. Ensuring consistently high standards across the whole of Kirklees remains a focus for us in the coming year.

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Procurement and Market Testing We have an approved Procurement Policy that is designed to ensure that NHS Kirklees’ procurement and contracting will be in proportion to risk and will be used to support clinical priorities, health and wellbeing outcomes and wider PCT objectives. We recognise a range of procurement routes including competitive tender, multiprovider models and working with selected providers. During the last year we have applied this policy to several initiatives and tendered for several new services, for example: • A predictive risk tool that will utilise information on GP practice systems and enable us to identify those patients most likely to experience deterioration in their condition. • A new alcohol treatment service – ‘ON TRAK’ which is now being delivered through a partnership of Lifeline Kirklees and Community Links, a mental health organisation. • An adult weight management service that will be delivered by Mid Yorkshire NHS Trust as lead provider with bespoke packages of care being commissioned from other independent providers such as Fitbug Ltd. In addition to these formal procurements, we have also, as part of our service redesign programmes, identified service areas such as respiratory services where our approach will be to work with existing local providers and commission a new service model from them. Working with Others Managing increasingly complex contractual relationships with a diverse range of providers is a key challenge for commissioning organisations, and we are

addressing this by working in collaboration with other PCTs, and strategic partners to improve our commissioning capabilities for example: • Lead commissioner arrangements are in place for all acute contracts, with NHSK taking the lead role with the Calderdale and Huddersfield NHS Foundation Trust. • For our main providers (acute and mental health), we have established Quality Boards. These Quality Boards bring together lead commissioners and associates, as well as clinical leaders to oversee the implementation of quality standards locally. • Through the Yorkshire and the Humber Specialised Commissioning Group we work with all PCTs in the region to commission those service that have a national classification as ‘specialised’. The Specialised Commissioning Group recently approved its strategy which set out our priorities for the coming 5 years. • Through participation in the Yorkshire and the Humber Commercial Professional Network we will jointly develop our skills in relation to market management and healthcare procurement, and deliver on jointly agreed projects to support the QIPP agenda. • By strengthening joint commissioning with the local authority we have identified areas – substance misuse services for children and young people - where we can bring together our resources and commission services to improve quality. This collaborative working enables us to make best use of specialist resource, share ideas and best practice and maximise our negotiation leverage.

Planned market development We are developing a market management strategy that will build on and supersede the existing PCT Procurement Strategy. This new strategy will need to reflect the new national guidance (Commercial Skills for the NHS and a revised PCT Procurement Guidance) signalled in the NHS Operating Framework for 2010/11. While the Operating Framework indicates that new guidance will be underpinned by an ‘NHS First’ approach, we will also prioritise the need to drive up quality and address underperformance, through robust contract management and wider market development where required. As part of this wider market management approach we are strengthening our understanding of the current and future provider landscape across all market sectors. We have already developed a framework, covering supply-side assessment, intervention strategies and service requirements, to guide market analysis for individual service strategies. The following drivers underpin our work on market analysis and development: • Increasing choice and diversity of service, giving more people more opportunity to define a range of responses to their health and social care needs; • Care closer to home where it is safe and effective to do so; • Improved access, both in terms of location and timeliness of services; • Maximising the opportunities available to us from an increasingly diverse market, while at the same time using strong contracts to manage any risks to delivery.

In the coming year, areas of market development include community health services and areas of specialised commissioning. Market Development: Transforming Community Services Our Commissioning Strategy for Community Services was approved by the PCT Board in October 2009. During the coming year we will build on this strategy by: • Taking forward service reviews identified as priorities within our Commissioning Strategy for Community Services, namely: - CAMHS; - Children’s community nursing; - Children’s therapies; - Chlamydia Screening and Sexual Health; - Community specialist respiratory services; - Continuing Care. - Health visiting; - Intermediate care services; - MSK services; - Non-surgical podiatry; - Primary Care respiratory pathway services - Primary Prevention CVD; - Inpatient provision for drug and alcohol misusers; - School nursing; - Therapy and rehabilitation services (adults); - Walk-in centre. • Agreeing an appropriate organisational structure for all community services currently provided by the PCT’s provider arm - Kirklees Community Healthcare Services (KCHS).

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

The market analysis on which the strategy is based uses a classification based on national Transforming Community Services categories. The Commissioning Strategy for Community Services includes a review of existing services, with rationale and plans for our high-priority services and indicative timelines for a broader range of community services. It is intended that this strategy may be used by community service providers and potential providers, in developing their own business planning priorities, identifying collaboration opportunities with other providers, and thereby supporting the development of sustainable market capacity to meet the current and future service needs. This is now of particular relevance in the light of the Operating Framework requirement for PCTs to agree the future organisational configuration for all PCT provided community services. In determining the future organisational arrangements for those services currently provided by KCHS, we will be guided by our Commissioning Strategy for Community Services. This strategy, was developed with a range of partners including the Local Authority and sets the context and objectives for NHS Kirklees’ commissioning of community services over the next five years. Market Development: Specialised Commissioning Through the SCG, we have agreed to prioritise the commissioning of those specialised services where it is judged that the most gain can be delivered against the headings of: • Price Control • Activity Control • Better Contract Terms and Conditions • Service Model Redesign

• Driving up Service Standards Yorkshire and the Humber SCG has identified service areas where a review of models of provision or increased capacity is required. It is recognised that major service change may be required as a result of these reviews, which may significantly affect the provider landscape. These include: • • • • • • •

Obesity surgery Cancer services Cardiac services Children’s services Fertility services Renal services Neurosurgery and long term neurological conditions • Specialist mental health services • Vascular surgery In some areas the SCG will need to manage and restrict entry into the provider market, in order to balance the tension between providing specialised services as close to people’s homes as possible, with the need for sustainable services, often requiring a critical mass of patients per service. This will deliver high quality, safe services which improve health outcomes for patients. In other instances, the SCG will need to stimulate the provider market to ensure that sufficient capacity is in place to deliver planned improvements in access and availability of services to patients, and to be able to offer patients a genuine choice of provider. There are some services where there is currently no pressing need to undertake significant commissioning activities and maintaining the status quo is a valid position to take. For all services the SCG will maintain an overview of the market and lead on service

designation. This involves assessing potential providers against a set of designation standards to ensure that they are able to deliver services in line with agreed service specifications. It is envisaged that designation will be for a maximum of 5 years, with a view to developing a rolling programme of designation to ensure continual service improvement. The intention is that through this process the provider landscape for specialised services becomes very clearly defined and is closely managed and monitored. Yorkshire and the Humber SCG is currently at the beginning of this process, and has awarded interim designation for a number of services. Choice The NHS Constitution emphasises the rights of patients to choice in relation to the services they access. 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.

3.6 Activity commissioned In line with the 2009/10 Operating Plan, the PCT has commissioned activity across service sectors to address: • projected population growth and demographic change, • strategic needs assessment, • projected changes in demand for services based on preceding years’ activity profiles, • delivery of national and local targets, • projected impacts of demand management and service re-design initiatives. NHS Kirklees works closely with the Yorkshire and the Humber Specialised Commissioning Group and also works collaboratively with other local PCTs (e.g. Calderdale and Wakefield District) and the Local Authority. We are the lead commissioner for our contract with Calderdale and Huddersfield NHS Foundation trust and are an associate commissioner for other main contracts including Mid Yorkshire Hospitals NHS Trust and Leeds Teaching Hospitals NHS trust. In-year acute activity is higher than planned. The PCT is working very closely with its Practice Based Commissioners and its main acute providers to understand the nature, impact and probable causes of the increases. A number of in-year actions have been taken to manage activity increases;

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

current position and future action will form an integrated part of future demand planning. 3.7

Financial Context

Current Financial Situation The PCT has performed well financially in recent years. It has made an operating surplus and met control totals agreed with the Strategic Health Authority (SHA) in each of the last 3 years. It is forecasting to deliver both the planned level of surplus and agreed control total for 2009/10. This provides the PCT with a sound basis on which to meet the more difficult financial climate that lies ahead. However, the financial position for 2009/10 is more challenging than at any time since the PCT was formed in 2006, mainly due to over trades on acute contracts. This is being aggressively managed to ensure the surplus and control totals are delivered and this more challenging approach will continue into 2010/11 and beyond. The PCT is moving towards the end of the current funding cycle, with the last year being 2010/11. During this period the levels of growth it has received have been relatively high compared with historic levels, and this continues into 2010/11. However, as we move into 2011/12 and beyond, the levels of growth indicated within the Operating Framework are at a much lower level. This plan has therefore been produced in the context of a more difficult financial climate and with greater uncertainty than recent times.

Future Financial Situation Background The PCT recognises the need to plan for financial sustainability in an uncertain economic climate. We have a financial plan which covers 3 different financial scenarios and which delivers financial sustainability under each of these. The scenarios take into account the financial planning information contained in the recently published Operating Framework, and the Strategic Health Authority’s guidance on the likely levels of PCT allocation growth, national tariff and other inflationary uplifts. In particular, under the base case financial scenario, the PCT is planning: • for growth in its allocation of 5.6% in 2010/11 and 1% each year in 2011/12 to 2013/14 • for no tariff inflation in 2010/11 and a net tariff reduction of -2% each year in 20011/12 to 2013/14 • to increase CQUIN (Commissioning Quality and Innovation) payments to providers from 0.5% of contract values in 2009/10 by 1% each year so that they stand at 4.5% in 2013/14 • to ensure that 2% of resources are either not committed or are only committed on a non-recurrent basis each year from 2010/11 onwards to increase financial flexibility • to deliver the SHA requirement of a 1.5% control total in 2010/11 which is an increase from the 1.1% control total in 2009/10 • to reduce the control total to 0.5% by 2013/14 • pick up its share of the £500m central funding responsibility being passed to the NHS in 2010/11, which equates to just under 0.6% of the PCT’s resources • to deliver the national annual efficiency requirement of 3.5% to

The consequence of these planning assumptions is to create a significant financial pressure in 2010/11. This amounts to a £15m gap between planned levels of expenditure and available resources. This equates to 2.3% of total resources available in 2010/11. In order to bridge this gap the following approach has been adopted: • invest only in unavoidable cost pressures and pre-committed developments of £26m in 2010/11 over and above pure inflationary pressures • delay investments planned for 2010/11 of around £7.5m to 2011/12, • realise additional recurrent efficiency savings of £7.5m in 2010/11 over and above those already planned for. In future years the PCT has unavoidable cost pressures and pre-committed developments of £7-9m in each of the years 2011/12 to 2013/14. It also has an underlying requirement to make additional recurrent efficiencies of a further £7m in 2011/12 and £1.2m in 2012/13 in order to bridge the financial gap in these years. However, if the PCT is successful in delivering these recurrent efficiencies then it creates the financial headroom to be able to make non-recurrent investments of around

£9m in each of the years from 2011/12 onwards. This investment will be made against the prioritised strategic aims of the PCT. However, as this investment will be mainly non-recurrent, the PCT will have to be creative in how this is done to maximise service innovation and transformation whilst maintaining financial flexibility. It is not until 2013/14 that the PCT is in the position to commit additional recurrent investment of around £1m. Figure 2 illustrates the relationship over the next 4 years between the resources available to the PCT, the underlying level of expenditure, and the resultant efficiency requirement. Figure 2 Base Case Funding Scenario 685 680 675 £m

4.5% on its own expenditure base by delivering efficiencies in primary care prescribing, management and agency costs, and community services which equate to between £4m to £5m each year • to fund the recurrent over trades experienced in 2009/10, some of which have been managed nonrecurrently in that financial year.

670 665 660 655 2010/11

2011/12

2012/13

2013/14

Resources Underlying Expenditure Before NHSK Efficiency

Note: the trend lines have been simplified to illustrate the scale of the efficiency gap

Figure 2 shows the significant efficiency requirement of £20m in 2010/11. It also shows that although this reduces in the years after this, there is still a significant efficiency requirement in these years in order to deliver financial sustainability.

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Financial Uncertainty In addition to the base case planning assumptions described in detail above, the PCT is planning for two alternative financial scenarios:

Figure 3 illustrates impact of the downside funding scenario on the PCT over the next 4 years, and in particular the additional efficiency requirement. Figure 3 Downside Funding Scenario

Under the downside scenario the main change to the financial position of the PCT is that the PCT would be required to make an additional recurrent efficiency of £8.5m to £9m from 2011/12 onwards. Generating this additional level of recurrent efficiencies would be challenging. In this scenario the PCT would ‘step up’ the processes already underway to deliver efficiencies during 2010/11 and deliver the additional £8.5m required from 2011/12 onwards. However, it is likely to be difficult to deliver all of this recurrently in 2011/12. In addition the total size of the efficiency requirement makes it more likely that some of it will need to be delivered from significant service transformation which takes time to plan, consult on, and implement. Therefore, the PCT would use the non-recurrent investment funds available to it in 2011/12 to help manage this position whilst implementing the changes required to deliver the efficiencies recurrently going forward.

685 680 675 £m

• a downside, where: - allocation growth is nil from 2011/12 onwards - net tariff reduction is 1.5% from 20011/12 onwards with a 1% offsetting increase in CQUIN payments each year. • an upside, where: - allocation growth is 2.5% from 2011/12 onwards - net tariff reduction is 1% from 20011/12 onwards with a 1% offsetting increase in CQUIN payments each year.

670 665 660 655 2010/11

2011/12

2012/13

2013/14

Resources Underlying Expenditure Before NHSK Efficiency

Note: the trend lines have been simplified to illustrate the scale of the efficiency gap

Under the upside scenario, the main change to the financial position of the PCT, is that in each of the years from 2011/12 onwards it would have an additional £4m to £5m to invest recurrently each year. In this scenario, the PCT would prioritise the application of these funds against the strategic objectives in light of the circumstances prevailing at the time. We would still need to deliver the underlying level of efficiencies required under the base case scenario in order to realise this investment opportunity.

Figure 4 illustrates impact of the upside funding scenario on the PCT over the next 4 years, and in particular the additional investment available from 2011/12 onwards. Figure 4 Upside Funding Scenario 715 705

ÂŁm

695 685 675 665 655 2010/11

2011/12

2012/13

2013/14

Resources Underlying Expenditure Before NHSK Efficiency

Note: the trend lines have been simplified to illustrate the scale of the investment potential

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Section 4

GOAL 1

Strategy

Raise male and female life expectancy at birth so that it is not significantly below the national average in any part of Kirklees

Shorter life expectancy clearly links to certain causes of death and thus factors affecting those. Most such causes and factors strongly link to poverty and a low sense of control over one’s life. Significant causes of death such as heart disease, stroke, diabetes, some cancers, especially lung, are caused or worsened by tobacco and poor diet as well as access to variable quality of NHS care, i.e. inequalities of access. So the PCT has a major role in leading the local NHS to tackle these. Other members of the Kirklees Partnership can influence wider factors such as low income, education, work prospects or social support. Overview

Rationale

Initiative improvements

Goal 1 aims to: For men • Improve their life expectancy at birth over the next 5 years by 1.7 years to 78.2 years • Reduce the Slope Index of Inequality (SII) for their life expectancy at birth at Local Super Output Area (LSOA) level over the next 5 years from 10.1 to 9.5 • * see footnote • Reduce the rate of deaths from heart disease, stroke, cancers and for infants to the national rates across all localities. • Reduce prevalence of smoking in routine and manual groups aged 16 and over by 2015 (VS)

Life expectancy at birth in Kirklees for men is: • Just below the national level. • One of the highest in our PCT cluster • Better than Bolton, our twin PCT.

To increase male Kirklees life expectancy to the national rate include reducing: • early deaths from CHD, stroke, pneumonia, lung cancer and chronic liver disease • Deaths in infants.

Across Kirklees life expectancy varies by 5 years from the lowest in Dewsbury (75.6) to the highest in Holme Valley (80.5).

These causes of death reflect WCC outcomes identified to address high levels of contributory factors i.e. smoking and alcohol use, obesity (risk factors for the majority of the above causes), prompt identification and treatment of heart disease and stroke as well as adding life to years for those with long term conditions.

See women’s section for cancer indicators.

So initiatives focus on Dewsbury and Batley in order to improve the SII.

Overview

Rationale

Initiative improvements

For women • Improve their life expectancy at birth over the next 5 years by 1.7 years to 82.3 years • Reduce the SII for life expectancy at birth at LSOA level for women over the next 5 years from 7.4 to 6.5 * see footnote

Life expectancy at birth in Kirklees for women is: • Statistically significantly below the national level. • In the middle of our PCT cluster • Better than Bolton, our twin PCT.

Significant causes of early death in women in Kirklees include heart disease, stroke, (both being vascular diseases), Chronic respiratory disease, pneumonia and lung cancer as well as deaths in infants. The greatest killer of younger women is lung cancer, for which the only real action is prevention by not smoking. Otherwise these causes of death reflect WCC outcomes identified to address high levels of contributory factors i.e. smoking and alcohol use, obesity (risk factors for the majority of the above causes), prompt identification and treatment of vascular and respiratory disease as well as adding life to years for those with long term conditions.

• Reduce the rate of deaths from heart disease, stroke, cancers and for infants to the national rates across all localities. (VS) • Reduce the prevalence of obesity (LAA, VS) • Reduce prevalence of smoking in routine and manual groups aged 16 and over by 2015 VS • Increase to 90 % by 201011, of pregnant women having a health and social assessment of needs, risks and choices by 12 weeks and 6 days of pregnancy. (VS) Cancer delivery indicators (for all) (VS) • Delivering the NHS NSR targets for Planned Care • A two-week maximum wait from urgent GP referral to first outpatient appointment for all urgent suspected cancer referrals; • A maximum waiting time of one month from diagnosis to treatment for all cancers; • A maximum waiting time of two months from urgent referral to treatment for all cancers;

However it is vital that we focus activities on improving life expectancy for women. Across Kirklees, female life expectancy varies by 4 years from the lowest in Batley (79.4) to the highest in Holme Valley (83.5). Both Batley and Dewsbury female life expectancy are statistically significantly below the national level.

Many PCT programmes will contribute to this improvement, particularly where early deaths can be avoided such as improving access to good quality care for those most in need, especially all vascular disease and early cancer detection, as well as improving health behaviours. Work with women of child bearing age who smoke focuses on Batley and Dewsbury localities as well as early support in pregnancy for clinical, health and social issues. Action is occurring for good nutrition for women before, during and after pregnancy is crucial for the health of their babies. So these foci of activities are crucial in reducing infant mortality and to reduce smoking related diseases in women.

