Strategic Commissioning Plan Growing Healthier 2010/11 - 2014/15 Final draft March 2010
www.medwaypct.nhs.uk1
CONTENTS PAGE
1. FOREWORD
4
2. VISION & VALUES
6
3. CONTEXT & CHALLENGES
8
o
POLICY CONTEXT
8
o
SENSE OF PLACE
10
o
POPULATION HEALTH
11
o
SERVICE PROVISION IN MEDWAY
17
o
COSTS
30
4. STRATEGIC DIRECTION
42
o
SETTING THE STRATEGIC GOALS
42
o
TARGETTING FINANCIAL RESOURCES
43
o
MEASURING SUCCESS
53
o
DELIVERING THE STRATEGIC GOALS
56
o o o o o o
Improving health Targeting killer diseases Care closer to home Supporting future generations Improved independent living and choice Improving mental health
57 63 73 79 85 94
5. MANAGING DELIVERY
101
o
GOVERNANCE
101
o
MANAGING RISK
106
o
ORGANISATION DEVELOPMENT
109
6. UNDERPINNING STRATEGIES
111
o
WORKFORCE
111
o
ESTATES
115
o
IM & T
116
7. CONCLUSION
118
8. BOARD DECLARATION
120
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APPENDICES: (separate attachments)
Appendix 1
List of Providers and current contract values
Appendix 2
Full set and status of NHS Medway’s current performance indicators
Appendix 3
Prioritisation Framework
Appendix 4
World Class Commissioning Outcome trajectories
Appendix 5
Workforce plans
Appendix 6
Estate Strategy
Appendix 7
IM&T Strategy
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SECTION 1 | FOREWORD NHS Medway has developed this Strategic Commissioning Plan to set out its vision and aims for the health of the people of Medway and the health services commissioned on their behalf. We need to be ambitious with and for the people of Medway if this plan is going to deliver significant improvements in the health status of local people. Medway – A great place to live, work and thrive – a vision shared with our partners. Our vision is for a healthy, safe and productive population in Medway where: •
individuals are empowered to take control of their own well being
•
individuals and communities have access to the very best quality of health care
The challenges facing NHS Medway are significant. In recent years, NHS Medway has received considerable increases in funding. However, over the next five years, in common with the wider NHS, we are planning for a real terms reduction in expenditure. Despite this, we will continue to strive to meet the growing health needs of people in Medway. In 2010 health outcomes in Medway are worse than the England and South East Coast average. Medway has high levels of smoking, obesity and teenage pregnancy. On average, people in Medway die two years before people in the rest of England. Indicators of deprivation, such as poverty, unemployment, poor physical health or poor housing, all of which are present in Medway, are strongly correlated with mental ill health. And our challenges will only increase as the population of Medway ages. By 2015, working with other NHS and non-NHS partners, NHS Medway will have delivered a step change in the life chances of people in Medway. By achieving our six strategic goals, we will reduce health inequalities, add life to years and years to life. At the same time, we and our partners will deliver substantial efficiency gains through the health system, and we will be relentless in our drive for quality. The plans set out in this document have been arrived at through active stakeholder engagement through the Board, the Professional Advisory Committee, key NHS and non partners including Medway NHS Foundation Trust, Kent and Medway NHS and Social Care Partnership Trust, Medway Council, local police, the Local Strategic Partnership Board, and a wide range of health and social care professionals, patients and the public.
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NHS Medway has identified 6 key health goals to deliver over the next five years IMPROVING HEALTH AND WELL BEING To reduce the high levels of smoking, obesity and teenage pregnancy TARGET KILLER DISEASES To reduce premature deaths in Cancer and Cardiovascular Disease and in doing so improve the end of life experience for patients CARE PATHWAYS – CLOSER TO HOME To develop the capacity and capability of local services whilst offering more choice and responsiveness SUPPORTING FUTURE GENERATIONS To secure better outcomes and access to services for children and young people in Medway PROMOTING INDEPENDENCE AND IMPROVED QUALITY OF LIFE To meet the challenge of the growing number of older people and people with long term conditions, maximising their independence and well being IMPROVING MENTAL HEALTH To improve access to a wide range of preventative and treatment services to improve the mental well being of people in Medway We have taken these goals and used them to drive our strategic change programmes and our associated financial strategy. Each year we will work toward these goals through our annual commissioning intentions, service improvement plans and business plan. Our plan is arranged in five chapters which allow you to trace the journey we have travelled. Understand our vision, the issues we face and the health outcomes we seek, our plans to deliver our strategic goals and the underpinning governance arrangements and strategies which will support their delivery. Thank you for reading our plan. This plan will be reviewed every year. We welcome comments, as there will always be things we can improve.
Denise Harker
Marion Dinwoodie
Dr Peter Green
Chairman
Chief Executive
Professional Advisory Committee Chair
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SECTION 2 | VISION & VALUES
MEDWAY A great place to live, work and thrive 2.1 OUR VISION Our vision is for a healthy, safe and productive population in Medway where: •
individuals are empowered to take control of their own well being
•
individuals and communities have access to the very best quality of health care
In order to achieve this NHS Medway will work in partnership with other agencies so that we, with the wider NHS and other partners, can: •
Add life to years and years to life
•
Reduce health inequalities.
NHS Medway has agreed six strategic goals, which, once achieved, will deliver this vision. The goals are: o
IMPROVING HEALTH AND WELL BEING Reducing the high levels of smoking, obesity and teenage pregnancy
o
TARGET KILLER DISEASES Reducing premature deaths in Cancer and Cardiovascular Disease and in doing so improve the end of life experience for patients
o
CARE PATHWAYS – CLOSER TO HOME Developing the capacity and capability of local services whilst offering more choice and greater responsiveness to local need
o
SUPPORTING FUTURE GENERATIONS Securing better outcomes and access to services for children and young people in Medway
o
PROMOTING INDEPENDENCE AND IMPROVED QUALITY OF LIFE Meeting the challenge of the growing number of older people and people with long term conditions, maximising their independence and well being
o
IMPROVING MENTAL HEALTH Improving access to a wide range of preventative and treatment services to improve the mental well being of people in Medway
Section 4 of this document sets out our plans for the achievement of these goals.
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2.2 OUR VALUES The Values which underpin this strategy are embedded within NHS Medway and include the need for: •
Respect and dignity: Treating people, whether patients or staff, as individuals – not as symptoms or resources
•
Commitment to quality of care: Earning others trust by insisting on quality and getting the basics right
•
Compassion: Finding the time to listen and understand
•
Improving lives: Striving to improve health and wellbeing through excellence and professionalism
•
Working together for patients: Putting patients first in everything we do
•
Showing that everyone counts: Using the resources we have for the benefit of the whole community
NHS Medway is strongly committed to ensuring that every organization and every individual in the local health economy plays their part in improving health outcomes, driving up quality and driving out waste. This Strategic Commissioning Plan focuses particularly on the PCT’s plans for service change, whether through increased efficiency or investment. However, the PCT expects all services at all times to seek and respond to the experiences of service users, and to strive for continuous improvement. NHS Medway particularly values the immense contribution made to strategic planning and service delivery by patients and health and social care professionals at all levels. Public and professional engagement is at the heart of all our planning processes. Every Strategic Change Programme Group has representation from primary and secondary care clinicians – doctors, nurses and therapists as appropriate. Many of the groups also have Medway Council representation. Some groups have patient membership, and all groups have forged links with patient groups, Medway LINks and other bodies which ensure that our plans for services are designed around the needs of the patient rather than the organisation.
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MMARY
SECTION 3 | CONTEXT & CHALLENGES 3.1
POLICY CONTEXT
The Strategic Commissioning Plan for NHS Medway is designed primarily to meet the needs of the people of Medway for health services, including services for the promotion of good health and prevention of ill-health. However, it also sits within a wider policy context. People have a right to expect that the National Health Service will deliver care to the same high standard across the country. NHS Medway is committed to the delivery of national health and social care policy as set out in documents such as ‘High Quality Care for All’ and ‘Putting People First’. The PCT will also ensure that the requirements of National Service Frameworks and their equivalents are delivered locally. During 2010 a number of rights for service users and staff which were set out in the NHS Constitution will be enshrined in law. These include the right to hospital treatment, where this is required, within certain timeframes, and the PCT will ensure that all commissioned services are able to deliver these rights. In December the Department of Health published its strategy for the NHS for the period 2010 – 20151. Entitled ‘From Good to Great: Preventative, People-centred, Productive’, this strategy sets out a vision for an NHS which is designed around the needs of the individual, and which uses a focus on quality and productivity to drive improvement. The strategy identifies six challenges which face modern healthcare systems: •
Ever higher patient expectations;
•
An aging society;
•
The information age;
•
The changing nature of disease
•
Advances in treatment
•
The changing workforce
All of these challenges are present in Medway, and this Strategic Commissioning Plan will set out our local response. ‘From Good to Great’ also describes the financial challenge facing the NHS. Nationally, the service is expected to deliver £15 - £20 billion of efficiency savings over the three years from April 2011. During this period allocations to PCTs will grow only by the costs of inflation. The costs of tackling the six challenges outlined above, and of meeting local needs, must be met through greater efficiencies. This plan will set out how the NHS in Medway will approach the need to balance investment in service improvement with savings delivered through the reduction of waste, increases in clinical productivity and the appropriate use of physical capacity. The most significant change we can expect to see is a shift in the delivery of NHS care for 1
http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_109 876
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people with long term conditions from hospital treatment to support in the community focused around the needs of the individual. In summary, the implementation of ‘From Good to Great’ will deliver: •
• • • •
• •
more rights for patients – to choice of hospital, and – subject to consultation – to a personal health budget, health checks and to choose where to spend their last days of life; accelerated improvements in quality across five key areas of care – cancer, cardiac care, stroke care, maternity care and patient experience; transformed services for those with a long term condition (such as diabetes, COPD, dementia); up to 10% of hospitals’ income, over time, being dependent on patients’ experience and satisfaction with services. NHS staff who are provided with a healthy workplace, with staff satisfaction measured systematically; and providing staff with the right training and skills to develop, and to deliver care effectively, including investing in the development of leaders across the system; The retention of national pay bargaining and continuing to help the lowest paid staff; and The potential for offering frontline staff an employment guarantee locally or regionally in return for flexibility, mobility, and sustained pay restraint.
The national strategy also emphasizes the continuing need to deliver the Next Stage Review visions developed for each Strategic Health Authority area. In South East Coast, ‘Healthier People, Excellent Care’ set out a local vision for the improvement of outcomes across eight pathways: • • • • • • • •
Maternity & newborn care Children’s health Staying healthy Mental health Planned care Acute care Long term conditions End of life care.
In total, the NHS in the South East Coast made 31 pledges2 to improve services and therefore improve health for local people. Despite the changing financial environment, these pledges remain important and section 4 of this plan will show how the pledges will be delivered within Medway. Both ‘Good to Great’ and ‘Healthier People, Excellent Care’ emphasise the importance of strong clinical leadership driving system change. In March 2009 the Department of Health published its vision for practice based commissioning.3 This describes a vision for practice based commissioning where clinicians can: 2
http://www.southeastcoast.nhs.uk/hpec/pledges.asp
3
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_108672.pdf
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•
Develop a greater range of more integrated services in community settings, designed around the needs of individuals
•
Secure greater investment in upstream interventions that keep people healthy for longer, prevent ill-health and reduce health inequalities
•
Drive continuous quality improvement and innovation across the whole system, securing better value for money in the process.
NHS Medway has strengthened the support given to our three practice based commissioning localities during 2009/10. Each locality is now functioning with a Chair, a clinical lead, a dedicated Commissioning Manager and additional support from finance, information and other PCT staff. PBC leads are strongly engaged in the delivery of NHS Medway’s strategic goals. In addition, secondary care clinicians are partners in the redesign process through Strategic Change Programme Groups. NHS Medway’s Medical Director works closely with his counterparts in local providers to ensure a consistency of approach and message to clinical staff across the whole health system. 3.2 SENSE OF PLACE NHS Medway leads the NHS in the area covered by the Unitary Authority of Medway Council in the Thames Gateway community 30 miles from London. NHS Medway has a population due to rise from approximately 274,000 to over 320,000 over the next 20 years. Medway includes the towns of Strood, Rochester, Chatham, Gillingham & Rainham, and the more rural population living on the Hoo Peninsula. The area is shaped by its history, as well as by its future potential. Medway has seen gradual economic recovery and diversification over the last 20 years, after the collapse of heavy industries and the closure of the Chatham Royal naval dockyard in the early 1980s. For 15 years selfesteem, confidence and levels of aspiration among the community were low but are now improving. Overall Medway is not a deprived area and does not attract deprivation based funding. Yet at ward level there are some of the most deprived as well as some of the most affluent areas in the country. Deprivation is particularly driven by low income and employment levels. The challenge is to close these gaps and address the multiple causes of deprivation where people in some areas experience the combined effect of unemployment, poor educational attainment, and crime, anti social behaviour and health problems. It is a unique urban area and a national priority area for regeneration and growth. It is anticipated that with more than £120 million of Sustainable Communities funding, far more private investment will be attracted to transform Medway over the coming 20 years.
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Regeneration in Medway, known as ‘Medway Renaissance’4 focuses on brown field sites along the waterfront, the redevelopment of Chatham as Medway’s city centre, as well as improvements to existing town centres. The regeneration will bring housing, jobs and investment in transport and community facilities. While 88 per cent of Medway’s population lives in the urban areas, half of the land is rural. This includes eight internationally or nationally designated areas of nature conservation. The challenge is to protect and enhance the environment and green spaces to maintain quality of life for current and future generations.
3.3 POPULATION HEALTH Over the last few years NHS Medway has commissioned a series of equity audits, a Joint Strategic Needs Assessment for Medway and a specific JSNA for Mental Health. These documents (full copies are available on request and through the NHS Medway website) outline the key issues relating to the health and wellbeing of the local population. The emerging themes from these documents are considered below alongside the priorities outlined in Medway’s Community Plan and the targets identified in the Local Area Agreement (LAA).5 3.3.1 DEMOGRAPHICS AND LEVELS OF DEPRIVATION The Office of National Statistics (ONS)6 projections suggest the population in Medway is expected to grow by at least 4.6% by 2018 from the baseline in 2006. Within this: Older People7 •
The number of people 65 years of age or over is projected to grow by 29% with the number of over 85 years growing by 32% by 2018
•
The proportion of people aged 65 or over living on their own is predicted to rise from 7,876 in 2009 to 10,326 by 2020, an increase of 31.1%.
Long term illness7 •
The number of people aged 65 or over with a long term limiting illness (not physical disability) is expected to rise from 16,509 in 2009 to 21,699 in 2020 , an increase of 31.4%
Carers7 •
The number of carers aged 65 and over is expected to grow in line with demographic changes.
Mental Health7 4 5 6 7
http://www.medwayrenaissance.com/site.html http://www.medway.gov.uk/index/council/policy/laa.htm Source: ONS 2006-based Sub-National Population Projections. Crown Copyright 2008 Source: POPPI (Projecting Older People Population Information System). Crown Copyright 2009.
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•
The prevalence of common mental health disorders amongst those aged 65 and over i.e. dementia, depression and severe depression, is predicted to increase by 30.8% in Medway from 6,349 in 2009 to 8,307 in 2020.
Learning Disabilities8 •
The total number of adults (18 and over) with learning disabilities living in Medway (both known and unknown to services) is predicted to rise by from 4,625 in 2009 to 4,886 by 2020, an increase of 5.6%
Children9 o
By 2018 the number of young children under 5 years of age is expected to grow by 7%.
Medway has a predominantly white population, with 7% of the population being from ethnic minorities. Although this is a lower proportion of ethnic minority groups than England as a whole numbers are increasing. The largest ethnic minority group is the Asian/Asian British group. Medway has a relatively diverse level of deprivation with three wards – Gillingham North, Chatham Central and Luton - falling within the 20% most deprived wards of England and two wards – Rainham Central and Hempstead & Wigmore - falling within the 20% least deprived. As expected those areas with high levels of deprivation typically suffer on most domains of deprivation; income, employment, health, education, crime and living environment. Within this children are marginally more likely to live in deprived neighbourhoods. Older people are more likely to live within the least deprived neighbourhoods. 3.3.2 BURDEN OF DISEASE Lifestyle and Risk factors NHS Medway faces considerable challenges in tacking high levels of smoking, obesity and teenage pregnancy. The high levels of these risk factors for ill health pose a significant threat to the future health and well-being of the population in Medway. Key issues to consider: •
The highest level of smoking of all 67 Local Authority areas in the South-East at 31.3% of the adult population10
•
The 6th highest percentage in the South East of people that are obese and joint lowest with Dartford and Swale Local Authorities at 21.8% of adults that consume five or more fruits or vegetables per day.
•
A high teenage pregnancy rate where 26% of 14 year old girls have become sexually active, but only 50% of this group know of some of the common STIs, and 33% do not always use contraception.
8
Source: POPPI (Projecting Older People Population Information System) & PANSI (Projecting Adult Needs and Service Information System). Crown Copyright 2009. 9 Source: ONS 2006-based sub-national population projects. Crown Copyright 2008 10 Source: Healthy Lifestyle Behaviours: Model Based Estimates 2003-05. The NHS Information Centre for Health and Social Care. Crown Copyright.
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Mortality & Morbidity There are significant differences in life expectancy at birth between wards in Medway11, with the most recent data showing a gap of 6.8 years between the ward with the lowest life expectancy (Gillingham North) and that with the highest (Cuxton and Halling). The life expectancy of a population is linked to deprivation. In Medway deprivation drives a significant loss of life years resulting from coronary heart disease and lung cancer. This is consistent with the link between deprivation and lifestyle risk factors such as smoking, poor diet and obesity. Deaths from Cancer12 •
The Standardised Mortality Ratio (SMR) from all cancers is higher for Medway than England and the SE rates as are SMRs for lung and colorectal cancers.
Deaths from circulatory disease •
The Medway SMR continues to be above the southeast and national rates
Because of the ageing population the number of people aged over 65 with a limiting long term illness is expected to increase by 34% to 21,700 people by 2020. This will have a significant impact on services for the management of long term conditions such as dementia, cardiovascular disease (CVD) and diabetes as well as acute conditions such as stroke as the incidence of these conditions increases with age. The table below sets out the current and projected prevalence of some of the most significant chronic diseases in Medway:
COPD
Number %
2006 6,019 2.4%
Stroke
Number %
2006 4,099 1.63%
2009 4,302 1.69%
2010 4,341 1.70%
2015 4,814 1.84%
2020 5,252 1.96%
Hypertension
Number %
2006 57,259 22.7%
2009 59,404 23.4%
2010 59,771 23.4%
2015 63,845 24.5%
2020 67,523 25.2%
CHD
Number %
2006 9,327 3.71%
2009 9,800 3.86%
2010 9,888 3.9%
2015 10,919 4.2%
2020 11,922 4.5%
2005
2009 Not available Not available
2010
2015
2020
11,531
13,021
14,744
4.5%
4.9%
5.4%
Diabetes
Number 10,067 %
4.0%
2009 6,252 2.5%
2010 6,291 2.5%
2015 6,737 2.6%
2020 7,188 2.7%
11 Source: Kent & Medway Public Health Observatory using Public Health Mortality File, 2004-08, ONS CAS ward data: SEPHO. 12 Source: The Information Centre for health and social care. Crown Copyright.
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Source: Annual Public Health Report 2009/10
3.3.4
ADDRESSING INEQUALITIES IN DEPRIVATION AND ILL HEALTH
The risk factors for ill health are not found uniformly across Medway. The map below shows the distribution of deprivation across the PCT by electoral ward.
During 2009/10 NHS Medway has joined the ‘Triple Aim’ project. This project supports improvement by using place as a unifying unit of analysis and action, putting the person in place at the centre of service design and assessment of benefit. Commissioners for conditions and population groups, with external public sector and community partners, are being supported to evaluate performance and redesign services based on intelligence about the experience of people in place. The basic steps in the process are: o profile a place to provide an in-depth understanding of the health outcomes, costs and resident experiences (the ‘triple aim’ measures) o
bring commissioners, providers and residents together to analyse opportunities for improvements in health, cost and experience
o
initiate redesign and alignment with partners to improve outcomes.
Provisional selection of the first pilot ward was based on a consideration of three broad criteria. These were: a. Need b. Assets/Opportunity
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c. Replication For each of these criteria we set 2 - 3 questions and collated the data to answer these questions. The questions were: Need: o Where do people live who have the highest rates of (the most significant) preventable mortality and morbidity? o Where do people live who have the highest rates of preventable service use and contribute substantially to health costs (per capita)? o Where do people live who have the highest rates of (the most significant) risky behaviour? Assets and Opportunity: o Where is the PCT focusing future service activity or redesign? o Where are stakeholders focusing current/future activity relevant to the determinants of health (eg Medway Council, CLG, Third Sector)? o Where are residents interested, organised or empowered to be involved in transforming their locality? Replication o Where is the area that best reflects the Medway ‘norm’ for health/services? o
Where is the area that in the future will be neither neglected nor the subject of particular attention?
On the basis of the response to the questions above, and discussions with community partners, Chatham Central Ward has been selected as the focus for the project. The project team is now agreeing the detailed indicator set for use to measure improvement in health outcomes, patient experience and value for money, and the milestone plan which will support this. Cardiovascular disease, as one of the main causes of early death in the area, will be included in the indicator set. 3.3.3 INEQUALITIES IN ACCESS FOR VULNERABLE PEOPLE Children and Young People In early 2007 NHS Medway and Medway Council undertook a child health equity audit. This audit identified that: •
Childhood vaccination rates in Medway are generally higher than for Kent and Medway and the South East region
•
Children in the most deprived wards in Medway have considerably worse oral health than those living in less deprived wards.
•
There is a lack of awareness and knowledge of sexual health issues amongst children and young people in Medway, which is reflected in their risk taking sexual behaviour.
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Adults with a Learning Disability There is clear national evidence that people with a learning disability have difficulties in accessing generic health services and that health outcomes for this part of the population are very poor. Work in Medway has highlighted that whilst people with a learning disability receive annual health checks, there is little evidence that there has been any significant improvement in the accessibility of general health services or that health outcomes are improving. Adult Mental Health A recent JSNA for adult mental health across Kent and Medway identified the following areas of concern: •
Mental ill health is strongly correlated with indicators of deprivation such as poverty, unemployment, poor physical health or poor housing
•
A diagnosis of schizophrenia reduces average life expectancy by 10 years
The projected increase in older people will need to be considered carefully given the already limited capacity in Older peoples services. Prisoner and Offender Health There are two prisons in Medway, which are both Young Offenders Institutions. NHS Medway has commissioned a JSNA specifically focusing on the needs of the prison population, and will develop a commissioning strategy based on its findings.
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3.4 SERVICE PROVISION IN MEDWAY 3.4.1
MARKET SUMMARY
NHS Medway commissions services from a number of different providers. A summary of the high level overview of the healthcare economy based on provider types is shown below:
•
• • • • • •
General Acute Medway NHS Foundation Trust Maidstone & Tunbridge Wells Trust Queen Victoria Guys and St Thomas Dartford and Gravesham NHS Trust East Kent Hospitals Foundation Trust
• • • •
• •
• • • • •
• •
Specialist Kings College Hospital NHS Foundation Trust UCL Hospitals NHS Trust Great Ormond Street Royal West Sussex The London Bridge Fertility, Gynecology and Genetics Centre Queen Victoria Hospital Royal Marsden
•
• • • • • •
Community Medway Community Healthcare Eastern and Coastal Kent PCT St Barts Voluntary Sector providers Care homes and domiciliary care providers
Mental Health Kent & Medway Partnership trust South West London and St. Georges MH South London and Maudsley
• • • •
• • •
Primary Care 67 GP surgeries 36 Dental Surgeries 48 Pharmacies 21 Optometry Practices
Independent Spire Healthcare BMI hospitals Care UK Independent Treatment Centre
Third Sector The Wisdom Hospice Age Concern Council for voluntary service (Medway) Hi Kent Medway Asthma Self Help The Stroke Association
In Medway the majority of acute provision is delivered by Medway Foundation Trust. Similarly in the Community care market the primary provider is Medway Community Healthcare.
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3.4.2
DIVISION OF SPEND BY MARKET SHARE
NHS Medway 2010/11 budget allocation
11% 12% 1%
48%
7%
Secondary / Tertiary Acute Care MH and LD Commissioning
11%
10%
Provider Services Other Continuing Care Primary & Community GP Prescribing
The chart above shows that the majority of our budget allocation currently focuses on secondary and tertiary acute care. As we move towards improving access and choice of services in the community we expect this picture to change with greater investment being focused on community based services. 3.4.3
ACUTE CARE
This illustration shows how acute care spend is distributed to our major providers.
Medway NHS Foundation Trust 4%
4%
4% Others
7%
Maidstone and Tunbridge Wells NHS Trust
13%
Queen Victoria Hospital NHS Foundation Trust 68%
Care UK ISTC Guy's and St Thomas' NHS Foundation Trust
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The acute care market in Medway is dominated by one local provider, Medway NHS Foundation Trust. Although this may be considered restrictive in terms of patient choice, it does provide NHS Medway with a real opportunity to work with the acute trust to reshape the health care economy in a more efficient way than could be achieved if there were a greater number of local providers. Use of Choose and Book is relatively high in Medway, at around 60%, which suggests that Medway patients do not feel disadvantaged by the market domination of Medway NHS Foundation Trust. The majority of hospital services accessed by Medway patients are available at Medway Foundation Trust. This means that in most cases patients can access acute services within 30 minutes. This is illustrated in the map below.
The limited number of general acute services that are not available at Medway Foundation Trust can be accessed at hospitals in neighbouring areas. Just over 30% of acute activity is provided outside of Medway or in the private sector. This sometimes creates issues of control and sustainability. Much of this activity is for specialised services. These services are commissioned from neighbouring Trusts when costs or expert knowledge prohibit the development of services in Medway. Responsibility for ensuring that these services provide strong patient outcomes and efficiency require close liaison with the lead commissioner. The purpose of such joint working is to give the PCT a much stronger negotiating position and providers a direction for positive improvement. The map overleaf illustrates the locality of services accessed by patients.
