North Somerset Clinical Commissioning Group Operational plan for 2014/15 – 2015/16

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 1

Foreword ...... 3 Introduction ...... 4 Our vision ...... 5 National Context ...... 8 Our Population ...... 10 Population growth predictions ...... 11 Inequalities ...... 12 The Health of the population ...... 13 Improving Outcomes and Reducing Health Inequalities ...... 16 The Financial Challenge ...... 26 Improving Quality ...... 29 Two Year Operational Plan ...... 36 Pathway Redesign ...... 36 Referral Management and Unwarranted Variation ...... 37 Enhanced Community Access, Services and Support ...... 38 Proactive management of known patients ...... 39 Primary Care Development ...... 41 Children and Young People ...... 42 Mental Health Services ...... 44 Enabling Workstreams ...... 49 Partnership Working Arrangements ...... 49 Research and Innovation ...... 51 Innovative Commissioning and Contracting Arrangements ...... 53 Developing CCG Capacity (Workforce and OD) ...... 55 Medicines Optimisation/NICE ...... 57 IT Strategy ...... 60 Governance ...... 61

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 2 Foreword

North Somerset Clinical Commissioning Group’s Operational Plan sets out how we aim to deliver improvements for the population of North Somerset over the next two years. There are significant challenges to be overcome but also great opportunities. We want our population to have access to safe, local services. Our aging population means that we need a whole system approach to keeping people healthy and active, but also to ensure that they get appropriate services when they are unwell. Our urgent care system has shown this winter that it can work really well resulting in great performance. The NHS Outcomes Framework gives us a clear structure and our five programme areas are locally determined to ensure the most appropriate delivery for North Somerset.

We will only achieve this by working in close partnership with our membership, North Somerset Council, the People and Communities Board, our neighbouring Clinical Commissioning Groups, NHS England and our Commissioning Support Unit. We want to develop our relationships with patients, carers and the public. Our providers and the third sector are also key players.

Our operational plan sets out how we will develop a secure financial basis while starting off the longer term strategic changes that are needed. As GPs working in the local community we want to co- produce the future health and social system that will deliver safe, affordable services for our population.

I want to take this opportunity to thank all who have worked with the Clinical Commissioning Group over the last year. We have a lot of hard work ahead of us but also great opportunities. Thank you for being part of it. Mary

Dr Mary Backhouse, Chief Clinical Officer North Somerset Clinical Commissioning Group

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 3 Introduction

North Somerset Clinical Commissioning Group is the organisation with responsibility for commissioning health services for the population of North Somerset (the same area covered by North Somerset Council)

We became a statutory organisation in 2013 following authorisation by NHS England.

We are led by the 25 GP Practices in the area and these GP Practices are supported by a team of other clinicians and managers. We are therefore a clinically led organisation which puts the needs of the patient at the centre of everything we do. A Governing Body oversees the organisation to make sure that everything we do is appropriate and makes the best use of the resources available.

We are responsible for commissioning emergency and urgent care (including ambulance and GP ‘Out of Hours service’) community health services, hospital services, maternity and children’s services, mental health and learning disabilities services. Primary care services (GPs, dentists, pharmacists and opticians) and specialised hospital services are commissioned and managed by NHS England, the national NHS commissioning body.

We work closely with a wide range of stakeholders to develop and deliver our plans and believe that the views of patients and the public are key to our success. We have therefore produced this document to show in detail how we will deliver our objectives between 2014 and 2016, so that we can be held to account

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 4 Our vision

We know that for people to be truly healthy it is not only the quality of healthcare services that matters. That is why we are committed to working together with our whole population, individuals and other organisations to create the healthiest communities. The diagram below shows the joined up system we are working towards.

Life in North Somerset Community engagement, Education involvement Employment and Reducing leadership inequalities

Health Vulnerable through groups wealth known Life and Society in Politics/ North civic life Somerset High impact families and Flexible/ integrated individuals deployment of (supported) public resources across N Som Commerce Integrated health and Seamless social care person centred pathways/ Sustainable Physical networks provider environment networks

As the system leader for local healthcare we have set out below how people will experience healthcare in North Somerset in five years time. We have also included an overview of the things we are doing to achieve a clinically and financially stable system.

We work with patients and carers to educate, encourage and support them to stay healthy, promoting lifestyles to reduce the risks of ill health. We equip patients with the knowledge and tools they need to maintain and, if possible, improve their health. We pay just as much attention to people’s mental health needs as their physical health needs

In order to achieve this we will: Shift resources from services which treat illness to those that prevent them wherever there is evidence to support this. Ensure that care is co-ordinated around individuals not organisations Ensure that we have systems to identify those people and families who are most in need of additional support to reduce inequalities. Communicate with individuals and communities to ensure that their views influence every decision we take.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 5 Our system is focussed around the needs of our population, and patients as individuals. For those who are at higher risk of illness or progression of illness, we understand their needs and develop care plans with them and their families so that they understand how to maintain quality of life, know the triggers to illness and what to do if their symptoms worsen suddenly or over time. . To achieve this we will: Develop truly integrated health and social care which links all our partners together to co- ordinate all the services that an individual person needs Develop the model of primary care in a way that maintains high quality while enhancing its availability to those with needs it can cater for and while accommodating its functional integration with other services. Work with healthcare providers to reduce the number of times people need to travel to hospital for appointments.

When people need care urgently we do everything we can to provide what they need as close to home as possible. When patients require urgent or emergency care they know where to go and that first point of contact is sufficiently qualified to be able to treat them, or direct them to the most appropriate tier of the system to assess, diagnose or treat.

To achieve this we will: Develop a range of alternatives for urgent care that provide easy access 24/7 Develop our A+E services so that they can meet the needs of the people that really need them

When a patient is admitted for hospital-based care, the whole system works together to get them back home as soon as they are physically fit enough with a plan for ongoing care. Those patients requiring rehabilitation and re-ablement services can access these close to home, with specialist advice and support to prevent further episodes of ill health.

To achieve this we will: Work with all the organisations who provide care (including specialised services) to make sure that there is sufficient capacity to meet the needs of individuals and that services communicate well Review the numbers and types of beds available and ensure these meet the needs of the population

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 6 Vision: North Somerset – Creating the healthiest community together Values and To be patient centred To be fair and equitable Behaviours To be inclusive To be committed to safe high quality and effective care To be compassionate and kind To be a good partner to work with to improve the health of the population To be a trustworthy, honest, open and listening organisation Purpose 1. Ensuring an integrated health and social care system for adults and children, driven by quality and innovation 2. Commissioning health care for the patients of North Somerset which is cost effective and delivers Health Outcomes in line with the NHS Outcomes Framework 3. Reducing health inequalities, working in partnership 4. Giving people confidence and skills to take care of themselves and stay as healthy as possible 5. Improving patient care by ensuring there is easy access to shared information, which is up to date, meaningful and accurate 6. Creating an environment which motivates member practices to be engaged commissioners and to deliver safe care, good patient experience and evidence based practice 7. Being a successful dynamic organisation that provides a rewarding place to work Strategic Developing a model of care which is clinically safe and sustainable Priorities Achieving financial sustainability Improving health outcomes and reducing inequalities Programmes Continuum of care for Adults Urgent Care Planned Care Children and Young Developing Primary of care People and Care Maternity Objective Improving Patient centred care Access to the highest quality Step change in the Developing care Support the development Promoting independence, intensive support urgent and emergency care productivity of elective focused around high of wider primary care and end of life care care impact families Parity of esteem between mental and physical health Interventions Ensure LTCs are effectively managed Increased out of hospital Improve referral Work with a range of Work with primary care Increase work with the voluntary sector accessible services management stakeholders to deliver providers to improve Supporting patients and their families to stay Increased ambulatory care and Develop pathways of high quality support quality and access. living independently at home. reduced length of stay care for children and Increased senior decision making support Reduced emergency admissions Increase productivity families. Develop locality approach Developing a new model of rehabilitation and ED attendances to prevention, early Providing high quality support for people with Improve public understanding of intervention and self-care. mental health problems urgent care services

Enabling Partnership Working Arrangements Better Care Fund Programme Workstreams Wider Resource allocation strategy (inc capital) Effective stakeholder engagement Innovative commissioning and contracting arrangements Management of NHS infrastructure Workforce strategy IT Strategy Knowledge management, research and evidence Developing the provider landscape Organisational Development Medicines Optimisation/NICE North Somerset CCG Operational Plan for 2014/15 – 2015/16) 7 National Context

In December 2013, NHS England published Everyone Counts: Planning for Patients 2014/15 to 2018/19. This set out the requirement for CCGs to produce a Five Year Strategic Plan with the first two years giving operational detail. This plan needs to ensure that we achieve the requirements of the NHS Mandate:

We want to prevent people from dying prematurely, with an increase in life expectancy for all sections of society. We want to make sure that those people with long-term conditions, including those with mental illness, get the best quality of life. We want to ensure that patients are able to recover quickly and successfully from episodes of ill-health or following an injury. We want to ensure that patients have a great experience of all their care. We want to ensure that patients in our care are kept safe and protected from all avoidable harm.