*Foot note: Concerns about the large variation in population estimates nationally for Kirklees (25,000 less than local actual figures) have led us to calculate life expectancy locally and to locality level. So the nationally produced data on the Slope is misleading locally 32

GOAL 2

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Improve health outcomes for children and young people, working in partnership to improve life chances and safeguard children.

Overview

Rationale

Initiative improvements

Goal 2 aims to: • Improve the psychological health and wellbeing of children as measured by the TellUs Survey from 72.1% to 77.3% by 2014. (LAA)

Childhood mental health problems link to risk, deprivation and vulnerability and can form a negative life journey resulting in social exclusion, low achievement, poor physical health, reduced social functioning, adult mental-health problems and relationship breakdown. Nationally, 10% of children aged 5 to 15 experience mental health problems and the prevalence rates have increased over the past 50 years (ONS)

Ensuring the Healthy and Extended Schools Programmes involve children and young people in planning, commissioning and providing emotional health and well being services and activity.

The strategic outcomes are: • Improved qualities of relationships children and young people have with their significant others. • Improved feelings of self worth • So feel more in control of self and choice of opportunities (As assessed in the JSNA.) Key process measures are: • Commissioning the full range of child and adolescent mental health services for children with Learning Disabilities. • Access to appropriate mental health services for 16 and 17 year olds • 24 hour cover for urgent mental health needs of children and young people and specialist mental health assessments within 24 hours • Early intervention support services delivered in universal settings and through targeted services

Involving schools as part of locality commissioning to improve the capacity of schools to deliver early interventions, so reducing the reliance on external services Ensuring that that specialist CAMHS services are comprehensive to achieve the required outcomes to meet the integrated locality services agenda. Implementing recommendations from the Think Family Initiative Implementing the parenting strategy including establishing a coordinated approach to accessing evidence-based parenting programmes for those children and families most at risk

Overview

Rationale

Initiative improvements

• Reduce the under-18 conception rate to 24.3 per 1,000 females aged 15–17 in 2010; (VS)

Sexual ill health has a great human and economic cost. Poor sexual health can result in ectopic pregnancies and infertility, HIV, cervical and other genital cancers, hepatitis, bacterial vaginosis and premature delivery, unintended pregnancies and abortions.

The Kirklees sexual health programme has the following key actions for reducing teenage pregnancy and STI transmission: • Provide accessible contraceptive and sexual health services for young people in schools and colleges • Maximise use of local data to target ‘hot spot’ areas • Make sure all professionals (including schools) working with vulnerable groups and in priority areas provide access to relationship, sexual health and contraceptive advice • Roll out the delivery of Long Acting Reversible Contraception and emergency Hormonal Contraception to young people • Target the most vulnerable young people and ensure intensive support is provided to minimise ‘risky’ behaviours • Provide opportunistic screening for Chlamydia in settings that young people access • Ensure partner notification of positive Chlamydia patients is carried out promptly to minimize onward transmission

• Increase to 25% of the resident population aged 15-24 accepting a test / screen for Chlamydia (VS)

Chlamydia is the most common bacterial sexually transmitted infection (STI) for UK men and women. Most have no symptoms, but left untreated, Chlamydia, can lead, in women, to infertility, ectopic pregnancy and chronic pelvic pain. In men it may cause urethritis and epidydimitis. In both sexes it can cause arthritis. Children born to teenage parents have: • higher rates of infant mortality than children born to older mothers, • More likely to be born premature – which has serious implications for the baby’s longterm health and have higher rates of admissions to A&E. In the longer term, • experience lower educational attainment • higher risk of economic inactivity as adults; The pressures of early parenthood result in teenage mothers being more likely to: • Have poor emotional health and well-being – which impacts on their children’s behaviour and achievement; • not achieve the qualifications they need to progress into further education and, in some cases, • have difficulties finding childcare and other support they Need to participate in Education, Employment or Training (EET).

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Overview

Rationale

Initiative improvements

• Halt obesity in children in Reception years at 9.6% (VS)

NHS Kirklees has a number of programmes in place which contribute towards reducing the incidence of childhood obesity. These include: • Obesity programme • Food programme • Physical activity programme • Healthy Schools programme

• Increase % of infants breastfed at 6-8 weeks to 47% by 2010 and 51% by 2011 (VS)

Obesity in children is rising nationally. Obesity is the imbalance between calories eaten and calories burnt off in physical activity. Childhood obesity is linked with numerous long-term and immediate health risks. It has a devastating effect on longer term health and is linked to earlier death and reduced life expectancy. Nationally around 3:10 boys and girls aged 2 – 15 were either overweight or obese and this is rising.

• Increase children’s levels of recommended physical activity to 64% by 2011. (LAA)

Across Kirklees: • In reception class 22% were either overweight or obese • 10% were obese

• Reduce the upward trend in Year 6 children who are obese. By 2014 17% of Year 6 children measured as obese.

These work very closely with partners especially specific Council directorates. Together they tackle the key factors of obesity and ensure interventions are in place to support children, young people and their families achieve and maintain a healthy weight.

In year 6 • 33% were either overweight or obese • 19% were obese, rising from 16% in 2007 • 14% were overweight

Overview

Rationale

Initiative improvements

• Reduce maternal smoking at birth 1% year on year in those localities that are below 18% and to 18% in those localities above this figure i.e. Dewsbury and Batley. (LAA)

Mothers’ smoking at birth (non South Asian) varies widely across localities (32% - 7%). Smoking at birth has increased in Dewsbury and Batley, 32% and 28% respectively (2008/09).They are also the localities with highest numbers of infant deaths.

The multiagency Kirklees Tobacco Control Alliance has developed a “Tackling Smoking in Pregnancy in Kirklees” Action Plan, including: • Promoting quitting to women of childbearing age. • Reaching pregnant smokers early and throughout pregnancy, e.g. through targeted work with GPs and ensuring brief intervention training is done by all midwives. • Increasing effectiveness of current interventions, e.g. responding to needs of more dependant smokers, first time mothers, young parents and isolated women through partnership work with Family Nurse Partnership, support workers in children’s centres using the regional “Significant Other Supporter” scheme to maximise outcomes. • Involving partners and families. • Maintaining postpartum quitting.

18% of white women are smoking at birth (national target overall is 15% 2010). Smoking during pregnancy is linked to pre-term birth and low birth weight, Babies born to women who smoke during pregnancy are more likely to die during the first four weeks of life. Nearly half of children and young people are exposed to tobacco smoked at home including maternal smoking. Estimates cost a complicated delivery by a smoker at 66% higher than that of a non-smoker. For every £1 spent helping a pregnant woman stop smoking, potentially £4 could be saved by the NHS

Smoke Free Homes is promoted widely as harm reduction for children and families, and a way for smoking parents to commit to quit. Increased support is available to referred families in Dewsbury, Batley and Spen.

GOAL 3

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Specific conditions and factors contributing most to inequality in health for people within Kirklees. All WCC outcomes are relevant from other goals, below are the specific inequality indicators where relevant. Overview

Rationale

Initiative improvements

Goal 3 aims to:

Personal health links to the sense of control felt over one’s life. In turn this is influenced by the opportunities available to feel supported, be able to make choices about helping oneself behave healthily, be well and function positively as a human being.

There are a wide range of activities for each of these specific conditions and factors, see the specific programme summaries.

Conditions: • Heart disease and stroke: Improve health functioning through improved quality of care universally but especially in Dewsbury, Batley and Huddersfield South; • People spend over 90% of their time on a stroke unit (VS) • 65% of high risk TIA patients are seen and treated within 24 hours by 2011 (VS) • Reduce % smoking or overweight / obese and increase physical activity • Emotional well being: Improve health functioning especially in Dewsbury and Huddersfield localities, those with vascular disease or pain • Enable people with mental ill health to have a job so improving self esteem and income and reducing isolation (LAA) • Pain incl. musculoskeletal: Improve health functioning • Reduce the prevalence of pain; • Enable pain sufferers to work so increasing self esteem and reducing isolation • Obesity: Reduce the prevalence of obesity in women of child bearing age, those of black African / Caribbean origin, those with diabetes, pain or vascular disease. • Diabetes: Improve health functioning; • Reduce prevalence of obesity; • increase good control i.e. HbA1c less than 7.5% (VS)

This goal underpins all commissioning and thus all goals. There are 3 key aspects: 1. The specific factors and conditions that contribute most to inequality in health for groups of people within Kirklees 2. Identifying the avoidable gaps in such factors and condition experienced locally and thus the appropriate interventions to close such gaps 3. Ensuring that commissioning is person centred, i.e. focuses on outcomes, enables people to take control and have choice of opportunity, involves local people in planning and delivery of activities / services, focuses resources on those most in need, so reversing the inverse care law. These are also core to WCC

Broadly activities focus on • Reaching those most at risk • To detect / diagnose • To enable the person to act quickly to alleviate the problem, including prompt referral where necessary. This means that appropriate care / support must be available promptly whether in primary, secondary or tertiary care as well as out of hours. It includes clear care pathways of interventions, referrals, multidisciplinary working across the types of care. The PCT is pursuing a quality improvement programme that should reduce variation between providers. Much of the health inequality focus is also on opportunities for normal living and within specific settings such as education and work. This involves the NHS in close working across the Kirklees Partnership with many directorates of the Council, the Police, the voluntary and independent sector to ensure

Overview

Rationale

Initiative improvements

• % offered screening for diabetic retinopathy (VS)

competencies.

that such focussed action is consistent for those most at risk.

Factors • Variation in the quality of care: primary care quality metrics by practice: (CQUINs) • Smoking: Reduce prevalence of smoking in routine and manual groups aged 16 and over by 2015 (VS) • Reduce % of women smoking at birth in Dewsbury and Batley to 18% by 2010/11, (LAA) • Reduce smoking in children aged 11-15 years (VS) • Food & nutrition: Increase % of infants breastfed at 6-8 weeks to 47% by 2010 and 51% by 2011 (VS) • Increase the take up of Healthy Start supplements to 6100 for children aged under 4; to 2669 for mothers of children aged under 4, esp. in more deprived localities • Reduce the number of 5 year olds with higher than average DMFT by locality to the Kirklees average • Physical activity: Reduce % of sedentary adults by 2011 to 15% aged 18-64 on low income, to 24% for those aged over 65, to 14% for adults with long term conditions (LAA) • Alcohol: Reduce rate of hospital admissions /100,000 for alcohol related harm to 2006-07 baseline of 1082 VS • Reduce binge drinking in young people, middle aged men, Denby Dale & Kirkburton • Reduce women of child bearing age who are hazardous drinkers to 27% by end of 2011, from 29% in 2008 (LAA) Wider factors are identified across the Kirklees Partnership that are beyond the scope of the local NHS to deliver substantially. Examples are educational attainment and skills; low income and worklessness, community cohesion

The NHS can support local people enormously in both taking good care of their health through prompt detection, treatment and support with the consequences of being ill as well as being able to have positive ways of coping rather than unhealthy behaviours. Variation in the quality of health care should only exist in respect of targeting those most in need, with good quality universal provision for all.

Further detail is within the relevant programmes.

GOAL 4

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Overview

Rationale

Initiative improvements

Goal 4 aims to:

Blood pressure is a major risk factor of cardiovascular disease which can contribute to related long term conditions. High Blood pressure impacts throughout the body especially the most sensitive organs such as the brain, heart and kidneys.

People with unhealthy lifestyle behaviour, obesity and uncontrolled blood pressure are likely to be at risk of developing long term health conditions and therefore patients should be aware of risk factors and therefore access to high quality primary care services to assess, advise, treat and continually care for these patients.

â&#x20AC;˘ Increase the percentage of people with CHD who have had their BP under control by 28% from a baseline of 52% to 90% (WCC) â&#x20AC;˘ Increase the number of people aged between 40-75 years who are offered a NHS health check (VS)

Supporting people to change lifestyle behaviour and make informed choices about their health and wellbeing will contribute to reducing the local incidence of cardiovascular disease Locally rates of heart disease, 5.6% is similar to national rates, 5.9%. Men aged under 65 years were 3 times more likely than women to have heart disease, 28% of men compared to only 9% of women. This was more than twice as likely for over 65 years, 37% men compared to 16% of women.

Quality of services will be improved by people with LTCs having more proactive and planned care with a focus on overall health and wellbeing. By implementing this approach we aim to achieve person centred care, reduce inequalities, improve quality and promote safety which are a number of key principles included in the 5 year plan.

Heart Disease is the second biggest cause of death locally in those aged under 75 years. Dewsbury had the most with heart disease aged 65, 4% with Mirfield the most aged over 65, 18%. Heart disease was highest in Dewsbury and Mirfield, 7% and least in Denby Dale and Kirkburton. Those aged under 65 years with heart disease were 2-3 times as likely to have high blood pressure as the overall population, 56% of those with heart disease compared to 22% overall.

Overview

Rationale

• Increase the proportion of people with diabetes who have HbA1c less than 7.5% (VS)

People with diabetes are at increased risk of cardiovascular disease and where diabetes remains poorly controlled the risk or diabetes combined with other risk factors for heart disease e.g. smoking, the risk is significantly increased

• Increase the number of people who feel supported and in control of their LTC (WCC, LAA)

In Kirklees over 200,000 people are living with a Long Term Condition (LTC) Unhealthy lifestyle behaviour is leading to an increased prevalence of LTCs and in Kirklees 1:5 people will be over 65 leading to a significant increase in those living with a LTC in the future. People with LTCs account for a significant and growing proportion of health and social care resources

• People with LTCs will have a personalised care plan

For people with LTCs to feel supported, care pathway development and redesign must incorporate opportunities for the individual to develop effective self care skills which should also include access to appropriate individualised information and resources to empower the individual to make informed choices about their health and well being. The aim is for everyone with a LTC to have a personalised care plan supported by and developed in partnership with a clinician.

Initiative improvements

The LTC programme is one of our 11 priority programmes and its vision and strategic objectives is to enable people living with or affected by a LTC to: • Self manage their own health and well being • Increase their sense of control and reduce isolation • Return to the lowest level of care possible for them • Have a dignified end of life All individuals with a LTC will: • Set their own goals supported by high quality information; • Take personal responsibility for their own health • Are the expert for the management of their condition; • Feel supported and in control; • Have a personalised care plan.

Baseline data (07/08) is taken from the Healthcare Commission Primary Care Trusts National Survey and records NHS Kirklees in the bottom 20% of all PCTs with only 54.4% of people feeling supported to be independent and in control of their condition. • Increase prevalence of patient involvement in their end of life care by 50% • Reduce the number of patients admitted to hospital for end of life care.

The number and percentage of patients who die (and whose death is expected/who have an Advanced Care Plan) in hospital within 24 hours of admission broken down to source of admission, i.e. home, care home, nursing home, etc.

The number and percentage of patients who are expected to die who have a preferred place of death recorded within an Advanced Care Plan, and the number and percentage of patients who have an Advanced Care Plan with

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Overview

Rationale

Initiative improvements

• Alignment to End of Life Healthy Ambitions Strategy and measures

The percentage of bed days used by people who are admitted and subsequently die in the same admission within hospital

preferred place of death and evidence to demonstrate that they died in their place of choice.

• Improve the percentage of people admitted with a stroke given a brain scan within 24 hours (VS) • Increase proportion of people who have a high risk TIA who are assessed and treated within 24hours (WCC, VS) • Increase proportion of people who spend at least 90% of their time on a stroke unit (VS) • Increase percentage of patients with confirmed stroke who are admitted directly (within 4 hrs of arrival at hospital) to a hyperacute stroke service, from Emergency Department, Ambulance or Community (CQUIN) • Increase percentage of patients with indications for immediate brain imaging receiving this within 1 hour of presentation at hospital (CQUIN)

Lifestyle behaviour and high blood pressure are key risk factors for stroke. Our JSNA identified a significant relationship between income and high blood pressure and stroke in Kirklees. Batley and South Huddersfield have the highest levels of stroke compared to other areas in Kirklees. There is an inequality in stroke provision across Kirklees. Not all people at risk or admitted with stroke are receiving necessary diagnostics and accessing specialist stroke care.

People at high risk of stroke or where stroke is highly suspected, or have a confirmed diagnosis of stroke should be able to access specialist assessment, diagnostics and treatment in a speedy manner 24/7 These outcomes will help to address inequalities between service provision and will help to improve quality of care and promote safety in Kirklees, two of the key principles in our 5 year strategic plan.

• Reduction of 35% in unplanned hospital admissions for ambulatory conditions from 08/09 baseline by 2014 • Reduction of 35% in emergency bed days for ambulatory conditions from 08/09 baseline by 2014 • Number of Community Matrons and LTC Case Managers

Ambulatory care sensitive conditions are those conditions which can be effectively and safely managed within primary care and should not therefore result in an unplanned hospital admission.

In Kirklees, there is a need for patients who have high risk of stroke or suspected stroke to have emergency transfer to a hospital who provide specialist stroke care, where they will receive specialist assessment, diagnostics, including brain imaging, which is high quality and speedy.

LTCs account for 70% of all inpatient bed days and 65% of all outpatient appointments There are significant productivity gains to be realised by more effective integration between health and social care practitioners and teams and through people with LTCs having their care needs through more proactive responsive care and improved self care skills.

Proactive care planning and the provision of adequate and timely resources and information to support self care will slow the progression of disease and prevent unnecessary hospital visits and admissions Proactive, preventative and personalised approaches to care and case management will improve the patient experience and reduce unscheduled use of hospital care

4.2

Initiatives (programmes) to ensure delivery of strategic goals We have worked 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 and programme objectives described above. These programmes are supported by a range of underpinning strategies and supporting activities. This strategic plan identifies how the PCTâ&#x20AC;&#x2122;s 11 programmes are used to ensure that work is directed towards achieving our vision, goals and outcomes. The WCC outcomes are an integral part of the Kirklees PCT outcomes as identified in Appendix 1, the Kirklees Programme Objectives and Outcomes. These programmes are 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. Our Health Improvement Teams (HITs) work within the 11 broad programmes, with Choosing Health and Long Term Conditions subdivided further into specific areas of work. All our HITs work within a cultural framework which is comprised of our visions and values, and our strategic goals as a â&#x20AC;&#x153;golden threadâ&#x20AC;? running through each specific programmes objective and influencing ultimate outcomes. New areas of strategic development are led by each of the HIT or PBC leads with full collaboration and support from enabling

functions such as performance and information, management teams, finance procurement, workforce and medicines management. For each of the 11 Programmes there is a detailed action plan developed and managed by the HITs identifying objectives, actions and outcomes. These plans include short term and long term outcomes and therefore provide a key link between the 5 year strategic plan and the annual operational plan.