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QUALITY OF ACUTE PROVISION
Medway Foundation Trust Kent & Medway Partnership Trust
G oo d
Guys & St. Thomas' Foundation Trust Kings College Foundation Trust Dartford & Gravesham F a ir
East Kent Foundation Trust Maidstone & Tunbridge Wells Queen Victoria Hospital NHS Foundation Trust
W eak
C Q C U s e o f R es o u rces R atin g
E xc elle nt
3.4.4
Weak
Fair Good CQC Quality of Services Rating
Excellent
As previously stated overall the quality of acute care provision accessed by the people is Medway is generally fair to excellent. However the quality and performance of some services within this provision is variable. This creates some issues which include:
Performance and sustainability of access targets within A&E Utilisation and slot availability of the Choose and Book system Incidence of Pressure damage Usage of mixed sex accommodation MFT scored within the bottom 20% in the national patient survey KMPT scored just above the bottom 20% in the national patient survey
We will continue to work with all our providers to ensure that quality is at the heart of care delivery. Where there are concerns we will work with and support providers to improve performance in order to maximise positive outcomes for patients. 3.4.5
SPECIALIST COMMISSIONING
During 2010/11 the Specialist Commissioning team will be conducting market assessments for those services that are currently outside the sphere of focused performance management and influence. This will ensure that specialist services are delivering the most effective outcomes for patients at a price that delivers value for money.
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3.4.6
MENTAL HEALTH SERVICES
The provision of mental health services is dominated by Kent and Medway Partnership NHS & Social Care Trust which limits choice and competition. There is however strong evidence to suggest that the market is developing in terms of both capacity and capability. This will increase the scope and opportunity to improve choice and outcomes for patients. There is a need to reshape and improve mental health services to ensure that they provide better health, patient and value outcomes. Where it is appropriate to do so, we will continue to use commissioning levers to achieve this. Where there is evidence to suggest that going to the market will achieve better outcomes this option will be pursued. An example of improving services in this way is the re provision of CAMHS level 4 services. The contract for the provision of this service was competitively tendered in 2009. The new contract for this service will commence in the Autumn of 2010. A number of other services previously provided by KMPT have been, or are in the process of being, tendered. These include prison mental health services, substance misuse services and wheelchair services. KMPT have also won tenders for newly commissioned services, such as psychological therapies. 3.4.8
COMMUNITY SERVICES
The community service market in Medway is currently highly concentrated by one m provider, Medway Community Healthcare (MCH). MCH is a £55 million business with nearly 1,350 staff, approximately £47m of this income is derived from Medway. Some important points to note are: Medway Community Healthcare provides a wide range of both planned and unscheduled care in local settings such as healthy living centres, St Bartholomew’s Community hospital, and people’s homes. It was formed in April 2009 from the services directly provided by NHS Medway, as a first step in separating the provision and purchasing of these services. Medway Community Healthcare services have a strong track record of partnership with local primary care clinicians, Medway NHS Foundation Trust, Medway Council and other key stakeholders. Working with Medway Community Healthcare often gives commissioners the opportunity to reshape services that deliver better outcomes for with minimal disruption to patients. Where it is determined appropriate to do so through the commissioning process Medway Community Healthcare are required to compete with other service providers from the NHS, independent and voluntary sectors for NHS contracts in the health service marketplace. During 2010/11, in line with the ‘Transforming Community Services’ policy, NHS Medway will be determining a new organisational form for Medway Community Healthcare. At the time of writing, the preferred organisational form is that of a Social Enterprise, potentially integrating health and social care service provision. However, it is likely that, following a review of pathways, some services currently provided by MCH will be vertically
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integrated with services provided by Medway NHS Foundation Trust, and Kent and Medway NHS & Social Care Partnership Trust. Conversely, some services currently provided by those organisations may move out to the social enterprise. 3.4.8
PRIMARY CARE SERVICES
General Practitioners
In 2009/2010, there were 67 practices within Medway. The market will experience a mild consolidation in 2010/2011. This will be driven by 3 practice mergers. Extended hours is currently offered by 83% of practices. All practice lists are currently open. On average there were 4208 patients per GP practice in January 2010. There are some access issues in the more rural parts of Medway. The map below indicates distances from Healthy Living centre to housing developments.
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The average walking time from a housing development site in Medway to the closest GP practice is 11 minutes. 51% of housing development sites are less than a 10 minute walk to the local GP. 32% are within 10-20 minutes and 17% are over 20 minutes. A key priority for the PCT is improving access to GP services as measured through the national GP patient survey. It is proposed that this area be targeted through development of a Local Enhanced Service (LES) to improve access and responsiveness. A range of options have been identified to increase capacity during core hours, access to information, improving patient attendance rates, capacity and demand analysis, stretching QOF access survey thresholds and patient participation. We will continue to work with our providers to explore opportunities to improve access to GP services where this is restricted. Overall QOF performance is good in absolute terms, but poor relative to the England average. However, in 2008/09 Medway moved from a ranking of 140th out of 152 PCTs to 102nd, and anticipates being above the England average in 2009/10. The average achievement in 2008/09 was 94.88%.
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37 of the 63 Practices were above the average score in Medway compared to 47 during 2006-7 (58.73% compared to 70.15%), while 35 Practices scored above 950 points compared to 46 last year (56% compared to 69%). More Practices are closer to achieving maximum points than in the first five years of QOF, and for the first time since its implementation in 2004, all Medway Practices are achieving above 800 points. The following QOF indicators were below 75% achievement during 2008/09. -
Palliative Care Multidisciplinary Care Review Meetings Diabetics with HbA1c of 7 or less CHD patients treated with beta-blockers Epilepsy patients with a record of 12 months seizure free
In addition to plans to reshape and improve provision NHS Medway currently offer additional visits to the 20 lowest performing practices to help support improvement. This is being reviewed in order that we can ensure that support is being directed appropriately in order to achieve maximum benefit for patients. Pharmacies There are currently 48 pharmacies in Medway with 2 services due to open later this year. One of these is in Hoo, the other will be in the new health centre at Balmoral Gardens, Gillingham. There are no concerns regarding patient access to pharmaceutical services. It is however anticipated that this addition provision will offer patients greater choice and flexibility. There are 3 pharmacies in Medway that open for 100 hours per week so there is good access early in the morning, late in the evening and at weekends. In addition the pharmacy on St Mary's Island, which is central to Medway, is open until 10pm on Saturdays and Sundays. During 2010 NHS Medway will be undertaking a Pharmacy Needs Assessment the results of which will inform us of any issues with access or gaps in service. Dentistry In 2009/2010, one dental provider left the market leaving 36 general dental practices. In early 2010/2011, it is anticipated that a further small provider will leave the market. Procurement plans for 2010/11 outline the intention to procure a new practice and issue 6 specialist contracts. This will reduce recent market concentration and stimulate the market. Access to dentistry in Medway has historically been excellent, and a relatively high proportion of patients from other PCTs are known to access NHS dentistry in Medway. Despite this, dental access was improved further during 2009/10. 32 of the 36 general dental practices are currently accepting new patients. 24 of these practices also have open access sessions that enable patients to make a same day/next day appointment or urgent care. Advertising of the Dental Helpline has been used to improve patient access.
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In 2009/10, the PCT plans to increase access by reducing orthodontist waiting times and increasing domiciliary access. 3.4.9 PATIENT SATISFACTION The chart below summarises the level of satisfaction with the various NHS services. The green bars indicate levels of satisfaction. Respondents using the NHS services recently were more likely to be satisfied than those who were not recent users.
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Overall, levels of dissatisfaction were quite low with the highest level of dissatisfaction at 10% directed at GP’s and Hospital inpatients. 9% were critical of hospital outpatients and 7% dentists. In general the group of respondents who had used the various services were more likely to be more positive than those not using services. [1] 40% of patients felt that NHS Medway buys effective healthcare for the community it serves. 56% of patients felt that NHS Medway offers a wide range of services that meet the needs of the community. 59% of patients felt that NHS Medway offers many services close to home. 51% of patients felt that NHS Medway helps to manage and improve the health of its local population. Positively, only 13% disagreed. The two areas that were perceived to need the least improvement were the availability of GP appointments at 55% (25% no need for improvement), and the time spent waiting for a hospital appointment at 34%. The three areas needing the most perceived improvement were the time spent waiting in A&E at 63% (42% a lot of improvement), the available information about local healthcare services at 53% (25% a lot of improvement), Hospital cleanliness at 52% (27% a lot of improvement). We will continue to work with our providers to improve levels of satisfaction. 3.4.10 MANAGING, SUPPORTING AND DEVELOPING OUR MARKETS The Procurement and Market Framework strategy sets out the principles, rules and methods we will work to in order to support the delivery of the activities set out in this plan. The strategy clearly outlines how and when it is appropriate to seek to introduce competition or to apply other commissioning levers to achieve the most beneficial and cost effective modes of delivery. Generating momentum, delivery of completed projects, and stakeholder engagement will be essential in the delivery of our strategic objectives. Rigorous and transparent processes will deliver viable and affordable services within defined timescales. We will develop the local health economy in Medway by encouraging new providers and supporting local and existing providers so they can participate fully. A vibrant market place for healthcare provision will encourage innovation, drive up quality, deliver choice and allow the organisation to clearly demonstrate value for money. Shaping services around the needs of people is crucial to developing Medway as a great place to live, work and to thrive. Procurement The broad process of procurement at NHS Medway follows two clearly distinct routes. These routes are simply defined as: • [1]
Competitive
Lake Market Research – “Survey of Patient Satisfaction for NHS Medway” – October 2009
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This means where we directly approach the market in order to procure services. • Single source This is where we approach a single provider or in some cases a group or consortium (either existing or new) thereby restricting access to the opportunity to deliver the service. Single source procurement includes the purchasing of individual services for users. We have developed a robust framework that enables procurement decisions to be made in a transparent and equitable way. This framework includes a Competition versus Cooperation analysis. The following summarises the broad themes of this analysis. CONTESTABILITY EXISTING/PREFERRED PROVIDERS To be used when:
To be used when:
•
Seeking innovation for old-fashioned services? (changing behaviours)
•
Demonstrable existing value for money
•
Demonstrable record of innovation
•
New technology/systems creating new/innovative provision?
•
Willingness to continue reflecting on and change practice
•
Concern (evidence) about poor value for money from existing services
•
Record on Clinical outcomes/patient experience
•
Evidence of poor clinical outcomes/patient experience from existing services
•
There is concern about local health economy being restricted or monopolised
Balancing Checks Balancing Checks
Test: •
o
•
Test:
How new provider help deliver: Continuity of Care / Holistic care; not a specific condition but for whole patient experience
Connectivity of new provider e.g. o
Clinician-to-clinician hand-offs (inc. information flows)
o
Org-to-org hand-offs
o
Clinical Governance
•
Transaction costs of managing plurality
•
Strategic Context o
•
Robustness against legal challenge from other providers
•
Option can demonstrate VFM
•
Length of contracts ensure a balance of provider willingness with potential for future contestability
•
Willingness of existing providers to engage with new providers who may come into system at later date
•
Robustness of arguments deployed about continuity/holistic care
Will market testing deliver the objective
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We recognise that for many providers in our market the experience of procurement and how to respond to opportunities in restricted. One of the measures we have in place to address this is a training programme which includes: Understanding the NHS Medway Procurement and Market Framework Strategy Guidance and training in responding to opportunities. Market Analysis We have undertaken a high level analysis of all our markets in Medway. This analysis has been used to help us understand which markets need priority focus. This high level analysis has been followed by a detailed analysis of specific market segments including: COPD and Coronary Heart Disease This analysis informs our commissioning decisions. Our priority programme of market analysis will continue to be expanded during 2010/11. Market Stimulation We have committed to undertaking a number of activities to stimulate, develop and support the market in Medway. These include: Publishing our competitive procurement plan. This will increase levels of supplier interest in working with NHS Medway, and develop the PCT’s understanding of the market. Improving skills and knowledge through the development of structured activities that will develop and improve the skill base of PCT staff and support to providers. This will ensure that our markets are informed and have the skills necessary to meet our commissioning priorities. Continue to develop programmes that support markets to develop. These programmes will outline how NHS Medway will stimulate and nurture the local health economy to create an environment where there is genuine competition and choice. Some examples of this are the procurement of level 4 CAMHS, Mental Health Prison service provision and the community Lymphoedema service. Seek input from the market at an early stage in order to assist in packaging and scoping any future procurement opportunity that may occur. This will also help NHS Medway to gauge the capability and capacity of the market to deliver the proposed requirements.
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3.5 COSTS 3.5.1 HISTORIC RESOURCE ALLOCATION The NHS in Medway has traditionally been funded significantly below its capitation based ‘fair share’ as calculated through the Department of Health allocation formula for PCTs. In 2005-06 NHS Medway was overspent by £2.5 million. In the following year, 2006-07, the overspend was repaid after a period of cost reduction. In 2007-08 NHS Medway received a significant funding increase of 12% worth £37 million. Coming as it did after a period of strong cost control, rapid investment of these additional funds in robust services was a challenge. In response the PCT prepared detailed strategies covering all major aspects of its business whilst investing heavily in its own provider services and the achievement of 18 week waiting for elective hospital patients. In 2009/10 NHS Medway is very close to its capitation target. 3.5.2 IMPACT OF CURRENT INVESTMENT To understand the effectiveness of the current pattern of resource usage comparisons are made with other organisations against 23 programmes of care. Information from 2007/08 programme budget returns has been used by NHS Medway as part of the information set to support strategic investment and disinvestment plans. Calculation of programme budgets Programme budgeting guidance is issued annually by the Department of Health for both PCTs which commission services, and provider organisations that provide them13,14. Provider organisations include hospital trusts and community services. Using this guidance each provider organisation calculates how much its care costs, assigns them to the appropriate category and informs its commissioners of their share of these costs. Each PCT then looks at its total expenditure and assigns it to programme budgeting category for all services that are commissioned from its various providers. The commissioner also has to split the spend in each programme budgeting category between primary and secondary care. There is no universally agreed definition of what is ‘primary’ and ‘secondary’ care, the pragmatic definition used is who actually pays for the care, so that primary care spend would include: • • •
General Practice, Dentists, Optometrists Pharmacies Prescriptions
13
NHS Manual for Accounts 2008-09 Programme Budgeting Guidance for NHS Health Care Commissioners. http://www.info.doh.gov.uk 14
NHS Manual for Accounts 2008-09 Programme Budgeting Guidance for NHS Health Care Providers, http://www.info.doh.uk
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•
All community work where the PCT carries out the activity via its provider arm (in the case of Medway this would be Medway Community Health Care)
Secondary services would include: • Ambulance services • Hospital services including mental health services, even if provided in the community. The resultant programme budget, which is the spending on services commissioned by the PCT is then submitted to the Department of Health. The DH publishes benchmarking information based on all programme budget returns during the following financial year. 2008/09 benchmarking information has recently been published and NHS Medway is reviewing the comparison between 2007/08 and 2008/09. In order to improve data quality, continual refinements to programme budgeting data collection have been implemented since the first collection. Although many refinements have been made, the programme budgeting figures should only be considered to be a best estimate of the actual expenditure on the categories. The underlying data that support the Programme Budgeting Collection are also subject to year on year changes. Changes in the way activity is coded and reference costs are calculated will therefore have an effect on the allocation of costs to programme budgeting categories from one year to the next. Therefore, it is not straightforward to make comparisons of expenditure between years. However, this presents a challenge as programme budgeting information taken in isolation by single year can result in drawing different conclusions about the appropriateness of spend from previous years when the underlying level of spend has not changed to a great extent or changes are a result of unplanned fluctuations by year.i This occurs because of changes in expenditure or allocation of expenditure in comparator areas which has an impact on actual and relative comparisons. This emphasises the need, when exploring issues of appropriateness of spend which are suggested through programme budgeting data, for an analysis of the finance, activity and outcomes achieved which sit behind the data. The 2009/10 Annual Public Health Report, to be published in March 2010, is themed around the use of programme budget information, and contains a detailed analysis of the position for each programme budget. The introductory chapter of the report is set out below, and provides an overview for NHS Medway. Expenditure in Medway 2008/09 The table below presents expenditure per 100,000 population for the 23 PB categories for NHS Medway, the cluster and England averages. Overall NHS Medway spent slightly less on all 23 programmes than the cluster and England average. It should be noted that in 2008/09 Medway received 3.5% below its capitation funding target and so relative low spends will have been due to lack of monies to invest rather than a decision to not invest. The largest expenditure was for the “other” category, followed by mental
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health disorder, problems of circulation and then cancers and tumours. This pattern was the same in the cluster average and England as a whole. Spend per 100,000 unified weighted population15 by programme budgeting category 2008/09.
Programme Budgeting Category 01 Infectious Diseases 02 Cancers and Tumours 03 Disorders of Blood 04 Endocrine, Nutritional and Metabolic 05 Mental Health Disorders 06 Problems of Learning Disability 07 Neurological 08 Problems of Vision 09 Problems of Hearing 10 Problems of Circulation 11 Problems of the Respiratory System 12 Dental Problems 13 Problems of Gastro Intestinal System 14 Problems of the Skin 15 Problems of Musculo Skeletal System 16 Problems due to Trauma and Injuries 17 Problems of Genito Urinary System 18 Maternity and Reproductive Health 19 Conditions of Neonates 20 Adverse effects and poisoning 21 Healthy Individuals 22 Social Care Needs 23 Other All
Spend per 100,000 unified weighted population (ÂŁ) Cluster England average average NHS Medway 1,569,447 1,523,926 2,345,644 9,535,393 9,076,176 9,455,005 2,077,458 1,848,053 1,950,212 4,462,521 4,350,816 4,339,455 14,450,465 17,263,381 19,121,515 5,222,342 5,426,135 5,611,091 6,783,739 6,294,782 6,767,417 3,314,467 3,617,465 3,295,434 868,441 592,511 815,757 11,626,091 11,416,883 12,993,582 6,125,908 6,713,510 7,796,769 7,313,571 6,432,989 6,243,572 6,949,823 7,444,071 7,788,606 4,336,031 3,133,058 3,234,375 7,675,650 7,106,399 7,969,542 7,159,938 6,062,194 6,354,238 6,679,383 6,788,442 7,377,513 4,647,774 6,576,483 6,044,223 1,943,578 1,757,623 1,722,642 1,539,737 1,624,349 1,831,307 4,021,186 3,561,576 3,574,482 3,275,360 2,616,854 3,650,616 24,891,368 26,357,723 22,770,624 146,469,670 147,585,397 153,053,619
Source: DH PB Toolkit v 1, 2010 Figure 1 below presents the variance in spending between NHS Medway and the cluster average in the main programme budgeting categories. Bars above the line represent categories where NHS Medway is spending more than the cluster average and those below are where NHS Medway spends less. These are indicators of how NHS Medway compares to similar PCTs, and the changes in investment that would be required to 15
The unified weighted population is the PCT responsible population adjusted using the national weighted capitation formula, for the age structure of the population, its additional need over and above that accounted for by age, and the unavoidable geographical variations in the costs of providing service
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bring NHS Medway in line with the cluster average. However it has to be considered that although the cluster represents similar areas, there may remain differences in populations which may impact on need. Also, not every other PCT in the cluster may be spending at the appropriate level for the population, impacting on the validity of the average as a comparator. In 14 categories NHS Medway spends more than the cluster average and in 9 it spends less per 100,000 population. The greatest variance is for mental health disorders (over ÂŁ2.8 million per 100,000 population below the cluster average), followed by maternity and reproductive health (just under ÂŁ2 million per 100,000 population below the cluster average). Figure 1: Column chart showing the variance of NHS Medway expenditure/100,000 population from cluster average for main categories.
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Programme budget expenditure and outcomes. In assessing the effectiveness of investment it is important to consider outcomes and expenditure for the different programme budget categories together. Figure 2 below depicts how far from the national average the programme is for expenditure and outcomes using a standard z score. Figure 2:
Outcomes and expenditure data in NHS Medway 2008/09 relative to other PCTs in England16 Spend and Outcome relative to other PCTs in England
Lower Spend, Better Outcome
Higher Spend, Better Outcome
2.5
2.0
1.5
Health Outcome Z Score
Dent Mat
1.0
Trauma 0.5
Neo 0.0
Gastro,Pois
Inf
Skin
LD,Musc,Soc Blood,End,Hear,Hlth
MH
-0.5
Neuro,Vision Circ
-1.0
Canc
Resp
-1.5
-2.0
-2.5 -2.5
GU
-2.0
-1.5
-1.0
-0.5
0.0
0.5
1.0
1.5
2.0
2.5
Higher Spend, Worse Outcome
Lower Spend, Worse Outcome Spend per head Z Score
No outcome indicators readily available Outcome indicators available
Source: Yorkshire and Humber Public Health Observatory, 2010
16
Interpreting the chart: A programme lying outside the solid pink +/- 2 z scores box, indicates that the data is significantly different from the England average. If the programme lies to the left or right of the box, the programme is statistically significantly different on spend, and if it lies outside the top or bottom of the box, the programme is significantly different on outcome. Programmes outside the box at the corners are statistically significantly different from the England average for both spend and outcome.
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Health outcome indicators Programme budgeting category Infectious diseases Cancers and Tumours Endocrine, Nutritional and Metabolic problems Mental Health Disorders
Neurological Problems of vision Problems of circulation Problems of respiratory system Dental problems Problems due to trauma and injury Problems of Genito Urinary system Maternity and reproductive health Conditions of neonates
Health outcome indicator Mortality from infectious and parasitic diseases Mortality from all cancers, under 75 years % of diabetic patients whose last HbA1c was 7.5 or less % of patients on enhanced CPA receiving follow up within 7 days of discharge Mortality from epilepsy, under 75 years Total sight tests per 10,000 population Mortality from all circulatory diseases, under 75 years Mortality from bronchitis and emphysema and COPD, under 75 years Decayed, missing and filled teeth 5 years Mortality from accidents Deaths within 30 days of admission all genito urinary admissions % of low birth weight births (live and still) < 2500 gms Neonatal infant mortality per 1,000 births
Source: Yorkshire and Humber Public Health Observatory, 2010 None of the Medway programme budgeting categories has a score significantly different (a z-score +/-2) to the national average, this suggests that for the majority of programmes Medway is within the expected ranges for the country for both spend and outcomes. However, using the national average means that the comparisons of expenditure may not take into account fully any differing levels of need in Medway that could impact on the required level of expenditure and the validity of the comparison. Although not significantly different a number of programmes have a z score of +/-1 or more, which could suggest a need for further exploration. Mental health, respiratory problems and problems of the genito urinary system, circulatory problems and respiratory problems feature in the bottom left quadrant signifying a lower spend and/or worse outcomes with a z score more than -1 than the national average. Genito-Urinary is almost on the line to signify a statistically significant worse outcome than the national average. For mental health and respiratory conditions there is a lower spend but the achievement of the outcomes used are nearer to the national average. This suggests a need for further exploration to assess whether greater investment or a change in the pattern of investment could result in better outcomes for the population. The maternity programme features in the top left quadrant, it has better outcomes but a lower spend. This suggests the need for an exploration of how the lower spend impacts on other outcomes.