The guidance further sets out how these improvements in care are to be measured:

Securing additional years of life for the people of England with treatable mental and physical health conditions. Improving the health related quality of life of the 15 million+ people with one or more long- term condition, including mental health conditions. Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital. Increasing the proportion of older people living independently at home following discharge from hospital. Increasing the number of people having a positive experience of hospital care. Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in general practice and in the community. Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care.

We know that there are significant challenges in delivering these improvements in care. The recent “Call to Action” set out some of these challenges:

An ageing society Increasing Expectations The rise of long-term conditions Increasing costs of providing care Limited Productivity gains Constrained public resources

Older people are forming a larger proportion of the population, with the greatest growth expected in the number of people aged 85 or older. This group are the most intensive users of health and social care. The health needs of the elderly are particularly apparent in non-elective care within the acute sector where:

Nearly two-thirds of people admitted to hospital are over 65. Unplanned admissions for people over 65 account for nearly 70% of hospital emergency bed days.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 8 When they are admitted to hospital, older people generally stay longer and are more likely to be readmitted. In addition to the ageing population, lifestyle choices amongst the rest of the community are impacting on demand. Around 80% of deaths in England are from major diseases, such as cancer, many of which are attributable to lifestyle risk factors such as excess alcohol, smoking, lack of physical activity and poor diet. Forecasts indicate that 46% of men and 40% of women will be obese by 2035. This is projected to result in 550,000 additional cases of diabetes and 400,000 additional cases of stroke and heart disease nationally.

Over 15 million people in England have a Long Term Condition (LTC), around 25% of the population and this cohort currently utilise:

50% of all GP appointments 70% of all hospital bed days 70% of the total health and care spend in England. People with one or more long-term conditions are the most important source of demand for NHS services:

The 30% who have one or more of these conditions account for £7 out of every £ 10 spent on health and care in England. Patients with a single long-term condition cost about £3,000 per year whilst those with three or more conditions cost nearly £8,000 per year. The number of patients with long term conditions is projected to grow by 50% in a decade.

This growth in demand is taking place at a time of austerity, which continues to put pressure on NHS funding. Even with NHS budgets protected in real terms, current forecasts point to a £30bn gap in funding by 2020/21.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 9 Our Population

The North Somerset population according to the 2011 census was 202,566. Three months later the ONS produced a mid-year estimate which was 203,091. However, both these estimates are still lower than the GP registered population. The GP registered population in 2011 for residents in North Somerset (regardless of where they are registered with a GP) was 213,177.

The population of North Somerset is less ethnically diverse than England and Wales with 199,618 (97%) of people living in North Somerset classifying themselves as belonging to a white ethnic group (including White Irish and Other White ethnic groups), a decrease of one percentage point since 2001. Of those from a black or minority ethnic group, 43% classified themselves as Asian and a further 37% classified themselves as mixed race.

There are 88, 227 households recorded for North Somerset and of these 85,594 have English as their main language. This equates to 97% of households.

The 2011 Census records disability as whether or not activity is limited. For North Somerset, the following information is provided;

Activity limited a lot – 17,335 (8.6%) Activity limited a little – 21,405 (10.6%) Activity not limited – 163,826 (80.9%)

In North Somerset the birth rate was recorded as 2,363 live births in 2012. Figures also record a general fertility rate of 68.3%. (This rate is calculated from the number of live births per 1000 women aged between 15 and 44).

The largest religious group in North Somerset is Christian at 123,545 (61%) with the next largest group stating that they have no religion at 60,867(30%).

The government states that 5% – 7% of the population is lesbian, gay or bisexual so North Somerset may have between 11,000 to 16,000 people who are lesbian gay or bisexual. It is also estimated that 0.6%- 1% of the population aged 16 or over, experience some degree of gender variance, which in North Somerset would equates to up to 1390 people.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 10

Population growth predictions One in five people in North Somerset are aged over 65 years. There was a 17% increase between census years (2001-2011) in over 65’s and a 26% increase in those over 85 years.

North Somerset faces significant demographic pressures with a population which is both ageing and growing. Between 2011 and 2015 in North Somerset there is expected to be per annum growth of 1.5% across all age groups. The largest increase will be in the 65-75 age group (4.3% per annum). A further 1.4% per year is expected across all ages between 2015 to 2020, when the largest growth will be in the 75-84 group (3.7% per annum) and the over 85’s (4% per annum).

Longer term projections suggest there will be a 45% increase in those over the age of 85 and a 25% increase in those aged 5-14 in North Somerset by 2021. However, the longer the projected time horizon the more inaccurate the modelling is expected to be, so this should only be used as an indicator.

The North Somerset Core strategy target was building 14,000 new homes by 2026. The majority in Weston super Mare. From 2006 to 2012 there were 5,465 homes built leaving approximately 9,000 additional homes to be built by 2026.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 11

Inequalities North Somerset has populations living in both the most and least deprived 1% of areas nationally and North Somerset ranks 7th in the Country for the largest inequality gap in terms of range in deprivation scores between areas.

The current slope of inequality in the gap in life expectancy between the most affluent and most deprived electoral wards in North Somerset is 9.9 years for men and for 6.7 years women. This is amongst the largest gaps seen in England.

Deprivation generally, and the inequalities that manifest across a variety of indicators are an important consideration for healthcare planning for a number of reasons:

People in poorer areas die earlier but also spend more of their shorter lives with a disability, which puts a financial strain on the NHS. The national cost to the NHS of inequalities is estimated to be £5bn. The fact that these inequalities exist, suggests in principle that it should be possible to attain the level of the best. It is unlikely that further efficiencies in healthcare services can fully address the impact on health of the wider societal and environmental inequalities and the increase in the age of the population.

We need to consider how we can influence action on the wider inequalities in order to reduce future pressure on healthcare services.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 12 The Health of the population

Overarching indicators In November 2013, indicators were released monitoring life expectancy and healthy life expectancy at the local authority and lower level. In North Somerset overall rates of life expectancy at birth are similar to England for males and better than England for females. Healthy life expectancy shows the opposite trend with levels significantly better in males and similar for females.

We have used a number of data sources and tools to identify the specific health needs of the population. These are summarised below:

Public Health England Segment tool to investigate inequality

This tool has data from 2009 -2011 and demonstrates the contribution to the gap in life expectancy. The major causes of death have between the most and least deprived quintiles. It is broken down for males and females.

The leading contributors to the gap in life expectancy in males are coronary heart disease (13.5%), external causes (excluding suicide) 13.1% and cancers (non-lung) 12.8%.

In females the leading contributors excluding ‘other causes’ category are coronary heart disease (14%), mental and behavioural disorders 10.5% and stroke 9%.

The overall profiles show in men circulatory diseases contribute 23%, external causes 21% and cancers 20% of the gap between most and least deprived quintiles. In females circulatory disease accounts for 29%, other causes 31%, respiratory 14% and cancer 13%.

Circulatory disease is the largest contributor to the gap in life expectancy between the least and most deprived quintiles.

As a combined group, ‘external causes’ which includes road traffic accidents, other accidents and suicides contribute to 21% of the gap in males.

We have locally investigated the causes of death across North Somerset using the Public Health England segment tool. Based on a comparison across a 10-year time frame we can see the impact that interventions to reduce risk factors for circulatory disease may be having in the terms of the contribution to the gap in life expectancy between the most and least deprived areas.

This is shown in the following table.

The difference between 2001-2005 and 2009-2011 in the contributors to the gap in life expectancy for men and women in North Somerset.

Disease Group Males 2001-2005 Male 2009-2011 Female 2001-2005 Female 2009-2011 Circulatory 28.9% 23% 34.6% 29% Cancer 14.7% 20% 16.7% 13% Respiratory 11.7% 13% 7.3% 14% Digestive 9.4% 9% 6.5% 6% External Causes 16.4% 21% 8.3% 5% Other 15.1% 9% 21.9% 31%

The trend shows that in both males and females the relative impact of circulatory disease to the total has reduced, despite remaining the largest contributor. In males the increase has been in

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 13 cancer (14.7% to 20%) and external causes (16.4% to 21%). In females the increase is seen in respiratory conditions, where the impact has doubled from 7% to 14%.