4.2.1 Adopting a formal programme approach NHS Kirklees has recently appointed a Head of Programme Management Office as a clear commitment to following a rigorous consistent programme approach in the management of its strategic programmes. The Programme Office will set out, implement and monitor adherence to minimum standards for project management, project governance and prioritisation based on factors such as alignment with the strategic priorities and goals, project budget, risk and costs of failure. This will give an organisational overview of programme progress, will identify linkages to offset risks, maximise benefits and inform investment / resource savings through better and more efficient management of the whole programme as opposed to individual projects. The Programme Office reports to the The Strategic Development Committee, a subcommittee of the Board, by means of giving assurance and governance on programme delivery, which includes risk assessment and key progress achievements. The diagram above describes how the Programme Office will offer support to

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Commissioning Process Stages

Project Board

Metrics on performance of process and outcomes

Start up PID

Commissioning Process Stages

Deploy Contract

Post Deploy

Results: Strategic objectives

Evaluation

Programme Office

Programme Office drives performance: • compares projects (e.g. stage by stage; benchmarks, satisfaction surveys ) • analyses productivity (cycle time, including hand-offs between stages) • compare plans/forecast vs actual and strategic outcomes

individual initiatives and projects. NHS Kirklees has recently invested in offering the Managing Successful Programmes course to programme /project leads, and thus all strategic programmes will be managed by using this methodology, by which there is a formal “project board” for each initiative:

4.3

Strategy under multiple financial scenarios

This strategy is the culmination of a detailed and co-ordinated process in which the PCT has refreshed and developed both its Strategic and Financial Plans together. This process has: • built on the existing Strategic and Financial Plans • refreshed them in the light of changes in economic factors • prioritised a range of investments and disinvestments in order to reach a balanced position in a way which leaves a manageable level of financial risk to be addressed over time. The PCT has taken into account the Operating Framework published in December 2009. From 2011/12 onwards the strategy reflects the lower levels of anticipated growth and increased

Figure 5 shows the financial impact of the PCT’s strategy under the base case scenario. This shows the additional resources received by the PCT over the 4 years and how these are to be invested in priority areas to deliver this strategy.

uncertainty facing the NHS, with the strategy considering three different funding scenarios as outlined in section 3.7. Within the base case scenario, the reduced level of growth in PCT resources places a greater emphasis on the delivery of efficiencies than in previous years. Against this background the PCT has reviewed the level of future investments it is able to make in order that it can:

Key points to note from Figure 5 are: • the increase in the PCT’s recurrent income of 2% reflects the reduced annual allocation growth of 1% per annum from 2011/12 onwards • the negative change in non-recurrent income reflects the fact that the PCT will draw down the last of its Strategic Investment Fund balance in 2010/11 • the relatively low level of increased spend with NHS and Foundation Trusts reflects the increase in activity due to demographic change partly offset by negative tariff inflation from 2011/12 onwards and the impact of initiatives to prevent hospital admissions and reduce lengths of stay • the increase in expenditure with Independent Sector Treatment Centres

• sustain already committed levels of investment in priority areas and meet underlying demands such as the implications of demographic change, policy changes, and the impact of the Operating Framework requirements; and • balance this with a level of efficiency required to support these investments which is both challenging and deliverable whilst maintaining financial sustainability.

Figure 5 Financial Impact of the PCT’s Strategy: Base case Scenario CAGR*

Income

Surplus/Deficit year ending 09/10 Changes in Recurrent Income

+2%

Changes in Non-recurrent income

-6%

Changes in Primary and Community

+1%

Expenditure

Changes in Mental Health and Learning Disability

-1%

Changes in Continuing Care Spend

+10%

Changes in NHS and Foundation Trust

+1%

Changes in ISTCs

+6%

Changes in Ambulance Trusts

-1%

Changes in Specialist Commissioning

+5%

Changes in Other PCT Commissioning Spends

+2%

Changes in Other PCT Spend

Changes in Contingencies

+70%

Surplus/Deficit year ending 13/14 0

Source: NHS Kirklees Five Year Financial Plan

30 £m

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Achieving Financial Balance Under the Base Case Scenario Figure 6 shows how the PCT plans to deliver a sustainable financial position and balance the underlying cost pressures, investments, and cost and efficiency programmes within the overall increase in resources available to it over the 5 year period covered by this plan.

Figure 6 shows that the PCT is able to sustain a level of investment over the next 4 years. However, this investment is also dependent on identifying and delivering a significant level of efficiency over the same period of time. The key points to note in figure 6 are that in delivering a sustainable financial position the PCT is able to invest £138m over the 5 years. However most of this is the investments made in 2009/10 and 2010/11. Investments are much reduced from 2010/11 onwards and the nature of

120 100 80 60 40 20

2013/14 Surplus

Strategic investments

Benefits from service charge

Direct CIPs incl prescribing

Tarif contract efficiency

CQUIN Payments

Inflationary Pressures

Non recurrent income

0 Non tarif contract efficency

•

140

Increase in recurrent income

•

160

2008/09 Surplus

•

Figure 6 Delivering a 5 Year Sustainable Position

£m

•

reflects the increased choice of hospital being exercised by patients the growth in continuing care reflects the impact of changes in legislation, demographic growth and the anticipated opening of care homes within the Kirklees boundary specialised commissioning spend is forecast to increase primarily due to the impact of increased expenditure on specialist treatments and drug therapies other PCT spend includes the balance of the contingent investment funds and the underlying position shows a reduction reflecting the Operating Framework requirement to reduce management and agency costs the change in contingencies reflects the underlying non-recurrent contingency of around 1% and the recurrent impact of the utilisation of this in future years.

Source: NHS Kirklees Five Year Financial Plan

them becomes more non-recurrent in nature. In order to sustain this level of investment the PCT is planning to make £40m of efficiency savings over the same period. Scale of Investment/Disinvestment under the different Scenarios The Strategic Plan has been developed with 2 alternative financial scenarios in addition to the base case as discussed in section 3.7. Under these scenarios the scale of investment and disinvestment decisions change and these are illustrated in figure 7. Figure 7 shows that in the down side scenario the PCT has less net resources available to it after taking into account its funding levels and national tariff inflation. This amounts to around £8.5m to £9m per year. In order to maintain the level of investment in the plan the PCT is therefore planning to make an additional level of efficiency in each of the last 3 years of the plan. 45

Figure 7 Scale of Investment/Disinvestment under the different Scenarios

Figure 7 shows that under the upside scenario, the PCT has additional resources available to it, on the assumption that it delivers the level of efficiency within the base case. This potential for increased investment is around £4m per annum from 2011/12 onwards. This investment is shown as a contingent investment within the plan and subject to the delivery of the required level of efficiencies it will be invested against the strategic priorities and initiatives of the PCT as outlined within this document. 46

Scenario 1 Cum Surplus 2013/14

-30

Basecase Cum Surplus to 2013/14

Scenario 1 Cum Surplus 2013/14

However, this represents a significant challenge. In order to manage the financial risk associated with this, the investments in the plan become contingent on the delivery of these additional efficiencies. If the PCT is unable to deliver these efficiencies then these investments will need to be delayed or even removed completely. If this is the case then there may be an impact on the scale and speed at which some of the priorities in the plan can be delivered.

-10

Income Shifts

£m

Source: NHS Kirklees Five Year Financial Plan

Charge in strategic investments

-30

30 10

New Benefits from Service Charges

-10

Basecase Cum Surplus to 2013/14

New CIPs

Charge in strategic investments

New Benefits from Service Charges

New CIPs

70 New Cost Pressures

New Cost Pressures

Upside Scenario 90

Income Shifts

£m

Downside Scenario 90

4.3.1 Quality, Innovation, Productivity and Prevention (QIPP) In August 2009, a report was presented to the NHSK Board on our approach to efficiency. This was tied to regional and national strategy around Quality, Innovation, Productivity and Prevention (QIPP) Productivity, efficiency and Value for Money The NHSK Board approved a Value for Money Strategy for the PCT in March 2009. In that Strategy the component parts of VFM were defined; • Economy: for a commissioner, minimising the cost of resources for an activity, in simple terms, the price. • Efficiency: a measure of productivity, how much do we receive for the resources put in • Effectiveness: a measure of the impact achieved, this can be qualitative or quantitative.

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Assessing VFM NHS Kirklees is a complex organisation commissioning a wide range of diverse services, providing services and managing both. We do start from a strong base, although not one from which we can be complacent. The Audit Commission in its Annual Governance Report 2008/09 stated: “Our work on the PCT's arrangements to secure economy, efficiency and effectiveness in its use of resources is complete and we have issued an unqualified certificate on the 10 June 2009.” Programme Budgeting Our approach to Programme Budgeting provides a retrospective appraisal of NHS resources broken down into programmes, with a view to influencing and tracking future expenditure in those same programmes to achieve the greatest health improvement per pound spent. The most recent data, for 2008/09 has recently been published. Ongoing work will analyse this data and relate it to outcomes. Initial consideration of the data has raised issues of data quality but has raised questions around those programmes where Kirklees expenditure is relatively high, for example in gastroenterology, and has posed questions whether that level of spend is relative to the need in Kirklees and whether the outcomes being achieved are commensurately high. Equally, for relatively low spend we will assess if the level of spend matches the level of need focussing on the possibility of significant levels of unmet need.

Benchmarking, value for money and efficiency across sectors Acute: Better Care Better Value The BCBV indicators show the productivity opportunity for NHS Kirklees. The savings opportunities are significant across a range of indicators. The importance of pursuing efficiencies across the health economy has been recognised by the two acute Trusts that provide most of the services we commission. The productivity opportunities appear to be massive. Whilst not all the productivity opportunities would accrue to NHS Kirklees, as commissioner there can be no doubt that we should work closely with both Trusts to pursue them. To that end we made it a condition of the contract with CHFT we establish an ‘efficiency board’ with Calderdale PCT to work as a health economy to enable the productivity opportunities to be achieved. Integrated health and social care is needed to help deliver services across the whole system. Working at Chief Executive level and including the two local Councils the terms of reference for a Whole System Efficiency Board have been finalised. Detailed work will be done by groups underneath this board. In the Mid Yorkshire Hospitals health economy, delivering the productivity opportunities for the Trust are critical to the deliverability of an affordable, workable system when the new hospitals open. This is being overseen by the Strategy Board attended by the Chair and Chief Executive of NHS Kirklees. Looking specifically at the NHS Kirklees scorecard, by far the largest productivity opportunity is in ‘Managing Variation in Emergency Admissions for 19 conditions’ which have been identified as ones where

community care can avoid the need for hospitalisation. This is what our Long Term Conditions work programme is targeted on and these efficiencies form part of our financial planning. We need to ensure that they deliver.

implementing a maximum NHS contribution to a package of care, and a number of these will be pursued. The Commercial Procurement Collaborative is also available to assist in ensuring the best value from contracts.

Acute: Other benchmarking tools NHS Kirklees has recognised the need to refocus on driving value for money and that benchmarking is an effective way of identifying areas to target for efficiency improvements. We will, over coming months, make better use of a number of tools that are available to us that have not been fully explored, such as the Audit Commissions PbR benchmarking tool. The PCT has improved the use of such information and this will be a focus of work for the Finance and Performance Committee, its Business and Financial Planning sub-group and the SLA management group.

Mental Health / Learning Disability service contracts This is a complex area with little available useful benchmarking information but that does not exclude the pursuit of efficiency. Since the establishment of the PCT we now have a definitive baseline value for all the services provided to us by SWYPFT. This has enabled some assessment of the value for money of services. Contract negotiations have pursued value for money through service redesign in addition to applying national efficiency targets. Unlike acute Trusts who potentially can cover the need for efficiencies through generating additional income from better coding, mental health services actually have to deliver efficiencies through reduced costs.

The PCT has recently purchased a benchmarking tool, together with a number of other PCTs in Yorkshire and the Humber and nationally, that is intended to provide us with user defined benchmarking analysis that will help to identify improvement areas but which should also facilitate a cultural shift in placing value for money higher up the agenda of managers and programme leads. Implementation of this tool is taking place at the moment. Continuing care Given the consistent increase in continuing care costs over recent years it remains vital that we pursue value for money in all our contracts. This will remain a key focus of the work of the Assistant Director of Commissioning over coming months. The Finance and Performance Committee has considered an initial paper on ways of saving money in this area, for example,

Community Services The PCT has recently made significant investments in community services, particularly in District Nursing and Health Visiting. This followed a reassessment of the implementation of a previous efficiency project. Value for Money in community services is difficult to assess as there is no national tariff and little, reliable, benchmarking information. There are reference costs for comparative purposes but until we have a full years data for a period when the investment in new staff has been fully implemented the reference costs comparisons are not entirely helpful. However, through the Transforming Community Services (TCS) work streams, there is a lot of work which is bringing greater clarity to the community services we commission from Kirklees Community

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Healthcare Services. This clarity, together with the management focus that the TCS agenda brings to community services, should deliver improved quality of community services. The improved data that is now being collected will enable better investment or disinvestment decisions to be made. Medicines management The costs of GP prescribing are well served by benchmarking data and this is reviewed at the Medicines Management Committee regularly and periodically by the Finance and Performance Committee. The PCT has purchased new software called Scriptswitch that effectively sits on a GPs computer so that when they make their prescribing decision the software prompts the GP to note that an equally effective but cheaper drug is available. Evidence from other PCTs using the product suggests that this is an effective tool in reducing prescribing costs. Primary medical care contracts There is increasing focus on ensuring that value for money is delivered from both forms of primary care contract but particularly from PMS contracts where, in many cases, additional services were provided by GPs for additional money. The PCT undertakes annual contract reviews with PMS contract holders to ensure that value for money is being obtained for additional payments. PCT officers are also currently engaged in discussions with LMC representatives to explore a range of primary care finance issues. The PCT has considered the wide range of contract values per registered patient that exist with Practices across Kirklees. There remains more to do and the current financial climate will refocus work in this area.

General Dental Services Although the new dental contract was only introduced relatively recently there appears to be continued dissatisfaction with it from both dental practitioners and Government. Nevertheless, the focus for the PCT must be to ensure that we get value for money from all our GDP contracts. That means continuing to ensure that the PCT gets the services it is paying for and that it ensures that income from patient charges is maximised. The allocation for dental services is currently ring fenced and the PCTâ&#x20AC;&#x2122;s dental team are focussed on this to free up as much resources as possible to invest in the commissioning of additional services to meet identified need. Corporate Services Based on analysis of the draft 2008/09 Annual Accounts of the PCTs in Yorkshire and the Humber, NHS Kirklees management costs per head of weighted population is the same as the average and the 9th highest of the 14. The recently published Operating Framework required all PCTs to reduce management and agency costs by 30% by 2013/14. In 2010/11 the PCT is targeting savings of around ÂŁ1m on its corporate budgets. One of the ways of achieving value for money from management is to avoid duplication of back office functions. NHS Kirklees has a good record in this area already. We have a shared HR & OD service with Calderdale PCT; we are part of the national Shared Financial Services and we have a shared Health Informatics Service. We have recently established a shared estates agency across three PCTs; that agency is leading a piece of work to tender facilities management services for at least two of the PCTs which it is planned will

deliver improved service levels at a reduced cost. The PCT also has collaborative arrangements with PCTs across Yorkshire and the Humber. The Commercial Procurement Collaborative reduces the need for each PCT to establish its own procurement expertise. The Specialised Commissioning Group likewise for specialised services. A number of Healthy Ambitions projects are being driven at a regional level to avoid duplication and waste. 4.3.2 Cost and efficiency programmes During 2009 / 10 significant additional investment of £9.2M was made across all our strategic programmes (see fig. 8). Moving forward into 2010 / 11, under the base financial scenario, NHS Kirklees needs to generate recurrent efficiency savings of £20m, £12m, £6m, and £5m in the next 4 years. To deliver these, each of our strategic programme areas will be required to make a 2% efficiency saving over this 4 year period. The profile of these savings mean that in 2010/11 the requirement is higher at 3% falling to 1% by 2013/14

4.3.3 Approach The approach for year one (2010/11) will be a tactical one which describes a delivery programme for achieving these savings. Programme leads have been asked to identify a range of potential efficiencies, along with the risks and impact of making those efficiency savings, and provide a prioritised list.

Typical examples of where savings for the first year might be made include: • Use of benchmarking tools to ensure value for money • Review value for money of primary care costs • Restricting financial uplifts on existing contracts • Capping costs on existing contracts Programme Leads were asked to utilise the NHS Kirklees prioritisation framework , the Programme Budgeting Factsheet and quadrant analysis model published by the Public Health Observatory, and finance / activity data available for each programme area. The approach for 2011/2012, given the extent of the challenge, will be more around addressing our strategic objectives and describing how the savings will potentially be achieved at a strategic level with options and impact assessment of radical service redesign. As we refine our planning assumptions over the forthcoming months this will be an iterative process, which will be subject to change and evolution. There will be a requirement to undertake consultation with our strategic partners and service users where we are planning radical service redesign which will obviously continue beyond the timescales of the publication of this plan, and therefore it should be expected that this piece of work will take us well into next year. A degree of pragmatism and “sense checking is required with a strategy which describes how we plan to achieve these challenging savings.

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

4.3.4 High priority initiatives There are a number of high priority initiatives which have been presented to NHS Kirklees by programme leads, which have been identified as a major financial challenge. These initiatives are deemed to be the most important in terms of supporting the achievement of our strategic goals and world class commissioning outcomes.

not fully delivered in 2011/12 then some of the initiatives might have to be further delayed until they are identified and delivered in order to maintain a sustainable financial position.