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The dental programme features in the upper right quadrant where better outcomes than average are being achieved; however this programme also attracts a higher level of expenditure than average. Access to dental services in Medway is excellent, and it is known that patients travel from other PCTs to Medway dentists. At present, NHS Medway’s allocation is adjusted for this. During 2010/11, the PCT will be exploring the implications of the inclusion of primary dental service costs into PCT baselines. Finally problems of skin has an almost statistically significantly higher spend than the national average (there are no outcome measures attached to assess). This higher spend will be further explored with information about local activity and outcomes. Comparisons to previous years Figure 3 below presents the changes in reported expenditure by main category for the last three financial years. The level of expenditure varies by year. Some of the changes in spending will be explained by the changes in the coding of activity and the allocation of reference costs. For example, between 2007/08 and 2008/09, there were changes in the methodology for allocating the different types of activity and for allocating costs between the subcategories in the mental health disorders and infectious diseases. The biggest change in expenditure has been for the “other” category. For mental health disorders and problems of circulation, the second and third highest spending categories, there was a decrease from 2006/07 to 2007/08 but an increase in spending for 2008/09. The fourth highest spending category Cancer and Tumours has seen an increase each year. Figure 3: NHS Medway expenditure per 100,000 population (£millions) by year. Source: Department of Health, 2010 Figure 4 below presents the change in percentag e funding for each of the main categories between 2007/08 and 2008/09 for NHS Medway, the cluster average
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and the national average. This shows that there is fluctuation in all of the categories for the cluster average and the national average as well as for NHS Medway. In some categories, for example adverse effects and poisoning (20) and neurological (7) there is a similar proportional change for all three areas. In other categories such as problems of hearing (9) and maternity and reproductive health (18) the percentage changes are negative for one or more of the areas and positive for the others. As in some categories there are positive and negative changes by area, this suggests that these are not only the result of changes in the methodology and coding. The other reasons could be a real change in the level of expenditure and/or lack of consistency in accurately attributing activity and expenditure in Medway and other PCT areas. Unlike other financial information, programme budgeting returns are not currently subject to an audit process. Figure 4: Percentage change in expenditure per 100,000 population 2007/08 â&#x20AC;&#x201C; 2008/09 by year for NHS Medway, cluster average and national average
% c h a n g e in fu n d in g 2 0 0 7 /0 8 - 2 0 0 8 /0 9
80%
60%
40%
20%
0% 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 -20%
-40%
-60% NHS Medway
Cluster average
Source: Department of Health, 2010
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National average
Figure 5 presents the variance between NHS Medway and the cluster average expenditure for 2007/08 and 2008/009. This shows that there are differences in the variance over the last two years, this varies by category. The information in the figures and data presented above suggests that by taking the information by single year, conclusions may be drawn about the appropriateness of the level of expenditure following a comparison with the cluster average, which could be misleading. For example, for 2008/09 a variance may appear for a category which suggests that Medway is out of step with the cluster average spending which was not apparent in 2007/08. However, this could be because there is a change in the cluster or national average and/or there was no planned change in Medwayâ&#x20AC;&#x2122;s expenditure but a natural year by year variation in activity and thus costs. Also, Medway may be investing in an area which puts it out of step with the cluster average but is important to meet the needs of the population or investing in the short term to make up for under-investment in the past. Single year programme budgeting information can therefore provide false reassurance or indicate an issue where there may not be one. For example, in figure 5 in 2007/08 the variance for problems of circulation (10) would have suggested that potentially investment would be required. In 2008/09 Medwayâ&#x20AC;&#x2122;s expenditure is slightly higher than the cluster average suggesting that no change is needed, providing reassurance. However, looking at the figure 4 not only did Medwayâ&#x20AC;&#x2122;s funding increase but the average cluster expenditure decreased meaning that Medway had to make a smaller change to reach parity. In fact, looking at figures from the previous year in figure 3 Medway is only spending slightly more in 2008/09 than it did in 2006/07. Further investigation in the spending and activity would be required to understand what has changed over the three years and whether anything has been done differently with the expenditure to improve overall outcomes. Figure 5: Variance between NHS Medway and Cluster average for expenditure per 100,000 population 2007/08 and 2008/09
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4,000,000 3,000,000 2,000,000 1,000,000 0 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 -1,000,000 -2,000,000 -3,000,000 -4,000,000 -5,000,000
Variance from cluster 07/08
Variance from cluster 08/09
Source: Department of Health, 2010 For the 2007/08 data a quadrant analysis was carried out in the same way as presented in figure 2 (YHPHO, 2009), which for each PCT identified those categories where spending and/or associated outcomes were significantly different from the national average. Using this technique, it identified the Hearing category to be significantly higher spending in Medway than nationally. Using the 2008/09 data this is not the case as expenditure decreased by 40% (the cluster had a similar percentage reduction) to a similar level to 2006/07 and in figure 2 is seen to be less than 1 standard deviation from the national average. If just the 2008/09 data are used, there could appear to be no issue but 2007/08 could be the year where the expenditure met the need of the population, or these fluctuations could happen every year giving a different indication of the appropriateness of the spend year by year. As a result of this, programme budgeting information needs to be used with care. Although, caution is advised using trend data this should be used when making conclusions about one years data to understand if a different picture is shown from one year to the next and the reasons behind it. Also, of importance is the use of outcome data to assess whether the money being spent effectively meets the needs of the population. 3.5.3 FINANCIAL CHALLENGE The PCT was notified of its 2010/11 recurrent Revenue Resource Allocation in December 2008. The SHA has also advised likely inflation scenarios for future years, and the National Operating Framework has also set out assumptions regarding tariff uplifts. Outside of these parameters, the PCT has considered a range of scenarios which present a variety of outcomes, and these variables are set out below:
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• • •
•
•
Revenue Resource Limits for 2011/12 to 2014/15 to be set at zero % uplift in two models, whilst the third scenario considers a 2.5% uplift each year. This assumption may only hold good until the General Election, after which Resource Limits may reduce. Tariff uplifts are set at a maximum of zero per cent for the period 2010/11 to 2014/15. The models considered reflect a tariff uplift of 2.5%, offset by efficiency savings of between 3.5% and 4.5% Any assumptions about inflation for the next one or two years reflect how well the Economy is expected to improve following the recession. It is less certain how inflation will behave after this since this is dependent on the speed of recovery and other external factors, and a range of options are considered. The PCT is planning to spend only 98% of its recurrent allocation recurrently, and to achieve a 1% surplus each year.
For planning purposes, these assumptions and variables have been modelled into 3 scenarios, low growth, medium growth and high growth. Medium Growth (model base case) This model assumes that there is zero per cent growth after 2010/11. Tariff inflation will be zero in 2010/11, and 2.5% increase from 2011/12, but with an expectation of 4.5% efficiency, giving a net 2% real reduction in tariff. Most of the other services have zero or low increases, except for GP Prescribing which has a 5% increase each year. Low Growth (model scenario 1) Like the Base Model, there is zero per cent growth after 2010/11, and similar tariff inflation rates apply. However, the efficiency factor is reduced to 4% creating a net 1.5% reduction in tariff, in effect giving a higher cost to the PCT of tariff services than in the Base Model. Other inflation factors remain unchanged. High Growth (model scenario 2) This model assumes growth of 2.5% each year after 2010/11. Tariff inflation remains at 2.5% after 2010/11, but efficiencies are only at 3.5%. This gives a net tariff reduction of 1%. Other inflation factors remain unchanged. This low level of efficiency, coupled to the highest rate of PCT growth of any of the models, produces the model with the highest net growth available to the PCT. For the purposes of the Operational Plan, the Medium Growth model has been adopted. Whilst the other models have their merits, at this stage there is no indication that the Economy will support growth rates of 2.5% each year after 2010/11, even after the General Election, and for this reason, the High Growth model was not adopted. The PCT faces challenging demands, and wants to create capacity to develop new services, more appropriately meeting the needs of its population. A model offering a net 1.5% saving on tariff would not give the flexibility the PCT needs to develop these services, and for this reason the Low Growth model was rejected. The following tables summarise the overall positions generated by these three scenarios:
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Summary - Base Model Medium Growth
2010/11
Income (£'000) Expenditure (£'000) Planned surplus (£'000) Summary - Low Growth Scenario 1
Expenditure (£'000) Planned surplus (£'000) Summary - High Growth Scenario 2
Expenditure (£'000) Planned surplus (£'000)
2013/14
445,001
448,970
441,066
-437,043
-440,682
-444,649
-436,741
4,317
4,319
4,321
4,325
2011/12
2012/13
2013/14
441,360
444,992
448,962
441,058
-437,043
-440,673
-444,641
-436,733
4,317
4,319
4,322
4,325
2010/11
Income (£'000)
2012/13
441,361
2010/11
Income (£'000)
2011/12
2011/12
2012/13
2013/14
441,360
455,312
469,860
472,799
-437,043
-450,993
-465,538
-468,473
4,317
4,319
4,322
4,326
The impact of these scenarios on investment decisions is described in chapter 4.
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SECTION 4 | STRATEGIC DIRECTION ION 4 | STRATEGIC PRIORITIES 4.1 STRATEGIC GOALS The strategic goals agreed in 2008/09 and set out below have been reaffirmed by the Board of NHS Medway.
o
IMPROVING HEALTH AND WELL BEING Reducing the high levels of smoking, obesity and teenage pregnancy
o
TARGET KILLER DISEASES Reducing premature deaths in Cancer and Cardiovascular Disease and in doing so improve the end of life experience for patients
o
CARE PATHWAYS â&#x20AC;&#x201C; CLOSER TO HOME Developing the capacity and capability of local services whilst offering more choice and greater responsiveness to local need
o
SUPPORTING FUTURE GENERATIONS Securing better outcomes and access to services for children and young people in Medway
o
PROMOTING INDEPENDENCE AND IMPROVED QUALITY OF LIFE Meeting the challenge of the growing number of older people and people with long term conditions, maximising their independence and well being
o
IMPROVING MENTAL HEALTH Improving access to a wide range of preventative and treatment services to improve the mental well being of people in Medway
The identification of these goals was derived from the robust needs assessment summarised in chapter 3 of this document and agreement to target those actions which will have the most impact on improving the health and well being of people in Medway. The delivery of the goals will be achieved largely through service and system redesign rather than through significant investment. However, there are some areas in which the PCT will need to make investments in order to deliver the required improvement in outcome. The resource to support these investments will be generated through the delivery of efficiency gains. In rising to the quality and productivity challenge the PCT will deliver reductions in expenditure by:
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•
•
•
Stopping doing things of limited clinical value, eg o
Protocols for surgical thresholds
o
Avoiding inappropriate admissions
o
Prescribing ineffective medication
Doing things more efficiently, eg o
Pathway redesign
o
Reduce length of stay
o
Reduce waste in medicines management
Doing more cost-effective interventions, eg o
Maximise prevention & early detection
o
Address variation in clinical practice
o
Prescribing of generics
4.2 TARGETTING FINANCIAL RESOURCES 4.2.1
AREAS FOR DISINVESTMENT
As the diagram in section 3 shows, in the ‘worst case’ scenario, where allocations are reduced in cash terms in 2013 - 2015, NHS Medway will need to deliver approximately £90 million of cost reductions over the next five years in order to generate the resource required to invest in strategic improvements and growth in activity. Ultimately, savings will be delivered through reduction in expenditure on buildings and staff. This requires both an increase in clinical productivity and a reduction in the inappropriate use of resources. The PCT has been carrying out its own analysis and working with Tribal Newchurch to identify the areas in which reductions in spend should be delivered, and categorising them as operational (using current systems more effectively), tactical (eg service redesign) and strategic (e.g. preventative and/or whole system redesign). These are summarized in the table overleaf:
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Savings (ÂŁm) 2010/11 2011/12
Initiative
2012/13
2013/14
2014/15
Cumulative
Operational: Reduce areas of payment growth Thresholds & protocols Reduction in referrals to acute care
5.1 1.7 0.5
2.3 2.4 0.5
1.5 3.7 1
1.5 3.6 0.5
0.5 2.9 0
10.9 14.3 2.5
Productivity in community/MH services Productivity in primary care Tariff 'unbundling' Informatics efficiencies Estates efficiencies
2.35 1.7 0.15 0.3 0.2
0.35 0.25 0
0.2 0.2 0
0.2 0.05 0
0 0 0
3.1 2.2 0.2
0.2
0.2
0.2
0.2
1.0
12
6
6.8
6.05
3.6
34.5
0.3 0.65 1.2
2.7 1.25 0.65
7 1.3 1.2
5 2.6 2.45
5 0.3 0
20.0 6.1 5.5
2.15
4.6
9.5
10.05
5.3
31.6
7.4 (4)
7.4 (3)
14.8 (8)
14.8 (7)
14.8 (8)
59.2 (29.7)
4
4
7
8
7
18
15
23
24
16
29.5 0.0 95.6
Sub-total operational Tactical: Application of medical care appropriateness protocols Better disease management Medicines management Sub-total tactical Strategic: Focused reduction in 'high risk' and 'very high risk' patients Community reprovision required Sub-total strategic Total
In addition, NHS Medway is adopting the principle that all investments must support system change and consequently deliver equal or greater levels of saving over a reasonable time period, ideally within year. The delivery plans described in section 4.3 below therefore include some further savings plans. It is recognised that the â&#x20AC;&#x2DC;payback periodâ&#x20AC;&#x2122; for some investments in primary prevention and public health will be longer than one year. Over the five year period, therefore, the savings plans set out in this table exceed the requirements summarised later in this chapter. Where relevant, further information on the impact of these initiatives is included within the plans for service redesign set out in section 4.4 of this document.
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4.2.2 PRIORITISING FOR INVESTMENT PCTs are responsible for commissioning health services within a statutory duty to break even. In a resource constrained environment there will always be competition for the allocation of resources. As such NHS Medway will ensure that a consistent, just, ethical and robust approach is consistently applied when prioritising investment. The approach used by NHS Medway builds on the prioritisation framework agreed by the PCT Board in March 2009. It has been developed further in partnership with KPMG and other South East Coast PCTs. The approach ensures that decisions are: •
Driven by the strategic priorities of the organisation
•
Built on an ethical approach, giving competing needs a fair hearing
•
Set within good corporate governance and operationally efficient
•
Able to increase public and patient confidence around the legitimacy of decision making
•
Helping achieve financial balance and provide better value for money
•
Reducing the risk of successful legal challenge
The prioritisation matrix used by NHS Medway is set out in Appendix 3. The KPMG model is strongly driven by analysis of programme budget data. Section 3.5.2 of this document describes the programme budget position for NHS Medway, and also sets out some of the caveats which must be applied when using this data to drive decision making. Given these caveats, whilst taking account of the programme budget position, NHS Medway has continued to use the PCT’s six strategic goals to prioritise the use of resources across all investment areas. In reviewing the Strategic Commissioning Plan and setting priorities NHS Medway has sought to identify areas where focused improvement will deliver improved health outcomes for Medway residents and enable better use of resources so that net savings can be delivered in line with the anticipated financial challenge. The following areas have been identified for particular focus over the period 2010-15: •
Primary prevention, including support to children and young people, and early diagnosis;
•
Urgent Care, to include the development of a single point of access, keeping people at home where possible and discharging smoothly where admission is required;
•
Clinical protocols for decision making thresholds at all interfaces of care (eg referrals, new to follow ups, intermediate care, 19 ambulatory care conditions,);
•
Long Term Conditions - especially COPD, CHD, diabetes, stroke;
•
Dementia – ensure services are able to identify need at an early stage and provide support for people in the community, including support for carers;
•
Adult mental health - complete pathway redesign;
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•
End of Life Care - considering the totality of redesign (not just cancer and palliative care).
During 2009/10 Strategic Change Programme Groups have used a wide range of information, including programme budget analysis, pathway review, national and regional priorities and performance indicators, to develop plans for investment and disinvestment. A short summary of each plan was submitted for consideration in this Strategic Commissioning Plan. In all, 137 proposals were made by Strategic Change Programme Groups. The proposals were independently scored against the prioritisation framework by members of NHS Medway’s Executive Team and by the NHS Medway Investment Decision Group, which includes Practice Based Commissioning lead clinicians, the Directors of Public Health and Commissioning, Deputy Directors of Finance and Commissioning and the Chair of the Professional Advisory Committee. In making a recommendation to the Board on the final list of investments to be made in this Strategic Commissioning Plan the Executive Team developed the following principles: •
Proposals which score less than half available points when applying the prioritisation framework will not be funded.
•
For proposals scoring more than half marks, priority has then been given to those which deliver national requirements which also have a significant positive impact on health in Medway, and to those which will deliver system change and consequently savings.
•
For each scheme, the detailed business case must set out monitoring arrangements for the release of savings. Business cases will be reviewed by the Investment Decision Group and the PCT Director of Finance before implementation commences.
The proposals which met these criteria and which will be implemented through this Strategic Commissioning Plan are set out in section 4.4. 4.2.3
INVESTMENT, DISINVESTMENT AND THE FINANCIAL MODEL
Even in the light of zero or negative tariff rates, savings exercises will be needed to deliver the planned 1% surplus. There will be a need to counterbalance any potential increase in costs in specific service areas. For example if the scale of demand from the acute sector does not reduce there will need to be cuts in other service areas which run contrary to the planned strategic directions which seek greater investment in prevention and services closer to home. In 2009/10 the PCT has experienced increases in acute activity and cost despite relatively static levels of A & E attendances and GP referrals, and this position cannot continue. Delivering recurrent surpluses across all scenarios will require effective prioritization and radical service redesign. Planning for a surplus is not only a requirement of the national Operating Framework, it is essential to ensure availability of funding for service redesign in future years. NHS Medway has identified a number of initiatives which will have a significant impact in costs across the whole system – for example changes in acute capacity, and then overlaying this with an investment and disinvestment strategy for each strategic commissioning goal, discussed further in section 4.
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Over the five years of this strategy, therefore, NHS Medway will target its approach to disinvestment on areas of waste and duplication, and in driving greater efficiencies through whole pathway design and productivity gains. This will enable the PCT to invest in areas which will improve the overall health of the population. The summary investment and disinvestment plans for the medium scenario are set out below: 2009/10 Inflation Real Growth Net Growth
2010/11 0.74%
2011/12
2012/13
2013/14
2014/15
5.42%
-0.57% 0.00% 0.00%
-0.37% 0.00% 0.00%
-0.28% 0.00% 0.00%
-0.28% 0.00% 0.00%
Income Recurrent Allocation Allocation Growth Non Recurrent Allocations Lodgements Underspends c/f
-388,627 -20,403 -3,681 -1,000 -5,002
-410,199 -21,232 -1,720 -4,500 -3,708
-431,431 0 -1,720 -7,532 -4,315
-431,431 0 -1,720 -11,500 -4,315
-431,431 0 -1,720 -3,593 -4,315
-431,431 0 -1,720 0 -4,315
Total
-418,713
-441,359
-444,998
-448,966
-441,059
-437,466
Baseline expenditure Inflation Less Non Recurrent spend Strategic Change Programme - total Acute overperformance = Other Contingencies Activity growth CQUIN Non Recurrent spend/ topslice CRES requirement from Primary care per Operating Framework Disinvestment
415,005
420,466 3,125 -1,250 3,660 14,000 5,067 2,073 8,628 -400 -18,325
437,044 -2,399 0 1,779 5,314 7,501
440,683 -1,564 0 353 7,471 7,784
444,651 -1,185 0 892 9,628 8,000
436,744 -1,185 0 613 11,732 8,000
-8,557
-10,076
-25,242
-22,753
Total
415,005
437,044
440,683
444,651
436,744
433,151
-3,708
-4,315
-4,315
-4,315
-4,315
-4,315
Expenditure
Income less Expenditure
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The table below shows the impact of investment across each Strategic Change Programme Group:
Name
Gross increased expenditure
Gross reduced expenditure
Net impact on expenditure
3 years (£000s)
5 years (£000s)
3 years (£000s)
5 years (£000s)
3 years (£000s)
5 years (£000s)
1 . Choosing Health
1,925
1,925
-
-
1,925
1,925
2 . Cancer
2,633
2,633
-
-
2,633
2,633
707
707
35
35
672
672
3 . CHD 4 . End of Life
27
27
250
250
(223)
(223)
5 . Primary Care
4,998
6,120
-
-
4,998
6,120
6 . Planned Care
1,188
1,188
-
-
1,188
1,188
7 . Urgent Care
151
223
43
43
108
180
8 . Learning Disability
351
351
-
-
351
351
1,373
1,373
-
-
1,373
1,373
10 . Stroke
258
258
-
-
258
258
11 . Diabetes & Renal
245
295
-
-
245
295
9 . Maternity & Children
93
93
750
750
(657)
(657)
13 . Adult MH (incl Substance
12 . Older People
2,434
2,434
29
29
2,405
2,405
14 . Capacity for Change/Other
2,477
2,477
611
611
1,866
1,866
Over the five years of this strategic commissioning plan, NHS Medway intends to shift the balance of investment from secondary care to primary and community services. The tables overleaf shows the impact of planned investments and savings by setting of care and by provider.
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Sustainable Financial Position: Actual and 5-year forecast
(ÂŁ000s)
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
CAGR*
New recurrent baseline
371,179
391,582
412,814
412,814
412,814
412,814
2.1%
4,141
17,448
18,617
18,617
18,617
18,617
35.1%
-
2,455
1,720
1,720
1,720
1,720
n/a
Other Miscellaneous allocation
1,258
1,169
-
-
-
-
-100.0%
Prior year lodgements
11,937
1,000
4,500
7,532
11,500
3,593
-21.3%
New lodgements
(28,093)
-
-
-
-
-
-100.0%
3,211
5,059
3,709
4,317
4,319
4,321
6.1%
Total
363,633
418,714
441,361
445,001
448,970
441,066
3.9%
Primary and community
117,693
143,484
140,888
143,600
144,427
145,331
4.3%
MH and LD commissioning
36,411
36,515
38,377
38,489
39,046
39,699
1.7%
Continuing care
4,484
5,198
5,757
5,814
5,871
5,985
5.9%
165,503
192,879
199,836
200,591
200,301
192,570
3.1%
Specialised Commissioning
7,014
7,995
8,933
8,775
8,617
7,459
1.2%
Other PCT Commissioning Spends
11,014
13,908
14,013
14,052
13,848
13,696
4.5%
Other PCT Spend
16,454
15,025
14,261
14,296
14,808
15,356
-1.4%
-
-
14,978
15,065
17,732
16,645
n/a
358,574
415,005
437,043
440,682
444,649
436,741
4.0%
5,059
3,709
4,317
4,319
4,321
4,325
-3.1%
Non-recurrent allocation received every year Non-recurrent allocation Resource
Return of previous year surplus/deficit
Secondary or tertiary acute care Expenditure
Contingencies Total Expenditure PCT Surplus/ (Deficit) Reported
*Compounded annual growth rate
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Provider
Medway
Existing or new provider
Existing
FY 2011/12
FY 2009/10
FY 2013/14
Medway
10 10
Medway Community Healthcare
Existing
Kent and Medway NHS and Social Care Partnership Trust
Existing
Maidstone & Tunbridge Wells
Existing
Guyâ&#x20AC;&#x2122;s and St. Thomas'
Existing
South East Coast Ambulance
Existing
East Kent Hospitals
Existing
King's College Hospital
Existing
Queen Victoria Hospital
Existing
Dartford & Gravesham
Existing
Medway Community Healthcare
9 9
Kent and Medway NHS and Social Care Partnership Trust
8 8
Maidstone & Tunbridge Wells
7 7
Guyâ&#x20AC;&#x2122;s and St. Thomas'
6 6
South East Coast Ambulance
5 5
East Kent Hospitals
4 4
King's College Hospital
3 3
Queen Victoria Hospital
2 2
Dartford & Gravesham
-
Total
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1 1
50,000
238,163
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100,000
150,000
-
50,000
100,000
225,548
150,000
-
20,000 40,000 60,000 80,000 100,000
196,720
The chart above shows the change in spend at the ‘top 10’ Providers for NHS Medway. Medway Foundation Trust remains the most significant provide, accounting for 60% of all acute activity. However, over the five year period, the contract value reduces from £121 m in 2009/10 to £82m in 2013/14. Activity in other acute Trusts shows small changes, but it also shows indicates how reliant the PCT is on the specialist providers. The move towards an increase in community provision shows expenditure on Medway Community Healthcare increasing, although in practice as the future organisational form for community services is established the provider location of this spend may change. The three following charts show the change in expenditure by setting of care in the three financial scenarios. The cumulative expenditure for all three scenarios show similar characteristics: •
• •
Income has increased by £21m in the Base Model and Scenario 1, arising from the growth received by the PCT in 2010/11. In addition, Scenario 2 also benefits from 2.5% growth per year from 2011/12, accounting for a further £32m Due to the uncertainties faced by the PCT, a significant amount of the increase has been identified as contingencies, to be applied wherever pressures arise Under Scenario 2, further development of services is possible, predominantly in Primary & Community , and Mental Health and Learning Disability services.
Base Model £000s Surplus/deficit year ending 09/10
Allocation
Change in Recurrent Income Change in Non-Recurrent Income Change in Primary and Community Change in Mental Health and Learning Disability
Change in Continuing Care Spend Change in NHS and Foundation Trusts Change in ISTCs
Expenditure Change in Ambulance Trusts Change in Other Secondary and Tertiary Change in Specialised Commissioning Change in other PCT Commissioning Spends Change in Other PCT Spend Change in Contingencies Surplus/Deficit year ending 13/14
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5,000
10,000
15,000
20,000
25,000
30,000
STRATEGIC COMMISSIONING PLAN 2008-13
I&E, Cumulative to 2013/14, £000s
Financial scenario 1
Financial scenario 2
Surplus/deficit year ending 09/10
Surplus/deficit year ending 09/10
Change in Income
Change in Income
Change in Primary and Community
Change in Primary and Community
Income
Change in Mental Health and Learning Disability
Change in Mental Health and Learning Disability
Change in Continuing Care Spend
Change in Continuing Care Spend
Change in Secondary and Tertiary Change in Secondary and Tertiary
Expenditure
Change in Specialised Commissioning
Change in Specialised Commissioning
Change in Other Commissioning Spend
Change in Other Commissioning Spend
Change in Other Spend (e.g., estates) Change in Other Spend (e. g., estates)
Change in Contingencies Change in Contingencies
Surplus/Deficit year ending 13/14 Surplus/Deficit year ending 13/14
-
5,000
10,000
15,000
£000s
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20,000
25,000
30,000
-
10,000
20,000
30,000
40,000 £000s
50,000
60,000
70,000
STRATEGIC COMMISSIONING PLAN 2008-13
4.3 MEASURING SUCCESS As part of the PCT assurance process the organisation’s performance is monitored rigorously by the Board against the key health outcomes identified through the World Class Commissioning process, the full set of ‘vital signs’ as well as other locally agreed performance indicators (See Appendix 2 for more detail). The indicators of success for delivery against each of the six strategic goals are set out later in this document and cover improved health outcomes, key performance indicators which seek to target inequalities in access and those tangible changes required to improve the patient and carer experience of local services. 4.3.1 IMPROVING HEALTH OUTCOMES In response to a vision of ‘reduced health inequalities’ and ‘added years to life and life to years’ two national targets have been set against which all PCTs in partnership with other agencies are measured. These are: o
Life expectancy at birth
o
Index of inequalities for life expectancy at birth at lower super output area
A range of other World Class Commissioning (WCC) targets have also been chosen by the Board. Some are proxies to measure improved health outcomes and reducing inequalities which are based on the priorities identified by the JSNA and linked to the PCT’s strategic goals. The local goals for NHS Medway are: •
Reducing smoking prevalence
•
Reducing the rate of CVD mortality
•
Improving the control of blood sugar in people with diabetes
•
Increasing the number of infants who are breastfed
•
Increasing the numbers of people admitted to hospital with a suspected stroke who are given a brain scan within 24 hours
•
Increasing the uptake of influenza vaccine in the over 65s
•
For IAPT services the proportion of service users assessed as moving to recovery
•
Reducing the rate of alcohol related hospital admissions
Working with our providers we have made real progress in improving the quality of health outcomes for the local population. These are described overleaf.