Health Profiles (2013)

The ratings of three indicators have changed since the previous profile, with two getting slightly worse when compared to England and one improving Teenage pregnancy – the rate has fallen in North Somerset but at a slower rate than England therefore rates in North Somerset are no longer significantly better than England. Hospital stays for self harm – the rates have continued to fall in North Somerset and are now significantly better than England. Life expectancy for males – has stayed the same in North Somerset, whilst rates in England have continued to improve therefore figures are no longer significantly better than England. Life expectancy for women living in North Somerset continues to be significantly better than England.

Public Health England Longer Lives Dataset (premature mortality)

Public Health England launched a new website showing large variations in early death rates across the country, The website, called ‘Longer Lives’, is a new initiative to allow people to see how local mortality rates, compare to the rest of the country and their peer group.

Premature mortality data throughout Longer Lives is based on directly standardised mortality rates for those aged under 75 years and are compared to peers.

In North Somerset overall mortality rates for those aged under 75 years are significantly better than the average in England. But when compared to just its peer group, North Somerset has the second highest rate and is significantly worse than its peers.

Rates of cancer and heart disease in North Somerset were better than average when compared to its peer group and England.

Rates of lung and liver disease in North Somerset were better than the average for England but worse when compared to the average for its peer group. However, neither findings were significantly different and are within the expected range.

Public health have commissioned the ONS to provide us with more detailed causes of death broken down by deprivation quintiles, gender and trends over a 10-year period to look at this in more detail and identify priority areas to reduce the gap in life expectancy between deprivation groups.

Public Health Outcomes Framework

In 2012 the Director of Public Health report looked at the public health outcomes framework and identified the total disability adjusted life years lost in North Somerset for all causes. The leading contributor to this group was mental health with nearly 7,000 years lost in an average year. In the 2013 report this was investigated further and the most common mental illness identified in North Somerset was found to be depression (with 16% of the GP population over the age of 18 diagnosed). Suicide is also an issue in North Somerset with higher rates than the National average. The latest data on suicide suggests that although rates have decreased they are still

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 14 significantly higher than England. Mortality rates for liver and respiratory disease were similar to those in England with trends over time fairly stable. The new provisional data remains consistent with this trend. Data on excess winter deaths shows that rates are higher for all ages and lower for those aged 85+, although neither results are significantly different from the England average. No further areas of concern have been identified as a result of the new data release.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 15 Improving Outcomes and Reducing Health Inequalities

(NB – In North Somerset the Health and Wellbeing Strategy is called the People and Communities Strategy and the Health and Wellbeing Board is called the People and Communities Board)

The People and Communities Strategy utilises the findings of the JSNA with further community engagement and has the following three overarching priorities:

Reducing alcohol related harm. Supporting Communities to meet their own needs including self-care and customer access to services. Delivering the High Impact Families programme to develop new ways of working which result in lasting change.

The priorities are linked to the following set of outcomes:

Improve health outcomes and reduce health inequalities Improve outcomes for adults by promoting independence and more choice and control over services Improve outcomes for children by enabling early help alongside greater choice and control over services Enable schools and academies to raise attainment levels Strengthen safeguarding for children and vulnerable adults Make our streets and communities safer Work with communities to better meet local housing need

The main focus of the public health and People and Communities strategy in North Somerset could be summarised as reducing inequality.

The underlying risk factors for the major contributors to years of life lost are known to be tobacco, raised blood pressure, high BMI, low physical activity and high alcohol consumption. The actions in the public health strategy reflect these risk factors as they are preventative measures to reduce the impact of these risks. Examples are support to stop smoking, increasing physical activity and maintaining a healthy weight. The NHS Healthcheck programme aims to detect a number of these risk factors in people over the age of 40.

As we know direct healthcare may influence around 20% of the gap and lifestyle choices and the wider social conditions account for a larger proportion, the public health and health and wellbeing strategies have a wider focus to support communities through housing, employment, education and other factors.

Within each programme area a number of actions are identified. For our operational plan priority areas of the continuum of care for adults, urgent care, planned care, children and young people and developing primary care the following public health actions have been identified as preventive measures that may influence outcomes.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 16 The table below demonstrates how these public health plans map to the overall CCG priority areas.

CCG plan on Continuum of Urgent care Planned care Children and Developing page priority Care for Young People Primary Care adults Public Health Expanding the Reducing Develop public Work with high Reduce underpinning NHS health alcohol and drug health impact families variation of priority from check misuse intelligence and to promote outcomes Public Health programme evidence to healthy lifestyles between GP Strategy* Support the support practice by Strengthen the community commissioning Support healthy raising the health trainer connect through the local schools standard of service within programme and core offer programme the lowest to the most needs of the frail including the the highest deprived elderly childhood communities. population. measurement programme. Reducing the Promoting Promote easy burden of understanding of Support referrals to smoking on health and NHS commissioning mental health health services by of an integrated services young parents to school nursing Increasing increase service Increase physical confidence. dementia activity awareness and early Promoting intervention. healthy weight

Increase uptake of Health Checks - The latest update demonstrates that whilst the percentage of people offered a Health Check in North Somerset has improved it is still significantly worse than England. Interestingly once people are offered a health check, uptake appears to be good with rates significantly higher than England. We will work with General Practice to increase the number of health checks offered and taken up. The NHS health check aims to identify a number of the underlying risk factors for heart disease and provide information to reduce lifestyle risk factors such as smoking, excess alcohol consumption and maintaining a healthy weight which are additional risk factors for premature deaths from respiratory diseases, liver diseases and cancers

Protect families and communities from tobacco-related harm - This includes:- raising awareness of the dangers of second-hand smoke and working with partners to address the problems associated with illegal tobacco use and supply, reducing the number of people who smoke by motivating and assisting every smoker to quit and encouraging young people to not start smoking (Smoke free Alliance Tobacco Control Plan). Smoking cessation is one of the key priorities identified in the Public Health strategy for North Somerset. Public Health in North Somerset Council commission GP practices and pharmacies to deliver a support to stop smoking service as well as directly providing the North Somerset support to stop smoking service. In 2012/2013 2880 people were seen by the service and 1408 successfully reached the 4-week quit milestone.

The People and Communities Commissioning Group, accountable to the People and Communities Board oversees the Joint Commissioning Group (JCG) for Crime, Alcohol and Drugs and has delegated authority to take key decisions about commissioning local crime, alcohol and drug services. Members of the JCG for Crime, Alcohol and Drugs are reviewing current services against these principles with the intention of:

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 17 - Finding efficiencies in the system through the integration of drug and alcohol commissioning and service provision; - Responding to the changing health needs of the local population by reviewing levels of investment in drug/alcohol and other public health services; - Considering the sustainability of services beyond a possible loss of ring fenced budget; - Working closely with service users, carers and providers to address these issues and offer choice where possible. The JCG has identified some potential opportunities to: - Develop collaborative working between providers; - Develop clear care pathways that are evidence based; - Engage with service users and carers; - Develop the provider market.

Increase awareness of responsible drinking through targeted education and communication; support and protect young people from alcohol harm; identify problematic drinkers and provide effective treatment; reduce alcohol related crime and disorder and associated harm and use licensing and legislative powers to address alcohol related harm and misuse (Alcohol Harm Reduction Strategy)

The Joint Commissioning Group for Heath and Social Care, Housing, Children and Adults has set the following objectives:

Improve breastfeeding rates especially in areas of high deprivation. Support the implementation of best practice for breastfeeding through the Baby Friendly Initiative (Breastfeeding strategy group)

Support and encourage adults and young people to undertake the recommended physical activity levels and to eat healthier diets to prevent obesity and malnutrition (Go4Life and the NHS Health Check)

Deliver accessible sexual health services to reduce and prevent sexually transmitted infections and unwanted pregnancy especially in teenagers (Sexual Health Strategy Action Plan)

Improve secondary mental health care services by enabling primary care liaison and access, shared care arrangements, workforce development and improving crisis response (Shaping the Future of Mental Health Services)

Reduce the risk of suicide in key high-risk groups; reduce access to the means of suicide; provide better information and support to those bereaved or affected by a suicide; support the media in delivering sensitive approaches to suicide and suicidal behaviour and support research, data collection and monitoring