As explained in section 3.7, 2010/11 is a challenging financial year requiring the PCT to make significant efficiency savings and re-prioritise investments. This reprioritisation of investments means that £7.5m of investments originally planned for 2010/11 have been delayed until 2011/12 and some planned investments have been removed. This means that investment in 2010/11 is largely limited to already committed investments and those required to meet underlying levels of increased demand seen in 20010/11, further demographic change, and other nonavoidable pressures.

Table 2 overleaf is intended to show:

Under the up side funding scenario, additional recurrent funds are available in 2011/12 which would support these initiatives.

• how the £2.7m investments in the high priority initiatives are now phased between 2010/11 and 2011/12 • how the balance of the delayed investment is now planned for 2011/12, but with the possibility that some of it might be delayed until 2012/13 if the required levels of efficiency are not delivered.

As the required levels of efficiency are delivered, funds then become available for investment and these will be prioritised and invested in supporting these high priority initiatives. In most cases this is expected to be during 2011/12 unless additional efficiencies are identified during 2010/11. In addition, from 2011/12 onwards the majority of the investment funds available to the PCT will be non-recurrent and therefore the nature of the initiatives may have to change to reflect this. Under the down side funding scenario, there is an additional requirement to generate efficiencies. This means that the investments planned for 2011/12 will be treated as contingent on the delivery of these additional efficiencies. If these are

Table 2: High Priority investments required 2010 - 2013 Strategic goal & Objective

Initiative

Children – Work jointly with young people, schools and the local authority to develop the Kirklees model for the Healthy Schools Enhancement

Improved health and wellbeing in schools

£140K

Children – Develop and agree new specifications for health visiting and school nursing and ensure effective delivery.

School nursing

£122K

Health Inequalities – Improve both the numbers of people treated and the community outcomes for people in alcohol services.

Alcohol treatment service

£300K

Long Term Conditions –

Increasing resource of continuing care team

£53K

Long Term Conditions – Reduction in the number of patients admitted to hospital or a care home as a result of a fall by 25%.

Falls scheme

£100K

Long Term Conditions – Reduce the reliance on secondary care services and increase the provision of care in a primary, community or home environment by the redesign and development of intermediate care services.

Intermediate Care

£500K

Children – Implementation of the healthy pregnancy strategy

Maternity

£600K

Long Term Conditions – Increase the percentage of stroke admissions given a brain scan within 24 hours to 90%.

Stroke

£250K

Long Term Conditions – Develop specialist LTC pathways in line with standards set out in NSFs, concentrating on bringing care closer to home and developing hospital services that offer rapid access to assessment, diagnostics and treatment.

Diabetes

£100K

Increase life expectancy – Implement improved breast cancer screening to meet national targets

Pennine Breast Screening

Sub total high priority initiatives Other Investments

TOTAL

Planned Investment 2010/11 2011/12 2012/13

£500K

£500K Other investments planned for 2010/11 now delayed

£2,165k £5,400k £8,065k

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Section 5

Delivery 5.1

Delivery schedule for initiatives, and achievement of critical milestones NHS Kirklees has adopted a formal programme approach to the management and delivery of its 11 strategic programmes. (See Appendix 1 for a detailed description of all our programme objectives, intended outcomes and critical milestone dates for delivery). All our programmes are monitored and co-ordinated through our Programme Management Office, and assurance given to our Trust Board through our Strategic Development Committee, which receives regular performance updates including critical risk assessment to maintain governance and control. The changing financial situation within not just our own organisation but throughout the NHS and our national economy presents us with some challenges around achieving our outcomes as per our originally specified timescales, but we are committed to working ever more efficiently and innovatively to ensure that our service delivers to the same exemplary quality standards in which we have always been proud. The scale of strategic challenge should not be underestimated. The NHS is facing the prospect of limited growth beyond 2011, following a period of relative prosperity. This calls for an approach that enables us to provide “more for less”, as demand will undoubtedly increase for services, as will demands for improved quality.

real benefit and has undoubtedly brought increased discipline into the commissioning processes of the PCT, which has proved invaluable and offers a great deal, as the organisation heads into more challenged financial waters. Given the financial position, commissioning capability and reputation and potential for creative thought of commissioners, we can demonstrate that we are capable of thriving in such challenging circumstances going forward. Building on the successes and achievements of the last two years which we aspired to in our first World Class Commissioning Strategic Plan (2008), our programme leads work ever more effectively in working within and setting challenging new targets for each of our strategic programmes. The QIPP agenda has provided a framework for utilising a variety of tools, such as programme budgeting and quadrant analysis, to ensure that our focus remains directed at those critical areas required to enable us to deliver our financial and performance targets. Key achievements are celebrated, and future aspirations are approached with confidence. Working within an ever more challenging financial envelope has promoted innovation and the realisation of efficiency savings, resulting in re-investment in critical areas of service which may not otherwise have been possible (see Section 5.2 – Past Delivery Performance – for examples). Examples of some of our achievements, and future aspirations, within 3 of our programme areas (Mental Health, Learning Disabilities, and Long Term Conditions) are:

The process, of considering the whole system impact, of commissioning and the focus on quality improvement, healthcare outcomes at a very low cost, has been of 53

Mental Health The Joint Mental Health Commissioning Strategy (2008-2011) is based on both national guidance and local needs assessment. Our work to address the needs identified in the JSNA is characterised by close partnership working, rooted in the local communities we serve. Recent national policy drivers focus upon a transformational agenda for health and social care services, particularly through the implementation of Putting People First for social care and Transforming Community Services for ourselves as commissioners and primary care providers. What we have achieved The PCT has worked with partner agencies to find real synergies which have brought better outcomes for service users and the broader community. Existing partnerships such as those with our Local Authority and specialist mental health provider have remained strong, we have also optimised the opportunity to explore other forms of partnership such as those involving the independent and not for profit sectors. During 2009/10 the PCT has consolidated the new, mental health services commissioned during 2008/09 and has further developed a number of these by progressing these to ‘ageless’ needs appropriate services. Additionally the PCT has commissioned a number of new service developments, including: • Community service for Adults with Deficit and Hyperactivity Disorder (ADHD); • Community Eating Disorder service; • Primary Care mental health service (IAPT)

What we will achieve The launch in December 09 of “New Horizons” will focus our attention on the further integration of health and social care along with an increasing focus on prevention, wellbeing and personalisation. During 2010/11 we will be refreshing the Joint Mental Health commissioning strategy, to ensure that it remains fit for purpose. As before, our work will be underpinned by the following 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 that offer people more choice and control. • There will be an emphasis on services that are designed to promote recovery. The personalisation of public services will assist. • The development and maintenance of sustainable communities will be supported in order 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.

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Learning Disabilities The PCT has the lead responsibility for ensuring that a commissioning strategy is fully 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, to meet the required and future needs of this vulnerable care group, within Kirklees. It is inevitable that, there will be significant impact on both primary care and specialist services. What we have achieved During 2009/10 the PCT has commissioned new service developments, including: • • • • •

Learning Disability Health Action Plans Vulnerable In-Patient (VIP) card Specialist Respite services Enhanced Primary Care services New Low secure service provision

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. What we will achieve In the coming year we will build upon our achievements to date, focussing on: • Ensuring existing robust commissioning and contracting relationships are maintained with providers. • Developing the PCTs regional and national reputation to support innovative approaches to service redesign and modernisation.

• Establishing a clear PCT profile to support and enhance the PCT’s reputation within the market and support relationships with key stakeholders. • Analysing of the market to explore opportunities to enhance contestability and plurality in the market, actively promoting competition from NHS and non NHS providers • Maintaining and strengthening relationships with partners and local communities. We will further develop our expertise in planning and commissioning services in partnership enhancing our good reputation for service user involvement and public engagement. The PCT intends to consolidate specialist learning disability pathway redesign for 2010/11. The overarching objective will be to continue to design a universal level of support for learning disabled individuals which will compliment & enhance the whole system of service delivery, increase the prioritisation of learning disabilities within primary & acute services, facilitate and promote and motivate learning disabled individuals to access appropriate services to meet their needs Local key performance indicators, agreed in partnership, will be further developed to stretch the Kirklees health economy, to maintain the profile and prioritisation of the learning disability agenda.

Long Term Conditions The refreshed Joint Commissioning Strategy (2010-2020) will be based on locally agreed goals and will use both national guidance and local needs assessment. It will be seen as a working document to guide and support future work via agreement on specific targets, measurable outcomes and dates for achievement. The launch in January 2010 of “Improving the health and well-being of people with long Term Conditions” will help support us in developing world class services for people with LTCs. What we have achieved During 2009/10 the PCT has redesigned existing LTC services previously commissioned and has further developed a number of these by progressing these to involve more responsive and personalised care and case management approaches. Additionally the PCT has commissioned a number of new service developments, including: • Increased self care support through increased investment in diabetes structured education programmes • Early Supported discharge for people with COPD • Community specialist COPD services • Family and carers support service for people following a stroke • 24/7 LTC generic workers • Increased number of Community Matrons, case managers and specialist nurses • Bespoke Kirklees predictive risk model • Assistive technology – single and multi user units deployed throughout Kirklees • Single point of contact for access to intermediate care services

• Redesigned acute care pathway for stroke and TIA • Redesigned pathways for neurological conditions What we will achieve Personalised care planning and self care support work together as part of care delivery that supports and promotes patient empowerment and choice and underpins excellent management of LTCs and end of life care, and completely supports the key themes described in Commissioning for Health and Wellbeing, Putting People First and High Quality Care for All • Genuine choices and better informed needs assessments will be achieved through personalised care planning • Collecting data from care plans will provide information on unmet need • Better evaluation and performance management of currently commissioned services • Consider all possibilities for increased efficiency and productivity within pathway development - Increased and improved seamless approaches to integration of health and social care - Successful implementation of single point of contact for access to health and social care – reducing waste driven by inefficient use of resources or duplication - Increased use of assistive technology to support more effective primary care assessment, monitoring, management and self care - Implementation in care homes - Support End of life care - Facilitate early and safe hospital discharge • More effective use of information to support preventative and proactive

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

health and social care provision through intelligent commissioning plans • Change the culture and behaviour of the workforce, people with LTCs and the public to develop a more proactive and person centred approach to LTC assessment and management

5.2.1 Delivery through new investment NHS Kirklees has invested a total of £9.2M across all its programme areas during 2009 / 2010 and is already starting to see dramatic improvements in performance as a result. Figure 8 shows the breakdown of investment by programme area: Figure 8: Breakdown of investment by programme area:

5.2 Past delivery performance NHS Kirklees improved its performance against the quality of services perspective of the Care Quality Commission in 2008/09. For the first time a rating of “Good” was achieved compared to “Fair” for the previous two years.

8% 9%

11%

4% 5%

On the areas where performance was underachieving, monitoring in year is already demonstrating that there has been improvement during 2009/10 for example around A&E, mental health targets and the number of people waiting longer than they should for treatment . This approach is embedded in our performance reporting and assurance systems so action can be taken at a much earlier point in the year, maximising the potential for achievement.

16%

5% 34%

Corporatate Drugs and Alcohol Team Children and Toung People Learning Disability Mental Health Long Term Conditions

As the organisation heads into more challenged financial waters., we believe that evidence of past delivery demonstrates that we are capable of thriving in such challenging circumstances.

Planned Care Infection Control Choosing Health Practice Based Commissioning Urgent Care

Moving into the challenges of the new financial year, and with a financial position which will not support further additional new spend, NHS Kirklees moves from a position of service improvement through new investment to innovation through efficiencies and reinvestment.

5.2.2 Delivery through re-investment and efficiencies Examples of service developments which have been achieved through reinvestment of efficiencies driven within existing financial envelopes during 2009/10 include: • The commissioning of the Admiral Nurse service: – this is to support the delivery of the PCTs dementia priorities. This was achieved by an assessment and reduction of inpatient bed requirements, whilst maintaining the ability to achieve the national ALoS trajectory for Kirklees. • The expansion of the Primary Care Counselling service:Through the review of the existing pathway, criteria, working practices and revised NICE guidance, the service specification was refined. This enabled the expansion of the service to cover an additional 32,000 of the Kirklees population achieved within the same financial envelope. • The redesign of learning disability low secure forensic services:Through the review of the existing pathway, criteria, working practices, referral patterns, average lengths of stay and revised DH forensic guidance, the service specification was refined. This enabled the commissioning of specialist inpatient bed requirements, maintaining the ability to achieve the national ALoS trajectory and a high quality service standard for Kirklees. Whilst also enabling the new commissioning of a learning disability community forensic service for the Kirklees population, whilst achieving a recurrent £34,000 saving. • Service redesign of drug and alcohol services for under 25s: Unlike adult services, young people’s

drug services have historically underperformed in Kirklees. With this in mind, an independent review recommended closer joint commissioning between children’s and adults commissioners. Budgets were pooled and a new service retendered. The new service, at no extra cost, will be able to see young people upto 25. A further benefit from this approach has been the joint commissioning, from shared efficiencies, of a safeguarding support service • The whole system redesign of services for people with LTCs and the infrastructure to support these services will be achieved by reinvestment driven by a 3 year efficiency programme resulting in a reduction in hospital admissions and length of stay for ambulatory care sensitive conditions. • Savings totalling £5.3 million will be reinvested to prevent hospital admission and facilitate effective and safe earlier hospital discharge by :- Increasing the numbers of community matrons and case managers - Implementing assistive technology for people with LTCs - Developing and implementing the role of the LTC Generic worker - Supporting the development of primary care through specialist skills and resources deployed within primary care through pathway redesign - The development and implementation of predictive risk and population stratification to target more effectively resources to prevent hospital referral and admission - Implementation of early supported

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

discharge schemes that will provide specialist resource to support people out of hospital with more complex needs - Increased specialist nurse and therapy resource in the community • Better management of LTCs can fully support the quality and productivity challenges that lie ahead and delivering more of the same is not an option. More proactive, preventative and personalised approaches can improve the patient experience and reduce the unplanned use of hospital care. However these changes require successful multiagency integration and transformational change supported by innovation and strong clinical leadership to drive this forward • Clinical audit within GP practices, with approximately 200 audits having been undertaken over 12 therapeutic areas. These audits have assessed the appropriateness of prescribing choices, and disease management, and have resulted in many improvements in relation to the medicines prescribed for patients. Equally, the summary outcomes from these are shared across the PCT to further improve the quality of patient care and prescribing for local patients. • Significant resource has been invested in developing GP decision support software and advice through the use of Scriptswitch, which is anticipated to deliver significant cost efficiencies, with the local “profile” going live in practices in December 2009. Initial data from less than 1 months activity indicates that efficiency savings of approximately £36,000 has been achieved, and is on course to deliver well in excess of the investment in the software package.

• Additional efficiency savings of over £150,000 have been realised through the work of the medicines Management team. This only takes account of actual changes to medication, and does not take into account changes in prescribing behaviours as a result of the work and advice of the medicines management team, if this is taken into consideration, the impact on prescribing cost efficiencies will be far greater than the figure quoted.

5.3 Risk management The Trusts system of risk management is based on an integrated approach to the assessment and management of risk at all levels across the organisation. To support this approach, the Trust utilises a software application tool supported by policies, procedures and staff qualified to manage risk. The system (Performance Accelerator) calculates risks via a scoring system based upon the AS/NZS 4360:1999 standard and provides a programme that demonstrates risk weighting, gaps in the management of risk and controls that are in place. The system ensures that risks are prioritised and managed across the Trust and include reference to Trust objectives and any risks that could effect the ability of the Trust to achieve those objectives. All items within the system have a risk tab attached to them, where risk controls and mitigating action are directly quantified. Specific directorate risks can also be added to the system. High level risks are reported too and monitored by the Board via the Board Assurance Framework with the management of risks being completed

through Directors, Directorates and committees with a specific function of managing risk. The overall co-ordination of risks is completed by the Risk Management Overview Group who are tasked with providing the necessary assurances to the Trust Governance Committee.

5.3.1 Financial Risk We recognise that the ability to deliver our strategic priorities heavily depends on the 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. • The efficiency schemes do not deliver, in particular those plans which aim to reduce admissions and length of stay in acute settings. • 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. • NICE approves more expensive drugs than those currently in the planning assumptions. • The forecast out turn for 2009/10 is under pressure and whilst this is expected to be managed, some of this might be non-recurrently in 2009/10 and the recurrent impact will have to be picked up in 2010/11. • Continuing Care expenditure continues to grow at a rate above that

included for within the plan. • The planned move to an activity based tariff for mental health services will introduce a degree of financial uncertainty and potential increased costs. • The PCT’s own community provider is unable to deliver the level of efficiencies required. • The constrained national financial position results in additional pressures falling on the PCT over and above those planned for in light of the Operating Framework.

5.3.2 Mitigating Actions These risks have been assessed for likelihood and financial impact. Based on this, an appropriate level of non-recurrent contingency is included within the plan which equates to around 1% of total resources each year. In addition, the plan acknowledges that in reality most applications of this contingency are actually recurrent in nature. It therefore includes the recurrent pick up of this contingency in future years. This level of contingency is higher than in previous years and reflects the increased level of financial challenge and uncertainty facing the PCT over the next 4 years. In addition, by planning for the recurrent pick up in future years this reduces the risk that the PCT will over commit resources going forward. The PCT is also planning for an increased surplus in 2010/11 and this will, if achieved, help to manage risk in years after this as it is returned and made available to support the delivery of the strategy.

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

5.4 In year monitoring NHS Kirklees has robust systems in place for performance managing key national targets such as Vital Signs and Care Quality 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. Progress has also been made throughout 2009/10 on the reporting systems across health and social care. The reporting structures now in place ensure that the information is consistent across NHS Kirklees and Kirklees Council and routinely produced. The emphasis is on exception reporting but full reports are produced to brief the joint Director of Public Health on all health indicators that overlap with the joint priorities of other local partners. The systems and processes will be built upon and improved in line with the principles set out in the Performance Strategy for NHS Kirklees, with an initial emphasis being on supporting the partnership agenda, including Local Partnership Strategy Boards. The Finance and Performance Committee, a sub-committee of the Trust Board, will continue to play a key role in the delivery of the operating plan & targets and providing assurance to the Trust Board. Part of this assurance process is also around focussed investigations into key areas of concern by the Director and Deputy Director of Performance and Information.