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STRATEGIC COMMISSIONING PLAN 2008-13
Health Outcome
Target 2013/14 56%
Baseline 2007/08 21%
Year 1 Progress 40%
Smoking quitters
932
665
839
Uptake of influenza vaccines for people aged 65+
76%
72%
75%
Stroke admissions given a brain scan within 24 hour
85%
38%
63%
Rate per 100,000 alcohol related admissions
1866
1450
1389
CVD mortality (DSR per 100,000)
64.5
81.04
75.54
Diabetes controlled blood sugar
70%
63%
67%
Infants breastfeeding at 68 weeks
Comments Peer support for mothers should encourage breastfeeding as Health Visitors in Medway are visiting earlier than before to ensure that the mothers receive the support they need. Change in smoking prevalence and population estimates within Medway that would alter the forecast. The uptake of influenza vaccines for the over 65 age group within Medway is above the levels achieved by the SHA and nationally In June 2010, MFT will have a MRI and a MRA scanner so will be able to improve their current performance. This target is measured from national inpatient data on SUS and uses diagnosis codes rather than any locally collected data The directly standardised death rate for 2006 to 2008 was 86.610 with a Upper Confidence level of 93.210 and a lower confidence level of 76.21 Awaiting confirmation on clinical appropriateness of continuous increase in percentage of patients with an HbA1c of 7.5 or less. QOF definitions have changed and will now measure patients with an HbA1c of 7 or less.
4.3.2 REDUCING INEQUALITIES In partnership with Medway Council and other community based organisations a number of targets and Key Performance Indicators have been agreed within the Community Plan and Local Area Agreement. These focus on improvements to the safety, health and wellbeing of the local people (a full list can be seen in Appendix 2). They also complement the national outcome measures focused on tackling issues of deprivation and in particular seek to: o
Improve the health and care of looked after children
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STRATEGIC COMMISSIONING PLAN 2008-13 o
Increase healthy lifestyle choices through reducing number of smokers, tackling obesity
o
Maintain the independence of the older population through more health promotion initiatives, support for carers as well as more intensive home and intermediate care
o
Increase the number of drug misusing adults in treatment
These are underpinned by a range of KPIs known as ‘Vital Signs’ which seek to drive up for the population as a whole improvements in the timeliness and responsiveness of local services. Equality of access needs to be borne in mind when reading each area for action. This is particularly relevant for those client groups who traditionally experience the worst health outcomes by virtue of the inaccessibility of services, for example people with learning disabilities. It is implicit in every initiative and supporting plan listed that reasonable adjustments are made to ensure that all areas of commissioning comply with Article 1 of the NHS Constitution and further the PCT’s discharge of its Disability Equality Duty.
4.3.3 IMPROVING QUALITY OF EXPERIENCE As well as addressing health inequalities NHS Medway will consider a range of other national and local targets designed to improve the quality of the patient experience e.g.: o
The implementation of national guidance including that from NICE
o
Access targets for elective and outpatient activity
o
Infection control and patient safety
o
Personalised care
NHS Medway welcomes the increased focus on patient experience highlighted by ‘Good to Great’. The PCT has already included measures of patient experience through the use of the Commissioning for Quality & Innovation (CQUIN) payment framework17 and will be developing this approach further in 2010.
17
http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_091443
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STRATEGIC COMMISSIONING PLAN 2008-13 4.4 DELIVERING THE STRATEGIC GOALS For each of the six strategic goals a framework has been developed which shows the case for change; the implications and impact of the actions agreed, including delivery of Healthier People, Excellent Care pledges; engagement, market management and enabling commissioning investment and disinvestment strategies within the delivery plan and risks associated with delivering the strategic goal. These are underpinned by crosscutting programmes to support the delivery of the PCT’s strategic objectives, including: transforming community services, strategic estates management, better use of informatics and a whole health economy approach to workforce and organisational development. The table below outlines how NHS Medway’s vision and strategic goals relate to the Healthier People, Excellent Care pathways, to World Class Commissioning outcomes and to the delivery vehicle of the Strategic Change Programme.
Vision
A healthy, safe and productive population in Medway where individuals are empowered to take control of their own well being and individuals and communities have access to the very best quality of health care
Strategic Goal
HPEC pathway
WCC Outcome(s)
Strategic Change Programme Group(s)
Improving Health & Well-being
Staying healthy
Smoking Prevalence
Choosing Health
Targeting Diseases
End of life care
CVD rate
Planned care
Diabetes controlled blood sugar
CHD Cancer End of Life Planned care Diabetes Primary care
Supporting Future Generations Promoting Independence
Maternity & new born Children’s health Acute care Long term conditions
Infants breastfed
Maternity Children
Improving Mental Health
Mental health
Stroke admissions given a scan within 24 hours Uptake of influenza vaccine by over 65s For IAPT services the proportion of service users assessed as moving to recovery Rate of alcohol related hospital admissions
Urgent Care Older people Long term conditions Learning Disabilities Stroke Mental health Substance misuse
Killer
Care closer home
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mortality
STRATEGIC COMMISSIONING PLAN 2010-15 4.4.1 IMPROVE HEALTH AND WELLBEING18 Case for Change The high levels of risk factors for ill health pose a significant threat to the future health and well-being of the population in Medway and without early action the demand on health and social care services will rise. Multiple risk-taking behaviours such as smoking, poor diet and substance misuse need effective interventions in order to control the prevalence of the lifestyle diseases the focus therefore for NHS Medway will be to: Reduce the high levels of smoking, obesity and teenage pregnancy and reduce inequalities in health Areas for Action • Stop doing things of limited clinical value (Do Less) • Deliver services more efficiently (Do things Better) • Deliver more cost-effective services (Do More to save elsewhere) Strategic work
Planned change (2010-2015)
streams
SMOKING CESSATION
Initiative
Impact on Activity
Establish Tobacco Control Alliance
19
Increasing capacity in stop smoking services - in particular: •
18 19
Financial consequence (year 1)
Improved patient / public experience
Key Performance indicators
Overarching Outcome measures
Do things Better
Do More to save elsewhere
OBESITY STRATEGY
What does this mean for local people (Impact)
Increased smoking cessation activity
£50,000
£115,000 Better access to stop smoking advice for hard to reach groups
Community outreach focusing on routine & manual groups
Do more to save elsewhere Breast feeding (see Strategic goal 4)
£100,000
To be found in the work streams within Medway Health and Wellbeing strategy for publication in March 2010 HPEC pledge: We will provide high quality tobacco control programmes, focusing on those most at risk of long-term harm
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Improve Life expectancy at time of birth Reduction in smoking prevalence
STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work
Planned change (2010-2015)
streams
Initiative
Community food Projects
Impact on Activity Increased support to community projects
What does this mean for local people (Impact) Financial consequence (year 1)
SEXUAL HEALTH AND TEENAGE PREGNANCY
20
Acesss to MEND (Mind, Exercise, Nutrition, Do it) programmes
•
Access to leisure facilities and one to one health advice and support for obese or overweight people
•
Develop accessible initiatives for people with learning disabilities
£75,000 Increased activity by health trainers and similar
Overarching Outcome measures
Better access to information on healthy weight available for parents
Reduction in levels of obesity in 21 childhood
Reduced Mortality rates from cancer and circulatory diseases
£150,000
Increase in adults involved in sport
Reduced percentage of obesity in a client group which is particularly vulnerable to weight gain
Do more to save elsewhere Provide a comprehensive range of sexual health promotion and treatment services for groups at highest risk e.g. target services for young people (CASH / C Card)
Key Performance indicators
£100,000
Healthy Weight – Physical Activity Pathway – develop capacity and opportunities including: •
Improved patient / public experience
Increased activity in sexual health services
£130,000
Appointment at sexual health clinics within 48 hours and at evenings and 22 weekends
Reduction in under 18 conception rate
Improved access to a range of sexual health promotion services;
Increased access to GUM service
HPEC pledge: By carefully targeting our interventions we will tackle health inequalities and raise the life expectancy of those most disadvantaged by 18 months.
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Reduced mortality rate of under 1 year olds per 1,000 live births
STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work
Planned change (2010-2015)
streams
Initiative
Impact on Activity
What does this mean for local people (Impact) Financial consequence (year 1)
Improved patient / public experience
Key Performance indicators
Increase coverage and uptake of the Chlamydia screening service particularly in areas of deprivation
Increased screening
£134,000
Reduced Prevalence of Chlamydia in under 25 year olds
Reduction in prevalence of Chlamydia
Increase capacity in the Speakeasy programme for parents
Increased activity with families
£75,000
parents and carers able to talk to their children about sexual health
Reduction in under 18 conception rate
Increased health promotion activity
£100,000
Access to brief intervention advice resulting in better health outcomes
Reduction in alcohol harm Admission rates alcohol 24
Increased health promotion activity
£308,000
More informed people in Medway able to take sustainable action to improve lifestyle
Range of Health improvement targets
Increased health promotion activity
£110,000
Improved mental health and wellbeing which will also impact on their physical
Range of Health improvement targets
ALCOHOL 23 STRATEGY (Safer Drinking)
Do more to save elsewhere
SOCIAL MARKETING
Do more to save elsewhere
MENTAL HEALTH PROMOTION
Do more to save elsewhere
Development of brief interventions in a range of settings
Campaign “A Better Medway” targeting all residents of Medway to raise health aspirations and support lifestyle change. HPEC25
Develop MH promotion strategy and commission training in the community:
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Overarching Outcome measures
Reduced index of deprivation for those communities 20 most at risk
STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work
Planned change (2010-2015)
streams
Initiative
Impact on Activity
What does this mean for local people (Impact) Financial consequence (year 1)
Improved patient / public experience
Key Performance indicators
Overarching Outcome measures
health Reduced consultation levels for mental illness BUILDING PUBLIC HEALTH CAPACITY AND CAPABILITY
£20,000
Development of Public Health champions Develop Health and wellbeing Strategy to ensure effective action on health inequalities. •
Increased health promotion activity
£66,000
Greater opportunity to improve lifestyle particularly for those in areas of deprivation
Develop the Healthy Places/Healthy Lives** workstream
COMMUNITY OUTREACH & PARTNERSHIP WORKING
Focus on place based partnership approach to health inequalities using Triple Aim Programme.
ORAL HEALTH
Develop prevention in primary care dental practice Collaboration with generic health promotion programmes
21
Medway LAA targets
£15,000 Health improvement Vital signs and Medway LAA targets Increased health promotion activity
Cost neutral
Reduction in oral disease and inequalities
Dental services vital signs
Improved oral health through a common risk approach
HPEC pledge; Everyone will be supported to achieve and maintain a healthy weight. By 2011 those who are overweight, or obese, will be offered appropriate and individual advice and support HPEC pledge: Sexual health clinics will offer appointments within 48 hours and at evenings and weekends Medway Alcohol strategy date? 24 HPEC pledge: We will work with partner organisations to reduce the harm from alcohol misuse 25 HPEC pledge: We will work with employers to improve the health of the workforce 22 23
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STRATEGIC COMMISSIONING PLAN 2010-15
Enabling Initiatives •
Engagement and Partnership working (Partners, Patients & Public, Clinicians)
Health improvement programmes are already delivered and facilitated through the Joint Public Health Directorate of NHS Medway and Medway Council. However for NHS Medway to make a more significant impact on health and health inequalities the scale and scope of these interventions needs to be much greater. A Strategy for Health and Wellbeing with Medway Council will be delivered in partnership and in support of the Local Strategic Partnerships ‘Sustainable Communities’ strategy as well as the NHS Medway strategic commissioning plan. For delivery of these work streams to be successful the work of the PCT and partner organisations will be supported by wide public and service based stakeholder engagement e.g. through the “A Better Medway” campaign; a wide range of targeted health promotion programmes; access to health trainers and community development initiatives. •
Market Management and Procurement
Health Improvement is the major area chosen by the NHS Medway for substantial new investment as so many of the health needs of the Medway population are related to unhealthy lifestyle. In transforming changes within the health status of the population the focus will be on commissioning evidence based services with clear output and outcome measures; targeting services at hard to reach groups as well as maintaining the health promotion role of main stream services. The PCT will follow its agreed procurement strategy in commissioning new services and re-commissioning existing services. This will include consideration of the appropriate use of competition and co-operation levers. •
Infrastructure and Capacity (premises, workforce, IT)
A range of settings will be needed to be used to optimise engagement of local people in these services. Experience of working within the Sunlight Centre, schools, and youth centres and other social and leisure settings will be built upon as well as those more traditional health centres i.e. GP surgeries, healthy living centres and hospitals and the individuals home. Based on feedback from local people about access to health and lifestyle services we will develop a high street based health hub to improve access. The development of public health skills throughout the NHS and wider workforce will be key to the delivery of this challenging programme and will be facilitated through a Public Health Champions Programme and a wide range of training programmes.
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STRATEGIC COMMISSIONING PLAN 2010-15 Risks to Delivery Nature of the Risk
Likelihood
Impact
Risk
Mitigating action
Insufficient sustainable investment to deliver scale of programme required
3
4
12
Ensure robust prioritisation process
Lack of accessible information for people who do not read or whose first language is not English, excluding vulnerable groups
3
4
12
Trust wide initiative to ensure that key documentation and individual communication styles are accessible
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STRATEGIC COMMISSIONING PLAN 2010-15
4.4.2 TARGET KILLER DISEASES Case for change In Medway, the average life expectancy for men is 76.4 years, and for women 80.4 years. This is slightly lower than the national figure, and substantially lower than in the south-east overall. This is attributed in the main to the higher than average age standardised mortality rates for cancer and cardiovascular disease compared to other areas in the south east or across England. In addition access to high quality end of life care is inconsistent with many people unable to access specialist palliative care services. Reducing premature deaths in Cancer and Cardiovascular Disease and at the same time to improve the end of life experience for patients Areas for Action • Stop doing things of limited clinical value (Do Less) • Deliver services more efficiently (Do things Better) • Deliver more cost-effective services (Do More to save elsewhere) Strategic work
Planned change (2009-2013)
streams
CANCER
Initiative
Impact on Activity
What does this mean for local people (Impact) Financial consequence
Improved patient / public experience
Key Performance indicators
Do Less Review the safe and appropriate use of chemotherapy
Improve framework for follow up care
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Reduced chemotherapy activity
Reduced chemotherapy costs
Reduced follow-up appointments
Reduced outpatient costs
Reduction in deaths within 30 days of chemotherapy
Fewer unnecessary hospital attendances and more efficient pathways
Reduced follow up appointments
Overarching Outcome measures
STRATEGIC COMMISSIONING PLAN 2010-15 Strategic work
Planned change (2009-2013)
streams
Initiative
Impact on Activity
What does this mean for local people (Impact) Financial consequence
Improved patient / public experience
Key Performance indicators
Overarching Outcome measures
Do things better Deliver ‘Going further on cancer waits’ strategy
Neutral
Cost neutral
Neutral
Cost neutral
Implement Enhanced Recovery programme in Medway Hospital
Review the use of in-patient beds for haematology
Reduction in waiting times for diagnosis and treatment
Shorter length of stay for surgery, reduced exposure to hospital acquired infections, better rehabilitation Reduced inpatient activity
Cost neutral Reduction in unnecessary hospital admissions
All patients to be seen in a maximum of 31 days from referral at each stage in their pathway Reduced length of stay Better patient reported outcomes
Reduction in inpatient activity, increase in planned same day treatment
Increased incidence of diagnosis
Do more to save elsewhere Extended screening services (ensuring equality of access for people with learning disabilities)
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Increased outpatient activity
£156,000
Improved access to breast and bowel cancer screening
Screening coverage in extended age range and for all groups
Patient seen by most
Reduction in emergency
Reduced mortality rates from cancer & CHD – SMRs will be in line with or lower
STRATEGIC COMMISSIONING PLAN 2010-15 Strategic work
Planned change (2009-2013)
streams
Initiative
Increased acute oncology services
Impact on Activity
Decrease in emergency admissions
Implementing NRAG recommendations for radiotherapy Increased radiotherapy activity
What does this mean for local people (Impact) Financial consequence
Cost neutral
Revenue neutral but capital investment required
Improved patient / public experience appropriate clinician
admissions for oncology patients
Improved experience of treatment, maximum of 4 week wait for radiotherapy, ability to treat a wider casemix of patients more effectively
Waiting times in radiotherapy in 26 line with NRAG recommendations
More ambulatory care Improved cancer diagnostics Reduced number of inappropriate diagnostics
Develop survivorship project
26
Reduced Cancer Nurse Specialist activity
NRAG â&#x20AC;&#x201C; National Radiotherapy Advisory Group report http://www.cancer.nhs.uk/radiotherapy/nrag.htm
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Cost neutral
Key Performance indicators
Overarching Outcome measures than south east and national rates
Fractions delivered in line with NRAG recommendations Increased patient selfmanagement Reduced bed days
Less invasive diagnostics
Improved support for people living with and beyond cancer
Improved patient experience
STRATEGIC COMMISSIONING PLAN 2010-15 Strategic work
Planned change (2009-2013)
streams
Coronary Heart Disease
Initiative
Impact on Activity
What does this mean for local people (Impact) Financial consequence
Improved patient / public experience
Key Performance indicators
Overarching Outcome measures
Do things better A primary angioplasty service across Kent & Medway
Reduction in activity with London providers
Cost-neutral
More local services, improved patient outcomes from treatment in specialist centre27
Increase in angioplasties undertaken in Kent/reduction in activity in London
Access to NHS Health Checks for all adults aged 40-75 over a 5 year cycle, early diagnosis of life-threatening conditions
Number of health checks delivered
Improved patient outcomes
Do more to save elsewhere Vascular checks in primary care
Commission local arrhythmia service
Increased prevention activity
£520,000
Reduction in disease, eg myocardial infarction
Estimate £180,000 saving in acute costs
Increased community activity, reduced outpatient & inpatient
£204,000 Estimate £100,000 saving in acute costs
Better community based support for people with arrhythmias. Support to primary care diagnosis
Number of referrals to other services
Numbers of people supported and with arrhythmia successfully managed without acute admission
Fewer admissions 27
HPEC pledge: By 2010, all appropriate heart attack, stroke and major trauma patients will receive specialist care from 24/7 services meeting national guidelines. By 2010 all such patients will be taken to the most appropriate specialist units under an agreement with South East Coast Ambulance Service and local hospitals commissioned by PCTs
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STRATEGIC COMMISSIONING PLAN 2010-15 Strategic work
Planned change (2009-2013)
streams
Initiative
Impact on Activity
What does this mean for local people (Impact) Financial consequence
Improved patient / public experience
Key Performance indicators
Development of cardiac rehab services for people with angina
Increased community activity, reduced outpatient
To be confirmed
END OF LIFE
Do more to save elsewhere
ÂŁ36,000
Implementing an integrated and cohesive model of care28
Marie Curie funding for specialist nurse
Reduce acute inpatient admissions for specialist nursing/Care; Improved coordination of care across agencies;
Most dying people able to die where they prefer - at home, in a hospital or hospice; reduce complaints; smooth patient pathway.
No. of people dying at home supported with a care plan;
To improve access & equity of provision
ÂŁ80,000
Reduction in complaints, more bereaved people supported
Reduction in complaints
Improved bereavement services
Better community based support and outcomes for people with angina
Overarching Outcome measures
to acute care for people with angina
Improved service user feedback Information from core and AAG outcome measures
28
HPEC Pledge: By 2012 all health, social care and third sector providers will provide evidence of achieving best practice in end of life care against recognised quality standards, including evidence of care plans
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STRATEGIC COMMISSIONING PLAN 2010-15 Strategic work
Planned change (2009-2013)
streams
Initiative
Education & awareness raising
29
GP MacMillan facilitator
29
Impact on Activity
What does this mean for local people (Impact) Financial consequence
Effective use of resources with early identification of patients approaching end of life and receiving appropriate care and support
ÂŁ62,000
Advice and support to GPs will facilitate Gold Standards Framework and greater awareness of end of life issues. Better use of resources in primary care
ÂŁ12,000
Improved patient / public experience Better understanding of death and dying; facilitate understanding in the use of end of life tools such as the Liverpool Care Pathway
Reduction in complaints
Greater awareness and understanding of End of Life Care issues by GPs will enhance service delivery and communication amongst primary care clinicians and specialist community staff.
Increase number of GPs using End
HPEC pledge: The NHS in Kent, Surrey and Sussex will actively work with staff, public and partners to raise awareness of end of life issues
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Key Performance indicators
Increased number of people supported to die at home or in other place of their choice
of Life care tools. (GSF)
Increase no. of patients on end of life register
Overarching Outcome measures
STRATEGIC COMMISSIONING PLAN 2010-15 Strategic work
Planned change (2009-2013)
streams
Initiative
Liverpool Care Pathway Facilitator
Impact on Activity 30
Increase Domiciliary care team
Reduction in acute bed admissions and therefore capacity as a result of plans set out above.
30
30
What does this mean for local people (Impact) Financial consequence
Use of Liverpool Care Pathway in Hospital will ensure care in the right place and support to carers at the right time.
£45,000
Increase capacity in community services and reduction in use of acute or specialist beds.
£180,000
Fewer people dying in hospital
Savings of £250,000
Improved patient / public experience Smoother patient journey; early identification of patient needs; signposting to right clinical or support service
at the right time.
Patient able to exercise choice; greater personalisation of care and support in the home
Patient able to exercise choice; greater personalisation of care and support in the home
Key Performance indicators
Overarching Outcome measures
Reduction in delayed discharges; Reduction in length of stay in an acute bed.
Increase no. of patients supported to die at home; Reduce no. of patients approaching end of life dying in hospital Increase no. of patients supported to die at home; Reduce no. of patients approaching end of life dying in hospital
HPEC pledge: By 2012, access will be available everywhere 24/7 to a rapid response service to help patients at the end of their life manage pain and other symptom control. Psychological, social and equipment needs will also be managed
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STRATEGIC COMMISSIONING PLAN 2010-15
Delivery Plan •
Engagement and Partnership working (Partners, Patients & Public, Clinicians)
NHS Medway will deliver the Cancer Reform Strategy by working within the Kent and Medway Cancer Network. Collaborative commissioning arrangements are in place across the three PCTs supported by links both to local stakeholders as well as the Kent and Medway Network Partnership. The Kent & Medway Cancer Network supports and is continually developing mature clinical networks in all tumour sites and in cross cutting areas. Further to this the network supports a patient participation forum and engagement of patients and carers in the pathway work it undertakes. The development of cardiac, stroke and vascular disease services in Kent are improved by working closely with the Kent Cardiovascular Network. The membership of the Medway CHD Strategic Change Programme Group includes clinical and non-clinical representation from key providers, primary care, the Cardiac Network and patient representatives. The End of Life Strategic Change Programme Group has provided a platform for engagement with stakeholders. Engaging the patients and relatives has been through the Wisdom Hospice Day care service and with relatives through the Relative Club. Both forums, although limited in scope in presenting a wider patient perspective has provided valuable insight into planned improvements for end of life care. •
Market Management and Procurement
Cancer services are subject to both national and local peer review and only Improving Outcomes Guidance (IOG) compliant services are commissioned. All cancer pathways are approved across Kent and Medway via the network governance structure and are all contracts are subject to maximum waiting times. The plan is to maintain services within Kent and Medway where sustainable building on the role of the Kent Oncology centre and local acute sites. Specified community support services will be commissioned from a range of providers and may need market testing. The position for CHD services is similar, with support from the Cardiovascular Network. The delivery of NHS Health Checks is being undertaken in three phases, firstly through general practice and secondly through pharmacies offering opportunistic screening. Both of these services will be procured through a Local Enhanced Service structure. The third phase will be delivery to ‘hard to reach’ groups, and the specification for this phase will be confirmed during 2010/11. The delivery of this service may well be subject to market-testing and is likely to be commissioned from a third sector provider with expertise in accessing a range of communities. Many specialised services for cancer and cardiovascular disease are commissioned from hospitals which provide other acute hospital care. The South East Coast Specialist Commissioning Group and the Acute Contracting Team work closely together to ensure that services are commissioned and performance managed in a co-ordinated and consistent way for NHS Medway.
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STRATEGIC COMMISSIONING PLAN 2010-15 Regarding end of life care, a market analysis exercise is currently underway to determine the strategic direction of travel, particularly to establish the impact of personal health budgets on types of services required to meet the needs of individuals approaching end of life. This work will inform the development of the joint commissioning plan for end of life care31. â&#x20AC;˘ Enabling Strategies (workforce / estate and IT) For cancer services, in order to meet the aspirations of the NRAG32 on the future development of radiotherapy then there will not only have to be ongoing funding for new linac machines but also new infrastructure to house the additional machines. The new chemotherapy unit at Medway will have to review continuously the way in which it uses its available space with the increasing demand on chair usage rather than in patient beds and the increasing move away from IV chemotherapy to oral chemotherapies. In order to implement the strategy for end of life care, it is recognised that there will be significant workforce implications in terms of roles, skills and tasks for the workforce overall. There will be a need to increase the skills of community nursing staff and hospital staff with the competencies required to deliver care at end of life, and GPs who will play an integral role in coordinating the care of these individuals. Specifically, the need for training will be in areas of symptom management, communication with patients so that patients and families are able to discuss the issues of end of life care, delivery of psychological and spiritual care and team working. This will present a challenge for commissioners over the next five years to bring about the changes regarding current practice and introducing the learning and best practice taking place nationally. The use of IT and web based support will also feature heavily in the development of care planning and improvement to communication amongst agencies. We will establish an end of life register utilising the Summary Care Record. This is seen as a crucial step in the delivery of care and support to patients and carers. Risks to Delivery Nature of the Risk
Likelihood
Impact
Risk
Mitigating action
Insufficient capital & revenue funding to support the ongoing development of radiotherapy
3
5
15
Development of a robust commissioning strategy across Kent & Medway demonstrating the need for additional radiotherapy capacity.
Cancer follow-up pathways not followed
3
5
15
Audit of follow up pathways and clear contracting in accordance with approved pathways
31
HPEC pledge: Primary care trusts will ensure a strategic approach, developed in partnership with the third sector and social services, to commissioning end of life care services to patients and their families 32 NRAG â&#x20AC;&#x201C; National Radiotherapy Advisory Group report http://www.cancer.nhs.uk/radiotherapy/nrag.htm
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STRATEGIC COMMISSIONING PLAN 2010-15
Poor uptake of NHS Health Checks offered by GPs
3
3
9
Extending offer of NHS Health Checks to pharmacies and community outreach
Poor identification of patients approaching end of life
3
5
15
Implement End of Life Register; Implement Liverpool Care Pathway across all sectors (care home/residential homes.
No reduction in number of A&E admissions of patients approaching end of life
3
5
15
Monitor A&E admissions; Increase awareness of end of life care across all sectors; Review coordination between agencies including District Nurses; Marie Curie and MacMillan support. Liverpool Care Pathway implemented across all sectors.