Improve dementia services including implementing plans for the Memory Assessment Service; enhancing the primary care elements of the Dementia Pathway to improve care and support for people with dementia, their family and carers, provide good quality, timely diagnosis and intervention for all and enhance dementia education for staff in caring roles(Dementia Strategy Group and the NHS Health Check)

Establish a model of integrated health and social care delivery that avoids service duplication and fragmentation, particularly for frail older people and adults with long term conditions as well as children with complex needs. Key enablers to delivering this model will be creating integrated community teams that combine the expertise of health and social care professionals, developing a single point of access and implementing joint assessment and care planning.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 18

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 19 Commissioning for Prevention

Commissioning for Prevention is a paper which highlights the following areas of poor performance nationally, compared to other countries:

Premature mortality = Ischaemic heart disease, Chronis Obstructive Pulmonary Disease, lower respiratory infections and breast cancer Disability = lower back pain, falls, neck pain, musculoskeletal and mental disorders, ischaemic heart disease, stroke, lung cancer and COPD

The paper provides a five step plan:

1. Analyse the most important health problems at population level 2. Set common goals with partners 3. Identify high impact prevention programmes 4. Plan the resource profile needed to deliver prevention goals 5. Measure impact and experiment rapidly

The CCG commissioned Musculoskeletal Service provided by North Somerset Community Partnership adheres to the National Institute for Health and Care Excellence (NICE) Clinical Guidelines on low back pain. There is further work on-going to scope improvements in these services that will involve further educating patients to self manage their conditions, improve pathways to include a more multidisciplinary approach to treating and preventing low back and neck pain.

Our Medicine Management team work with GP practices, acute trusts and stakeholders to ensure optimum use of medication in line with national and local guidelines to prevent primary and secondary complications e.g.; statins, antihypertensive, antiplatelets and anticoagulants to prevent cardiovascular events.

We are also commissioning psychological therapy support for people with long term conditions which will support self-management of long-term symptoms and disabilities.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 20 Equality and Diversity

The Public Sector Equality Duty (PSED) is a duty placed on public authorities (such as North Somerset CCG) by the Equality Act 2010. Part of this is a specific duty which requires us to publish information to demonstrate our compliance with the substantive part of the PSED, the general duty. This general duty requires the CCG, in carrying out its functions, to pay due regard to the need to:

• Eliminate unlawful discrimination, harassment, victimisation, etc

• Advance equality of opportunity

• Foster good relations between different groups of people (“protected groups”).

Workforce

We have systems and procedures in place to implement the aims of the general equality duty:

Elimination of discrimination, victimisation and harassment:

I. We have two staff representatives that deliver a confidential service to their colleagues with a dedicated email inbox. The staff representatives offer drop in surgeries to discuss new policies which may have an impact on their working lives.

II. The Quality Assurance Group (sub-committee of the Governing Body) has delegated powers to approve policies and have been appraised of their role in relation to the requirements of the Equality Act and PSED in ensuring we meet our relevant duties.

We are a comparatively small, public sector organisation and do not have the critical mass to sustain our own staff networks. Instead, staff are able to join any Bristol, North Somerset and South Gloucestershire wide Black and Minority Ethnic, Disability and Lesbian, Gay and Bisexual and Transgender staff networks which exist for NHS employees. These networks and their meetings are promoted through staff bulletins and induction sessions.

Patients and the Public

We promote the use of equality impact assessments to ensure that the North Somerset CCG is meeting the general duty. We also require our commissioned providers to comply with equality legislation.

The North Somerset CCG works proactively to engage with community interest groups for the protected characteristics across the population. For example, we regularly engage with the North Somerset BME Network, the Older People’s Champions Group and Senior Community Links, the Disability Access Group, the Physical and Sensory Impairment Group, the Learning Disability Partnership, Children and Young People’s groups, Parents groups and the North Somerset Lesbian, Gay, Bisexual and Transgender group. We seek to develop these relationships further through delivery of our Voices for Healthcare Strategy.

The North Somerset CCG will be using the NHS Equality Delivery System to assess its equality performance. The aim is to achieve at least a developing/amber grade, if not an achieving/green grade. We will report on our performance after our first full year’s work in the summer of 2014.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 21 People who have worse outcomes

National data demonstrates outcomes are poor for those with mental health problems, learning disabilities and certain hard to reach groups such as Gypsy and Travellers and ethnic minorities.

People living in poorer areas have worse health outcomes than those in more affluent areas. North Somerset has areas in both the most and least deprived 1% of Lower Super Output Areas nationally. North Somerset ranks 7th in the Country for the largest inequality gap in terms of range in deprivation scores between areas.

The health needs of the local population are assessed as part of the JSNA. We have completed in depth needs assessments and chapters related to local health issues such as child poverty, alcohol misuse, adult drug misuse, coronary heart disease, the frail older population and suicide.

We have recently conducted chapters on the Gypsy and Traveller population, cancer and childhood emotional wellbeing. Current work includes COPD and a refresh of our obesity and weight management chapter.

The leading contributor to disability in North Somerset is mental health and mental disorders. This was demonstrated in the 2012 DPH report for North Somerset based on World Health Organisation data. An in depth mental health needs assessment and JSNA chapter have been conducted on mental health in adults and older people as well as separate needs assessments and JSNA chapter on child emotional health and wellbeing. Public mental health was the focus of the 2013 Director of public health report. A mental health strategy is being produced during 2014 to focus and co- ordinate work with partners on this area but we have already taken action to address the issues raised. For example, we have appointed an Advanced Nurse Practitioner who will work with the population in Weston to increase access to mainstream NHS services and signpost to other services. This will increase the level of potential support that can be offered to this vulnerable group and integration between these services.

The people and communities strategy identifies improving secondary care mental health services, reducing the risk of suicide in key high risk groups, and improving dementia services.

We use the findings and recommendations of the JSNA chapters to inform priorities for commissioning in these areas.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 22 Outcome Ambitions

The tables below summarise how we anticipate the plans we have to improve the health of population will impact on outcomes and how we will measure this

Outcome ambition 1 - What is your ambition for securing additional years of life from conditions considered amenable to healthcare

PYLL = Potential Years of Life Lost – This is a measure of the number of people who are dying early.

E.A 1 PYLL (Rate per 100,000 population) Baseline 1947.0 2014/15 1885.0 2015/16 1824.0 2016/17 1766.0 2017/18 1709.0 2018/19 1655.0

Potential years of life lost from conditions considered amenable to healthcare is a rate generated by number of amenable deaths divided by the population of the area. The baseline figure is based on published 2012 data available via the Levels of Ambition Atlas. CCGs are to project a 3.2% annual reduction to 2019.

Outcome ambition 2 - What is your ambition for improving the health-related quality of life for people with long term conditions?

EQ-5D = A questionnaire which measures self-reported quality of life

E.A 2 Average EQ-5D score for people reporting having one or more long-term condition Baseline 73.67 2014/15 74.93 2015/16 76.19 2016/17 77.45 2017/18 78.71 2018/19 79.97

This indicator is based upon self-reported health status for those with long term conditions recorded in the annual Health Survey for England. CCG’s are expected to set annual trajectories from the baseline 2012/2013 data to increase levels of quality of life amongst their population.

Outcome ambition 3 - What is your ambition for reducing emergency admissions?

This emergency admissions composite indicator is comprised of: Unplanned hospitalisation for chronic ambulatory care sensitive conditions. Unplanned hospitalisation for asthma, diabetes and epilepsy in fewer than 19s. Emergency admissions for acute conditions that should not usually require hospital admission. Emergency admissions for children with lower respiratory tract infections

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 23 Emergency admissions E.A 4 composite indicator

Baseline 1238.1 2014/15 1171.6 2015/16 1147.8 2016/17 1123.9 2017/18 1100.1 2018/19 1076.2

Success in this indicator is a reduction in emergency admissions influenced by effective collaboration across the health and care system. The baseline is set on 2012/13 rate derived from HES data and published via the Level of Ambitions Atlas.