Operating Plan 2010/11 have been included in individual director’s objectives for delivery through their teams. There will be a clear cascade of these from director to individual’s objectives. Through this clear cascade of priorities and targets it is expected that accountability and ownership from staff across the entire organisation will continue to increase.

5.4.1 Board Assurance and Governance of Programmes 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&FP, with associated efficiency savings, intended outcomes and performance measures, to ensure strategic fit and effective governance. Spend up to a limit of £100,000 can be approved at B&FP, with spends of up to £0.5M referred to the Finance and Performance Committee, on behalf of Board. The Strategic Development Committee, a subgroup of the Trust Board, meet monthly, and with representation including Nonexecutive Directors review the progress of and governance of all strategic programmes within the PCT. There is a rolling quarterly programme of reporting whereby Programme leads use a standardised reporting framework (based around the MSP methodology) and which reports on progress to date, programme spend, performance achievements, critical risks and mitigating actions. All new strategic programmes are agreed by the SDC on behalf of the Trust Board.

The Operating Plan 2010/11 will inform the individual and/or directorate business plans. The actions and requirements of the

5.5

Organisational requirements and enablers In order to deliver on our programmes we have a number of supporting activities which are necessary to ensure that we have the resources to deliver out plans. The key activities are: • • • • • •

Workforce Planning Performance Management Communications and Engagement Changes In Technology Estates Procurement Medicines Reconciliation

5.5.1 Workforce planning at NHS Kirklees At NHS Kirklees, we recognise that we will deliver our ambitions for the health of people of Kirklees through the quality and effectiveness of the people we, and our wider system employs. We released our key workforce document, Workforce Ambitions for a Healthy Kirklees 2009 – 2014, in September 2009, which sets out our vision and intentions for the coming years. See Appendix 2 for our Workforce Planning Strategy.

5.5.2 Performance Strategy The Performance Strategy for NHS Kirklees sets out the framework within which NHS Kirklees will work to drive and deliver improvements in performance. A substantial element of the strategy is around ensuring the systems and processes for monitoring performance are robust and provide the various views of performance required for a world class commissioning organisation. The number of indicators used across the health and social care agenda are used to provide assurance

against the full range of views. The strategy sets the inter-relationship between the indicators and views graphically to emphasise the interdependencies and overlap. The performance framework set out within the strategy will ensure that we can see success and learn from it as well as recognise failure and correct it. This framework shows a clear line of sight from the vision and corporate objectives through to individual and team objectives. This ensures there is clarity of accountability and requirements combined with robust systems and process for delivery and demonstrating delivery and impact. Delivery and impact is maximised through the use of performance tools such as reporting software and benchmarking. However, the framework in itself will not deliver if the culture of the organisation does not support it. We need to operate within a culture where people are empowered and supported to improve performance across all aspects of PCT business. This is not purely about individual skills and confidence but also the systems and processes and the communication of these. Leadership and learning are fundamental building blocks for delivering a performance culture and should be harnessed to maximise the opportunity and ability to achieve excellence. These are not purely relevant to the delivery of the performance strategy but are cross cutting organisational development requirements, which are being addressed through the organisational change and development programmes being established.

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

5.5.3 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 people’s behaviours on public health issues and health choices. A joint Marketing Board now oversees campaigns and social marketing across the PCT and Council. This is covered in detail in our communications plan. 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. We have 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.

5.5.5 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 current financial challenges we are addressing means that all potential investment will be prioritised and focused upon urgency.

5.5.6 Procurement Strategy 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).

We are working to develop a number of key messages for our different stakeholders. For further detail please see the full Communications and Engagement Plan.

NHS Kirklees approved a Procurement Policy in November 2009 and use this policy to underpin our decisions on whether or not to tender for the services we wish to commission. The policy aims to:

5.5.4 Changes in Technology We will continue to deploy the Connecting for Health sponsored solutions for changes in IT Technology. This will include continued investment in our GP practices, community pharmacists and collaborative use of Data Warehouse. Further detail is provided in Appendix 3.

• 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.

5.5.7 Medicines Management and Community Pharmacy Please see Appendix 4 for our Medicines Management and Community Pharmacy Strategy.

5.5.8 Equality Impact Assessment As part of the process in developing this Five Year Strategic Plan, a full equality impact assessment has been performed and this is attached as Appendix 5.

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Section 6

Declaration of Board Approval 6.1

Board challenge, ownership and monitoring of strategic plan delivery 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 as taking the strategic lead through Board Briefing workshops and formal Board discussions.

6.2 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 27th January 2010. These plans are thus submitted for assessment under the World Class Commissioning Framework.

Rob Napier Chairman

The Commissioning College and 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. In addition, the Strategic Development Committee, on behalf of the Board, formally oversees the progress and risk management of all of our strategic programmes, and membership includes two of our Non-Executive Directors, as well as membership from our PEC and Commissioning College. The Board has set out through its approval of the business planning framework, scheme of delegation and practice based commissioning systems and process the way the PCT will develop its plans. The links with the Council through the Local Public Service Boards on which the PCT Board members sit has also enabled Board members to make sure that partnership working is a key theme within plans.

End of Life

Maternity and Newborn

Planned Care

Acute care

Mental Health

Childrenâ&#x20AC;&#x2122;s Health

Long Term Conditions

Staying Healthy

Key priorities from Healthy Ambitions:

Primary care

Planned care/18 weeks

Urgent care

Partnership commissioning

Long Term Conditions

Choosing Health

NHS Kirklees Programme Areas:

11. Primary Care

9. Healthy Pregnancy Maternity Service Strategy 10. Planned Care including Cancer and Palliative Care, Musculoskeletal

8. Urgent Care

4. Childrenâ&#x20AC;&#x2122;s and Young Peoples Strategy 5. Drugs and Alcohol Commissioning Strategy 6. Learning Disabilities 7. Mental Health

3. Long Term Conditions (including Physical and Sensory Disability)

Food

1. Choosing Health 2. Infection control

Cardiovascular disease Stroke Respiratory Diabetes Neurology

Long Term Conditions HIT Programmes

Tobacco

Sexual Health

Self Care and Expert Patient Programme

Physical Activity

Oral Health

Obesity

Better Health at work

Alcohol

Accident prevention

Choosing Health HIT Programmes

Kirklees HIT Programmes:

Figure 9: Mapping our Delivery of Healthy Ambitions to our Programme Areas

Appendix 1

Programme Strategies

• Tackle health & well-being inequality priorities through specific programmes • Promote healthy behaviours for all through working in partnership to embed evidence based programmes

Accidents • Reduce emergency hospital admissions caused by unintentional and deliberate injuries to children and young people per 10,000 people (aged 0-17) by 2% in 2010/11

Alcohol • Reduce the rate of hospital admissions per 100,000 for alcohol related harm to the baseline of 1082 set in 2006-07

Obesity • Halt the increase in the number of Reception aged children who are obese from a baseline of 9.6% • Halt the increase in the number of Year 6 aged children who are obese from a baseline of 16.7% • Halt the increase in the number of adults aged 16 and over who are obese from a baseline of 18% • Increase the total number of people aged 16 and over on GP register, with a BMI recorded in the last 15 months

Smoking • Increase 4 week smoking quitters among people aged 16 or over to 707 per 100,000 population by 2010/11 • Reduce prevalence of smoking in routine and manual groups aged 16 and over to 17% by 2015

Vital Signs

Vital Signs/WCC/L AA Local

LAA Local target

Vital Signs

LAA Local Target/WCC

LAA Local target

Infant Mortality • Reduce the number of women of child bearing age who are hazardous drinkers to 27% by the end of 2011, from a baseline of 29% in 2008. • Reduce the % of women known to be smoking at birth in Dewsbury and Batley to 18% by 2010/11 • 85% of pregnant women have had a health and social needs assessment by 12 weeks and 6 days • Starting with children under one year, by 2010 to reduce by at least 10% the gap in mortality between the routine and manual group and the population as a whole

Choosing Health

The Choosing Health in Kirklees (CHIK) programme will:

Source

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives

The partnership health inequalities programme

Quality Improvement will support service redesign and patient experience

Commissioning strategies for Children and Young People, Maternity, Drugs / Alcohol and Mental Health

Care Closer to Home

Long Term Conditions Strategy

Linking themes / dependencies

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Programme Objectives

Key Actions • Delivering effective targeted action to support behaviour change using social marketing where feasible. This involves the target groups in the design and delivery of actions to improve their health • Industrialise motivation and support to encourage vulnerable groups to change their behaviours, including roll out of training in brief interventions across key front line services • Promote accurate and consistent information about healthy behaviours using effective methods to target groups and front line staff • Promote expansion of physical and social environment to support healthy behaviours

Better health at work • Reduction in those moving from employment to claiming incapacity benefit to 0.7% by 2011.

Sexual health • Reduce the under-18 conception rate to 24.3 per 1,000 females aged 15– 17 in 2010 • Increase to 35% of the resident population aged 15-24 accepting a test / screen for Chlamydia by 2011 • 100% Guaranteed access to a genito-urinary medicine clinic within 48 hours of contacting the service

Food and nutrition • Increase the infants breastfed at 6-8 weeks to 47% by 2010 and 51% by 2011 • Increase the take up of Healthy Start supplements to 6100 for children aged under 4: to 2669 for mothers of children aged under 4. • Reduce the number of children with higher than average dmft by locality to the Kirklees average by 2013.

Vital Signs

Physical activity • Reduce the % of adults who are sedentary by 2011 to 15% aged 18-64 on low income, 24% for those aged over 65, 14% for adults with long term conditions • Increase children’s levels of recommended physical activity to 64% by 2011.

LAA

Vital sign

Vital Signs/LAA

Local

Vital Signs

LAA

Source

Key Outcome measures (inc. WCC outcomes) and outputs

Linking themes / dependencies

Programme Objectives

• Workforce development of public health skills e.g. outcome focussed, evidenced based, interdependencies to a wide range of other programmes within relevant and defined staff groups across the partnership • Commission appropriate and accessible services to deliver equitable outcomes • Ensure choosing health outcomes are embedded into all relevant PCT and Local Authority commissioned programmes • Challenge all the programmes/services tackling the factors affecting health to ensure they are targeting those with most to gain with effective interventions wherever possible • Improve strategic co-ordination of the wide range of interventions aiming to support behaviour change across specific populations with the greatest need, in defined settings e.g. workplaces, education and communities

Key Outcome measures (inc. WCC outcomes) and outputs

Source

Linking themes / dependencies

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

• Ensure infection prevention and control central to the delivery of safe cost effective health care.

• Provide suitable and sufficient information to patients and the public

• Embed the effective prevention and control of HCAIs into everyday practice and applied consistently by everyone

• Achieve full compliance with the H&SCA 2008 registration with care quality commission.

• All NHS Kirklees employees will attend mandatory training

• Adhere to appropriate policies and protocols for the prevention and control of HCAIs

Key Actions: • Create a safe environment for service users, visitors and health care workers • Promote best practice through a programme of education and audit to reduce HCAIs. • Support health care workers who are delivering services to individuals by providing them with a clear framework for managing infection prevention and control • Reducing HCAIs part of legislative framework • Effective root cause analysis investigation to minimise and manage HCAIs • 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 HCAIs. Minimising HCAIs is embedded in the governance systems of the organisation to strengthen responsibility for HCAIs. • Communicating with service users and the public about HCAIs in the health economy and to ensure the information meets the needs of the local population • 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 understand their role in preventing infections • Ensure that infection prevention is an integral part of delivering care • Change behaviour through consistent leadership at every level and ensure accountability for infection prevention and control is explicit. Local

Healthy Ambitions

Vital Signs

LAA

NHS Plan

• Reduce Clostridium difficile infections by at least 30% in 2010/11 compared to a 2007/08 baseline. • annual reduction in MRSA cases to 2012-13 based on the median and best quartile rate of the 12-month period October to September of the preceding year.

Infection control We will:

• Reduce the number of avoidable HCAIs to zero across Kirklees.

Source

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives

Quality Improvement will support service redesign and patient experience

Primary Care will support improved choice options and enhanced services in primary care

Community Hospitals Programme will deliver Care Closer to Home

Linking themes / dependencies

People with a long term condition will be supported to be independent and in control of their condition and can make informed decisions to manage their self-care needs.

People with LTCs will receive high quality personalised care which offers increased choice and services commissioned to meet the needs as determined by the individual

People with LTCs will not be inappropriately reliant on secondary care services for their care and management as there will be adequately responsive services available in a primary, community or home environment

Local Indicators • People with LTC supported from 54% to 85% by 2014. (World Class Commissioning, metric number 54) • Increase the number of patients with CHD in whom the last BP reading was 150/90 or less in the past 15 months from 52% to 90% by 2014 • (World Class Commissioning, metric number.) • Reduction of 35% in unplanned hospital admissions for ambulatory conditions from 08/09 baseline by 2014 • Reduction of 35% in emergency bed days for ambulatory conditions from 08/09 baseline by 2014 • All patients with LTC will have a personalised care plan by April 2010

Local

NHS Plan

Vital Signs

Healthy Ambitions

LAA

WCC

National Indicators • Rates of hospital admissions for the 19 Ambulatory care sensitive conditions per 100,000 (VSC21) • Proportion of people with LTC supported to be independent and in control of their condition (VSC11, LAA, N1124) • Proportion of people who have a high risk TIA who are assessed and treated within 24hours (VSA 14) • Proportion of people who spend at least 90% of their time on a stroke unit (VSA 14) • Percentage of patients with confirmed stroke who are admitted directly (within 4 hrs of arrival at hospital) to a hyperacute stroke service, from Emergency Department, Ambulance or Community (CQUIN) • Percentage of patients with indications for immediate brain imaging receiving this within 1 hour of presentation at hospital (CQUIN) • Number of people aged between 40-75 years who are offered a NHS health check (VS Tier 3) • Proportion of people with diabetes who have HbA1c less than 7.5% (VS) • Number of Community Matrons and LTC Case Managers (VS)

Long Term Conditions & Intermediate care

People with Long Term Conditions will receive high quality, effective and integrated seamless health and social care which includes care at end of life

Source

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives

Primary Care will support delivery of practice based services

Care Closer to Home will deliver locally based LTC services

Medicines Management will deliver community based services for those with an LTC

Choosing Health programmes will address health inequalities and behaviours eg; smoking, diet and lifestyle

Quality Improvement will support service redesign and patient experience

Linking themes / dependencies

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Key LTC programme outputs: • Commission and implement a risk stratification tool to identify people with LTCs • Development/implementation of a generic care and a self care pathways for LTC • Implementation of intermediate care and falls pathway. • Implement single point of access for health/social care services • Improve our approach to LTC and introduce new pathways of care for service users with a sensory impairment • Develop specialist LTC pathways in line with the standards set out in NSFs, concentrating on bringing care closer to home and developing hospital services that offer rapid access to assessment, diagnostics and treatment. • Address any health inequalities which will require a focus on improving services in those areas where choice is limited and/or traditional services are having little or no impact • Work with localities to commission services that are appropriate to individual communities matching approach to need and improving access • All commissioned LTC services will demonstrate high levels of patient reported satisfaction and outcomes measures and professionals can advise people how to access support networks and participate in planning, development and evaluation of services. • To ensure practitioners can easily access a wide range of resources and support to facilitate self-care approaches (that is wider than NHS alone) • Engage with professional groups and support awareness, training and development of self-care skills. • Commission appropriate self-care skills training for health and social care professionals. • Develop resources to inform professionals and patients about self-care options in Kirklees through the development of self-care toolkits. • Market and promote self-care opportunities to public and professionals to increase referral and uptake of self-care options. • Support the health trainer service to access training, resources and support to enable them to provide consistent advice and information to their clients. • Commission self-management courses for patients that are part of service redesigns for long term conditions via HITs. • Ensure professionals and public can access self-care information via the public health resource centre and library services.

People with LTCs will be provided with the care they require by a workforce that has the capability and capacity to be effectively responsive to the needs of people with LTCs and can communicate effectively to enable individuals to identify their needs and develop and gain confidence in selfcare.

People can access appropriate information resources, assistive technology and a range of other self care resources which will facilitate and support self care.

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives Source

Linking themes / dependencies

• To provide an innovative exemplar of intermediate tier services to meet patient need through a cohesive and timely range of provisions.

• To develop and maintain the single point of access

• Provision of seamless services for patients requiring intermediate care

• Work in reducing hospital length of stay for patients requiring transfer to IC services

• Data streams to be clarified and simplified in order to inform quarterly monitoring meetings with providers, NHS Contracting and Clinical Development and Innovation. This will include Patient Reported Outcome Measures (including quality of life) and Patient Reported Experience Measures (PREMs)

Single point of contact across Kirklees for all intermediate tier services to be maintained and developed in response to patient need.

Working together with our health and social care providers we aim to agree service specifications for: • Intermediate care teams (including rapid response function) • Intermediate care residential bed bases • Single point of contact • Community hospital bed base.

High Quality Care for All

Intermediate care – Halfway Home (DoH 2009)

Our aims are to: • Provide community based care which will promote independent living through effective treatment and /or rehabilitation. This pathway is for those people who do not require acute hospital care of long term care. • Prevent unnecessary acute hospital admission or premature admission into long term care. (see LTC target – reduction of 35%) • Support timely and effective discharge for people to where their care needs can best be met, preventing delayed discharges from secondary care.

Intermediate care services

• Emphasis upon the right care in the right place

Source

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives

Personalisation agenda

Continuing Care and End of Life Care

Quality Improvement and Nice Guidance to support service redesign

Primary care development in relation to services to Care Homes

Choosing Health Programmes for physical activity, food, accidents etc.

Mental Health programme will deliver increased quality of care for the population

LTC programme will deliver increased quality of care

Delayed hospital discharge

Linking themes / dependencies

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

1) Dementia Strategy Working with colleagues from mental health and older people services across Kirklees to implement the Kirklees Dementia Strategy

• To develop implement the dementia strategy. • Older People with dementia will receive high quality, effective and integrated seamless health and social care which includes care at end of life • To develop a falls and bone health strategy • Services will be provided to prevent older persons admission to hospital, where these can be avoided • Seamless services will be provided, ensuring patient choice and personalisation • To reduce length of stay for the older person, by effectively and efficiently using intermediate care and independent service providers • To provide a seamless falls and bone health pathway, thereby reducing admissions to hospital through falls and fractures. • Support care homes in providing high quality services and preventing the need for admission to hospital • Emphasise the promotion of independence and protection of older people within communities.