Lack of integration between health and social care
3
3
9
Development of joint strategy with shared priorities across health and social care.
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STRATEGIC COMMISSIONING PLAN 2010-15
4.4.3 PLANNED CARE PATHWAYS - CLOSER TO HOME Case for Change The benefits of locally accessible health and social care are well articulated in ‘NHS Next Stage Review: Our Vision for Primary and Community Care’. Care provided close to home is welcomed by patients and service users and often makes the best economic use of NHS resources, ensuring that hospital facilities are focused on providing services for people who are acutely ill and in need of specialist expertise and equipment, whilst enabling the cost-effective delivery of less acute care in community settings. Increasingly local community and primary care providers will provide some services currently being provided by acute hospital providers, such as minor surgical procedures and specialist assessment and diagnostic procedures. Developing the capacity and capability of local services whilst offering more choice and responsiveness Areas for Action • Stop doing things of limited clinical value (Do Less) • Deliver services more efficiently (Do things Better) • Deliver more cost-effective services (Do More to save elsewhere)
Strategic work
Planned change (2009-2013)
streams
TIMELY ACCESS TO QUALITY SERVICES
33 34 35 36 37 38 39
Initiative
Impact on Activity
What does this mean for local people (Impact) Financial consequence
Improved patient / public experience
Key Performance indicators
Overarching Outcome measures
Do less Enhanced Recovery Programme at Medway Hospital to reduce length of stay and improve patient experience
Neutral
Cost neutral
Reduced length of stay, improved outcomes following surgery and reduced exposure to
Reduced length of stay Better patient
HPEC pledge: Many hospital stays will be shorter, through improvements in technology and enhanced primary and community care. Medway’s Patient Offer 2009 HPEC pledge: Waiting times for hospital treatment will be shorter, falling to an average of less than nine weeks by 2009 HPEC pledge: People will be able to book a GP appointment more than two days in advance, and up to six weeks in advance if convenient to them HPEC pledge: The time from referral for an everyday diagnostic test to the result being available will be 72 hours for urgent tests and two weeks routinely for all others HPEC pledge: More diagnostic tests requested in primary care will be available outside a traditional hospital setting: for example, on the high street, and in health centres and GP surgeries HPEC pledge: Everyone will be able to see a GP, or other primary care professional, on the same day if urgent, and within 48 hours routinely
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STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work streams
Planned change (2009-2013) Initiative
Impact on Activity
What does this mean for local people (Impact) Financial consequence
Improved patient / public experience hospital acquired infections
PBC led reduction in total level of GP referrals to secondary care through more consistent provision and thresholds in primary care
Application of low priority treatment policy and other thresholds consistently with other SEC PCTs
Reduced outpatient appointments
Reduced outpatient & inpatient activity
Savings of £500,000
Fewer unnecessary outpatient appointments, care provided closer to home
Savings of £1.7 m
Fewer procedures of limited clinical value undertaken
Cost neutral
Reduced waiting times for planned care across specialist, secondary and primary care35 36 37in line with national standards
Do things better Develop pathways that expand the range of services delivered ‘closer to home’ and at a reduced waiting time33. Practice Based Commissioning priorities for 2010/11 are community based gynaecology, rheumatology, glaucoma, dermatology, diagnostic services. This range of services will increase over the time period of this strategy.
Increased community based activity, reduced outpatient activity
More day surgery available in primary and community care Diagnostic tests in primary care (e.g. general practice and pharmacies) will be available on the local high 38 street.
Community based anticoagulation and lymphoedema services
£637,000 less current expenditure Increased community based activity,
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Key Performance indicators
Overarching Outcome measures
reported outcomes
Maximum wait of 18 weeks from referral to treatment
Improved comparative performance in Better Care, Better Value indicators
Maximum wait of 18 weeks from referral to treatment
Reducing health inequalities measured through the gap in all age all cause mortality rate within Medway.
STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work
Planned change (2009-2013)
streams
Initiative
Impact on Activity
What does this mean for local people (Impact) Financial consequence
Improved patient / public experience
Key Performance indicators
Net savings £50,000
Timely access to expertise from local optometrists, with fewer unnecessary out-patient appointments
Increase in number of people with ophthalmic problems managed in primary care, reduction in out-patient activity
£205,000 less current expenditure
Improved access to phlebotomy in more local settings
More clinic times available
More timely access to 39 primary care services
Improved patient satisfaction with access to GP services
reduced outpatient activity Primary Eye Care Acute referral Scheme (PEARS) Increased optometry activity, reduced acute activity Review the provision of phlebotomy services across Medway
Locally Enhanced Services (LES) scheme to improve access and responsiveness including Extended GP hours of opening Promoting the ‘Patient offer’
34
o
Develop the services provided by pharmacists
o
Introducing new primary care providers into the local market
Increased phlebotomy in community
Increased primary care activity
‘List cleaning’ exercise to ensure validity of patient numbers
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£500,000
Response to the Quality Development framework for General Practice Reduced activity in MedOCC/Walk-in centres and A & E Savings of £500,000
NHS Medway will be in the top 50% of PCTs for overall QOF achievement in 2010/11 and in the top 25% by 2015
Overarching Outcome measures
STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work streams
IMPROVING PATIENT CHOICE
Planned change (2009-2013) Initiative
Impact on Activity
What does this mean for local people (Impact) Financial consequence
Continuing the implementation of 40 ‘Choose & Book’ Accessible systems and information available to support local people in making an informed choice about the services they use Improving primary care premises
£600,000
Improved patient / public experience
Key Performance indicators
Referrals to all planned care services will be made electronically. An extension of choice of services for elective care, maternity services and primary care
Slot unavailability will be maximum of 5%
Overarching Outcome measures
Primary care services will be delivered from premises which are fully fit for purpose and attractive to patients
Delivery Plan •
Engagement and Partnership working (Partners, Patients & Public, Clinicians)
NHS Medway’s commissioning strategy for primary care includes a comprehensive Quality Development Framework which collates a wide range of information about the quality of general practice. Public awareness will be improved through information collected from the Quality Development Framework and published by NHS Medway that will enable patients to make a more informed choice of practice. Confederations of practices will be encouraged to deliver improved quality and outcomes along with increased productivity. There may be opportunity to rationalise practice premises, for example through the further development of Healthy Living Centres. The membership of the Planned Care and Primary Care Strategic Change Programme Groups include clinical and non-clinical representation from key providers, primary care, Practice Based Commissioning and patient representatives.
40
HPEC pledge: Many hospital stays will be shorter, through improvements in technology and enhanced primary and community care. Patients will be able to choose the day of their surgery more often
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STRATEGIC COMMISSIONING PLAN 2010-15 •
Market Management and Procurement
Commissioning and finance staff from the PCT and practice based commissioners meet regularly with the Acute Contracting Team to ensure that they are commissioning services in line with local commissioning intentions, and that PCT staff are fully briefed on performance on acute hospital service level agreements. The achievement of the 18 weeks waiting time target has already led to substantial investment in planned care. Further investment will be based on revising care pathways. This work is expected to be funded by more effective use of current resources. Investment in primary care capacity continues to be stimulated through the procurement of additional GP practices and a GP Led Health Centre, through the Fair Access to Care Programme. Spending on Dentistry in Medway is high as identified in the national Programme Budgeting work, though this is affected by patients who travel from other PCTs as access is good. ‘The Patient Offer’ described in the commissioning strategy for primary care sets out the services that a patient should expect to receive in a primary care setting. If there are gaps, the PCT has the opportunity to consider re-commissioning those enhanced services from alternative providers. Introduction of the Quality Development Framework (QDF), increases practice awareness of performance against benchmarking information, where available. This process will result in the publication of local and national data identifying best practice and will improve performance through peer pressure in addition to closer scrutiny by NHS Medway. Improved monitoring and support for the Quality & Outcomes Framework (QOF) process will improve prevention and quality and support the SCP target of 50% in the upper quartile. Practices in Medway improved their overall performance on the QOF in 2008/09 relative to other PCT areas, moving from 140th to 102nd in the ranking of 152 PCTs nationally. •
Enabling Strategies (workforce / estate and IT)
The Enhanced Recovery programme should result in a reduction of required capacity at Medway Hospital. This will have implications for the future workforce and estates needs of the Trust. In addition the shift of services closer to home will be facilitated with the increased use of Healthy Living Centres and this will further impact on the requirements of the Trust. NHS Medway will support practices with the introduction of enhanced technology to improve efficiency in respect of appointment booking, (e.g. touch screen check-in, web-based solutions, SMS reminders). Development of Practice Based Commissioning (PBC) will be a priority to deliver more cost effective and appropriate patient care pathways. Risks to Delivery Nature of the Risk
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Impact
Risk
Mitigating action
STRATEGIC COMMISSIONING PLAN 2010-15
Nature of the Risk
Likelihood
Impact
Risk
Mitigating action
Insufficient funding to develop phlebotomy
3
5
15
Commission cost-effective services using a robust business case
Increased activity as a result of acute capacity released through Enhanced Recovery
3
5
15
Ensure that bed capacity is reduced as part of the project.
The pattern of primary care in Medway is unusually biased towards small practices, and the GP workforce is an aging one, which presents risks to the delivery of the â&#x20AC;&#x2DC;patient offerâ&#x20AC;&#x2122;.
3
4
12
Younger GPs are more likely to seek the flexible working arrangements which larger practices or federations of practices offer and which will be required to deliver the offer. The PCT is actively seeking to attract trainee GPs to Medway, and to retain them once they are qualified to work in general practice.
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STRATEGIC COMMISSIONING PLAN 2010-15 4.4.4 SUPPORTING MEDWAY’S FUTURE GENERATION’S41 Case for change Medway has a high proportion of children compared with the national average, reducing the adverse health outcomes for children in Medway is therefore vital in securing the future health and economic prosperity of the population of Medway. Securing better outcomes and access to services for children and young people in Medway Areas for Action • Stop doing things of limited clinical value (Do Less) • Deliver services more efficiently (Do things Better) • Deliver more cost-effective services (Do More to save elsewhere) Strategic work
Planned change (2009-2013)
streams
CAMHS
41 42
42
Initiative
Impact on Activity
Do things better CAMHS review implementation of recommendations that will require re-design across the tiers to reflect the needs of local children, young people and families. Reduced waiting list.
Procurement of new service for the in-patient element of service for children and young people
Shift to local in –patient service with
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Financial consequence
£205,000
Review of systemic services input to children and young people to ensure clear pathways to access care and support for emotional needs of children and young people. CAMHS tier 4
Children and Young Peoples Partnership / plan Medway CAMHS strategy 2009
What does this mean for local people (Impact) Improved patient / public experience There will be a single point of access for Tier 2 and 3 CAMHS,
Key Performance indicators
Meeting national standards for CAMHS services
Improved access and timely interventions
LSP Indicators and LAA indicators.
To reduce length
Length of stay in line with or lower than national
£150,000
Overarching Outcome measures
Improve Life expectancy at time of birth
Reduced mortality rate of
STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work
Planned change (2009-2013)
streams
Initiative
with Mental Health needs.
NEW PATHWAYS OF CARE
Impact on Activity
What does this mean for local people (Impact) Financial consequence
outreach as an addition.
Improved patient / public experience of stay , provide more care and treatment at home where clinically appropriate.
Key Performance indicators benchmark
Do things better Child Development Centre. Re-design of service to ensure clear pathways and range of services to meet the needs of children and families in the Medway area.43
Reduced levels of crisis admission to hospital
Cost neutral
Working closely with partners to ensure that people with complex disabilities enjoy a smooth transition from children’s to adult services including participation in “Getting a Life”.44
Improve service model for children’s audiology to ensure children are seen within timescales. Improved patient pathway across Newborn Hearing and Children’s hearing services
43
An increased range of children’s care in the community and outside of hospital.45 Provide children with disabilities different and positive experiences.
Cost neutral
Children with hearing problems are able to achieve and live a normal live like their peers.
Appropriate local testing facilities; 6 week diagnostic target for paediatric audiology 95% within financial
HPEC pledge:Teams of health and social care givers will co-ordinate care ‘around the child’ by 2011 HPEC pledge: By 2011, there will be dedicated transitional care teams across the region to help individual vulnerable young people making the move to adulthood 45 HPEC pledge: More children’s care will be available in the community and outside of hospital 44
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Overarching Outcome measures under 1 year olds per 1,000 live births
STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work
Planned change (2009-2013)
streams
Initiative
Impact on Activity
What does this mean for local people (Impact) Financial consequence
Improved patient / public experience
Key Performance indicators year. 100% screening rate for newborn Hearing screening;
Do more to save elsewhere Developing children services - “ Aiming High” providing more focussed and dedicated respite care for children with disabilities. Providing services that will enable carers of disabled children a break from caring in a timely and effective way. Family nurse Partnership. A new initiative to provide intensive Health Visiting support to young mothers and their babies for two years following birth.
PROMOTING HEALTH
46
Increased respite care and fewer emergency admissions
Increased community activity and fewer subsequent pregnancies and related activity
£200,000 Prevent carer/parent breakdown. Improved health outcomes for young children. £272,000
Improved educational attainment .
Do more to save elsewhere Implement breastfeeding strategy
46
Increased community
Reduced numbers of unplanned second pregnancies.
Included in ‘Choosing
Mothers and babies receive high quality post natal care,
Increase in the percentage of infants breast fed at 6-8 weeks
HPEC pledge: By 2010, we will ensure that all mothers and babies receive high quality postnatal care, for example support with breastfeeding for at least 6 weeks
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Overarching Outcome measures
STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work
Planned change (2009-2013)
streams
Initiative
Impact on Activity activity
MATERNITY MATTERS 47 (improving the quality of experience)
Increased support to vulnerable groups: • Children’s Trust Supporting parenting programme (antenatal care, information) • Young persons one stop scan service • Drugs and alcohol 48 49
Improved choice and responsiveness
Supporting women with complex needs including mental health needs50
Increased mother & infant MH services activity Full implementation st of 1 trimester screening
What does this mean for local people (Impact) Financial consequence Health’ section
£130,000
Improved patient / public experience
Key Performance indicators
including support for breast feeding for at least 6 weeks;
(WCC);
Increased access to a consultant presence on the 51 labour ward
Reduction in Caesarean rates,
women individually supported by a healthcare professional throughout their labour and 52 birth
Overarching Outcome measures
Rising Immunisation rates
Increase in Vaginal Birth after caesarean (VBAC). Compliance with national screening programme requirements
Access to specialist services when required
47
Maternity matters http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073312 HPEC pledge: By 2010, every woman will be able to make an informed choice about place of birth in the knowledge that the NHS will be able to meet her preference for a home birth, birth in midwife-led unit, or birth in a consultant led unit 49 HPEC pledge: By 2011, 90% of pregnant women will see a midwife within 12 weeks of confirmation of pregnancy to discuss their individual needs and preferences about how and where to give birth. We will focus in particular on making contact with women from vulnerable groups 50 HPEC pledge: By 2011, all pregnant women and new mothers will be able to get the help they need with mental health problems. 51 HPEC pledge: By 2010, there will be a consultant present for at least 60 hours of every week on the labour ward in every consultant-led obstetric unit (with the exception of units with fewer than 2,500 births a year where 40 hours will be the minimum) 52 HPEC pledge: By 2010, all women will be individually supported by a midwife throughout their labour and birth following confirmation of established labour 48
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STRATEGIC COMMISSIONING PLAN 2010-15
Delivery Plan NHS Medway work in partnership with the Local Authority in delivering all aspects of the commissioning services for children and young people. The Collaborative is underpinned by the local Children’s Trust of which NHS Medway is a key member. Children’s services are cross cutting and involve working with a range of providers both statutory and third sector where strong working relationships exist to achieve improved outcomes for children and young people in Medway. With all the initiatives either in development or underway professional staff work alongside parents, families and the children and young people themselves to achieve the desired outcomes. We work with children and young people either directly or via the Young Commissioners and young inspectors to provide us with their views about existing services and aspirations for future services.
•
Market Management and Procurement
Children’s services in Medway are monitored via the Children’s Trust where a whole range of providers are fully engaged to delivering a whole system approach to the needs of children and young people. Where services require to be reviewed or re-designed to meet changing need we will work collaboratively to achieve the desired changes or if thought to be necessary services will be re-tendered to support local delivery needs using the NHS procurement framework. We plan to work via the Children’s Trust in developing a greater level of mixed economy in the children’s service arena working with Health Care providers from Birth through to all the stages of education and then to support young people with specific needs into either paid or unpaid employment.
•
Enabling Strategies (workforce / estate and IT)
To achieve the high standards expected by the Department of Health more will be spent each year on maternity care. Most of this will be used to recruit more midwives to ensure that mothers receive high quality personal care. Medway FT are recruiting a consultant midwife to focus on normal birth – this post will support work to reduce caesarean rates, improve VBAC rates and facilitate the introduction of the Midwifery Led Unit when it comes on stream.
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STRATEGIC COMMISSIONING PLAN 2010-15 The continued development of integrated working across all agencies will result in improved and more cost effective care pathways for children and young people enabling them to access a range of services from a more preventative perspective. We will work with our partner agencies in developing our collective workforce to deliver interventions and services using a range of different skills and where required we will “skill mix” teams to ensure that the whole range of children’s and young peoples needs are met. Risks to Delivery Nature of the Risk
Likelihood
Impact
Risk
Mitigating action
Partnership agenda different priorities for delivery.
3
5
15
Collaboration via Children’s Trust and Chief Executive and director level full engagement.
Service re-design not adequately resourced
3
5
15
Review analysis and present detailed business case
Lack of integration in children services (FNP and other Children’s community services)
3
5
15
Audit and Review service delivery plans;
Inefficient use of resources resulting in long term high cost placements
5
5
25
Implement IT database patient management system to manage children’s placements in CAMHS and Children’s Continuing care
Lack of appropriate facilities for children’s hearing services resulting in poor patient and family outcome
3
5
15
Engage with current provider and monitor service improvement plan for children’s hearing services.
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STRATEGIC COMMISSIONING PLAN 2010-15
4.4.5 PROMOTING INDEPENDENCE AND IMPROVED QUALITY OF LIFE Case for change Both demographic changes and inequalities will drive a growth in relatively high intensity users; it is likely that service demand will grow proportionally quicker in Medway than the UK as a whole. This will have a significant impact on services for the management of long term conditions such as dementia, cardiovascular disease (CVD) and diabetes as well as acute conditions such as stroke as the incidence of these conditions increases with age. It will also have an impact on preventative programmes such as influenza vaccination for the over 65s. Meeting the challenge of the growing number of older people and people with long term conditions53 54, maximising their independence and well being
Areas for Action • Stop doing things of limited clinical value (Do Less) • Deliver services more efficiently (Do things Better) • Deliver more cost-effective services (Do More to save elsewhere) Strategic work streams
URGENT CARE
Planned change (2009-2013) Initiative
54
55 56
Impact on Activity
Financial consequence
Improved patient / public experience
Increased community activity, fewer A & E attendances and non-
Cost neutral
More timely direction to appropriate services, avoidance of unnecessary A & E attendances and admissions
Key Performance indicators
Overarching Outcome measures
Do things better On-going implementation of system redesign through 55 56 Urgent Care Action plan
53
What does this mean for local people (Impact)
Reduction in admissions through A & E Achievement of 98% A
HPEC pledge: By 2010, all patients with long term conditions and their carers will be offered ongoing support; education and training to help them better manage their own condition HPEC pledge: We will work with employers to rehabilitate people of working age with a long term condition so that they return to work at the earliest opportunity. HPEC pledge; There will be closer integration of community and social services to support people with urgent care needs HPEC pledge: By 2010, people can expect the same outcomes and level of care, regardless of which part of the health service they first approach
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STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work streams
Planned change (2009-2013) Initiative
Impact on Activity
What does this mean for local people (Impact) Financial consequence
Improved patient / public experience
Key Performance indicators & E target
elective admissions
Achievement of ambulance targets Reduction in delayed transfers of care
Implement findings of audit of short stay non elective care to ensure appropriate pricing for activity Do more to save elsewhere Implementation of Paramedic Practitioners
STROKE
Improve Life expectancy at time of birth
Savings of £5m Neutral
Increased community activity, fewer A & E attendances and nonelective admissions
Reduction in strokes following TIA
57
Reduction in ambulance conveyance rate
£50,000 investment to deliver £100,000 saving
Do things better Improvement in the care pathway • Assessment • TIA • Rehabilitation and recovery
Overarching Outcome measures
£169,000 less saving £50,000 on strokes prevented and £150,000 on ‘tariff unbundling’
Access to specialist assessment, diagnostic and intervention in the community
Standardised mortality rates will be lower or inline with south east or national rates
Increase in the percentage of stroke admissions given a brain scan within 24 hours
HPEC pledge: By 2010, health and social care will be jointly planned and purchased for long-term conditions where appropriate, so that people will receive co-ordinated and personalised care that is tailored to their needs
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STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work streams
DIABETES
Planned change (2009-2013) Initiative
Impact on Activity
What does this mean for local people (Impact) Financial consequence
Do more to save elsewhere Patient training and education through the X-PERT patient in Diabetes – targeting vulnerable groups (BME, LDis, Low English literacy)
Availability of local insulin pump therapy for young people with type 1 diabetes
Fewer emergency admissions
Fewer emergency admissions
£85,000 less £40,000 reduction in admissions
£76,000 less current expenditure in London providers
Local pathway for Diabetes Care to improve access to community service
Improved patient / public experience
Key Performance indicators
Stable patients under the care of their GP or other community service
90% of patients with long-term conditions with personal care plans
People with a long term condition supported to be independent and in control of their condition
Improvement in the percentage of patients with diabetes who have an HbA1c of 7.5 or less
support, education and training available to help patients better manage their own conditions
Reduction in emergency admissions
Being in control of diabetes and improvement of quality of life Care close to home
Referral rates
Customer satisfaction
Seamless health and social care services for people with Diabetes
Social care as integrated partner in Diabetes Care
RENAL
Do more to save elsewhere ACR testing available in Medway
NEUROLOGICAL
Do things better
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£32,000
Improved health outcomes through early detection of renal failure
All diabetic patients to have ACR test annually
Overarching Outcome measures
STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work streams DISORDERS
Planned change (2009-2013) Initiative Developing Community Neuro Rehabilitation
Tysabri Infusion Service
LONG TERM CONDITIONS (general)
OLDER PEOPLES SERVICES
What does this mean for local people (Impact)
Impact on Activity
Financial consequence
Improved patient / public experience
Increased community activity, fewer outpatient attendances
Cost neutral
Improve patient experience with high quality service
Neutral
Neutral
Key Performance indicators Number of personalised 58 care plans delivered Goal Attainment Scale
Personalised budgets pilot
To be confirmed through pilot
£552,000
Improved management of long term conditions and planned care in the community
Increased community activity, fewer outpatient attendances
Savings of £950,000 through less inappropriate use of nonelective admission
Reduced use of inpatient beds
£79,000
Improving patient experience through people with Multiple Sclerosis not having to travel to London for treatment
All tysabri infusion funding to Medway Hospital rather than London Hospital
People with a long term condition supported to be independent and in control of their condition
Number of personalised care plans delivered
Do more to save elsewhere Dementia Advisers
58
Maximise quality of life by providing sufficient support and capacity to ensure that quality of life is achieved
Reduction in A&E attendances
Overarching Outcome measures There is a health and social care system where all people with dementia have access to care and support they would 57 benefit from. People with dementia receive support that enables them to remain cared for at home
People receive an early diagnosis and receive the support required to live well with dementia.
Reduction in Ambulance call outs
HPEC pledge: By 2010, all patients with a long term condition will be offered a care plan. By 2011, 90% of those with complex long term conditions will be identified and able to manage their own personalised and negotiated care plan. Case manager support will be provided when necessary
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STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work streams
Planned change (2009-2013) Initiative
Impact on Activity
Enhance Admiral Nursing
Increased community activity and reduced use of inpatient beds
What does this mean for local people (Impact) Financial consequence
Improved patient / public experience
ÂŁ90,000
Carers of people with dementia will have an assessment of their needs and support given to enable them to continue in their caring role Carers of people with dementia will be trained to understand and manage the people they care for. GPs receive support and training on the management of dementia
Intermediate Care (Step Down model) for people with dementia
Increased community activity and reduced use of inpatient beds
Key Performance indicators Reduction in A&E attendances
Reduction in admissions
Reduction in inappropriate referrals to memory services Reduction in referrals to acute trusts outside of Medway
ÂŁ375,000 People with dementia are cared for in the appropriate place
Reduction in delayed discharges
People with dementia receive the right care, at the right time.
Reduction in length of stay
Reduction in residential care placements
Reduction in OPMHN
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Overarching Outcome measures
STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work streams
Planned change (2009-2013) Initiative
Impact on Activity
What does this mean for local people (Impact) Financial consequence
Improved patient / public experience
Key Performance indicators nursing placements
£4,000
Kent & Medway Dementia Web
People with dementia and their carers have a greater understanding of dementia People with dementia receive an early diagnosis
Increase in the number of people with a confirmed diagnosis of dementia Increase in QOF registers for dementia.
People with dementia know what support is available to them
£750,000 saving
Reduction in acute in-patient expenditure as a result of measures above Learning disabilities
Do things better Improving specialist community support for people with learning disabilities, particularly development of psychology and behavioural support services
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Increased access to psychology
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£100,000
People better supported to remain living in Medway rather than being placed out of area
Reduction in high levels of social support
Numbers of people with learning disabilities living independently in their own homes
Overarching Outcome measures
STRATEGIC COMMISSIONING PLAN 2010-15
Delivery Plan Engagement and Partnership working Whole system engagement in taking forward the revision of the care pathways for people whop have a long term condition, for elders and those people who have dementia is crucial. Through the Strategic Change Programme Groups for Older People, Long term Conditions, Diabetes and Stroke NHS Medway is are working with a wide range of professionals, families, service users, patients and carers 59 to help with the development of pathways that will reduce hospital admissions This work is be led by Health and Social Care leads in the Medway area to develop services that have a strong preventative element and support people and their and families to be as independent as possible.