Local Priority 1 - Enhanced Access to Health Checks:

Local Enhanced Access to Health Priority Checks Programme 2014/15 55%

Parity of Esteem

This year we focused a chapter for our Joint Strategic Needs on Mental Health . As part of this we are ensuring that there is a parity of esteem – this means that mental health will be given the same focus as mental health in both service planning and the day to day delivery of care. To support this we have included the following recommendations:

Improve equity of access to Improving Access to Psychological Therapies (IAPT) services, promoting access in older people and those from deprived areas and monitoring the impact of expanding access to those with long term conditions. Improve completion of data recording around ethnicity and employment. Review the quality of service provision of self-harm in primary care. Develop a co-ordinated and ongoing mental health programme of continuing professional development for GPs and other primary care staff, including addressing issues of cultural sensitivity. Ensure carers of those with a diagnosed mental illness are included on the carers register. Review the accessibility of primary care for those with mental ill health, including those with drug and alcohol problems. Practices should make ‘reasonable adjustments’ to service provision for those with poor mental health. Review primary care provision and referral patterns of people dying as a result of suicide and people with serious mental ill health who have died prematurely. Raise awareness in primary care of voluntary and community sector provision, developing a care pathway to support access to services. A social prescribing model could be used to support this. Psychiatric liaison provision in acute trusts should be developed to better align with the needs of patients in A&E and on the wards. Evaluation of the primary care liaison service is due in 2013 and should be used to inform service developments including provision of those at high risk of suicide. Improve information provision to older people particularly concerning the use of medication and talking therapies. Provide a holistic response to those who are stepping down from specialist mental health services, ensuring awareness of the range of services available to support health, social and emotional needs, including services in the Voluntary and Community Sector.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 24 Ensure the mental health needs of people in reablement and enablement services are met. Consider a review of current service model to ensure we meet future demand on this service. The statutory sector must be explicit in its commissioning intentions to support the voluntary and community sector to remain viable in the market in the context of mental health clusters. Work with people in care homes to ensure the workforce is skilled and has knowledge in the care of people with dementia and other mental health problems.

We are ensuring delivery in this area through the development of a joint CQUIN for community and mental health providers.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 25 The Financial Challenge

North Somerset Clinical Commissioning Group (CCG) is facing a financially challenged period both because of the historic funding position and as the impact of the global economic crisis is felt on the public sector funding settlement for the foreseeable future. Our 2 year plans is set within a challenging financial context. NSCCG is accountable for close to £250m of NHS spending, more than half of which is acute spending. Nearly 90% of acute spend is with local acute providers.

The construct of the funding formula means that North Somerset requires a greater level of efficiency than other CCGs. As a result, North Somerset CCG and its predecessor organisation (North Somerset Primary Care Trust) have relied on non-recurrent support in order to break even.

We have been notified of its revenue allocation for the next two years and planning assumptions for the period after. By 2015/16 we will have had a 7.25% increase in funding which amounts to a cash increase of £17.2m. Although this increase is 2.6% % above the national average for all CCGS we expect to still be under the ‘fair shares’ allocation determined by the national allocation formula by some 4.7% (equivalent to £12.4m). North Somerset CCG will continue to be one of the lowest funded CCG nationally and North Somerset Council remains one of the lowest funded authorities.

For 2013/14 we are forecasting an underlying deficit of £17m through non-recurring savings to reduce this deficit to £4m in this year. Going forward, whilst we have benefited from the recent revisions to CCG allocations these are likely to be insufficient to match the growth in demand for healthcare, resulting in considerable financial pressure for all organisations should there be no reform to the model of care.

We have produced a two year plan that shows significant deficits in 2014/15 and 2015/16 and challenging savings targets. Our current plans are to deliver recurrent financial balance from 2016/17 onwards. The schemes required to deliver the savings needed are being developed and implemented and whilst the financial plans carry a degree of risk we are confident that significant gains can be achieved by properly resourcing the delivery of the schemes identified. The North Somerset health community will need to make significant savings in order to meet increased demand and quality standards and stay within budget. In addition acute providers are expected to deliver efficiency savings of 4% to offset inflation and give commissioners a 1.4% reduction in prices. Non acute providers are expected to deliver 4% CRES to fund inflation and give commissioners a 1.7% reduction in prices

In order to demonstrate financial sustainability and capacity to manage in year financial risk all CCGs are expected to plan for:

• A 1% surplus on revenue budgets • A 1.5% fund to be used non- recurrently in 2014/15 and only with the approval of the NHSE • A 1% transformation fund to be used non-recurrently • A local contingency of at least 0.5% • £5 per head for over 75 care to reduce emergency admissions • Risk pooling arrangements with other CCGs where appropriate • Non recurrent contribution to CHC national risk pool CQUIN payments, equal to 2.5% of contract, are to be used to reward providers who deliver a level of quality over and above the NHS Standard Contract.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 26

Financial Strategy

Our financial plans have been developed on the basis of:

• Accounting for the need to repay the previous year’s deficit • Planning for recurrent balance within three years • Prioritising investment to meet the demographic demand, mandatory cost pressures and pre commitments, achieve unavoidable key targets, and support delivery of Quality, Innovation, Productivity and Prevention (QIPP) savings • Risk sharing contracts • Using Commissioning for Quality and Innovation (CQUIN) Scheme and other incentives to lever change • Keeping expenditure within the running cost allowance of £25 per head

Key planning assumptions for 2014/15 and 2015/16 are:

• Repayment of the in year deficit of (£4m in 2014/15) • Budgets funded at outturn • Tariff deflation of 1.4% (acute providers) and 1.7% (non- acute providers) • Prescribing uplift of 5% gross • The impact of demographic growth estimated at 1.7% of total programme budget • Headroom and surplus will be utilised in support of the in- year financial position • Contingency of 0.5% of budget • Cost of new technologies and drugs based on National Institute of Clinical Excellence (NICE) college horizon scanning • Investment restricted to mandatory cost pressures and pre commitments, achieving unavoidable key targets and cost of QIPP

Based on these assumptions the gap between resources available and planned spend is £20m.

Progress on savings

In order to achieve recurrent financial balance and meet national operating standards we will need to deliver some £16.5m of recurrent savings over the next 3 years.

In addition we will need to deliver non recurrent savings of £22m over the same period.

In 2014/15 the required savings total £10m.

We have been successful in sourcing a small amount of additional resource to support the planning process including a review of the Quality, Innovation, Productivity and Prevention (QIPP) initiatives. This work will scope opportunities for additional savings and help develop implementation plans. A new Delivery and Performance Group, chaired by the Chief Clinical Officer will provide oversight and performance management of the QIPP programme.

We have identified potential recurrent savings in 2014/15 worth some £5.8m with an estimated impact of £2.2m in 2014/15. In addition we have identified potential non recurrent savings of £2.5m.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 27 Our interim finance plan submission assumes that capital grants will be available at the same level as last year providing additional non recurrent funding of £2.9m.

In order to respond to the changing needs of the population and to secure safe and sustainable clinical services we are working with partners and stakeholders to scope the changes needed to achieve the structural change and reform of the health and social care system required to deliver safe, high quality and affordable services for the future.

Risk Assessment

The following are the key risks will influence delivery of the 2014/15 – 2015/16 plan:

• Further work is needed where potential savings have been identified to develop detailed implementation plans supported by robust cost analysis • Plans to manage unidentified savings need to be developed urgently • Capacity within the community to deliver system change and associated savings • Acute hospital activity/costs cannot be managed within contracted levels • Prescribing growth and/or inflation exceeds planned levels • The cost impact of new technologies and drugs is higher than the NICE college estimates included in the plan • Unpredictable costs associated with individual patients with complex needs • Unplanned financial pressure from continuing realignment of CCG and Specialised Commissioning budgets • The availability of capital funding

Mitigation

In order to support delivery of the plan and manage risks we have identified possible mitigation as described below:

• New QIPP projects developed and implemented in line with the strategic commissioning intentions • Application of the headroom funding has been assumed in our plans • No planned surplus for the period • Access to additional capital to support revenue grants • Application of contingency reserve

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 28 Improving Quality

2013 has been a watershed for the NHS with a series of major reports that have brought the issues of quality and patient experience into sharp relief. These reports included the publication of the second Francis Report into the events at Mid Staffs NHS Foundation Trust, the Berwick report into patient safety and the Keogh review into acute hospital care.

We have considered each of these reports and fully endorse the degree of ambition and challenge that they represent for commissioners as well as providers of care. We are committed to driving up the quality of care including the experience of patients and carers. We have worked in partnership with clinicians, patients, carers and their representatives to develop key priorities and ideas for improvement which apply to every service, care home / nursing home and every GP surgery from which we commission services. The values and ambitions outlined here are the entitlement of all North Somerset residents whether they are children, of working age, older or living with a long term condition.