• To implement case finding for bone health and primary / secondary prevention (75% of patients to receive primary / secondary prevention) • Develop a care pathway incorporating primary prevention, falls assessments, fracture care and secondary prevention • Provide support to care homes in relation to preventing falls and reducing hospital admissions related to falls by >5% • Reduce hospital admissions due to fractures by > 10% • Develop self-help models for older people to promote bone health and client independence • Reduce hospital length of staff for #NOF to <19 days • % #NOF re-admissions < 7% • % discharged to usual place of residence >53%

2) Falls and Bone Health Strategy Develop a local strategy and staged implementation plan to co-ordinate work across the health and social care economy relating to falls prevention, response to falls, self-care, pain management and to facilitate the development of common pathways of care for local use.

Improving public and professional awareness of dementia Access to information and support for all Early intervention and diagnosis of dementia Improved quality of care for dementia patients in hospital Prevention of hospital admission for people with dementia. To develop and maintain champion workers for people with dementia Implementing the new deal for Carers Development of peer support and learning networks Living well with dementia in care homes To increase number of people returning to their own home to >40% To reduce number of extended bed days for people with dementia Improved end of life care for dementia sufferers Developing an informed and knowledgeable workforce

Older People Strategic Priorities

Older People

• • • • • • • • • • • • •

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives

Local

Healthy Ambitions

Vital Signs

Next Stage Review

NHS Operating Framework

High Quality Care for All

Payment by Results

National Dementia Strategy

Intermediate care – Halfway Home (DoH 2009)

NSF Older people

Source

Personalisation agenda

Continuing and End of Life Care

Quality Improvement and Nice Guidance to support service redesign

Primary care development in relation to services to Care Homes

Choosing Health Programmes for physical activity

Mental Health programme will deliver increased quality of care for older people

LTC programme will deliver increased quality of care for older people

Linking themes / dependencies

Programme Objectives

Working closely with commissioning colleagues, clinicians, service providers and colleagues from contracting, finance, performance and information, we will measure the outcomes of our collaboration and report on progress via Vital Signs, Perform and Performance Accelerator.

Working with care home commissioners and providers: • Support development of best practice within care homes • Reduce acute Trust activity from care homes by >5% • Review LES services and make changes to improve service provision to residents

3) Acute Hospital Care and Long-term Care Working with commissioners, providers and other key stakeholders to: • reduce avoidable hospital admissions by 35% • reduce excess bed days by > 20% • Reduce re-admissions within 28 days • Increase number of people returning to usual place of residence >40% • optimising use of intermediate care provisions • develop the market for respite care provision • look at developing innovative provisions for interim care • promote self-care and independence.

Key Outcome measures (inc. WCC outcomes) and outputs

Source

Linking themes / dependencies

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Jointly commission a substance misuse service to meet the identified needs of young people.

Commission services to meet the needs of children and young people who have a disability, complex health needs, life limiting conditions, palliative care needs, those in transition.

Improve psychological well being and mental health of children and young people.

Implement the Teenage Pregnancy Strategy and NST Action Plan to reduce unwanted/unplanned teenage pregnancies.

Ensure delivery of FNP programme and develop a sustainability strategy.

Review the acutely ill child pathway and re-commission services

Commission the Healthy Child Programme

Key Actions: • Ensure all commissioned services work in line with the statutory framework as reflected in Working Together to Safeguard Children. • Ensure all service specifications include safeguarding responsibilities and performance indicators are monitored • Implement the agreed service model and specifications for health visiting, health in schools and midwifery and ensure effective delivery and integration with all stakeholders • Establish effective monitoring systems and ensure evaluation against outcomes. • Following discussion and agreement with practice based commissioners develop a project plan to review the acutely ill care pathway to ensure services are commissioned that are in the right place at the right time on an integrated pathway to meet the needs of children, young people and their parents and carers. • To ensure A&E attendances are appropriate and unplanned hospital admissions are reduced to average benchmark levels as identified through our “family of PCTs” • Effectively monitor the programme and maintain Programme Management approach over time period of project. • Develop a sustainability strategy subject to the satisfactory evaluation against the agreed licence standards • Review and implement the revised joint commissioning arrangements for teenage pregnancy across the partnership. • Develop and implement the Action Plan following the NST visit to agreed timescales that will be performance managed by the Joint Commissioning Executive. • To implement the Joint Commissioning Plan for the Psychological Well Being and Mental Health Strategy.

• Reduce percentage of obese children in year 6 to plateau at 17% by 2011. • Baseline for emotional health of children to be established through national Tellus Survey in Summer 2008 69.8% with targets for 09/10 72.1% and 10/11 74.3% • Reduce the percentage of 16 to 18 year olds who are not in education, employment or training (NEET) from 7.9% (08/09) to 6.5% (10/11) • Reduce the under 18 conception rate to 24.3 by 2011

Children and Young People

Ensure Safeguarding is at the core of all services commissioned and provided

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives

Local

Vital Signs

Healthy Ambitions

WCC / LAA

WCC

Source

Every Child Matters

Kirklees Children & Young People Plan

Choosing Health Sexual Health programme will target teenage conceptions

Primary care programme will deliver family based services in areas of highest need

Choosing Health programmes will support healthy behaviours eg obesity and sexual health especially in education settings Healthy Lives, Brighter Futures Choosing Health Obesity strategy

NICE Guidance

Working Together 2006

Children Act 2004

Improved quality of patient experience

Linking themes / dependencies

• To commission an integrated, high quality multi-disciplinary pathways for ADHD, ASD, LD/CAMHS, TaMHS to ensure effective assessment, treatment and support for children, young people and their families. • To ensure age appropriate provision is in place for all children and young people who require hospital admission • Jointly review complex cases and out of area placements to ensure effective commissioning of local service to meet the needs of children and young people with complex health needs, life limiting conditions and palliative care needs. • To implement the National Continuing Care Guidance for Children and Young People. • To ensure transition planning is included in all service specifications and contracts and that this is actively managed. • Develop and agree a service model for substance misuse services following consultation with young people. • Develop the options for aligning/pooling of resources. • Procure the service model to the agreed service specification involving young people in the tender evaluation process. • Performance manage the implementation of the new service following the tender process. • Ensure through the developing Carers Strategy the needs of young carers are identified and services are commissioned to meet their needs. • Work with children and young people and schools to inform the strategy and identify unmet needs across the Children’s Trust. • Ensure that children and young people are fully involved in the development of the Healthy Schools Enhancement and influence its development and commissioning of services. • Through the joint commissioning unit develop a framework to support schools in their commissioning role to achieve the healthy schools enhancement and improve the outcomes for children and young people.

Ensure the needs of young carers are identified in the developing Carers Strategy.

Healthy Pregnancy and Maternity

Infant mortality

Sexual health

Food

Obesity

Long term conditions, asthma, diabetes, epilepsy

Ensure integration with PCT programmes for:

Work jointly with young people, schools and the local authority to develop the Kirklees model for the Healthy Schools Enhancement.

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives Source

Carers Strategy

Breastfeeding Strategy Statutory Guidance for Children’s Trusts

Children’s National Service Framework

Aiming High for Disabled Children

Linking themes / dependencies

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Safeguarding Children, young people and vulnerable adults

Programme Objectives

Key outcome and Measure Ensure practice reflects statutory safeguarding responsibilities

Programme Objectives To safeguard and promote the welfare of children/Vulnerable Adults

Delivering quality services by increasing innovation and productivity within a whole care pathway approach, from prevention to rehabilitation, has always been central to World Class Commissioning assurances. NHS Kirklees is committed to safeguarding children and vulnerable adults and will continue to work collaboratively with partners to further develop robust, quality and safe services in order to improve outcomes for these vulnerable groups, by ensuring safeguarding remains central to all services commissioned and provided.

Within the current climate safeguarding children and vulnerable adults brings new challenges for all those commissioning and providing services.

Key Outcome measures (inc. WCC outcomes) and outputs

Source

Linking themes / dependencies

Develop effective partnerships to deliver collaborative advantage and benefit to service users and wider communities

Quality to be enshrined in the commissioning process via service restructuring and enhanced clinical leadership

Improved access to, and successful discharge from drug, alcohol and offender health services

Development of a person centred approach that improves user, family and community, wellbeing and social inclusion

Key Actions: • Commission services that are increasingly personalised and responsive to individual needs including recovery, re-integration and harm reduction • Develop more pathways in and out of treatment, including offering a wider range of primary care services and better access to mental health, family interventions, housing and employment • Develop a preventative approach based on overall service user well-being, including improved access to harm reduction services, blood borne virus services and counselling services.

• Number of service users in shared care increases from 200 (08/09) to 350 (2011/12) • Number of service users accessing individual budgets and direct payments increases from 5 (08/09) to 50 (2011/12) • Number of practices delivering Screening and Brief Interventions increases to 80% • Reduce the number of hospital admissions to 1191 per 100,000 population • Reduce hazardous and harmful drinking in Batley, Birstall and Mirfield to the Kirklees average (31%)

• NTA 2008/09: 85% of service users in effective treatment o 2009/10:87% o 2010/11:88% o 2011/12:89% o 2012/13:90%

• Number of service users in effective treatment increases from baseline: o 2008/09: 3% (1507 people) o 2009/10: 2% (1537) o 2010/11: 2% (1568)

LAA

Darzi and personalisation agenda Putting People First (Social Care improvement agenda)

KMC Adult Social Care

WCC/Vital Signs/LAA

Local Area Agreement Plus Offender Management Agenda

Choosing health supports behaviour change

LAA – Choosing Health/Offender Health strategy/Darzi

Linking themes / dependencies

NTA

Vital Signs/NTA

Vital Signs/ National Treatment Agency/LAA

LAA – National Drug Treatment Monitoring System

• Increase numbers in alcohol treatment and successful completion rates o 2008/09: 450 people treated, 60% successful completion o 2009/10: 960 (65%) o 2010/11: 1200 (70%) o 2011/12: 1300 (75%)

Drugs and alcohol

Improve both the numbers of people treated and the personal and community outcomes for people in drug and alcohol services

Source

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Key Actions: During 2009/10 the PCT has commissioned new service developments, including: • Learning Disability Health Action Plans • Vulnerable In-Patient card (VIP) • Specialist Respite services • Enhanced Primary Care services • New Low secure service provision • The PCT intends to pursue / consolidate specialist learning disability pathway redesign. • To increase improved access to appropriate primary care health care & acute services through planned programme management.

Local

Healthy Ambitions

Vital Signs

LAA

• Baseline mapping of primary and specialist care completed against all national recommendations • Increase number of practices with agreed LD registers to 82.6% - March 09 to 93.3% - March 10 – to 98% - March 11 • Increase number of patients on LD registers who meet agreed diagnostic criteria 632 - March 09 1332 - March 10 – & increased to 1592 – March 11 • 100% will be in receipt of HAPs / VIP cards • Number of agreed patients receiving annual health checks will be maintained at 76% of the total registered 480 - March 09 1013 - March 10 & increased 80% of the total registered – March 11

Learning Disabilities

• 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. • To improve access to healthcare and provide effective support for families and carers through meaningful involvement.

Source

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives

Care Closer to Home will deliver locally based services

Quality Improvement will support service redesign and patient experience

Linking themes / dependencies

• Community service for Adults with Deficit and Hyperactivity Disorder (ADHD); • Community Eating Disorder service; • Primary Care mental health service (IAPT)

Key Actions: During 2009/10 the PCT has consolidated the new, mental health services commissioned during 2008/09 and has further developed a number of these by progressing these to ‘ageless’ needs appropriate services. Additionally the PCT has commissioned a number of new service developments, including:

Local

NHS Plan

Vital Signs

Healthy Ambitions

Vital Signs

• Identify 26 new cases of Psychosis per quarter and to achieve the required PCT share of the national trajectory of 192 new cases by Dec 09 • There after 192 new cases will be identified and supported by the service on a 3 year rolling average • Implementation of IAPT service: 3342 new referrals seen by end March 2010 and 5013 seen by end March 2011 • In line with agreed protocol & criteria – achieve a statistically significant reduction in the number of individuals under sc 136 detained within police cells by end 2009/10 • That use of police cells for individuals aged 14 upwards, detained under Sc136 will be the exeption as per new specification • Reduce the requirement for OoA placements for eating disorders and adult ADHD through commissioning redesigned pathways • Baseline of 45 learning disabled young adults require transition into adult service • Agreed Psychological therapy waiting list backlog will be cleared by the end financial year 09/10 • Agreed access standards set within national best practice, develop an agreed demand and capacity modeling tool by Sept 09 • Provide routine practice level reports from qtr 3 09/10 • To increase the number of adults in contact with mental health services and employed by 1.25% 09/10 and 2.6% 10/11

Mental Health

• Emphasis on the promotion of independence and protection of vulnerable people. • Work on reducing reliance on institutional care • Emphasis on prevention and wellbeing. • Changes in directly provided services along with work to grow the voluntary and ind sector. • Develop and maintain sustainable communities to support and address social exclusion. • Development of need appropriate/ageless services across 3rd sector. • To develop a wide range of services that deliver care for individuals as close to home as possible • To engage in closer partnership working, rooted in the local communities we serve based on a principle of co-operation and collaboration with partner agencies

Source

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives

Care Closer to Home will deliver locally based services

Quality Improvement will support service redesign and patient experience

Choosing Health will deliver targeted programmes in a range of settings aimed at improved lifestyle choices through leisure, sports and recreation as well as issues affecting patients with MH problems, such as smoking and diet

Primary Care programme will build support

LTC programme will deliver increased quality of care for older people including those suffering from dementia

Linking themes / dependencies

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Programme Objectives

â&#x20AC;˘ Ensure existing robust commissioning and contracting relationships are maintained with providers, influence the mental health market through enhancing relationships.

The PCT will engage in close partnership working, rooted in the local communities we serve. This will be based on a principle of co-operation and collaboration with partner agencies and local communities, leading to not only improvements in direct care and treatment, but also broader community benefit, for both the service user and the public at large.

Key Outcome measures (inc. WCC outcomes) and outputs

Source

Linking themes / dependencies

• Integrate a new “Access and Assessment” service for WY that will provide consistent information for our service users and a central point for their urgent care needs to be addressed;

• Ensure that high quality standards of care are delivered;

• Ensure that urgent care services are integrated and of high quality;

Key Actions: • We will develop a full and comprehensive programme for urgent care that will deliver improvement over the next 3 – 5 years. • Urgent care centres will be developed on or be ‘virtual’ with, our main A&E sites to provide a breadth of high quality and timely access for service users as outlined in Healthy Ambitions. • We will integrate the Walk in Centre with the A&E service at Dewsbury hospital • We will improve performance in urgent care centres by working closely with our acute providers at MYHT and CHFT. • We will expect our intermediate care teams to work with and visit the main hospital sites to ensure that discharge is timely, delays are minimised and patients are directed to community services where appropriate. • We will have integrated primary care streaming services in our A&E departments • We will achieve a marked improvement in our YAS performance through joint action planning. • Services that deliver urgent care will be fully integrated. This includes OoHs services, A&E departments and ambulance services. These services will also work in tandem with GPs, secondary care and social care services. • We will performance and contract manage our urgent care service providers ensuring best value and efficiency. • We will continue to work with our communities and partners to improve the quality and accessibility of urgent care services and reduce inequalities of care by continued social marketing and seeking feedback about our services. Local

Healthy Ambitions

Vital Signs

Next Stage Review

NHS Plan

• Achieve and maintain 98% A&E 4hr wait standard. • Reduce A&E minor injury and illness attendance by 10% in 2010/11 (by using streaming and other alternative to A&E services as appropriate) • Deliver the outcomes of NHS NSR for Acute Care

Urgent Care

• Develop an Urgent Care Strategy which sets out a proposed vision and how that will be achieved over the lifetime of the Strategic Plan

Source

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives

Quality Improvement will support service redesign and patient experience

Primary Care will support improved choice options and enhanced services in primary care

Health Care Commission Urgent Care Review 2008

Linking themes / dependencies

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Infant mortality Indicator: Starting with children under one year, by 2010 to reduce by at least 10% the gap in mortality between the routine and manual group and the population as a whole (national target).

• Place women and families at the centre of their pregnancy journey by listening and supporting them to identify and address their needs

• Ensure that all services engaging with women and families promote and support breastfeeding

• Ensure that services are configured and organised to provide choices for women and families for accessing maternity care, type of ante- and post-natal care they receive and place of birth.

• Develop and implement Care Pathways for pregnancy, addressing complex needs through a multi-agency response

• Ensure women have access to effective support to make sustainable lifestyle changes

Key Actions: • Mainstream learning and effective practice from the Family Nurse Partnership Programme. • Disseminate learning from the peer led “salon” approach in Dewsbury to encourage more opportunities for women to support each other through peer groups in a range of settings familiar and comfortable to them. • Implement the Healthy Pregnancy and Maternity Services Strategy to deliver better health outcomes for women and families, particularly for the most vulnerable families, through effective performance management of the Service Specification • Develop a service specification for family support to work alongside maternity services and peer groups to support women and their families to identify and address the range of social care needs for their family. • Establish effective user-led Maternity Services Liaison Committees for Kirklees. • Develop effective approaches to involvement of women and families in improving service delivery.

Trajectory of Breastfeeding Coverage3 Rate at 6-8 weeks 09/10 – 90% 10/11 – 95%

Trajectory for Breastfeeding Prevalence2 Rate at 6-8 weeks: 09/10 – 47.5% 10/11 - 51%

Breastfeeding Indicators: Increase the % of women initiating breastfeeding at the birth of their baby. Increase the % of mothers breastfeeding on discharge from midwifery services. Increase the % of infants breastfed at six to eight weeks.

Maternity Indicator: Increase the % of women in the relevant PCT population who have seen a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks and choices by 12 weeks and 6 days of pregnancy Target: 09/10 = 85% 10/11 = 90%

Healthy Pregnancy and Maternity

• Ensure safeguarding is effectively prioritised throughout the pregnancy care system

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives

Local

Healthy Ambitions

Vital Signs

LAA

NHS Plan

Source

Quality Improvement will support service redesign and patient experience

Primary Care will support improved choice options and enhanced services in primary care

Community Hospitals Programme will deliver Care Closer to Home

Linking themes / dependencies

Programme Objectives

• Develop ways to improve access to appropriate genetic awareness information, particularly around autosomal recessive inheritance so that informed choices can be made • Implement the Breastfeeding Strategy for Kirklees and support community-based children and family services to promote breastfeeding. • Work towards Baby Friendly Initiative accreditation for community health services.