â&#x20AC;˘
Market Management and Procurement
NHS Medway will work with colleagues from Medway Council to learn from the pilot sites for personalised budgets for healthcare and to develop a programme to introduce these budgets in Medway. The National strategy for Dementia requires us to review all existing services and look to providing a range of different types of service such as intermediate care and â&#x20AC;&#x153;step downâ&#x20AC;? beds where true alternatives to hospital can be offered. Where services need to be altered we will work collaboratively with the providers to do so or look to procuring new services using the NHS procurement process. The PCT will work in partnership with Medway Council to procure integrated service provision for people with dementia.
Enabling Strategies (workforce / estate and IT) Where we have estates and buildings that current services are provided from we will review the need for such buildings and look to providing support and care from a model known as hub and spoke where we aim to work much closer to people in their own homes and local communities. We will skill mix where we need to ensure that the outcomes for service users/patients are most appropriate and most efficient . 59
HPEC pledge: To improve quality of care, commissioning and to achieve best outcomes for patients, disease-specific clinical networks will be developed and managed across the whole of health and social care. The networks will engage the third sector and patients and will identify, share and promote evidence-based best practice
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STRATEGIC COMMISSIONING PLAN 2010-15
The approach to better care involves a multidisciplinary approach and presently there is a shortfall in the skill mix i.e. neuropsychology, orthoptist, occupational therapist etc. to ensure the continued improvement and achievement of standards in stroke care. The need for workforce development in dementia care is profound and training in this area is required across the health and social care system.
Risks to Delivery Nature of the Risk
Likelihood
Impact
Risk
Mitigating action
Lack of pump priming funds to develop services.
3
5
15
High priority for Health and Social Care with strategic leadership sign up.
Partnership working different priorities.
3
4
12
Partnership engagement across the system
Lack of integration in Intermediate Care services for people with dementia
5
4
20
Map current provision across health and social care
Inefficient use of resources resulting in long term high cost OPMHN nursing placements
5
4
20
Carry out assessments of people in Darland House
Lack of appropriate facilities to enable a step down model of care resulting in poor quality of life, long lengths of stay and inappropriate admissions to residential/nursing care
5
4
20
Remodel current service to deliver step down approach
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Carry out an options appraisal for remodel.
STRATEGIC COMMISSIONING PLAN 2010-15
Health, social care and care home staff do 5 not have the necessary skills to provide the best quality of care in the roles and settings where they work
4
20
Specify training requirements in service specifications and monitor the performance Pct and Local Authority to identify local workforce development resources. PCT and Local Authority to work together to develop the workforce.
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STRATEGIC COMMISSIONING PLAN 2010-15
4.4.6 IMPROVING MENTAL HEALTH Case for change Good mental health is fundamental to the well-being and prosperity of Medway. It is also linked with good physical health and many other benefits for individuals. It can also be seen that deprivation such as poverty unemployment poor physical health or poor housing is strongly correlated with mental ill health. Long lengths of stay and high numbers of delayed transfers particularly for older people would also suggest that patients are not always receiving the right care in the right place. Improving access to a wide range of preventative and treatment services to improve the mental well being of people in Medway Areas for Action • Stop doing things of limited clinical value (Do Less) • Deliver services more efficiently (Do things Better) • Deliver more cost-effective services (Do More to save elsewhere) Strategic work streams
GENERAL ADULT MENTAL HEALTH
Planned change (2009-2013) Initiative
Changes in Activity
What does this mean for local people (Impact) Financial consequence
Do more to save elsewhere Access to Individual Placement and Support (IPS) for mental health service users who have severe and complex mental 60 health needs (HPEC)
To be confirmed
To be confirmed
24 hour access to the Medway Crisis and resolution home treatment (CRHT) team to release MASTT team to concentrate further on improving
Increased community activity & reduced use of in-patient beds
Included in community investment below
60
Improved patient / public experience Service users back into open employment, training or normalised vocational activity, or ensuring retention of employment through education of workplaces.
Key Performance indicators
Overarching Outcome measures
Tba
Seamless 24 hour service – leading to reduced time waiting in A&E (HPEC)
interventions by CRHT complete within 6 months
Speedier access to MASTT for assessment and
intake team to assess all routine
Life expectancy to increase
HPEC pledge: We will work with employers to maintain employment for those with mental health problems. Those who need to return to work will be rehabilitated so that they can do so at the earliest opportunity.
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STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work streams
Planned change (2009-2013) Initiative
Changes in Activity
What does this mean for local people (Impact) Financial consequence
communication and links with Primary Care.
61
£132,000
Improved patient / public experience
Key Performance indicators
treatment
referrals within 4 weeks
Greater access to the service
National targets in line with the Policy Implementation Guide (PIG)
Increased capacity in the Early Intervention Psychosis (EIS) service linked to the appointment of additional 2.83 wte care coordinators
Increased community activity meeting target caseload
Improving access to and outcomes for psychological therapies (IAPT) to enable people to recover from mental ill health through a clinically reliable method of treatment.
Increased community activity
£233,000
Access to a NICE compliant model of care for the provision of talking therapies for those with common mental health problems including depression and 61 anxiety. (HPEC)
National targets and waiting times
Commission a 20 bed Adult Mental Health Low Secure Inpatient Service
Reduce out of area placements
By providing a local service reduce costs through block contract purchasing from one provider.
Service Users will receive services closer to home. Improved continuity of care with local services.
HoNOS- Secure, Patient Satisfaction Survey – to be further developed as part of tendering, contracting and procurement process
Improving access to and
Shift from out of
Included in
Local services will ensure
Activity and
Reduce duration of ongoing psychosis Improvement in quality of life and enabling continued functioning within social networks
HPEC pledge: There will be access to psychological therapies in primary and secondary care in line with best practice
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Overarching Outcome measures
STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work streams
Planned change (2009-2013) Initiative
Changes in Activity
What does this mean for local people (Impact) Financial consequence
Improved patient / public experience
Key Performance indicators
outcomes for local specialised services, including aspergers and ADHD.
area services
community investment
people will no longer need to travel long distance to receive required care.
outcomes measures
Ensuring service users have access to a robust Community Recovery and Support system, which ensures that individuals reach their full potential within a supportive environment.
Intensive Supportive Housing as an alternative to hospital admissions.
£500,000
Improved quality of life
Reduced Inpatient admissions
Mental Health Promotion Training (linked to PH Strategic goal)
Training to be rolled out to Voluntary, Private and Statutory organisations who work with high risk groups
Mental Health First Aid (MHFA) Applied Suicide Intervention Skills (ASIST) Skills Based Training in Risk Management (STORM) Emergency Department Mental Health /Liaison Psychiatry
62
24 hour service 7 days a week
Ensuring that people’s needs are met in an environment that is the least restrictive and leads to recovery. In Choosing Health
Improved mental health and wellbeing which will also impact on their physical health
Overarching Outcome measures
Reduce use of residential care
Range of Health improvement VS and LAA targets
Reduced consultation levels for mental illness Reduction in suicide
£313,000 less £150,000 reduction in short stay nonelective admissions
Improved access to timely mental health assessment when attending the A&E to prevent unnecessary 62 admission. (HPEC)
Activity and outcome measures
The impact of physical ill health on psychological health is acknowledged and
HPEC pledge: There will be effective support for people with urgent mental health needs HPEC pledge: As there is no health without mental health, we will improve life expectancy year on year of those with severe mental illness. We will also improve the recognition of mental health needs in the treatment of all those with physical conditions 63
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STRATEGIC COMMISSIONING PLAN 2010-15
Strategic work streams
Planned change (2009-2013) Initiative
Changes in Activity
What does this mean for local people (Impact) Financial consequence
Improved patient / public experience
Key Performance indicators
addressed. There is an understanding of the need for a holistic approach when assessing someone in a general hospital setting 63 (HPEC) EATING DISORDERS
Do more to save elsewhere Access to early effective systemic family therapy for those suffering with eating disorders; working with people and their families To provide a clearer faster path to specialist treatment for eating disorders through the appointment of a CNS for eating disorders
DRUGS AND ALCOHOL
Tier 3 alcohol treatment services providing assessment, prescribing, structured psychosocial interventions, harm reduction and community detoxification with follow on care as required
Additional 12 families/couples individually each week.
Investment commenced 2009/10
a caseload of 15 people 10 appointments for individual therapy per week
Increased community activity Reduced acute admissions for alcohol related harm
enhanced patient experience of treatment and sustained recovery
best outcomes are delivered when individual therapy is provided in an outpatient setting by a specialist clinician
ÂŁ150,000 offset by savings in DAAT
Reduced dependency and side effects of harmful drinking
HONOS/CORE to measure clinical outcomes TBA with post holder
Numbers of users in treatment and supported to recovery Reduction in Alcohol related hospital admission rates
NB: a mental health promotion post is key part of the mental health strategy but described in Goal 1 - Health and well being
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Overarching Outcome measures
STRATEGIC COMMISSIONING PLAN 2010-15
Enabling Initiatives •
Engagement and Partnership working (Partners, Patients & Public, Clinicians) (HPEC)64
Adult mental health services are commissioned within a Kent and Medway strategic framework and supported by the Kent and Medway Mental Health commissioning team. Local partnership plans are developed along side stakeholders at the local Joint Mental Health commissioning group. Dementia services are commissioned jointly with NHS Medway’s integrated commissioning team for Adults and older people and mental health promotion strategies are developed with NHS Medway Public Health team. A range of engagement strategies are employed to gain service user and carer involvement in both the monitoring and development of local services including regular attendance at Local Planning and Monitoring Groups (LPMG’s) as well as the development of a Service User Engagement post. The post holder meets regularly with Mental Health Service Users in Medway and feeds information and concerns into the Joint Commissioning Group. Service users are actively encouraged to attend meetings regarding the redesign of services and the Commissioning Team actively engage with local partners and clinicians to seek their views regarding current services. Through the use of ‘Map of Medicine’ for the depression pathway has already been published and will continue to be used for other areas of priority including schizophrenia. To ensure the successful implementation and uptake of the IAPT programme, a robust interface with the primary care programme is essential. The New Horizons policy guide clearly links improved mental wellbeing with improved public and health promotion therefore strong links with between mental health commissioners and public health colleagues will be required in order to drive this through successfully. Drugs and alcohol services will be commissioned by the Medway DAT linking NHS Medway with colleagues at Medway council, Police and voluntary sector •
Market Management and Procurement
Recently services have become more effective through a change in service provider. Additional investment, building on this, has been planned. Some of this investment will be spent in partnership with Medway Council through jointly developed schemes. In line with the ‘Choice Themed Review’65 choice on mental health services focuses on supporting service users to be more involved in their treatment supported by strong user advocacy, so addressing issues of inequality and social inclusion. NHS Medway will increase the level of choice for local mental health service users by: o
Offering more choices about treatment
64
HPEC Pledge: We will campaign with our partner organisations to overcome discrimination against people with mental health problems and take action to reduce inequalities and social exclusion 65 Department of health document ‘choice themed review’ 2005
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STRATEGIC COMMISSIONING PLAN 2010-15
â&#x20AC;˘
o
Choices in care planning
o
Choices in advance directives and statements
Infrastructure and Capacity (premises, workforce, IT)
Services are currently provided from a range of building and estates, some of which are no longer fit for purpose. There will be a review of settings will take place which will seek to increase the use of Healthy Living Centres across Medway. The aim will be to ensure that people using Mental Health services have a wider choice of where they are seen in order to minimise stigma and discrimination. Community services will be moved away from the main body of the hospital and redesigned to offer more services in peoples own homes or make use of independent sector accommodation or public places if this is more acceptable to the service user. The IAPT workforce will be developed in line with government policy to provide a service that delivers to the population of Medway in a timely and effective manner. Staff have already been appointed into posts within both Eating Disorders and Mother and Infant Mental Health Services (MIMHS) and the capacity of other teams, such as Assertive Outreach as well as Community Mental Health Teams will continue to be reviewed and assessed. NHS Medway will support the implementation of IT systems that are robust and enhance the sharing of information between professionals and ensure that staff are adequately trained in the use of such systems. There will be continued review of both community and inpatient services in order to ensure that delivery of services are best placed to meet need. Risks to Delivery Nature of the Risk
Likelihood
Impact
Risk
Mitigating action
Increase in the number of crisis admissions and those referred to secondary mental health services due to lack of preventative work.
high
high
high
Increase hours of availability of CRHT and undertake Regular audit of admission rates and referrals to secondary mental health services.
EIP does not meet its target and deliver an equitable service to the population
high
high
high
Increase capacity else service remains as it is
Non compliance with NICE guidance and achieving IAPT outcomes
2
4
8
Investment plan overseen by steering group
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STRATEGIC COMMISSIONING PLAN 2010-15
Nature of the Risk
Likelihood
Impact
Not compliant with NICE 2004 Guidelines for eating disorders. NICE suggest that people and their families should be offered Family Therapy.
high
moderate
Seek funding for 1WTE for a full time Systemic Family Therapist to respond to the guidelines and offer Family therapy to people affected by eating disorders.
Longer waiting times in Eating Disorder Service without access to dedicated CNS
high
moderate
To employ a clinical Nurse specialist for the Medway Locality
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Risk
Mitigating action
STRATEGIC COMMISSIONING PLAN 2010-2015
SECTION 5 | MANAGING DELIVERY 5.1 GOVERNANCE The delivery of this Strategic Commissioning Plan is the responsibility of the Board of NHS Medway. The NHS Medway Board is responsible for assessing and planning for future health demands of the population of Medway and the local capacity to meet them. It is also responsible for the performance of service providers contracted to provide services to patients, including GP practices, and the organisation's own performance as both a commissioner and a provider. It will deliver this role in partnership with its key stakeholders and within the context of an integrated commissioning framework with Medway Council. 5.1.1 LEADERSHIP FOR STRATEGIC CHANGE In 2009 NHS Medway established its Strategic Change Programme. This was led by the Strategic Change Programme Board, reporting to the Board of the PCT through the Chief Executive. The Strategic Change Programme Board is currently the group accountable to the PCT Board for: o
Identifying new work streams to develop the services outlined in the strategic commissioning plan.
o
Monitoring and ensuring that local investment plans and change programmes are delivered to timescale and budgetary requirements.
Although all Strategic Change Programme Groups sitting beneath the SCP Board are multi-agency and multi-disciplinary, the membership of the SCP Board, being made up of the Chairs of all the groups, has until now been entirely composed of NHS Medway officers. In order to rise to the challenges set out in this document, the health and social care system in Medway will require firm focused delivery plans which deliver year on year change. Plans must deliver the ‘triple aim’ of improved quality, improved service user experience and better value for money. Chairs and Chief Executives in Medway have supported the need to move faster to create a Medway-wide programme office to ensure whole-system delivery of strategic change. This will be owned and resourced from organisations across the economy, and steered by a Medway Whole Systems Delivery Board which will replace the existing Strategic Change Programme Board and which will report to the Health Partnership Board. Given the changed financial circumstances facing the NHS from 2011/12 onwards, the Health Partnership Board has taken the view that there is a need for a new set of principles within which the partner organisations and programme will work to deliver the objectives. This reflects similar discussions across the wider Kent and Medway area. The ‘concordat’ which has been supported by Chairs and Chief Executives across Kent and Medway states that:
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STRATEGIC COMMISSIONING PLAN 2010-2015 •
• • • •
• •
This is a total health economy and partners leadership issue. Sustained and continued clinical leadership in partnership with managers is essential to help deliver the changes needed. We recognise the importance of engaging with our stakeholders and the need to involve citizens throughout our planning and delivery of services. Each organisation pursuing business as usual will not get us through the gathering storm. Consider the impact on partner organisations. Discuss plans and problems early to avoid damaging consequences. Every organisation has to be willing to modify its strategy and consider/concede some resources/flexibility to partners to ensure success. Boards must balance this with their core governance role and the tensions inherent within the system. We commit to a no surprises/mutual trust and risk sharing approach based on collaboration and transparency. Our aim is to create collectively the conditions for success, including mutual support for Boards and individuals who are leading the way in transforming services.
The Medway Health Partnership Board endorses these principles and further adds that in Medway • •
• •
•
The objectives of the Programme, Providers and Commissioners will be fully aligned; Partners will co-operate to identify opportunities for changing services and releasing/reusing resource where joint actions can be more productive than individual organisational effort; Finances will be discussed on an ‘open book’ basis; Where an organisation’s proposals and issues impact on other organisations, these will be fully and openly discussed and modified through agreement prior to implementation; None of the partners will attempt to achieve an undue advantage over other partners.
It is recognised that partners will need to work with other organisations operating outside the Programme, based on the pattern of services and contract agreements. Governance Structure The relationship between the Whole System Delivery Board and partner organizations is shown in diagram 1. In order to support the Whole System Delivery Board and the Strategic Change Programme Groups which sit beneath it, an ‘engine’ of public health, commissioning, finance, informatics, estates, workforce and public engagement will be required, with work co-ordinated through a Programme Office. This structure is shown in diagram 2. Throughout the governance structure there will be formal and informal engagement with service users and the wider public.
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STRATEGIC COMMISSIONING PLAN 2010-2015
Medway Council
NHS Medway Board
NHS Medway Executive Team
Local Strategic Partnership
Provider Executive Teams
Health Partnership Board and Childrenâ&#x20AC;&#x2122;s Trust Board
Kent & Medway Collaborative Commissioning: Adult Mental Health Acute Contracting Team Clinical networks (eg Cancer, CHD, Stroke) Specialist Commissioning
Diagram 1:
Boards of provider organisations
Medway Whole Systems Delivery Board
Governance Structure Medway Whole Systems Delivery Board
Cancer CHD Planned Care Children Maternity Stroke Diabetes Learning disability Substance misuse
Diagram 2:
Choosing Health Urgent Care Older people Long term conditions
Finance & Information PROGRAM ME OFFICE
Mental health
Engagement & communication s Group
End of Life
Project Management Structure
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Workforce Group Informatics Group Estates Group
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STRATEGIC COMMISSIONING PLAN 2010-2015 Explicit in the move to the new governance arrangements is a commitment to shared organizational objectives and coherent action to deliver these. Demand for services will be managed to achieve a reduced cost and increased cost effectiveness in the economy within the affordability envelope to be determined for the health economy, whilst maintaining quality and service user experience. All partners will co-operate actively in monitoring and managing activity levels and costs to targets identified in the Activity and Capacity Model and financial models, when agreed. Where activity or cost is shown or projected to increase above these levels, partners will discuss these and agree on action or service changes to offset these increases and return to planned activity and expenditure levels. The capacity required to deliver care to service users across the economy will be sized according to planned activity levels for future years. Capacity will be removed as service redesign/transfer is implemented. It is recognised that future planning will need to deliver service and financial viability for each individual organisation as well as being compatible in delivering viability across the health and social care economy. Risks will be identified and shared equitably across partners. Incentives will be developed where necessary to facilitate changed behaviours across the system. These will incentivise the redesign of services and reductions in the amount of activity being referred to acute care and the total amount of activity and costs in the local health and social care economy. The financial benefits from incentivised service redesign will be shared across partner organisations. Achieving activity and capacity reductions and resource release will be measures used, among others, to judge the progress and success of projects. 5.1.2 MEASURING IN YEAR PERFORMANCE Following approval of the Strategic Commissioning Plan the PCT will develop an Operational Plan for 2010/11 which will describe the key objectives to be achieved in delivering the first year of the strategy. The PCT Board will monitor the delivery of the SCP through the receipt of regular reports on the following key performance indicators: o
Vital signs (National and Local)
o
World Class arrangements
o
Local Area Agreement Targets
o
Business Objectives (including Operational Plan commitments not otherwise covered by targets)
o
Financial & Contracted Activity Performance targets
commissioning
outcomes,
competencies
and
governance
The Board will also receive regular reports on the work of the Whole Systems Delivery Board, and regular assurance that risks to delivery are being handled through its risk assurance and integrated governance framework.
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STRATEGIC COMMISSIONING PLAN 2010-2015
5.1.3 ENGAGING STAKEHOLDERS As noted in section 4, NHS Medway has, through Strategic Change Programme Groups, engaged a wide range of stakeholders in the development of its strategic commissioning plans. In addition, between November 2009 and February 2010 NHS Medway is holding a number of public meetings in a range of locations across Medway, and in November 2009 held a system-wide event at which a wide range of stakeholders considered the potential impact of the economic challenges facing the NHS, and the opportunities this offers for driving forward whole system improvement. The PCT has also made a number of presentations during 2009 to both adult and children’s Health Overview and Scrutiny Committees on aspects of commissioning strategy, including urgent care, older people, Child and Adolescent Mental Health Services and Primary Care and will be presenting the full Strategic Commissioning Plan on January 21st 2010. The plan will also be presented to the Medway Council Cabinet, and shared with all provider organisations. Public and Patients NHS Medway has made considerable progress in the quality and quantity of its patient and public engagement and communications in the past year, however there is still more to be done to achieve the aspirations of World Class Commissioning, particularly adapting communication styles to ensure that they are accessible to people with learning disabilities. All Strategic Change Programme Groups have direct and indirect patient representation. The PCT was an ‘early adopter’ of the new Local Involvement Network (LINks) and has worked closely with the Medway LINk as it has established its role. During 2009 the PCT’s Public, Carer and Patient Involvement Group made the decision to merge with the LINk, thus ensuring a common voice for public views on health issues. During 2009 the LINk brought the attention of the PCT to a number of service concerns highlighted by their members, and these have been addressed. Input through LINks members into Strategic Change Programme Groups has also been invaluable. Clinicians Clinicians are key players in strategic planning and service design. Practice based commissioning in particular is a key driver for innovative and transformational change The key routes for clinical engagement in commissioning decisions and service redesign involve members of the Professional Advisory Committee and the Practice Based Commissioning Groups. As Strategic Change Programme Groups have been established lead clinicians have been identified to provide both primary and secondary care perspectives. Support to Practice Based Commissioning has been increased considerably in 2009 with the appointment of a third Clinical Lead and a dedicated management team and consortia are starting to see the benefits of their engagement in service redesign. Each locality is represented on the Professional Advisory Committee, thus ensuring a strong relationship between PBC priorities and the wider strategic plans of NHS Medway.
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STRATEGIC COMMISSIONING PLAN 2010-2015 Primary care clinicians are also involved as practitioners in the delivery of new models of care particularly in the role of GP with a special interest e.g. CHD, diabetes. Whether through the pathway discussions nationally, across South East Coast or for local models of services clinicians of all disciplines are key players in shaping local services.
5.2 MANAGING RISK The PCT Assurance Framework will be the key governance tool. It will provide assurance to the organisation that its objectives are being met and highlight any gaps and deficiencies. In addition to the risks identified for each strategic goal in section 4, the most significant risks to the overall delivery of this strategic commissioning plan are: Risk
Mitigating factors
Financial assumptions in model Inflation higher than assumed National funding to the NHS is lower than expected
Uplifts for 2010/11 have been confirmed and it is clear that minimal inflation funding only will be applied in 2011/12 and 2012/13. Tariff uplift confirmed as zero for 4 years.
Revised national tariffs impact on affordability
Tariff to be published in mid-February. Contingency reserves in place.
Higher activity levels than planned
The development of the Medway Whole Systems Delivery Board will ensure joint accountability and consistency of financial incentives locally. The PCT will be making greater use of contract levers with all providers to ensure that payment is made only for appropriate activity.
Greater number of High cost treatments
Health of our population NHS Medway unable to meet the health needs of our population either through capacity, need or other factor. Increased focus on Kent & Medway and SHA-wide functioning results in a loss of local Medway focus.
A new Individual Funding Request process has been instituted in 2009, together with a Policy Development Group which will consider requests for the funding of unusual or high cost treatments.
JSNAs clearly setting out needs of Medway population compared to the wider region. Development of practice based commissioning focusing at sub-Medway level. Strong partnerships with Medway Council to ensure joint objectives taken forward locally.
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STRATEGIC COMMISSIONING PLAN 2010-2015 Coordinating and leading the local health economy in Quality Innovation and Productivity Scale of delivering strategy in economic downturn will require radical solutions county and SHA wide. Autonomous organisations failing to work in partnership and own the agenda to deliver required change. Capacity and competency to deliver strategic commissioning plan at pace and scale required while living within available resources.
Commissioning Collaborative in place across Kent & Medway with all PCT Chief Executives committed to driving change.
‘Storm’ event and follow up actions designed to ensure commitment of partners across Kent & Medway.
Organisation Development Plan and Talent Management Strategy designed to develop and sustain strong managerial and clinical leadership at all levels.
Lack of effective whole system service change needed to deliver reduced cost, increased clinical productivity and tailor capacity to contracted need
Commitment of all partners to ‘Medway Delivery Board’ with joint programme office to drive delivery of agreed objectives. CQUIN and other local targets to be tailored to demonstrate productivity and quality gain.
Inability of acute providers to tailor capacity downwards if demand is not reduced and/or diverted.
Strong engagement with clinicians on pathway redesign and review of thresholds through practice based commissioning and strategic change programme. Referral management systems in primary care. Urgent Care pathway to maximise appropriate diversions from acute hospitals. Strong audit of contract activity to ensure appropriate payment.
Highest quality of services threatened by potential instability of all community services and consequent inability to deliver stated quality, cost and volume requirements. Prevention programme, primary care service and early diagnosis of ill health will be insufficiently prepared to have the required impact on the health of our population.
Future plans for provider arm to be confirmed by end March 2010.
Significant emphasis in 2010 on social marketing and health improvement working directly with the local population
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STRATEGIC COMMISSIONING PLAN 2010-2015 Workforce Inability to implement whole health and social care system plans by having insufficient staff with appropriate training and flexibility to adapt to changes in pathway design.
Workforce plans agreed with all key partners
Inability to develop the culture of taking ownership through the empowerment of staff to embed professional best practice.
Estates and Facilities Standard of estate is insufficient and inappropriate to enable effective delivery of primary and community services. Inability to rationalise the acute estate downward matched with the necessary reduction in overheads.