We have developed plans for quality under 8 key headings:

Action Area 1: Helping people to stay independent, maximising well-being and improving health outcomes Action Area 2: Working with people to provide a positive experience of care Action Area 3: Delivering safe, high quality care and measuring impact Action Area 4: Building and strengthening leadership Action Area 5: Ensuring we have the right staff, with the right skills, in the right place Action Area 6: Supporting positive staff experience Action Area 7: Safeguarding of children and adults Action Area 8: Seven Day Working

Action Area 1: Helping people to stay independent, maximising well-being and improving health outcomes

We want to prevent people from dying prematurely, with an increase in life expectancy for all sections of society. We want to ensure that those people with long-term conditions, including those with mental illness, dementia and learning difficulties, get the best possible quality of life.

We want to ensure patients are able to recover quickly from episodes of ill health or following injury. We also want to ensure that access to all services is on an equal footing, with an emphasis on providing the best possible care for the most vulnerable and excluded in society. It is for these reasons that we have focussed on 4 key patient groups; people with severe mental health, people with learning difficulties, people with dementia and children, particularly disabled children.

Action Area 2: Working with people to provide a positive experience of care

We expect providers to engage, empower, and actively listen to patients and carers throughout their care pathway. As a CCG we are committed to acting as the system leader that delivers effective patient and carer leadership and empowerment, not only at the strategic level but also via its individual providers.

We will expect all our providers to be collecting ‘real time’ patient experience feedback and to demonstrate how they are using this to improve the way they deliver services. We ask that providers share with us the measures they are taking to improve patient experience for those areas where there North Somerset CCG Operational Plan for 2014/15 – 2015/16) 29 is poor patient experience and share good practice as learning outcomes from the Friends and Family Test.

We will be working with providers and patient representative groups to agree key measures of patient/carer experience that can be used across the whole pathway.

We will be working with our providers to ensure the full implementation of the Clwyd/Hart Review of the NHS Complaints process. In particular we will expect:

Improved performance on response times to complaints Evidence of service changes and improvements in response to listening and responding to complaints Assurance that patients and carers are satisfied with the process of handling their complaint Evidence that responsibility for complaints and patient feedback is ‘owned’ at all levels of the organisation and especially by the Board

We expect providers to share these findings, not only within their organisations, but also with us and patient groups as evidence of transparency and openness. As commissioners we would expect to know about all complaints that highlight any breach in fundamental standards.

Outcome ambition 5 - What is your ambition for increasing the proportion of people having a positive outcome of hospital care?

E.A 5 The proportion of people reporting poor patient experience of inpatient care Baseline 155.6 2014/15 140.0 2015/16 126.0 2016/17 113.4 2017/18 102.1 2018/19 91.9

Outcome ambition 7 – What is your ambition for increasing the proportion of people having a positive experience of care outside hospital, in general practice and the community.

E.A 7 The proportion of people reporting poor experience of General Practice and Out of Hours Services Baseline 6.10 2014/15 5.46 2015/16 4.92 2016/17 4.43 2017/18 3.98 2018/19 3.98

These numbers represent the results of patient surveys of in patient care, general practice and out of hours services. The baselines used above have been sourced from Levels of Ambitions Atlas, derived from 2012 survey results as per National guidance.

Action Area 3: Delivering safe, high quality care and measuring impact

We will continue to ensure that all our commissioning activities promote and enhance the safety of North Somerset CCG Operational Plan for 2014/15 – 2015/16) 30 patients and service users in the care system. We will draw upon the growing evidence of what works and will expect to commission services from organisations that share this overarching value.

All Trusts, including Mental Health Trust and other providers will be expected to have implemented the use of an appropriate early warning system and have clinically appropriate escalation procedures for deteriorating, high-risk patients - in particular at weekends and out of hours.

A key priority for us in 2014/15 is to improve the transfer of care from one provider to another. This intention will focus on the quality and timeliness of transfer and discharge communication (including discharge summaries to GPs). We support an electronic approach to improve the accuracy and speed of discharge summaries to general practice and this is a local CQUIN priority for 2014/15 to allow sufficient staff resource to this important area. We and our member practices want to engage with providers in undertaking patient note audits, as a way assessing the quality of communication on transfers of care and/or hospital discharge.

We will introduce an outcomes based approach to the commissioning of knee replacement surgery. Three years of Patient Reported Outcome Measures (PROMS) combined with a peer review of comparative NHS Trusts during 2013/14 gives us a good baseline on the health gain as reported by patients following knee replacement surgery, we intend to commission knee replacement surgery based on an improved health gain for 2014/15.

Through CQUIN, we will continue to work to achieve a year on year reduction in HCAIs by tacking MRSA and C. Difficile across the whole health and social care community including acute Trusts, community providers, primary care and care homes. We will continue to expect the ‘zero tolerance’ goals to be supported for MRSA and have introduced Post Infections Reviews for all cases of Clostridium Difficile across all care settings.

Supporting Measures 5 – Healthcare acquired infection (HCAI): C Difficile numbers

E.A.S.5 Number of C.Difficile infections 2014/15 73

During 2014/15, the CQC and CCGs will be working to ensure that they are making better use of data to understand and demonstrate quality and drive improvement. There will be a greater focus on patient outcomes in relation to high quality care. We will be looking for evidence that Provider Boards are being accountable and taking responsibility for quality across each and every service they provide, and that this can be supported by patient feedback. As commissioners, we too will be expecting to use service level data, both qualitative and quantitative to drive our commissioning, gain assurance on the quality of services provided to patients and focus our priorities. It is for this reason that we have provided a set of monthly quality metrics for providers to report on both to the Clinical Commissioning Leadership Group and publically through our Integrated Quality and Performance report to the Governing Body

Where there are concerns regarding the quality of care for a particular specialty or provider, we will undertake thematic reviews which include a review of both quantitative and qualitative information in order to improve care pathways and quality of care for patients.

We will take a more rigorous approach to its scrutiny of provider Quality Accounts and the commentary we provide as a reflection of our commitment to transparency. We will particularly be looking for openness by providers on what has worked well in 2013/14 and what has not worked well, along with plans to improve the quality of care for patients.

We will expand the use of the NHS Safety Thermometer for mental health care and care homes that

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 31 can be used by organisations to support local improvement in activity and keep patients free from harm.

The CQC has recently produced its first ‘bandings’ of local hospitals as a result of its Intelligent Monitoring System. We will work with Trusts to understand the issues especially where the banding and or any of the quality indicators within each of the bandings gives cause for concern and will work with regulators and others to either ensure that standards improve. Where possible we will use external information, in addition to provider information to drive up the quality for patients.

Action Area 4: Building and strengthening leadership

The Francis Report (2013) placed the need for the NHS to address the issues of culture and leadership at it’s the heart, almost considering it as the necessary pre-requisite of quality. We recognise the importance of culture with respect to our own organisation and across the wider NHS.

We will therefore require evidence and assurance from its providers that they have used an appropriate methodology to assess their own organisational culture and are addressing any issues emerging from this work. In addition, we will seek further assurance that the values, principles and behaviours outlined in the NHS constitution are at the heart of the organisations’ decision making.

We will also look for evidence that staff are engaged and report being able to participate in developing their organisation’s strategy and delivery of this strategy. With the introduction of the Friends and Family Test (FFT) for staff in April 2014, we ask that this information is shared openly and publically with patients and their carers visiting each ward and department.

Making better use of data and intelligence, the Keogh report highlighted that ‘too often, boards were honing in on data that reassured them they were doing a good job, rather pursuing data that revealed inconvenient truths, thereby missing opportunities for improvement’. We will seek assurance that providers are working to put accessible, accurate and relevant information into the public domain. We will seek assurance as to how the provider Board has reviewed its system of governance to ensure clarity of accountability within the organisation.

Action Area 5: Ensuring we have the right staff, with the right skills, in the right place

We intend to commission from providers who have the right number of staff with the right skills and behaviour and working in the right place to meet the needs of the people they care for. We recognise that staff need time to learn, to reflect and to re-energise and they need to be supported by organisations that promote compassionate and caring culture and values and which dedicate time to valuing these. The quality standards for all contracts include a requirement to monitor Compassion in Practice (6Cs)

We intend to engage with providers to better understand the most suitable staff mix of competency, experience and education required to improve the experiences of service users and staff. For this intention we want to work closely with providers in their use of a set of sensitive workforce measures that enable providers to openly publish staffing levels to patients and visitors to wards, services and departments. We will review staffing levels using evidence based tools/methodology, its links with quality and patient experience and ensure appropriate action is taken.

Continuity of care is important to us and for this reason we promote the allocation of a named nurse, health or social care professional who is responsible for co-ordinating a patient’s care.