Key Outcome measures (inc. WCC outcomes) and outputs

Source

Linking themes / dependencies

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Planned Care: • Redesign pathways to better manage demand and deliver care in the appropriate setting • Reduce the reliance of hospital based services • Capacity and demand planning • Commission capacity to achieve standard • Monitor and react to stretch targets.

Cancer / Palliative Care: • Develop a local Cancer Strategy based on the needs of the local population, incorporating the recommendations of the Cancer Reform Strategy • Commence the National Bowel Cancer Screening Programme • Implement improved breast cancer screening • Monitor Cancer Waiting Times to ensure we are meeting local needs and targets • Develop local Skin Cancer Services • Monitor, review and link with Community End of Life Services to be developed through the recruitment of a facilitator to reduce hospital admissions and improve EOL care in the home. • Develop programmes of education and training.

Further development and enhancement of community based services for people suffering from musculoskeletal conditions means that service users have greater choice of provider and that care is delivered closer to home.

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 conditions. Individuals and their families will be at the core of how care is commissioned and delivered.

Key Actions:

• Delivering the NHS NSR targets for Planned Care • A two-week maximum wait from urgent GP referral to first outpatient appointment for all urgent suspected cancer referrals; • A maximum waiting time of one month from diagnosis to treatment for all cancers; • A maximum waiting time of two months from urgent referral to treatment for all cancers; • Increase choice of provider, setting and treatment options

Planned care including Cancer and Palliative Care

We have commissioned services and worked with providers to ensure that the 18 week standard is achieved. Continued joint work with our secondary care providers needs to continue to ensure sustainability of the 18 week standard in all speciality areas.

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives

Local

Vital Signs

Liverpool Pathway

End of Life Gold Standards Framework

Delivering Healthy Ambitions

Local Area Agreement

Joint Strategic Needs Assessment

Primary Care – to improve rapid referral rates and screening

Planned Care programme – delivery of the 18 week target

Quality Improvement – patient experience

WCC

The Cancer Reform Strategy

Choosing Health will improve healthy behaviour including tobacco (WCC Outcome and LAA target)

Linking themes / dependencies

NHS Next Stage Review

Source

Maximise health benefits through personalised medicines management

Ensure that access to community pharmacy is equitable according to need particularly in deprived areas

Provide greater choice and access to optometry, delivering care closer to home and reducing referrals to secondary care

Ensure that access to primary dental care is improved

Improved primary care premises in identified areas

To achieve average list size of 1750 Greater choice and accessibility for patients

Key Actions: • Establish primary care quality benchmarking tool • Identify practices and localities with highest list size and agree commissioning plans to address. • Creation of a balanced scorecard approach to quality in primary care • Continue to review the extended hours offered by practices to ensure they reflect service user’s preferences as reflected in surveys. • Review and strengthen access to dental care • Commission a community based cataracts assessment and referral service • Commission a Primary Eyecare and Referral Service (PEARS) • Ensure that access to community pharmacy is equitable according to need, particularly in deprived areas, ensuring that services users have choice and an assured quality service • Promote the use of community pharmacies as healthy living centres, providing extended services such as minor ailments schemes, long term conditions management and involved in screening and monitoring of conditions such as heart disease and hypertension. • Review and strengthen existing arrangements for commissioning medicines, including High Cost drugs, non NIHCE/ Non Tariff drugs through the use of WCC competencies and frameworks.

Local

Vital Signs

WCC

Delivering Healthy Ambitions

NHS Plan

• Achieve average list size of 1750 by 2013 • An increase in the number of training practices from our current baseline of 11 by 2013 • Commission a new primary care out of hours service from April 2009 • Increasing the number of children receiving immunisations in line with national guidance • Increase primary dental care capacity within the Kirklees area so that by 2011 anyone who needs to see a dentist will be able to do so

Primary Care

Improved quality of primary medical care by reducing variations across Kirklees

Source

Key Outcome measures (inc. WCC outcomes) and outputs

Programme Objectives

Choosing health will improve health behaviours and requires input from primary care to access those most at risk

New Out of Hours service will ensure continuous 24/7 care improving quality and access

Quality Improvement will support service redesign and patient experience

Primary Care will support improved choice options and enhanced services in primary care

Community Hospitals Programme will deliver Care Closer to Home

Linking themes / dependencies

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Appendix 2

NHS Kirklees Workforce Planning Strategy Workforce Planning in Partnership As leader of the local NHS, we hold a system-wide overview of the workforce implications of our commissioning strategies and workforce-related risks to their delivery. Whilst Providers are responsible for the design and delivery of their own workforce plans, where risks are identified, we have a role in working with relevant partners to ensure that they are comprehensively addressed. Our successful health economy workforce risk assessment workshops will continue in 2010 and beyond as we continue to forge and maintain our strong partnerships with Providers and partners, including Kirklees Council. Such partnerships have already enabled us to work collaboratively on key workforce issues, including: • Health economy compliance with the European Working Time Directive • Major PCT-led workforce planning project across NHS Kirklees, Kirklees Council and Acute Trusts to develop a joint workforce to support the Kirklees Under 5s population • Development of skills for staff from all healthcare sectors and organisations providing services in the community • The introduction of a new Apprenticeship scheme in support of local employment opportunities and succession planning across the health economy Workforce elements, for example EWTD compliance, already feature in our regular

contract performance meetings with our main providers. We seek to develop this with the inclusion of further workforce metrics for the performance monitoring of Providers in 2010 and beyond.

Delivering the NHS Staff Pledges We work hard to ensure that our own, directly-employed workforce is motivated, developed and shaped to perform at its optimum level. Central to this is our HR Strategy. Our delivery to our staff of the four Pledges from the NHS Constitution forms a key element of the HR Strategy, and will enable us to achieve and maintain Employer of Choice status. In support of the Pledges we are continuing to build on the excellent work already carried out, for example in relation to the quality and takeup of appraisals; as well as the introduction of robust Leadership Frameworks for both the Provider and Commissioner functions. In 2009 NHS Kirklees was awarded Investors on People (IIP) status. Our IIP Assessment reported that staff identified a high level of staff engagement and involvement as well as a commitment to service improvement A Staff Survey return rate of 69.2% in 2009, combined with well-attended staff engagement & feedback events around major changes such as Transforming Community Services and the move to a brand new NHS Kirklees HQ building points to the level of involvement that we are pleased to offer our staff. The introduction of the “Kirklees Way” programme, which is an externally facilitated development programme focussing on commissioning and service development, will help to ensure that our

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

staff are best-placed to deliver World Class Commissioning for the people of Kirklees.

considerations are central to their planning and delivery within the organisation.

Motivated, skilled staff are well placed to respond flexibly to the challenging and stimulating healthcare environment. This has been effectively demonstrated during 2009 and early 2010 through our workforceâ&#x20AC;&#x2122;s swift and effective response to the Swine Flu pandemic. We are confident that our staff will continue to demonstrate similar innovation and flexibility in their response to future challenges.

Workforce Planning & Information Capability We continue to develop our internal workforce planning capability, particularly in our Provider, Commissioning and HR Directorates, to ensure that workforce planning remains an integrated element of our commissioning and business planning.

Workforce integration with QIPP As a forward thinking organisation, we develop workforce projections for each of our directly-employed staff groups. This enables effective financial planning, and informs regional education commissions.

In addition we continue to develop our capacity for the production of robust workforce information to inform business decisions. The regular NHS Kirklees Workforce Scorecard ensures that key workforce performance and cost statistics are monitored and effectively managed. We are introducing benchmarked statistics to ensure that our workforce runs at the best possible levels of efficiency.

NHS Kirklees recognises workforce planning as a key tool in achieving its QIPP goals of quality, innovation, productivity and prevention. From 2010 â&#x20AC;&#x201C; 2014 we and our main acute care Provider have predicted a workforce trajectory showing no growth in overall staff numbers. We work with all of our main provider organisations to understand and influence their workforce projections. Effective use of existing staff resources and the development and commissioning of innovative, cost-efficient roles and services, will deliver the best possible value for money without compromising the quality of services for our population.

Our engagement with the Strategic Health Authority in its regional Data Quality Programme and workforce planning initiatives will help to ensure that we remain in the vanguard of good practice.

Workforce Planning in Summary We have made excellent progress in the development and integration of workforce planning activity over the past two years. This stands us in good stead for ensuring the healthcare workforce is effectively managed, developed and deployed to the best effect for the people of Kirklees during the next five years.

Local initiatives including the introduction of vacancy control processes are helping us to continue focusing our resources according to our most important priorities. Where programmes of efficiency and service improvement are identified, workforce

Appendix 3

Changes in Technology We will continue to deploy the Connecting for Health (CfH) sponsored solutions. During 2010 we will have completed the deployment of the TPP SystmOne solution to our Provider Services arm, where suitable and appropriate. This will be complimented by the completion of the rollout of mobile devices to our clinical provider services staff. We are upgrading the TPP SystmOne solution across the Local Health community to version 3.01 and 4.01 through out 2010. This will permit appropriate sharing of detailed care records where approved. We will support the implementation of TPP SystmOne into our local Hospice.; we will continue to support the increased use of TPP SystmOne in our main Acute providers, particularly for A&E and therapy services. We will continue to upgrade and refresh the IT equipment in our GP practices and to support their use of an accredited GP Systems of Choice (GPSoC) clinical system. 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 commence. 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 deploy the Electronic Prescribing Service (EPS) to our community pharmacists and have commenced the EPS2 project. 90

In 2010/11 we will commence using Map of Medicine to assist in Pathway design and usage. The required investment level in CfH solutions is estimated to be ÂŁ250,000 per annum over each of the next five years. In support of commissioning, we are expecting to use a data warehouse and presentation tools 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 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 expand the existing pilot telehealth service to increase the support to vulnerable people in their own homes. In this way we will offer real

Ambitions for a Healthy Kirklees Five Year Strategic Plan 2008 - 2013 : Revision March 2009

time access to support for users and carers 24 hours a day. With the completion of the move to our new Headquarters we will also implement a full Voice over IP (VoIP)_ solution across the Commissioner and Provider Services estate.

Appendix 4:

NHS Kirklees Community Pharmacy and Medicines Management Strategy 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. To support and ensure services are targeted to the areas of greatest need, the PCT will develop a Robust Pharmaceutical Needs Assessment linked to the Joint Strategic Health Needs Assessment. This will help to guide what Pharmaceutical services are required in different parts of the PCT, and will facilitate the targeting of resources to gain maximum health benefit for patients. 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

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

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.

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. Medicines constitute approximately 20% of the total NHS budget, it is therefore crucial to ensure the continued promotion of cost effective and evidence based management of medicines by Health and Social Care professionals, patients and carers to maximise the health benefits medicines can provide. The following are a summary of the key areas for development that are documented within the Medicines Management and Non-medical Prescribing Strategies: • Cost –effective use of medicines – with the Significant financial pressures placed upon the NHS in the current financial climate, a major aspect of medicines management will be to ensure that only cost-effective medicines are promoted and used locally. This will improve the efficient use of resources by the PCT, and will assist the PCT in achieving financial stability. • 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 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 non medical 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.

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Appendix 5:

The plan is relevant to all equality strands:

NHS Kirklees 5 year strategic plan: 2010 – 2015 Equality Impact Assessment (EIA) 1. Purpose 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’.

• • • • • •

An EIA can be limited by lack of local data / evidence (or lack of disaggregated data). Data collection is a key consideration, as are organisational efforts to: • Embed quality in the organisation and its contractors; • Involve members of the communities and carers; • Work in partnership (e.g. Local Authority, voluntary, not-for-profit agencies) • Learn and develop (e.g. training, capacity, organisational context)

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 20184. NHS Kirklees strives to design and implement services, policies and measures that meet the diverse needs of our service population and workforce, ensuring that none are placed at a disadvantage over others. This Equality Impact Assessment has been performed to consider the needs of and assess the positive, adverse or neutral impact of our five year Strategic Plan on all groups within our local communities. The purpose of this equality impact assessment is to examine the NHS Kirklees Strategic Plan 2010 – 2015 and assess the actual or potential impact on specific population groups and communities. The Plan is a new strategy focussed on health outcomes and achieving value for money over a 5 year period for the people living in the Kirklees area. It is part of the World Class Commissioning approach to improve healthcare.

Age Disability Ethnicity / race Gender and transgender Religion or belief Sexual orientation

Vision and values

Our vision is:

• Show understanding, dignity and respect for all our clients, partners and staff; and • Be accountable for the decisions we make, the work we do, the resources we use and our impact on the environment.

3. Process The work of NHS Kirklees is driven by a vast array of political, social and economic drivers. This section sets out the significant factors influencing NHS Kirklees today which form a basis for identifying upon the principles which we form our strategic plan and detailed programmes. In order to ensure that the needs of our population are understood, we need to; • have a good understanding of public expectations and political drivers; • have active engagement with local people; and • involve clinical leaders in assessing local needs and shaping priorities. Other key factors which drive our strategic decision making are the national and local priorities, local population demographics and needs as shown in the Joint Strategic Needs Assessment, working with partners, the service provision and the requirements of World Class Commissioning. Our choice of outcomes for world class commissioning reflects these. These, together with our existing priorities, e.g., Vital Signs for the LAA, form the basis of our future performance regime. Various consultation exercises have been undertaken to ascertain feedback on delivery of health services in the Kirklees area. The outputs of these exercises, along with various other metrics associated with

the Plan, have been used to formulate the evidence required to produce this Equality Impact Assessment report.

3. Consultation and 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 these activities include: • Social Marketing approach to help support healthy personal behaviours of women before, during and after birth looking specifically at behaviours relating to Food, Physical Activity, Alcohol and Smoking • Social Marketing approach to halt the rise in obesity on 16-24 year olds • Involvement of local target audience in developing new stop smoking groups and associated marketing materials using a social marketing approach • Involvement of both non service and service users (adults and young people) and clinicians in setting up weight management services for both adults and young people • Alcohol: Developing a social marketing approach to target specific

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

• •

•

• •

•

target audiences grouped according to age, location but also motivation. The overarching behavioural goals will be to: - increase awareness around drinking levels - take people from precontemplation to contemplation Involving people with long term pain in redesigning care Involving young people with ADHD and their parents / carers in redesigning the ADHD pathway this included conducting interviews, discussion groups, questionnaire and establishing two service user reference groups, one for the young people and one for the parents / carers. The regular triennial and biennial surveys of adults and 14 year olds on health and well being Working with groups of people in our localities to develop locality plans Taking a Camper Van to a number of events being held in Kirklees over the summer to film members of the public giving their views on NHS Kirklees Developing a database of members of the public that have expressed an interest in being involved in the work of NHS Kirklees Developing a newsletter to let the public know how they can get involved and what has happened as a result of them being involved Public consultations on major changes to services, e.g., MYSS, Looking to the Future (2005/06 and continuing) Service user surveys – whether organised nationally or locally by ourselves or by providers. We work with practices on a regular basis to 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 Reference groups of service users established for all Long Term Conditions HITs Establishment of a joint Readers’ Panel with Kirklees Council, to ensure that our public information leaflets are easy to read and understand Consultation on the introduction of GP led health centres, this includes members of the public being involved in the selection of the new providers e.g. patient reps have been / are involved in Dewsbury Health Centre, Victoria Medical Practice A diabetes survey to obtain feedback for action on the care and support which local people with diabetes receive LINks; (which replaced the PPI Forums) Specific focussed consultations within communities whether issue or sociodemographic specific; and The local Overview and Scrutiny Committee.

3.1

The Current Living in Kirklees (CLIK) Survey 2008 This survey resulted from joint working between NHS Kirklees and Kirklees Council. The purpose of the survey was to provide real information about health and social inequalities which could be used in the planning of services and programmes of work, and for comparison purposes with the previous Surveys in 2001 and 2005. The survey was a postal questionnaire sent to a random sample of 70,000 addresses, selected from the Kirklees Land and Property Gazetteer. One postal reminder (with another copy of the questionnaire) followed the first mailing to non responding

households. Ipsos MORI North administered the questionnaire dissemination; data entry; and provided a clean dataset, top-line results and preliminary data analysis. This had a 31% response rate in Kirklees, 21000 adults. The results were weighted to be representative of the population of Kirklees. The survey asked about a range of issues. These were chosen because they are known to have significant impact on health and something can be done about them locally. CLIK survey content: • Aspects of health status functioning, using the SF 36 including perceptions of physical and emotional health and pain. • Disability and certain long-term conditions. • Being a carer. • Personal behaviours such as smoking, drinking alcohol, diet, physical activity. • Employment status and income. • Housing quality. • Migration plans, isolation and feelings about local people. • Age, sex, ethnicity, sexual orientation, area of residence to identify groups of people. The survey included instructions that it should be completed by an adult aged 18 or over.

4. Assessment of Impact Taken as a whole, NHS Kirklees’ Five Year Strategic Plan is unlikely to create an adverse impact. If initiatives are successful, it will help reduce health inequalities. The lack of local data on equality target groups provides a significant challenge in terms of addressing specific local issues and showing health improvements for specific

groups of people. While it is recognised that elements of the plan require a targeted approach, regular monitoring will be important to see where the results are occurring. It will also be important to do more work to address barriers which could inhibit access and realisation of the benefits of the Plan for different groups of people. Specific feedback from our consultation with patients, the public and service users, along with ongoing dialogue with other strategic partners, will help provide understanding of barriers so as to find appropriate solutions. However, there is no expectation that any of the quality groups listed will be affected disproportionately. “Choice” is part of the strategic theme to provide more personalised services, which are closer to home and deliver services which are of the highest quality and value for money. All patients, including those from target groups, are expected to have the same opportunities for choice. Where no information is available in the Plan or consultation, it does not mean that an equality target is excluded. It is simply an absence of data.

Realising our Ambition Five Year Strategic Plan 2010 - 2015 : Revision January 2010

Equality Impact Assessment

What is being Equality Impact Assessed? TThe NHS Kirklees Five Year Strategic Plan 2010 - 2015, and associated supporting documents including the NHS Kirklees Operating Plan.