Estates Strategy to be approved by Board in January.
The development of the Medway Whole Systems Delivery Board will ensure joint accountability for estates management.
IM&T Inability to implement radical and timely solutions to deliver new ways of working supported by Informatics.
IM & T Strategy to be approved by Board in January. Improvements in technology have led to cheaper and more versatile solutions being available to the NHS. All business cases are supported by robust benefits realisation programmes.
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STRATEGIC COMMISSIONING PLAN 2010-2015 5.3 ORGANISATION DEVELOPMENT NHS Medway has developed rapidly since 2006 when it was deemed to be a reconfigured PCT. The task of the PCT then was to rise to the challenges resulting from a period of turbulence, personal uncertainty and change and the need to create a strong positive financial foundation. Through a fundamental review of its organisational and management structure significant improvements in strategy, governance and delivery capability were recognised in the World Class Commissioning panel report of November 2008. Throughout 2009 NHS Medway has sought to fulfil its ambition to make Medway a great place to live, work and thrive and whilst the World Class Commissioning report highlighted a number of key achievements, NHS Medway remains determined to improve its standing year on year in the review process. The decision of the Board in March 2009 to separate community healthcare services from the commissioning role of the organisation brings its own challenges and opportunities and requires NHS Medway to put in place a robust framework which allows the PCT to focus very strongly on our core mission of health improvement. In March 2010 the Board of NHS Medway will receive for adoption a revised Organisation Development Plan (ODP), which summarises learning to date, supports the delivery of NHS Medway’s Strategic Commissioning Plan and the PCT’s journey to becoming World Class Commissioners. It seeks to ensure that as an organisation the PCT has the leadership, organisational structure and workforce capacity and capability to deliver our ambitious work programmes. This ODP sets out the steps that NHS Medway will take over the next 5 years to ensure that NHS Medway becomes a World Class Commissioner. It identifies 4 development themes each with its own clear ambition and underpinning cluster of development priorities. In assessing progress during the refresh of this plan and taking stock of our current position in light of our need to focus effort even more on delivering further against our 6 strategic goals in the changing economic climate, and the results of staff surveys, key themes have emerged into which the development priorities for future years will be clustered. These themes are: o o o o
Transformation & innovation Leadership Effectiveness People
Clustering activity into these themes will focus thinking, demonstrate maturity of the organisation, join up activities which make a similar contribution to the development of NHS Medway and give clarity of message and sense of purpose to our stakeholders, including staff, about our intentions. Inevitably there will be overlaps between the activities clustered under each theme but this will only serve to support the holistic whole system approach to Organisational Development. Underpinning these 4 themes is an overarching theme of Quality in everything we do. The diagram overleaf, drawn from the ODP, shows how the ODP supports the implementation of all of the PCT’s strategic and operational priorities:
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STRATEGIC COMMISSIONING PLAN 2010-2015
‘Our
Thread’
MEDWAY MEDWAY AAgreat greatplace placeto tolive, live,work workand andthrive thrive Policy Policy Drivers Drivers
Joint Joint Strategic Strategic Needs Needs Assessment Assessment
STRATEGIC STRATEGIC OBJECTIVES OBJECTIVES
Local Local Area Area Agreement Agreement WCC WCC Outcomes Outcomes
NHS NHS Operating Operating Framework Framework
NICE NICE NSF NSF Darzi Darzi & & HPEC HPEC
OPERATIONAL OPERATIONALPLAN PLAN Delivering Deliveringthe theSCP SCP
ORGANISATIONAL ORGANISATIONAL DEVELOPMENT DEVELOPMENTPLAN PLAN
DIRECTORATE DIRECTORATEBUSINESS BUSINESSPLANS PLANS Sets Setsout outoperational operationalactivities activitiesofofthe theDirectorate Directorate
INDIVIDUAL INDIVIDUALOBJECTIVES OBJECTIVES Sets Setsout outindividual individualactions actionstotoachieve achievestrategic strategicobjectives objectives Our Golden Thread
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STRATEGIC COMMISSIONING PLAN 2010-2015
SECTION 6 | UNDERPINNING STRATEGIES 6.1
Workforce Strategy
Over 70% of all NHS expenditure is on staff. Delivery of the plans set out in this document is dependent on having an efficient and effective workforce. However, delivering the savings required over the period of this strategy will require a net reduction in workforce. The challenge facing the NHS in Medway is, therefore, to ensure the development of a leaner, more efficient workforce, with staff having the range of skills which will enable them to work flexibly across a range of settings. NHS Medway is working with all local providers to develop a detailed workforce plan which is consistent with the content of this strategy. The workforce plan will be agreed by the Board in March 2010. In five years time, there will be a net reduction in the total size of the workforce, and a net shift from acute hospitals to community based services. PCTs and SHAs have been challenged to deliver a net reduction of 30% in management costs across the SHA area. It is not yet clear how this target will fall to individual PCTs. However, NHS Medway will seek opportunities to work with partners to reduce costs by, for example, the development of the Commercial Support Unit across South Eats Coast and by closer working with Medway Council. NHS Medway has agreed a Talent Management Strategy and an approach to the development of clinical leadership which, together, will ensure that future leaders at all levels are identified and nurtured. Again, the PCT is working with partner organizations to ensure that opportunities for development are shared within the wider health and social care system. This strategic commissioning plan portrays the vision for future healthcare services in Medway in the next three to five years. The PCT recognises that to achieve the vision the whole health care system in Medway needs to have the right workforce, at the right time, in the right place and at the right cost. NHS Medway has a leadership, developmental and assurance role in workforce planning and education commissioning across our health community. In the current economic climate it is even more essential that workforce plans are comprehensive and integrated with financial plans. This section of the plan reaffirms the roles and responsibilities for workforce planning and education commissioning across the South East Coast region. It also outlines the timeline for submission of workforce plans to NHS Medway and the proposed assurance process for workforce planning. NHS Medwayâ&#x20AC;&#x2122;s Director of Workforce and Organisational Development is the Local Partnership Group Chair of the Medway Strategic Workforce Group and Local Education Partnership Group. These groups meet on a regular basis throughout the year. The membership of the groups includes representatives from NHS Medway, all Provider organisations, Higher Education Institutes and Further Education representatives as well as the Local Authority. The purpose of the groups is to:
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STRATEGIC COMMISSIONING PLAN 2010-2015
•
increase the understanding and planning between health, care and education in Medway.
•
ensure that the commissioning strategies and plans for the population of Medway are both informed by and informing of local health, education and care workforce development plans.
•
oversee the development and implementation of plans which ensure the right health, education and social care workforce in the short, medium and long term for in the Medway economy.
In 2010 NHS Medway will be working with Eastern and Coastal and West Kent PCTs to establish a ‘county workforce hub’ which will replace the current arrangements. This is likely to be based around an overarching Kent & Medway Strategic Workforce Group chaired by a Chief Executive. Workstreams beneath will include education commissioning, service development and so forth. All providers will be engaged in this. Roles and Responsibilities The Role of the SHA The SHA is responsible for quality assuring that workforce plans align with finance, activity, leadership and information plans and that NHS priorities will be delivered. An annual regional plan will be produced, aggregating the LHC plans. The SHA will provide support and guidance to PCTs as they develop but in the longer term the vision is a devolved structure with the SHA ensuring that workforce risks are managed effectively by PCTs/County Hubs and that education commissioning plans are based on sound evidence. The roles and responsibilities for workforce planning across the system are in keeping with the requirements set out in a High Quality Workforce NSR report. The Role of the PCT Commissioner The role of the PCT is three-fold. • Providing Guidance through the Strategic Commissioning Plan on Workforce Planning, Development and Education Commissioning Requirements of Provider Organisations • To assess the quality, sustainability and deliverability of provider workforce plans • Lead & Coordinate LHC Strategic Workforce Planning The Role of Provider Organisations HR Directors in Provider organisations will work in partnership with their PCT colleagues, producing workforce and education plans for their organisations that reflect the changes outlined in the PCT Strategic Commissioning Plans (SCP’s), identify current and future requirements for staff, including numbers, skill mix, education and training requirements. Key Considerations for inclusion within the plans
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The workforce plans should include national and local priorities which are listed below or are mentioned within other areas of the PCT’s Strategic Commissioning Plan. National priorities • • • • • • • • • • •
Existing policies such as Our Health, Our Care, Our Say (2006), Choice, 18 weeks, Maternity Matters and Every Child Matters. Modernising Healthcare Careers and continuous professional development European Working Time Directive High Quality Care for All - Next Stage Review final report A High Quality Workforce: Next Stage Review report Our NHS Our Future: NHS Next Stage Review - Leading Local Change report NHS Constitution The Workforce Review Team annual Assessment of Workforce Priorities (2009) as well as their recent Care Area Reports (see box below) Effective use of the Electronic Staff Record and Learning Management Systems Meeting Equality and Diversity and Human Rights duties
Workforce Review Team Annual Assessment of Workforce Priorities and draft Care Area Reports Annual Assessment of Workforce Priorities (2009) Cross Cutting• Diagnostics • Dementia • Mid-grade Doctors • Therapeutics Specialties & Professions• Nationally planned specialties • Nursing • Operating department practitioners • Pharmacy Care Areas – • Children, including Health Visitors • Maternity & newborn, including obstetrics and gynecology • Staying healthy Appendix 5 includes details of key actions and next steps for the workforce across the eight Healthier People, Excellent Care pathways.
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Local priorities • Medway’s 6 key health goals and 16 Strategic Change Programmes • The South East Coast Region response to High Quality Care for All- Healthier People Excellent Care • Response to the current economic climate together with initiatives to support the local community i.e Apprenticeships. • The Widening Participation agenda to ensure skills and engagement with vocational workforce – all Medway LHC organizations have signed the skills pledge. • Work with local NHS organisations on identified priority areas including maternity and childrens’ services • Building capacity and ensuring the development of the neo natal workforce. • Reflect the outcomes of the Mental Health: Improving Access to Psychological Therapies Programme in workforce plans. • Effective utilisation of the Knowledge and Skills Framework to secure benefits. • ‘Lean thinking’ and paybill efficiencies assuring improved productivity. • Solutions for under doctored areas. Provider organisations workforce plans should include the best quality estimates of their workforce over the five years of the plan across specific staff groups. For detailed guidance on the structure of the provider workforce plans then please see NHS South East Coast Workforce Planning Framework Appendix D. The plans should include information on how new roles are being developed and identify any implications for education commissioning changes. Plans will have full clinical engagement and involvement of all the relevant stakeholders. Any principles to be used in making staff changes will need to ensure they meet with NHS Employers guidance, working in partnership with trade unions and pledge NHS values engagement in it. In the assessment of provider workforce plans the PCT will refer to the guidance set out in the document ‘Workforce planning and education commissioning in South East Coast 2010/11 -Version 8 (27 November 2009)’ as well as the Operating Framework for the NHS in England 2010/11.
Workforce Plan Assurance Provider organisations submitted the 1st cut of their workforce plan in December 2009. The final cut of Provider plans should be submitted to the PCT in March 2010. The first iteration of the Local Health Economy workforce plan was submitted to the SHA on the 25th January 2010. The final cut should be submitted by the 31st March 2010. This plan will be the foundation for the Education Commissioning plans for 2011/12.
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First Iteration: Provider workforce plans are being reviewed by key stakeholders within NHS Medway following the December submission. The Assistant Director for Workforce Planning at NHS Medway reviewed the submissions with the workforce lead for each provider organisation in early January prior to the LHC submission to the SHA on the 25th January. Final Iteration: The PCT invited Provider organisations to present their workforce plans to key stakeholders within NHS Medway week commencing the 15th February 2010. This gave Provider organisations the opportunity to demonstrate and assure the PCT that their future workforce plans are robust, evidence based and sustainable. A final plan will need to be submitted to the PCT on the 9th March 2010. 6.2
Estates Strategy
The Board of NHS Medway has approved the following principles around the use of PCT owned estate: • • •
The development of community hubs providing access to health and other services and leading to greater integration. Improved utilisation of accommodation Improved training opportunities, impacting positively on recruitment and retention.
The Estates Strategy, attached at Appendix 6, develops these principles and enables NHS Medway to: •
• •
•
•
Identify appropriate locations and facilities for the population of Medway to deliver our commissioning requirements. These intentions have been agreed to meet local health need with local access as a key principle where appropriate Fully utilise our estate to ensure maximum value for money and appropriate use of resources. Balance the need for investment in facilities at a time when public spending will be increasingly under challenge. Where possible to ensure new developments or changes are cost neutral or cost minimal and that overall the programme of investment is value for money. Ensure all facilities from which services are provided are fit for purpose. Within this will be a need to balance investment where current infrastructure is poor or has limited capacity against opportunities for development to enable innovative service provision. Address national policies around carbon efficiency and sustainability.
This estate strategy takes a whole health economy perspective. It covers NHS and non NHS facilities where these affect the delivery of care including: • •
Primary Care Facilities i.e. GP premises, dentists and pharmacists Community Facilities including bases for peripatetic services such as district nursing
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• •
• •
•
Specialist Community Services e.g. Children’s services and Intermediate Care Beds Acute General Hospital facilities for both outpatient and inpatient services. The PCT and partners will factor into these plans the desire for local access whilst ensuring greater efficiency and maintaining appropriate control over acute capacity Mental Health Services for community, outpatient and inpatient services The Voluntary and Charitable sector especially around the opportunities for colocation and integrated working e.g. the community cafes in the Healthy Living Centres Social Care and Education services where these are best collocated with heath. Opportunities for co-location and collaboration with Medway Council e.g. with Social Services, Education etc
Continual engagement with our partners will be undertaken to understand their aspirations and marry them with those of NHS Medway. This collaboration will provide us with the opportunities to rationalise the use of the wider estate whilst maintaining local access It is consistent with national policy around ensuring better use of facilities e.g. through the “Total Place” and “Single Conversation” initiatives. This is a significant piece of work and will not necessarily result in short term solutions but over the ten year period of the estates strategy will be an influencing factor in the transformation of the estate. 6.3
IM & T Strategy
NHS Medway has reviewed its IM & T strategy during the development of this Strategic Commissioning Plan. The revised strategy, attached at Appendix 7, sets out NHS Medway’s priorities and plans to deliver technology enabled change across the local health community. The strategy reflects the key principles and priorities set out in the Department of Health, Informatics Review issued in July 2008. It also reflects key priorities identified by the Chief Information Officer for NHS South East Coast and consultation with key stakeholders in the Kent and Medway Health Economy. When a patient accesses health services they have a right to expect that their information will be kept secure, shared appropriately and with consent, and be in the right place at the right time to ensure that care is delivered safely and effectively66. In an age when patients can access information from a variety of sources – some of them evidenced and some not, NHS Medway has a duty to support well informed patients. The PCT will achieve this by making sure that information on pathways of care and their effectiveness is published and accessible, using new technologies and sign posting patient to reliable sources. The PCT will also ensure that the patient voice is heard by using electronic media to collect and analyse patient opinions and by encouraging patient and public engagement with the design and methods of providing electronic patient information. In future, the patient journey should involve giving information once at the initial point of contact, and employing systems to ensure that the information travels through integrated 66
HPEC pledge: By 2012, all patients will have unrestricted access to their summary medical records.
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STRATEGIC COMMISSIONING PLAN 2010-2015 systems accurately and securely. Most patients believe that this is already the case, and are surprised and often frustrated to find that their information has not followed them to their next care setting. At each stage of the journey access, choice and information will be supported by the Informatics Programme â&#x20AC;&#x201C; from secure primary care systems to Choose and Book, through electronic results reporting, electronic prescribing and community services which are mobile and close to home. Within the IM & T strategy, programmes of work are aligned to the goals of the Strategic Commissioning Plan and the business objectives of the organisation, focusing on NHS Medwayâ&#x20AC;&#x2122;s role as the leader and driver of development and innovation across our providers. Focusing on high quality Informatics improves patient experience and enables staff to make better use of information to improve the quality of care. There has been significant investment in the past two financial years. Future high priorities are in systems integration and in driving further benefit from the current baseline infrastructure; through acknowledgement that technology has the ability to unlock improvements and savings and is now a mainstream consideration in the design of services and integrated care pathways.
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SECTION 7 | CONCLUSION The commissioning and delivery of health services is a dynamic process. NHS Medway is has made significant progress in reviewing how it can improve health services for the people of Medway. However, over the next five years this progress must continue in a very different financial environment. To improve services and outcomes, and to rise to the demographic challenge facing the PCT, NHS Medway will continue to invest in a range of service developments. However, the funding required for this must be generated through better use of existing resources. The use of hospital services must be as efficient and effective as possible, releasing finance and workforce to deliver more services closer to people’s homes. Inefficiency and waste will not be tolerated. The PCT and its partners will be focused on stopping doing those things which are of little clinical value, on delivering services more efficiently and on commissioning and delivering more cost-effective services. The content of this strategic commissioning plan will form the basis of the NHS Medway’s annual Operational Plan, which will set out: •
the levels of service this PCT plans to commission for the coming year,
•
priorities for service change and investment in that year,
•
progress on the local commissioning objectives,
•
progress on key local and national targets, and
•
its response to the national NHS Operating Framework
The Operational Plan will also be used to assure the Professional Advisory Committee (PAC), PCT Board and local service users and the public that the PCT is delivering on the commissioning objectives set out in this plan. NHS Medway’s corporate objectives include the development of a number of key strategic plans that will influence the delivery of health services in Medway over the next 5 years. In 2009/10 the majority of these strategies have been agreed by the Board, and their delivery is crucial to the success of this overarching Strategic Commissioning Plan. With a clear focus on local needs, and strong patient and public involvement, NHS Medway is now following a clear ‘commissioning cycle’, which includes analysis of need, planning against priorities for investment, managing the opportunities that exist in local people and services and seeking real health gain.
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1 2
Assess Needs
7
Provision review and equity audit
Manage and evaluate performance
Analyse
Real Use Benefits
6
Plan
Formalise and communicate change
Decide priorities and investment
3
Manage Change
Define service Shape structure of supply
4
5
To secure the delivery of some very specific targets over the next five years NHS Medway will change the way it has traditionally commissioned healthcare. With the help of partners both professional and lay members NHS Medway commits to securing transparency in its decision making and accountability in all it seeks to achieve.
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SECTION 8| DECLARATION OF BOARD APPROVAL The Board is continually engaged in both the development of service and organisational strategy and in seeking assurance on its delivery. The Strategic Commissioning Plan has been discussed on a number of occasions both informally and formally at the Board and members have contributed to its shape and content. This document reflects the key initiatives that the Board through the Strategic Change Programme agree as its highest priorities.
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STRATEGIC COMMISSIONING PLAN 2010-2015 Appendix 1: List of Providers and current contract values Nb excludes contract values less than £100,000
Service provider Medway NHS Foundation Trust Medway Community Healthcare Kent & Medway Partnership Trust Maidstone & Tunbridge Wells Trust Guys and St Thomas South East Coast Ambulance and HEMS East Kent Hospitals Trust Kings College Hospital NHS FT Queen Victoria Dartford and Gravesham NHS Trust Haemophilia Consortium - Croydon PCT West Kent Treatment Centre UCL Hospitals NHS Trust Royal Brompton and Harefield PICU Consortium - Hillingdon PCT Royal National Orthopaedic Marsden Bone Marrow Consortium - Hillingdon Lead The Royal Hospital Trust Great Ormond Street St Georges Healthcare Royal Free Hampstead Clinical Genetics Consortium Bexley,Bromley & Greenwich H.A Imperial College Hammersmith Spinal Injuries Consortium - West Kent PCT Cleft Lip & Palete Consortium Haringey PCT Lewisham Queen Elizabeth NHS Trust Moorfields Chelsea & Westminster Trust North West London hospitals Paediatric BMT - Bexley PCT
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Initial 2009/10 Contract value £113,775,769 £24,280,000 £10,952,217 £10,327,579 £6,707,811 £5,598,338 £5,287,592 £3,771,034 £3,192,400 £1,847,383 £1,500,000 £885,890 £721,379 £694,500 £634,648 £559,868 £530,800 £528,688 £509,462 £465,105 £461,486 £419,200 £409,512 £349,300 £218,300 £186,691 £172,100 £147,829 £140,603 £134,055 £117,400
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Appendix 2: Vital Signs and other performance indicators 2009/10 Target
2009/10 Latest Performance
Comments
90.00%
93.93% as at 31/10/2009
The target for December 2008 was for 90% of patients whose treatment includes a hospital admission to be treated within 18 weeks of referral. This was achieved and has been sustained to October 2009.
95%
96.46% as at 31/03/2009
95.00%
97.17% as at 31/10/2009
The target for December 2008 was for 95% of patients whose treatment is carried out in an outpatient setting to have commenced within 18 weeks of referral. This was achieved and has been sustained to October 2009.
Direct Access Audiology waiting times
100%
100% as at 31/03/2009
100.00%
100% as at 31/10/2009
Access to Genito-urinary medicine (GUM) Clinics within 48 Hours
100%
2008/09 98.935%
100.00%
YTD Oct 09 99.82%
2008/09 Target
2008/09 Outturn
90%
94.25% as at 31/03/2009
18 week Referral to Treatment Times - Reported waits for Non Admitted elective care
Vital Signs Description
18 week Referral to Treatment Times - Reported waits for Admitted elective care
Access to Primary Care Patient reported measure of GP access
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89%
82% (Patient Survey 2007/2008)
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For 2008/09 this was the average of the five elements of access to primary care - telephone access, see GP within 48 hours, book GP consultation 3+days ahead, see a specific GP and GP practice opening times) For 2009/10 this will be a three part indicator based on results from the GP Patient Survey, using figures aggregated for the whole 2009/10 year from the four quarterly surveys. PCTs will be expected to perform well across the three themes (fast access, booking ahead and satisfaction with opening hours) to achieve the overall indicator.
STRATEGIC COMMISSIONING PLAN 2010-2015
Vital Signs Description
2008/09 Target
2008/09 Outturn
Access to Primary Care Practices offering extended opening hours
50.75%
81% as at 31/03/2009
Access to Primary Dental Services
153,300
162,635
165,864
All-age all cause mortality (AAACM) rate per 100,000 Female
2008 520.20
2007 544.56
2009 510.50
All-age all cause mortality (AAACM) rate per 100,000Male
2008 721.20
2007 780.32
2009 702.10
All Cancers: One month diagnosis (Decision to treat) to treatment
Qtrs 1 to 3 100% Qtr 4 96%
Qtrs 1 to 3 99.7% Qtr 4 96.6%
31-Day Standard for Subsequent Cancer Treatments (Surgery and drug treatment (chemotherapy)) All treatments to start within 31 days of patient being added to the waiting list for that treatment.
Qtrs 1 to 3 Not Collected Qtr 4 Surgery 94% Drug Treat 98%
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Qtr 4 Drug 100% Surgery 94.7%
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2009/10 Target
2009/10 Latest Performance
Comments
This indicator is not included in 2009/10 Care Quality Commission Performance Assessment YTD Sept 09 166,098
For 2009/10 this will be measured as the number of patients seen in the 24 month period ending 31 March 2010
96.00%
Qtr 1 97.5% Qtr 2 98.0%
From quarter 4 2008/09 Operational standards have been set for the Cancer waiting times targets as the new methods of data collection do not allow adjustments for patient choice. First treatment for all cancers - 96%
Drug 98% Surgery 94%
Qtr 1 Drug 100% Surgery 95.2% Qtr 2 Drug 98.6% Surgery 98.5%
From quarter 4 2008/09 Operational standards have been set for the Cancer waiting times targets as the new methods of data collection do not allow adjustments for patient choice. Subsequent treatment Surgery - 94% Subsequent treatment Drug Treatment - 98%
STRATEGIC COMMISSIONING PLAN 2010-2015
Vital Signs Description
2008/09 Target
2008/09 Outturn
2009/10 Latest Performance
Comments
From quarter 4 2008/09 Operational standards have been set for the Cancer waiting times targets as the new methods of data collection do not allow adjustments for patient choice. Subsequent treatment Radiotherapy - 94%
31-Day Standard for Subsequent Cancer Treatments (Radiotherapy) All treatments to start within 31 days of patient being added to the waiting list for that treatment.
Qtrs 1 to 3 Not Collected 85% by Qtr 4 2008/09 (SHA Stretch target)
Qtr 4 100%
All Cancers: Two month GP urgent referral to treatment
Qtrs 1 to 3 100% Qtr 4 85%
Qtrs 1 to 3 98.8% Qtr 4 82.7%
Extended 62-Day Cancer Treatment Targets. Percentage of patients who receive a first definitive treatment for cancer within 62 days of an urgent referral from the national screening programme
Qtrs 1 to 3 Not collected Qtr 4 90%
Qtr 4 100%
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2009/10 Target
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94%
Qtr 1 100% Qtr 2 100%
85.00%
Qtr 1 92.6% Qtr 2 80.6%
From quarter 4 2008/09 Operational standards have been set for the Cancer waiting times targets as the new methods of data collection do not allow adjustments for patient choice. First treatment for all cancers -85%
90.00%
Qtr 1 100% Qtr 2 100%
From quarter 4 2008/09 Operational standards have been set for the Cancer waiting times targets as the new methods of data collection do not allow adjustments for patient choice. First treatment from national screening referral -90%
The expansion of the standard to incorporate radiotherapy treatment is required to be achieved by December 2010 in the Cancer Reform Strategy. SEC SHA have set interim stretch targets to be achieved and the PCT seems to be achieving but we are aware that not all Providers are fully submitting this data yet. Therefore there may be a dip in performance as more data is submitted.