Action Area 6: Supporting positive staff experience

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 32 Staff satisfaction is an important indicator of quality. There is good evidence that happy, well- motivated, and supported staff deliver better care and that patients have better outcomes. We recognise that NHS staff work very hard and we will support providers to ensure that their staff are able to do the best job they can. We need assurance that providers can demonstrate strong and credible clinical leadership in front line teams, and that they are supported to drive innovation and provide high quality care for their patients. All providers should ensure that all staff access staff appraisal, that staff are supported in times of stress and demonstrate evidence of professional and personal development through staff appraisals. The Friends and Family Test (FFT) is to be rolled out to include what staff think of services provided in their own organisation, which will provide greater triangulation of quality and perception of services.

Action Area 7: Safeguarding of children and adults

NHS England provided Safeguarding guidance for CCGs in March 2013. Safeguarding of all those deemed vulnerable is significant responsibility for all of us who work in the NHS. We have set standards for the safeguarding of children and adults which give details of our expectation for all our commissioned services in 2014/15.

Action Area 8: Seven Day Services

The Seven Days a Week Forum has reported how NHS services can be improved to provide a more responsive and patient centred service across the seven day week. It is the Forum’s view that there are significant variations in outcomes for patients admitted to hospital at the weekends across the NHS. As a first stage, we ask providers to focus on urgent and emergency care services, and their supporting diagnostic services. All providers are challenged to provide the same level of services across a seven day period. There is evidence that supports this way of working and that can have significant impact on current lengths of staff and delayed discharges home.

We intend to implement a set of clinical standards describing the standard of urgent and emergency care that all patients expect to receive seven days a week. Each provider is asked to provide an Action Plan to deliver the 10 clinical standards. We will also work with primary care providers to establish how services can be developed to support care throughout the week.

We are also working with Social Services to deliver a seven day approach to working. Specifically we are planning to:

Make equipment available at weekends Undertake assessments at weekends Improving discharge and early discharge processes Improving access to independent Social Care Work to deliver alternative packages in the community to prevent admissions Weekend discharges Extension of community meals service to weekends.

Quality Premium

The quality premium is intended to reward clinical commissioning groups for improvements in quality of the services they commission and for associated improvements in health outcomes and reducing inequalities.

The quality premium will be based on six measures that cover a combination of national and local priorities. These are:

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 33 reducing potential years of life lost through causes considered amenable to healthcare and addressing locally agreed priorities for reducing premature mortality (15 per cent of quality premium); improving access to psychological therapies (15 per cent of quality premium); reducing avoidable emergency admissions (25 per cent of quality premium); addressing issues identified in the 2013/14 Friends and Family Test (FFT), supporting roll out of FFT in 2014/15 and showing improvement in a locally selected patient experience indicator (15 per cent of quality premium); improving the reporting of medication-related safety incidents based on a locally selected measure (15 per cent of quality premium); local measure that should be based on local priorities such as those identified in joint health and wellbeing strategies (15 per cent of quality premium). For North Somerset this has been agreed as access to health checks.

Meeting Statutory Requirements

Whilst we are committed to ensuring that all the services we commission meet the standards set out in the NHS Constitution, the health community is currently facing some considerable performance pressures. We are working with local providers of care to ensure that plans are robust and that the standards set out in the NHS constitution are delivered in 2014/15. At present we do not feel it appropriate to state confidence that delivery against all standards will be met throughout the two year period. The significant areas of concern for North Somerset patients are as follows

RTT Non Admitted and Incomplete Standards 6 week waits for diagnostic tests A&E 4 hour standard Cancer 62 day standard Ambulance Category A standard Red 1 Response times

We are in the process of reviewing provider CIPs to ensure that they are deliverable without impacting on the quality and safety of patient care from 2014/15 to 2018/19. Plans which require significant change are going through the contracting process and we will be fully assured by the end of April 2014.

We have agreed, in conjunction, with the People and Communities Board and NHS England Area Team a specified increased level of reporting of medication errors from specified local providers between Q4 13/14 and Q4 14/15

We have also agreed with the People and Communities Board that we will set Quality Premium targets for increasing the level of Health Checks in line with our plans for improving health outcomes across the population.

CQUINS

We have implemented national CQUINS across all contracts as set out in Everyone Counts Planning Guidance. In support of the FFT CQUINs we have also adopted the primary care based FFT as our area for local focus for improvement. Local CQUINS have been developed to ensure a system level approach with a focus on the following areas:

Improving Staff Knowledge to enhance Quality of Care: North Somerset Community Partnership and Avon and Wiltshire Mental Health Partnership NHS Trust both have a CQUIN to offer reciprocal training and use specialist skills to improve knowledge and skills in across both organisations. The two providers will complete a training needs analysis for specific teams identified in their own organisations and develop a training package to be delivered in each other’s organisation. The aim of

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 34 this CQUIN is to continue promotion of the strong partnership working between the two organisations, to support the mutual aims of improving physical healthcare to reduce premature mortality in people with severe mental illness and, to ensure the mental health needs of patients in community services are considered and addressed

Enhanced Communication: A CQUIN has been agreed with Weston Area Hospital Trust to ensure general practice is in receipt of discharge summaries for all patients who have had an inpatient episode of care within 48 hours of discharge, with the summary setting out the agreed management plan and any associated medicine changes that need to be reflected in primary care prescribing. The CQUIN also identifies several out-patient specialities where the Trust will ensure the patient and general practice are in receipt of a management plan as part of a discharge summary, or on-going care record, that ensures all parties have documented awareness of the secondary care clinician and patients approach to their care.

Support to Frail Older People accessing urgent and emergency care: CQUINS have been agreed with the Weston Area Hospital Trust, North Somerset Community Partnership, South West Ambulance Services Trust and Avon and Wiltshire Mental Health Partnership NHS Trust that focus on clinical information sharing that supports continuity of care and enables retrospective review of individual cases to support service improvement. Included in this approach will be clinical audit of case notes, patient interviews, community based implementation of the National Early Warning System, staff surveys on cross organisational communication learning and multi-agency case note reviews. In addition, NSCP are being commissioned through a CQUIN to provide training to local community groups/carers in identifying people who might be considered clinically frail and ensuring they are signposted to an appropriate service.

End of Life Care: In line with the wider BNSSG health community a system CQUIN has been developed to enhance the experience of patients approaching their end of their life. This CQUIN seeks to support clinicians open discussions with patients with long term conditions, where ascertaining their prognosis is very difficult, and plan for their end of life care. This CQUIN aims to ensure that all patients have an equitable opportunity to plan for their end of life care, no matter what their diagnosis, and ensure that they are able to receive the care in their final days in the setting of their choice.

Sepsis: Increasing awareness of patients potentially presenting with sepsis to ensure early diagnosis and interventions. In addition to a roll-out of pre-hospital protocols for adult sepsis in the ambulance service, a CQUIN has been agreed with SWASFT to develop enhanced clinical assessment of sick children presenting with pyrexia and ensure early warning to a receiving hospital where clinically required. In addition, a CQUIN has been agreed to ensure patients presenting to WAHT ED with suspected sepsis receive the appropriate care bundle for one hour and two hour interventions.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 35 Two Year Operational Plan

To deliver our vision and create a sustainable health and care system for North Somerset, we will need to implement significant changes to the way care is delivered. We are confident that our priorities for the first two years will address both the financial challenge in the system and make significant progress towards the delivery of our strategic vision. We will review our systems and processes to ensure that we are delivering the ‘day job’ as efficiently as possible through:

Robust and effective management of contracts – including coding and counting challenges Performance and delivery monitoring for quality, finance and activity Root cause analysis of areas for improvement Driving system productivity and efficiency

We have undertaken detailed analysis of the work required to deliver our objectives and identified six groups of interventions which cut across the five programme areas. This recognises the complexity and interdependencies of the programmes. The table below sets out how the interventions align to the programme areas.

ry Care ry

Continuum of of Continuum care Urgent Care Care Planned Children, People Young Maternity and Prima Pathway Redesign 2 2 1 2 1 Referral Management and Unwarranted Variation 2 2 1 2 1 Enhance community access, services and support 1 1 3 2 1 Proactive Management of known patients 1 2 3 2 1 Children and Maternity 2 2 2 1 1 Mental Health 1 2 2 2 1 (1. Leading intervention. 2 Significant impact. 3 Some impact. 4 Minimum impact)

We are confident that our priorities are aligned with those contained in the Better Care Fund, full details of which can be found in the Better Care Fund submission.