Description of the function being Equality Impact Assessed: To ensure that all elements of our Five Year Strategic Plan, Operating Plan and associated documents meet the principles around Equality and Diversity, specifically around our commissioning strategy and programme areas.

Lead contact person for the Equality Impact Assessment: Samantha J Williamson Head of Programme Management Office NHS Kirklees

Who else is involved in undertaking this Equality Impact Assessment: The Five Year Strategic Plan and Annual Operating Plan is owned by NHS Kirklees Trust Board who therefore will sign off this piece of work and monitor its evaluation and implementation

Sources of information used to identify barriers etc • Individual programme commissioning plans detailing strategic objectives and key outcome measures • Other enabling strategies – e.g. Finance, Organisational Development, Communications and Workforce Planning • Our Joint Strategic Needs Assessment • The Kirklees Local Area Agreement

What does your research tell you about the impact your proposal will have on the following equality groups? BME Groups: Kirklees is comprised of 7 distinct locality areas which enables us to model and focus our strategic planning, embracing cultural diversity where relevant to capture the needs of our population.

In the Batley locality, a larger proportion of that population are of the South Asian origin than in Kirklees as a whole. More than 1 in 5 young people under 19 in Kirklees are now of South Asian origin, whilst overall 86% of the total population are white. The total numbers of births are also increasing amongst families of South Asian origin. Our programme planning therefore represents this particularly where a health issue may be related to ethnic background, for example South Asian people are up to 6 times more likely to have diabetes than White people. Minority ethnic achievement in Kirklees is complex. Overall, students from the largest minority ethnic group, Pakistani origin, performed below the Kirklees average at KS1, 2 and 3. This persisted up to KS4 where students of Pakistani origin were least likely to achieve the 5+ GCSEs at grade A*-C, and therefore programmes of work which encompass children and young people will ensure that these factors are considered. Access to employment, rather than to Higher Education, is the issue for the local Pakistani population, and again this will be a factor in our planning processes.

Disability Groups: Adults with a physical disability: The CLIK survey asked respondents to report any long- term illness, health problem or disability which limited their daily activities or the work they could do, as well as visual and hearing impairment. Further questions asked people about the level of help they needed within the home or outside the home and covered issues such as income, employment and isolation. 27% of adults said they had a long-term illness, health problem or disability which limited their daily activities or work they could do. Overall, 18% of adults were dependent in needing help or support with some form of physical functioning compared to 20% in 2005. Huddersfield South and Dewsbury & Mirfield localities had the most people with needing some form of support at 21%. Adults with a sensory disability Sight impairment 8.7% of adult respondents reported sight impairment. It is important to note that 55% of sight-impaired people declared they had another disability. Income was low with almost 85% of those reporting a sight impairment living in a household with an annual income below ÂŁ30,000. Hearing impairment 14% of adult respondents reported a hearing impairment. Significantly 55% of hearing-impaired people declared they had another disability. Income levels were

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low, with 62% living in a household with an annual income below £30,000, but markedly better than for those with sight impairment or other disabilities. Key themes for action There is a great deal of information about the local picture of disability and impairment, and needing help and support with various daily living tasks. It does not however give a picture of how these people access services, what services are available, or indeed how well the services meet the needs of disabled people. So a comprehensive needs assessment for adults with physical disabilities and sensory impairment is required to understand how opportunities can be improved. This would comprise an analysis of the disabilities experienced along with service evaluation and gap analysis, and direct consultation with disabled people and their carers. Children with a disability The needs of disabled children, young people and their families are unique to them, often complex, and change over time. The challenge is to understand these needs and develop a system around them that is flexible enough to meet the needs of the person and their families. There are many different types of impairment both visible and invisible, e.g. a child paralysed with cerebral palsy has a visible impairment, but children with epilepsy, hearing impairment, and different types of learning disabilities usually have no visible impairment. Most impairment is not severe and most disabled children can become independent in activities of daily living. Locally, the review of the Children’s NSF for standard 8 disabled children and young people and those with complex needs showed problems with: • Achieving the targets within this standard for the integration of service delivery e.g. a multi agency strategy for access to services i.e. health care such as therapies and rehabilitation, family support. • Early identification of an intervention to meet needs such as assistive technology and equipment. • Supporting and strengthening families. • Facilitating access to recreation and leisure, short term breaks and respite care. Locally Very limited, credible, hard data was available locally. In 2006, 4.3% of children aged 0-18 had some form of learning difficulty, Statement of Educational Needs or some other disability. Total number was approx 4,000. About 3% of students had a Statement of Educational Needs, varying from 4% in Denby Dale & Kirkburton and Huddersfield South to 1.8% in Batley, in 2006. Needs of children with disabilities are currently being assessed and will be reported in the next JSNA.

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Gender: Women of child bearing age (WoCBA) The 2008 Infant Deaths in North Kirklees Report examined why North Kirklees localities had high infant death rates, as Batley and Dewsbury had twice the national average. Four localities across Kirklees showed an upward trend, with 3 of these being in North Kirklees. Over half of the infant deaths were amongst babies born prematurely (before 37 weeks of gestation), and in over half of the deaths, the babies had low birth weight (less than 2.5 kg). One of the key findings of the report was that maternal behaviours such as alcohol consumption, diet, physical activity and particularly smoking in pregnancy profoundly affected the health of the unborn child. The number of mothers with poor health behaviours varied across Kirklees, but the highest rates of smoking, alcohol consumption and overweight or obesity were found in North Kirklees and Huddersfield North localities. As well as impacting upon infant deaths, maternal obesity has been found to be a major factor in 35% of maternal deaths nationally. It should also be noted that more local women aged under 65 developed lung cancer, than nationally in 2006, 60% compared to 43%, see cancer section. Smoking in pregnancy Smoking in pregnancy is of significant concern in Kirklees: 18% of White women smoked at birth, as in 2007. This varied from 32% in Dewsbury to 7% in Denby Dale & Kirkburton. The highest levels in 2007, 1 in 3 were in Dewsbury and Batley, which dropped to 24% and 21% in 2007-08 respectively. Sadly they have risen again to 32% in Dewsbury and 28% in Batley, in 2008-09. Local research has uncovered some of the complex factors involved in womenâ&#x20AC;&#x2122;s motivation with regards to smoking. Themes for action Whilst many women do stop smoking during pregnancy there is also a high relapse rate amongst this population. Offering relapse prevention and also creating a smoke free home for the developing child are also important areas for work with this population group. The promotion of a smoke free home can be a positive way in which the topic of smoking can be raised with a client, and research has shown that many families who make their homes smoke free later go on to stop smoking â&#x20AC;&#x201C; even where this was not their initial intention. Working with frontline professionals to change the way that smoking cessation information and advice is given to pregnant women is also a key area for future work. Offering brief interventions advice and referrals should be an integral part of the work of health professionals who work with women of childbearing age and their families. Involving partners in supporting pregnant women to stop smoking is a critical factor in the success of a quit attempt and in the prevention of relapse.

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Age: Older People (those aged over 65) There were over 61,000 people aged over 65 living in Kirklees, 14% of the total population. By 2025 this will have increased to over 84,000 – an increase of 38%. So by 2025 nearly 1 in 5 (19%) of all those living in Kirklees will be over 65. The over 85 population is currently 7,800 and this will increase to 12,700 by 2025 – an increase of 63%. Life expectancy and overall health • Life expectancy at 65 continued to increase. It rose for men by 0.8 years to 82.3 years, but for women only by 0.2 years to 84.3 years, for 2005-07. So at 65 men could expect to live a further 17.3 years and women a further 19.3 years. • Men aged 65 in the Holme Valley had the longest life expectancy, whilst men aged 65 in Dewsbury and Mirfield had the shortest life expectancy at 81.6 years, a gap of 1.9 years between the longest and shortest. • Women aged 65 in every locality had longer life expectancy than men. Women in Holme Valley had the longest life expectancy at 86.1 years. Women in Batley had more than 1 year shorter life expectancy than Kirklees overall at 82.6 years, a gap of 3.5 years between the longest and shortest. • Healthy life expectancy at age 65 measures the number of years of healthy life a person aged 65 can expect to live, using modelled data from the 2001 Census. In Kirklees in 2001 healthy life expectancy for men at age 65 was 11.5 years and for women 13.3 years. The estimated figure for 2008 is 12.4 for men and 14.3 for women. The projected figures for 2011 are 13 years for men and 14.8 years for women. So the gap between overall life expectancy and healthy life expectancy for men is 4.7 years and for women 4.9 years . Themes for action The largest increase in the next decade in the numbers of people in this group will be amongst the 65 – 75 year olds. Enabling them to enter later life as well equipped as possible to lead longer and healthier lives will be crucial to both making the most of this new generation of older people but also to mitigate the impact of the significant growth in the numbers of more vulnerable older people. There is increasing evidence of the benefits of physical activity in relation to disease prevention especially musculoskeletal pain, mobility and balance, independence and quality of life. Inactivity can be life limiting, physical activity has important beneficial effects on both the physical and mental health of older adults and the quality of people’s lives. See physical activity section. Continuing to increase life expectancy by focussing on the main causes of death under 75 years, including cardio-vascular disease, cancers and respiratory conditions. Also close the gap between between different geographical areas and at the same time closing the gap between overall life expectancy and healthy life expectancy

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which currently stands at 4.7 years for men and 4.9 years for women. The prevalence of long term conditions amongst older people means that development of the way these conditions are managed and the increased emphasis on self-care need to reflect the capabilities, aspirations and expectations of older people. Substantial increases in services will be required in order to keep pace with the dramatic projected increases in the numbers of older people with dependency needs, living alone and undertaking some form of caring responsibility. As older people generally prefer to remain in their homes as long as possible, developing services to enable them to do this will be particularly important and range from â&#x20AC;&#x2DC;handy personsâ&#x20AC;&#x2122; schemes to assistive technology and telecare. The growth in the numbers of those aged over 85 is a significant factor as this group has substantially higher levels of dependency and potentially multiple health needs. Therefore there is likely to be a higher demand for health and social care services. Children and Young People: The main challenges facing children and young people continue to be: Dying before their first birthday (infant deaths) Personal unhappiness and social isolation* Obesity The key issues affecting the main challenges above were: Emotional well-being Educational attainment Food* Physical inactivity Smoking tobacco* Drug misuse Alcohol use* Teenage pregnancies and sexual health Disabilities* Safeguarding children Themes for action Accurate information in an appropriate format needs to be available for children and young people and families. Particularly important to many is information to enable them to make choices and access activities that make them feel good. Provision of appropriate activities is also important, in particular for those children and young people who are least active i.e. activities which build confidence and are fun! Programmes of activity also need to be differentiated on age, gender and socio economic status where appropriate. Family based initiatives are also needed including those which promote lifestyle activity.

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Motivation of the less active children and young people remains a key challenge. Whilst offering motivation and support from other young people i.e. the “someone like me” approach, programmes need to be developed to do this working with families, particular parents. Appropriately trained and knowledgeable leaders/teachers and coaches is also a key area for development. Ensuring “active environments” for children and young people is also needed to facilitate changes in lifestyles. The physical activity agenda needs to be considered on a wider range of agendas including planning. Kirklees commissioners of interventions for children and young people, both preventative and treatment based, have committed to targeting vulnerable groups in Kirklees in 2009 and beyond. Reducing sexual health inequalities for young people across Kirklees can be helped by improving access to sexual health services for young people. These include promoting healthy behaviour, support and advice, contraceptive services and support screening services for some Sexually Transmitted Infections (STIs) including Chlamydia screening for 15 – 24 year olds. Ongoing work with GPs and pharmacists to increase access to contraception, including long acting reversible contraception (LARC) and emergency hormonal contraception (EHC). Young people at greatest risk of teenage pregnancy need to be identified and supported through effective targeted intervention. An outreach service supports positive lifestyle choices by the provision of sexual health promotion and some sexual health services to vulnerable young people, along with the provision of SRE training for voluntary and statutory organisations working with young people.

Sexual orientation: There are no accurate statistics available regarding the profile of the LGB population. Sexual orientation is not incorporated in the census or most other official statistics. Central government estimates that 5-7 % of the total population identifies as lesbian, gay or bisexual. If applied to Kirklees, this would account for 20,000-28,000 of the Kirklees population. Local data from the most recent CLIK Survey (2008) identified that nearly twice as many LGB people compared to heterosexual people experience mental and emotional health issues: • 39% of LGB respondents reported suffering from depression, anxiety and other nervous illness in the previous 12 months, compared to 21% of heterosexual respondents

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• 40% of LGB respondents reported accomplishing less because of emotional problems in the last 4 weeks, compared to 23% of heterosexual respondents • 19% of LGB respondents reported feeling lonely or isolated for all or most of the time, compared to 5% of heterosexual respondents. Other health issues within the LGBT community locally and nationally include: • Increased risk of deliberate self-harm • Increased risk of suicidal behaviours • Higher levels of drug, alcohol and tobacco consumption • Bullying and harassment • Sexual health. For young LGB people, a similar but even starker picture emerges. National data shows that compared to young heterosexual people, young LGB people are: • Four times more likely to suffer major depression • Three times more likely to be assessed with generalised anxiety disorder. In comparison with heterosexual young men, young gay and bisexual men are: • Seven times more likely to have attempted suicide • Three times more likely to have suicidal intent. In comparison with heterosexual young women, lesbian and bisexual girls are: • Almost 10 times more likely to smoke at least weekly • Twice as likely to have consumed alcohol in the past month. (All data from the Department of Health briefings ‘Reducing health inequalities for lesbian, gay, bisexual and trans people - briefings for health and social care staff’ http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH_078347) The Kirklees Sexual Health Strategy aims to improve people’s knowledge and skills and support them to make choices that will enhance their sexual health and wellbeing, and to reduce the prevalence of undiagnosed HIV and sexually transmitted infections. Specific actions include developing a programme of campaigns to support the promotion of sexual health messages to increase awareness around sexual health issues and services; to continue to develop and evaluation relationship and sexual health courses in schools and colleges across the district to increase relationships and confidences of young people; to commission effective GUM, HIV and services targeting specific groups such as men who have had sex with men, and some minority groups; to commission effective HIV family support services; to commission effective services for people affected by HIV and AIDS and to commission research into the local specific health needs of lesbian, gay, bisexual and transgender, transsexual and transvestite people.

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Religion and belief: Kirklees is a district with great cultural diversity, representing a number of faiths and beliefs across its entire population. Our strategic goals reflect this, and all our programme objectives represent these principles and deliver services which are culturally sensitive and â&#x20AC;&#x153;place the person at the centre of everything we doâ&#x20AC;?. This involves commissioning services which, irrespective of cultural background, faith or belief, encompass prevention, detection, treatment and the consequences of ill health and health inequalities, and will achieve equality of outcomes through targeting resources to follow needs. Issues such as barriers to communication, sensitivities around administration of treatment which may contradict religious or cultural beliefs and ensuring personal beliefs are understood and respected is reflected across our entire commissioning strategy. We constantly strive to improve quality and promote safety by encouraging new and innovative ways of delivering services that are sensitive to the diverse needs of our community, promote local sensitivity through effective commissioning by setting outcomes and actions that reflect local needs and priorities.

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Apendix 6

References Kirklees Joint Strategic Needs Assessment http://www.kirklees.nhs.uk/public-information/publications/reviews-and-assessments/

NHS Kirklees Organisational Development Plan http://www.kirklees.nhs.uk/fileadmin/documents/publications/KPCT_Org_Dev_Plan_Web_lowres.pdf

NHS Kirklees Local Operating Plan http://www.kirklees.nhs.uk/fileadmin/documents/publications/KPCT_Local_Operating_Plan_Web_lowre s.pdf

NHS Kirklees Medium Term Financial Plan http://www.kirklees.nhs.uk/fileadmin/documents/publications/KPCT_Finance_Plan_web_lowres.pdf

Kirklees Children’s and Young Peoples Strategy http://www.kirklees.nhs.uk/fileadmin/documents/About_Us/Kirklees_Children_and_Young_People_Plan _2008_-_2011.pdf

Kirklees Joint Mental Health Commissioning Strategy http://www.kirklees.nhs.uk/fileadmin/documents/publications/Kirklees_Joint_Mental_Health_Commissi oning_Strategy_-_2008.pdf

NHS Kirklees Estates Strategy http://www.kirklees.nhs.uk/fileadmin/documents/publications/estates/KPCT-07234%20KIRKLEES%20ESTATE%20STRATEGY%20DOC%20v4%20101207.pdf

NHS Kirklees Communications and PPI Strategy http://www.kirklees.nhs.uk/fileadmin/documents/About_Us/KPCT_Com_Engage_web_lowres.pdf

NHS Kirklees Teenage Pregnancy Strategy http://www.kirklees.nhs.uk/fileadmin/documents/publications/teen_preg_strategy_3_.pdf

Kirklees Alcohol Strategy http://www.kirklees.nhs.uk/fileadmin/documents/About_Us/Kirklees_Alcohol_Strategy.pdf

Kirklees LAA (Local Area Agreement) http://www.kirklees.gov.uk/you-kmc/bigpicture/storypdfs/CTI24LAAandLPSB.pdf

Kirklees Local Public Service Boards – Work Programmes 2009 https://www.kirklees.gov.uk/Secure/meetings/pdfs/0309/lpsb05030934720D.pdf

Kirklees CAA (Comprehensive Area Assessment) http://www.audit-commission.gov.uk/reports/NATIONAL-REPORT.asp?CategoryID=&ProdID=63FF7DFAD1DB-46D0-B72E-39DA12AEF9E1&fromREPORTSANDDATA=NATIONAL-REPORT

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Apendix 7

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 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 – Specialised Commissioning Group SHA - Strategic Health Authority SWYPFT – South West Yorkshire Partnership NHS Foundation Trust WCC – World Class Commissioning YAS – Yorkshire Ambulance Service

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Further information about the PCT can be found on the PCTâ&#x20AC;&#x2122;s website (www.kirklees.nhs.uk) or by contacting the PCT at: Kirklees Primary Care Trust Broad Lea House, Bradley Business Park Dyson Wood Way Bradley Huddersfield HD2 1GZ Tel: 01484 464000