STRATEGIC COMMISSIONING PLAN 2010-2015
Vital Signs Description
2008/09 Target
2008/09 Outturn
2009/10 Target
2009/10 Latest Performance
No standard set
Qtr 1 100% Qtr 2 100%
From quarter 4 2008/09 Operational standards have been set for the Cancer waiting times targets as the new methods of data collection do not allow adjustments for patient choice. First treatment from consultant upgrade - has not been set as there have been insufficient numbers for a robust calculation of an operational standard
93%
Qtr 1 96.4% Qtr 2 95.3%
From quarter 4 2008/09 Operational standards have been set for the Cancer waiting times targets as the new methods of data collection do not allow adjustments for patient choice. Two week wait to be seen by a specialist -93%
Qtr 1 100% Qtr 2 50%
From quarter 4 2008/09 Operational standards have been set for the Cancer waiting times targets as the new methods of data collection do not allow adjustments for patient choice. Two week wait to be seen by a specialist - 93%
Extended 62-Day Cancer Treatment Targets. Percentage of patients who receive a first definitive treatment for cancer within 62 days of a consultant decision to upgrade their priority status.
Qtrs 1 to 3 Not collected Qtr 4 No standard set
Qtr 4 100%
All Cancers: Two Week Waits
Qtrs 1 to 3 100% Qtr 4 93%
2008/09 99.42%
Breast Symptom Two Week Wait (Two week wait standard for patients referred with 'breast symptoms' not currently covered by two week waits for suspected breact cancer)
Qtrs 1 to 3 Not Collected Qtr 4 93%
Qtr 4 40%
93%
Breast cancer screening for women aged 53 to 70 years
National Target to achieve >= 70%
81.2% aged 53-64 79.1% aged 65-70 (KC63 07/08)
National Target to achieve >= 70%
Ambulance Trust - Category A Calls meeting 8 minute standard from call connect
75%
2008/09 75.15%
75%
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Comments
This is an annual collection so no further info is available. The tolerance for achievement may increase as part of the CQC assessment for 2009/10
YTD Oct 09 77%
This is the performance of the South East Coast Ambulance Trust (SECAmb). NHS Medway, along with the other Primary Care Trusts in the South East Coast area, commission their
STRATEGIC COMMISSIONING PLAN 2010-2015
Vital Signs Description
2008/09 Target
2008/09 Outturn
2009/10 Target
2009/10 Latest Performance
95%
2008/09 96.91%
95%
YTD Oct 09 98.4%
95%
2008/09 94.57%
95%
YTD Oct 09 93.8
Ambulance Trust - Category A Calls meeting 19 minute standard Ambulance Trust - Category B Calls meeting 19 minute standard Cervical Screening for women aged 25 to 64 years
Comments Ambulance services from SECAmb. The achievement of the Category A targets and the performance on Category B reflect the high level of effort and commitment from everyone in the Trust.
Additional indicator for 2009/10
Childhood Obesity Measured in Year R (Reception)
8.65% (86% coverage)
8.0% (83% coverage)
9% (88% coverage)
Results of the 2009 National Child Measurement Programme should be published in December 2009
Childhood Obesity Measured in Year 6
18.68% (86% coverage)
20.4% (87% coverage)
19% (88% coverage)
Results of the 2009 National Child Measurement Programme should be published in December 2009
17%
14.94%
25.00%
YTD at Qtr 2 12.3%
3
3 as at 31/03/2009
3 as at 31/03/2010
3
Chlamydia Prevalence (Screening) Percentage of population aged 15 to 24 screened or tested for Chlamydia Commissioning a comprehensive child and adolescent mental health service (CAMHS) Has a full range of Child and Adolescent Mental Health Services (CAMHS) for children and young people with learning disabilities been commissioned? (Scale 1-4)
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Vital Signs Description
2008/09 Target
2008/09 Outturn
2009/10 Target
2009/10 Latest Performance
3
3 as at 31/03/2009
3 as at 31/03/2010
3
3
3 as at 31/03/2009
3 as at 31/03/2010
3
Commissioning a comprehensive child and adolescent mental health service (CAMHS) Do 16 and 17 year olds who require mental health services have access to services and accommodation appropriate to their age and level of maturity? (Scale 1-4) Commissioning a comprehensive child and adolescent mental health service (CAMHS) Are arrangements in place to ensure that 24 hour cover is available to meet urgent mental health needs of children and young people and for a specialist mental health assessment to be undertaken within 24 hours or the next working day where indicated? (Scale 1-4)
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Comments
STRATEGIC COMMISSIONING PLAN 2010-2015
Vital Signs Description
2008/09 Target
2008/09 Outturn
2009/10 Target
2009/10 Latest Performance
Commissioning a comprehensive child and adolescent mental health service (CAMHS) Is a full range of early intervention support services delivered in universal settings and through targeted services for children experiencing mental health problems commissioned by the Local Authority and PCT in partnership? (Scale 1-4)
2
2 as at 31/03/2009
3 as at 31/03/2010
3
Commissioning of Crisis Resolution / Home Treatment Services
473
2008/09 512
473
YTD July 09 172
Commissioning of Early Intervention in psychosis services
33
2008/09 20
32
YTD July 09 14
85%
2008/09 85.457%
85%
<3.5%
>3.5% (5.921 per 100,000)
Data Quality on ethnic group
Delayed Transfers of Care
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<3.5%
Comments
Threshold may be increased by Care Quality Commission (NB Threshold was increased by 5% for 2008/09 Annual Healthcheck) Qtr 1 22 Qtr 2 20 (10.36 per 100,000)
Review of cause of delay in moving patients from acute and non acute beds will be undertaken as part of the Urgent Care Strategic Commissioning Programme
STRATEGIC COMMISSIONING PLAN 2010-2015
Vital Signs Description Diabetic Retinopathy screening - Percentage of diabetes patients identified by the practices who have been offered digital retinopathy in the last 12 months (less exclusions) Self reported experience of patients/users (National priority for local delivery)
2008/09 Target
2008/09 Outturn
2009/10 Target
2009/10 Latest Performance
100%
99.94%
100.00%
YTD Qtr 2 90.9%
80.9
Indicator for 2009/10 to be agreed by CQC
Smoking Prevalence (Number of 4 week Smoking Quitters who attended NHS Stop Smoking Service)
1165
1675
1175
YTD at Q2 916
Rate per 100,000 population aged 16 and over for Smoking Quitters
569
569
570
YTD at Q2 444
Incidence of C Diff (Commissioner) Includes hospital and community acquired infections for NHS Medway registered population
118
2008/09 112
131
YTD Oct 09 45
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Comments
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79% of target achieved by Q2
STRATEGIC COMMISSIONING PLAN 2010-2015
2008/09 Target
2008/09 Outturn
2009/10 Target
2009/10 Latest Performance
Incidence of Community Acquired C Diff (NHS Medway Provider)
37
2008/09 53
52
YTD Oct 09 224
Inpatients waiting longer than the 26 week standard
0%
2008/09 0.027%
0.00%
YTD Oct 09 0%
NHS staff survey based measures of job satisfaction
2008 3.6
2008 3.596
2009 3.7
Number of Drug Users recorded as being in effective treatment
630
693
636
Outpatients waiting longer than the 13 week standard
0%
2008/09 0.059%
0%
YTD Oct 09 0.035%
Patients waiting longer than three months (13 weeks) for revascularisation
0%
2008/09 0%
0%
YTD Oct 09 0%
Vital Signs Description
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Comments
National Average for PCTs was 3.571 (418 respondents)
As at Oct 09 15 patients have waited longer that 13 weeks for a first outpatient appointment
STRATEGIC COMMISSIONING PLAN 2010-2015
Vital Signs Description
2008/09 Target
2008/09 Outturn
2009/10 Target
2009/10 Latest Performance
Prevalence of Breastfeeding at 6-8 weeks (Totally or Partially breastfed) of mothers due a 6-8 weeks check
39.90%
2008/09 22.65%
Qtr 4 2009/10 49.50%
Qtr 2 2009/10 28.11%
Percentage of children with a Breastfeeding status recorded at the time of their 6-8 weeks check
85%
2008/09 55.36%
Qtr 4 2009/10 92.5%
Qtr 2 2009/10 66.05%
95%
2008/09 96.4%
95%
Qtr 1 2009/10 96.1%
95%
2008/09 92.8%
95%
Qtr 1 2009/10 95.2%
95%
96.50%
95%
Qtr 1 2009/10 95.8%
Immunisation rate for children aged 1 who have ben immunised for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b - All 3 doses Immunisation rate for children aged 2 who have been completely immunised for Pneumococcal infection (PCV booster) Immunisation rate for children aged 2 who have been completely immunised for Haemophilus influenza type b, meningitis C (Hib/MenC booster)
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Comments
STRATEGIC COMMISSIONING PLAN 2010-2015
Vital Signs Description
2008/09 Target
2008/09 Outturn
2009/10 Target
2009/10 Latest Performance
88%
93.80%
92%
Qtr 1 2009/10 88.1%
95%
93.50%
95%
Qtr 1 2009/10 92.9%
95%
94.50%
95%
Qtr 1 2009/10 88.1%
Immunisation rate for children aged 2 who have been immunised for measles, mumps and rubella (one dose) Immunisation rate for children aged 5 who have been immunised for Diphtheria, Tetanus, Polio, Pertussis (4 doses) Immunisation rate for children aged 5 who have been immunised for measles, mumps and rubella (2 doses) Immunisation rate of 90% for human papilloma virus vaccine for girls aged around 12-13 years Immunisation rate for children aged 13 to 18 who have been immunised with a booster dose of tetanus, diphtheria and polio Cancer Mortality Rate (People aged under 75) rate per 100,000
90%
90%
90%
90%
2008 112.20
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2007 125.80
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2009 109.40
Comments
STRATEGIC COMMISSIONING PLAN 2010-2015
Vital Signs Description CVD Mortality Rate per 100,000 (Heart disease, stroke and related diseases in people aged under 75) Quality stroke care Proportion of people who spend at least 90% of their time on a stroke unit Quality stroke care Proportion of people who have a high risk of TIA who are scanned and treated within 24 hours Teenage conception rate (number per 1,000 females aged 15-17) Early Access for Women to Maternity Services (Number of women seen within first 12 weeks of pregnancy as a proportion of the total number of women at 12 weeks of their pregnancy) Proportion of people suffering from a heart attack who receive thrombolysis within 60 minutes of calling for professional help
2008/09 Target
2008/09 Outturn
2009/10 Target
2008 79.20
2007 86.18
2009 79.20
75.00%
2008/09 69%
37.50%
2008/09 16%
35 per 1,000 (aged 15-17)
2007 48.4
2009 29
80%
94%
85%
Total time in A&E: Four hours or less
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68%
82.76%
68.00%
98%
2008/09 97.1%
98.00%
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2009/10 Latest Performance
Comments
Figures for 2008 will be published in February 2010
Qtr 2 2009/10 >95%
Threshold may be increased by Care Quality Commission (NB Threshold was increased by 10% for 2008/09 Annual Healthcheck) SECAmb Call To Needle (CTN) - Qtr 2 YTD 71.3% YTD Oct 09 98.81%
STRATEGIC COMMISSIONING PLAN 2010-2015
Vital Signs Description
2008/09 Target
2008/09 Outturn
2009/10 Target
2009/10 Latest Performance
Comments
Additional Indicators
Smoking at time of Delivery
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2008/09 19.33%
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YTD Qtr 2 20.12%
Target was originally set to decrease year on year.
STRATEGIC COMMISSIONING PLAN 2010-2015
Appendix 3: Prioritisation matrix Criteria
Score High 5
Score Medium 3
Score Low 1
Score None 0
Weighti ng
Proposal makes major contribution to priority in SCP and one or more targets There is evidence to suggest that the proposal will reduce identified health inequalities
Proposal makes contribution to priority in SCP and to one or more targets There is evidence that the proposal may reduce identified health inequalities
Proposal contributes to priority within SCP
Proposal does not contribute to priority within SCP or targets.
25%
There is no evidence that the proposal will reduce health inequalities or health inequalities not identified
The proposal may worsen health inequalities
15%
Proposal is supported by robust evidence from RCTs or NICE Service costs have been benchmarked and are lower than alternative services for better outputs. The proposal is more cost effective than current services for the same indication and is within the limits used by NICE (ÂŁ30k per QALY)
Proposal is supported by trial evidence
Proposal is supported by professional bodies
No evidence to support the proposal
15%
Service costs have been benchmarked and are lower than alternative services for comparable outputs. The service is cost effective within the limits used by NICE (ÂŁ30k per QALY)
Service costs have been benchmarked and are comparable to alternative services for comparable outputs. The planned intervention is no more cost effective than other interventions for the same indication
There is no benchmarking or service costs more for similar outputs. There is no cost effectiveness evidence, or is above the NICE threshold or is less cost effective than current interventions fo the same indication
15%
Strategic fit Strategic Commissioning Plan Vital signs LAA target WCC outcome Addressing health inequalities
Cost effectiveness Strength of evidence for the proposal
Value for money
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STRATEGIC COMMISSIONING PLAN 2010-2015
Quality and risk Clinical standards
Clinical Risk
Stakeholder views Patient acceptability
Partner acceptability
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There is a legal requirement to provide this service or it is covered by NICE Technological Appraisal Guidance The lack of service has a risk score of 15 or above on the corporate risk register
The service is covered by national guidance eg NICE, NSF,
The service is considered to be best practice eg guidelines of professional bodies
There is no requirement that the PCT commissions this service
15%
The lack of service has a risk score of 812 on the corporate risk register
The lack of service has a risk score of 4-6 on the corporate risk register
Not on the risk register or score less than 4
5%
Evidence of patient involvement in developing proposals
Limited patient involvement in developing proposals and likely to be acceptable Limited stakeholder involvement in developing proposals
No patient involvement and patients would not have a view on acceptability No stakeholder involvement but unlikely to be opposed
Likely to be unacceptable to patients
5%
Likely to be opposed by some stakeholders
5%
Evidence of stakeholder involvement in developing proposals
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STRATEGIC COMMISSIONING PLAN 2010-2015
WCC Health Outcomes Forecasts and Plans- Medway PCT ONS cluster: new and growing towns
Medway PCT Infants breastfed
Life expectancy at time of birth
Slope Index of Inequality for Life Expectancy
86
12.00
Smoking quitters
0.6
1200
0.5
1000
Uptake of influenza vaccinations by over 65s
Instructions: Click on
84
0.8
10.00
82
0.7 0.4 per 100,000 >=16 yrs
78
0.3
76
4.00
800
% at 6 week check
Age (years)
0.2
74 2.00
0.6
600
0.5
0.4
0.3
400
72
0.2 0.1 200
Percentage of stroke admissions given a brain scan within 24 hours
SHA Planned
0.60
0.8
CVD mortality
SHA Planned
2013/14
2012/13
2011/12
2010/11
2006/07
2013/14
2012/13
2011/12
2010/11
2009/10
2008/09
2007/08
2006/07
Period
PCT ONS
ENG
ENG
Select benchmarks to display (where available):
Diabetes controlled blood sugar
100
0.8
90
0.7
'Select outcomes' to choose eight health outcome indicators. Data is displayed for the PCT selected in the drop down menu, and includes selected benchmarks. All regional benchmarks are SHA unless stated (e.g. 'REG' is South East region). To enter plans for mandatory and selected indicators, click 'Input plans'. To clear any plans, click 'Reset plans' button.
0.50
2000
0.7
Period
SHA Planned
2009/10
2012/13
PCT ONS
2008/09
2011-2013
2010-2012
2009-2011
2008-2010
2007-2009
2011/12
ENG
For IAPT services the number of people assessed as moving to recovery as a proportion of those who have completed a course of psychological treatment
2500
0
0
Period PCT ONS
Planned (F)
Rate of hospital admissions per 100,000 for alcohol related harm
0.9
2010/11
Planned (M)
2009/10 Q4
Planned (M)
PCT (F) REG (F) ENG (F) HPEC (F)
2009/10 Q3
Planned (F)
Period
2009/10 Q2
PCT (M) REG (M) ENG (M) HPEC (M)
2009/10 Q1
PCT (F) SHA (F) ENG (F) ONS (F)
0.1 0 2008/09 Q4
PCT (M) SHA (M) ENG (M) ONS (M)
2006-2008
2005-2007
2004-2006
2002-2004
Period
2003-2005
70
2010-2014
2009-2013
2008-2012
2007-2011
2006-2010
2005-2009
2004-2008
2003-2007
2002-2006
2001-2005
0.00
2007/08
SMR
80
% uptake
8.00
6.00
CONTROL PANEL
0.9
80 0.6
60 50
1000 0.3
% HbA1c <=7.5
0.4
Not currently available 0.30
0.5
DSR per 100,000
Available by acute trust only
1500 % people
30
0.2
500
0.10
SHA 0.4
England
.
0.3
40
0.20
ONS Cluster
0.2
20
0.1
HPEC LE pledge
0.1 10
SHA Planned
ENG
PCT ONS
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ENG
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PCT ONS
ENG
SHA Planned
ENG
PCT ONS
ENG
2013/14
2012/13
Period
SHA Planned
2011/12
2010/11
2009/10
2008/09
2007/08
2013
2012
2011
2010
2009
2008
Period PCT ONS
2006/07
0 0 2007
2013/14
2012/13
Period SHA Planned
2011/12
2010/11
2009/10
2008/09
2007/08
2013/14
2012/13
Period
SHA Planned
2011/12
2010/11
2009/10
2008/09
2007/08
0
2006/07
0.00 2006/07
Period PCT ONS
2013/14
2012/13
2011/12
2010/11
2009/10
2008/09
2007/08
2006/07
0
2006
0.5
PCT
70
0.40 per 100,000
% admissions
0.6
STRATEGIC COMMISSIONING PLAN 2010-2015 Appendix 5: Workforce Plans Draft Care Area Reports Suggested key actions and next steps Maternity and newborn
Various reports, including the NAO 2007 ‘Caring for Vulnerable Babies’ and the Healthcare Commission, July 2008 ‘Towards Better Births’, reinforce the need for expansion in maternity and neonatal services. The most recent GAD birth projections estimate the birth rate in England will continue to increase, which is likely to lead to an increase in demand for maternity and neonatal services. To cope with the increased demand for maternity services, organisations may choose to change skill mix. The development of the maternity support worker (MSW) role enables there to be an additional member of staff to assist the midwife by undertaking routine tasks, such as taking blood samples, preparing equipment and clearing up after deliveries. Increasingly, staff such as scrub nurses are taking over from the midwife and preparing women for caesarean sections.
Children’s health
Health visitors- Evidenced room for growth. The Child Health Strategy places health visitors at the centre of the community healthcare team to promote children’s and young people’s health (Healthy lives, brighter futures – The Strategy for Children’s and Young People’s Health, DH, 2009). It is expected that the health visitor workforce will work in a variety of community and primary care settings, including children’s care centres and GP surgeries, in addition to being required to deliver intensive schedules of home visits. It is likely that growth in the current health visitor workforce will be necessary to ensure each Sure Start Children’s Centre has access to one named health visitor (the Government has pledged provision for 3,500 centres nationally by 2010, see ttp://www.direct.gov.uk/en/)
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STRATEGIC COMMISSIONING PLAN 2010-2015 School nurses - Evidenced room for growth. Due to new initiatives in 2004 to implement one school nurse per secondary school and its associated primary schools by 2010, the number of school nurses has risen from 476 in 2003 to 1,447 in 2008 (204%), however additional school nurses will still be needed to meet the 2010 target. In the next 5-10 years around 15% of school nurses are expected to retire. Childrenâ&#x20AC;&#x2122;s nurses - Broadly in Balance. The Operating Framework for 2009/10 has reiterated the key priority of improving childrenâ&#x20AC;&#x2122;s health and reducing health inequalities. In the future, it is expected that nurse to doctor ratios will increase and the role of nurses will expand with more specialist nurses providing care for children and young people. Currently, overall supply of the nursing workforce largely meets demand on a national basis (with regional variations). Child psychologists - Broadly in balance. WRT has identified significant geographical inequalities in the provision of child and adolescent psychotherapy, with many districts across the country having limited or no provision. Paediatricians - Evidenced room for growth. In the absence of any clear evidence that more posts will be created, WRT suggests training numbers are maintained at current levels. Paediatric surgery - Evidenced room for growth. WRT believes that there is only a limited amount of growth that the service can provide, with issues surrounding national capacity to train paediatric surgeons.
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STRATEGIC COMMISSIONING PLAN 2010-2015 Dieticians - Broadly in balance. There is a shortage of band seven grade dieticians. Band 6 dieticians prefer to stay in post and this has an impact on graduates trying to move along the career path. Structured development is needed to help to break down the barrier to moving up to band 7. Funding is needed for continuing professional development for higher posts. The development of prescribing rights may make the employment of senior AHPs more attractive and this may increase the demand for senior dieticians. General Practitioners - Evidenced room for growth. Together with increasing training numbers, an integrated approach, taking into account plurality of provision and employment, is required in order to meet the growth in primary care demand. Speech and Language Therapists. Broadly in balance. The recent Bercow report (2008) and the Stroke Strategy (2007) both suggest that the demand for qualified speech and language therapists (SLTs) will grow in the future. If these initiatives result in a large expansion in posts for qualified SLTs, SHAs may need to increase training numbers and consider using short term options to increase the workforce. In particular, collaborative working to undertake surveillance and monitoring of children with complex needs (eg PCTs and local authorities). Staying healthy
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Accurate, comprehensive data on the outlay of the dedicated public health workforce and its efficacy is an essential first step towards enabling effective workforce
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STRATEGIC COMMISSIONING PLAN 2010-2015 planning for Staying Healthy. Until there is a clearer picture as to which services work, and under what conditions and staffing configurations they are delivered, it is difficult to make firm recommendations on precisely which staffing groups should be increased and/or where in the country they are most needed. Two separate strands of data need to be addressed: the lack of both robust data on intervention service efficacy and the collection of more finegrained information on the dedicated public health workforce. Acute care
There is a significant relationship between acute care and the other Darzi areas,, especially long term conditions and planned care. As shown in the WRT â&#x20AC;&#x2DC;bathtubâ&#x20AC;&#x2122; model there is a need to design the workforce to accommodate the flow of patients. There needs to be appropriate filtering of patients from their entry into the acute care setting, to the treatment they receive and where they go after the acute care episode. The model highlights the need for collaboration between primary and secondary care, with added awareness of the benefits of clinicians that can work in both settings, such as ECPs. New settings for healthcare such as UCCs highlight the need for appropriate training for leadership roles for nurses and other healthcare professionals. In addition, new roles to accommodate the changing demands on acute care need to be designed in line with professional standards and service needs.
Planned care
Focus on preparing the current AHP & nursing workforce to take on extended and specialist roles in community settings and to focus on developing the workforce on AFC bands four and below to take on some of the tasks traditionally performed by qualified staff. WRT analysis indicates demand for mental health care is anticipated to rise. A number of demand drivers including the national dementia strategy and IAPT, will lead to
Mental health
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STRATEGIC COMMISSIONING PLAN 2010-2015
Long â&#x20AC;&#x201C; term conditions
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improvements in mental health service provision; mental health services will be further enhanced by 'New Horizons' a DH strategy expected to be formally released later this year. Workforce development will be very important in meeting future demand; all health and social care staff involved in the care of people who have mental ill health and learning disabilities should have the necessary skills to provide the best quality of care in the roles and settings where they work. To help enable this to happen, mental health care needs to be embedded in training curricula at all levels and for all staff groups. New models of service, including a â&#x20AC;&#x2DC;self-careâ&#x20AC;&#x2122; approach, will require different types of professional roles to those employed in the past, as focus will shift towards educating patients and enabling them to make their own decisions, as well as peripheral support. Greater use of multidisciplinary teams, and reshaping of the workforce, may mean that boundaries between roles become blurred; this will require a greater emphasis on training. An important implication of flexible working in this sense is the need for adequate support and supervision for staff. Finally, in order for long term conditions care to be successful, services need to ensure that sufficient care, including transitory care, is provided at/between every level, and at every stage. As a priority, training should be provided for band 7 nursing to deliver intermediate care. The contribution of community matrons and the social care workforce in this care area is vital in order to provide rehabilitation care and continuing support and medical assistance to patients in their homes, and to prevent readmission to hospital. Health and
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STRATEGIC COMMISSIONING PLAN 2010-2015 social care commissioners will need to work jointly to identify and put in place a workforce that can deliver this continuum of care. End of life care
The report makes evident four key areas of focus. 1. The need to address supply/demand disconnects within the SPC workforce in particular the 20.7% vacancy rate within nursing (band eight) and consultants. 2. The development of the workforce in middle grades to allow nurses to take on some tasks undertaken normally by consultants. 3. The development of the workforce below band five allowing them to carry out some of the tasks normally carried out by registered nurses. 4. A continued focus on strategies to expand the capacity of the therapeutic radiography workforce. End of life care pathways such as the Gold Standards Framework, the Liverpool Care Pathway, and the Preferred Priorities for Care by the general workforce, are critical to ensuring that the needs of the patient are met.
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STRATEGIC COMMISSIONING PLAN 2010-2015 Appendix 6: Estates Strategy See paper to be presented to Board as separate item
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STRATEGIC COMMISSIONING PLAN 2010-2015 Appendix 7: IM & T Strategy See paper to be presented to Board as separate item
i
Department of Health, (2010). 2008-09 PCT Programme Budgeting Bench Marketing Tool 1.0
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It’s your NHS Make your experiences count Find us
Get involved
NHS Medway Fifty Pembroke Court North Road Chatham Maritime Chatham Kent ME4 4EL
Share your opinion and help us make services better for you. email: itsyournhsmedway@nhs.net phone: 01634 335173
01634 335020
Patient Advice and Liaison Service (PALS) PALS is here to help when you need health advice, have concerns or don’t know where to turn. email: pals@medwaypct.nhs.uk freephone: 0800 014 1634
Customer Care Listening and acting on your comments, compliments or complaints. email: nhsmedwaycomplaints@nhs.net freephone: 0800 014 1634
Medway Local Involvement Network (LINk) This guide has been produced by NHS Medway. Information in it can be made available in other formats and languages on request to itsyournhsmedway@nhs.net or by ringing 01634 335173
The Medway LINk is your local independent network of local people and community groups working together to influence and improve Medway’s health and social care services. The LINk provides a forum for concerns about service provision and quality, and works with those who plan and run services to bring about real change. Why not join the LINk and help shape local services? email: info@kmn-ltd.co.uk phone: 01303 297050 website: www.themedwaylink.co.uk
2 www.medwaypct.nhs.uk