Operating Plan Programme Summaries

Elective Care

Pathway Redesign

This programme consists of a rolling programme of systematic, speciality based, pathway design to support the development and commissioning new pathways of elective care that:

Promote self-management, reduce unnecessary secondary care use and maximise what can be managed in primary care, moving away from the only opportunity to access consultant support being face to face contact to commissioning different service levels e.g. telephone advice and guidance to increase the ability to manage patients within primary care Remove restrictions to GPs being able to access some diagnostics services directly and agree pre-clinic work-ups to ensure that when a patient sees a consultant for the first time they are able to get maximum benefit from that appointment

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 36 Reduce unwarranted variation in intervention rates for surgical intervention, including the use of shared decision making Support patients to review their treatment options available to them and make an informed decision which best suits their needs and expectation

Recognising the need to develop confidence in the health system that pathway changes can be delivered and to address the financial and quality challenges, the priority specialities for pathway redesign within the two year operating plan are - Dermatology, Diabetes and Ophthalmology identified as specialities with opportunity to improve services and realise quality and spend benefits quite quickly due to good relationships and the need to address some operational issues. We are also focusing on Musculoskeletal as a high volume, high cost surgical speciality with significant opportunities, balanced with a high degree of complexity and need to build relationships that will take longer to realise the benefits.

Applying a Select and Tailor approach to pathway design to ensure delivery of rapid results, the approach will be:

1. Identify best practice examples (national and international) that deliver a reduction in secondary care activity for specialty 2. Engage GPs in selecting preferred model, that is most appropriate for North Somerset and tailor as required to ensure best fit 3. Stakeholder communication and engagement re proposals, including public and providers 4. Confirm commissioner intentions and define outcomes for preferred pathway 5. Engage providers (management and clinician) to identify and resolve system constraints Stakeholder communication and engagement planning to implementation 6. Process mapping to confirm As Is and To Be position 7. Develop delivery plan 8. Model and phase expected impact on provider 9. Begin project implementation 10. Go live with pathway 11. Review and evaluate pathway and delivery of expected benefits 12. Refine pathway to address any shortfall

Additionally this programme will explore opportunities to develop alternatives to face to face consultation to support the increased ability to manage patients within Primary Care, including the development of advice and guidance clinics, follow-up ratios and consultant to consultant referrals

This work will start with a pilot in Urology and following evaluation and refinement will continue with a phased roll-out across all specialties

In addition this work programme will build on the work undertaken to date to analyse, understand and address the root causes of unexpected high spends in particular specialities / programme areas for example the higher than expected spend in elective cancer procedures.

Referral Management and Unwarranted Variation

This programme aims to support referral management and decision making in primary care to reduce unwarranted variation and improve the quality of referrals. The approach we are taking in delivering this work programme is:

Systematic use of data about GP referral rates by speciality presented in a format that enables understanding and peer comparison and supports the management of referrals to agreed thresholds including more detailed audits at practice level.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 37 Developing clinically driven protocols with input and buy in from both primary and secondary care clinicians. Ensuring consistent application of low priority procedure policies and referral thresholds – NB these should be applied to all referrals including Consultant to Consultant referrals. Systematic approach to communications and establishing best practice, including a feedback loop to influence and change clinical behaviour – including practice support visits and ‘Top Tip’ communications. Programme of GP education and pathway awareness sessions on a rolling speciality basis (tackling high use / high opportunity specialities as a priority) this will include engaging the GP community in the application and identification of systematic pathway improvement opportunities e.g. pre-clinic work up, telephone advice & guidance and direct access to diagnostics. Support the optimisation of care by providing access to comprehensive, evidence based guidance, and clinical decision support at the point of care supported through the use of Map of Medicine or similar system. Review and optimisation of our Referral Support Service. The aim and expected outcomes for the elective care programmes are:

A reduction in new outpatient appointments particularly in Diabetes, Dermatology, Orthopaedics, Ophthalmology and Urology, through increased support and management in Primary Care, Advice and Guidance and alternatives to face to face consultation

A reduction in follow-up appointments, resulting from earlier discharge back to primary / self- care and improved productivity and effectiveness of initial consultation from pre-clinic work-up

A reduction in surgical intervention rates, supported by Shared Decision Making, particularly in hips and knees where Dr Foster indicates a higher than expected intervention rate

A reduction in elective care spend from improved contract management around coding, increased focus on consultant to consultant referrals and a review of policy compliance and further opportunities associated with procedures of limited clinical value

Urgent and Emergency Care

Enhanced Community Access, Services and Support

We are adopting a system-wide approach to reducing unscheduled care admissions and ED attendances through the development of enhanced community access, services and support to manage an increased number of patients in a community setting across the system

Building on our existing work around ED attendances we will:

Conduct a review of ‘frequent attenders’ to determine and subsequently address the root cause of attendance - data shows 4,525 patients attending ED more than two times in last year (2,052 are working age adults)

Undertake an urgent care assessment and review, producing recommendations for Primary Care, Minor Injuries Units, Urgent Care Centre and ED, with the aim to ensure that patients receive the right care, at the right time in the right place, in setting closest to home

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 38

Similarly in respect of emergency admissions we will:

Conduct a review of admissions to understand patient care requirement, assess potential to extend / enhance community teams / services to manage that care in an alternative setting

Support the implementation of seven day services of health and social care to support patients being discharged and to prevent unnecessary admissions at weekends

Facilitate earlier discharge from hospital and maximise the independence of patients using rehabilitation and reablement

Target care homes with higher than expected admissions, providing education and support to reduce unnecessary admissions

Support independent living using Community Connect as the framework for clear sharing of information across the health and social care systems and help to live at home with a range of preventative approaches that will influence health, wellbeing and independence.

Initial analysis has also identified a higher than expected admission rate for maternity non-elective admissions, and this programme will determine and subsequently address the cause for any unnecessary admissions

Proactive management of known patients

This programme will adopt a targeted approach to reducing unscheduled care admissions and ED attendances through the proactive management of known patients – Frail Elderly and patients with Long Term Conditions. The majority of this work is included within the plans for use of the Better Care Fund which have been developed with our partners to ensure a more integrated approach to care.

In terms of keeping people well we will:

• Use Risk Stratification to identify and proactively manage those patients at risk of admission

• Develop individual care and treatment plans, including ‘what to do if I get worse’ plans, including those patients on an End of Life pathway and ensure these are widely shared and understood across the system

• Develop and implement care co-ordination to provide an holistic approach to patient care in health and social care terms.

• Build on our integrated community teams to facilitate the care being delivered by the right person in a timely manner.

• Develop a community geriatric team to support the management of patients in primary care with access to proactive assessment, advice and guidance for vulnerable patients

• Use telehealth and the new Motex centre to assess, arrange and in some cases fit, telecare and telehealth devices in the homes of individuals, in accordance with care plans, using lessons learned and recommendations from the pilot with COPD patients.

• Use telecare to provide assistive technology to enable patients to live an independent life at home with a wide array of devices to assist them with their disabilities

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 39 • Support carers by providing respite care and support groups, including psychological and counselling services

• Provide condition specific services / support, including Dementia seven day services and Mental Health day care

Where rapid support is required in a crisis, we will provide this as close to home as possible through the development of:

• A single point of access, directing referrers to the most appropriate service – phase one - GPs and phase two ED

• Extended and enhanced integrated community teams

• A Rapid Response Team

• Community wards

• Safe haven and community step-up / step-down beds

The aim and expected outcomes for the urgent and emergency care programmes are:

• A reduction in the demand for urgent and emergency admissions and ED attendances

• An improvement of the proactive planning and primary care community management of known patients to reduce the demand for urgent and emergency admissions and ED attendances

• Joint care between health and social care to ensure high quality coordination of care.

• Working with all stakeholders including the acute, community, mental health and third sector/voluntary providers.

Community Services Re-procurement

In order to support the development of services closer to home we are currently undertaking a procurement process for community services. The procurement process aims to deliver benefits to patients, providers and commissioners and to improve productivity and efficiency of our services it will:

Make better use of available resources Improve service user satisfaction Reduce health and age discriminatory inequalities offering a mode, working around health and social care boundaries. Improve care pathways Improve joint working with other providers and agencies Offer innovative and radical solutions to systemic problems Create efficient processes which reflect best practice resulting in safe, effective care

Assumptions

Service users’ and carers’ interests are paramount Proposals must reduce age discrimination and develop functional need-specific services as opposed to age-specific. Proposals must enable joined up health and social care service , third / voluntary sector provision

Critical Success Factors North Somerset CCG Operational Plan for 2014/15 – 2015/16) 40

Project Structure in place and sufficient project management input Agreed commissioning principles Agreed action plan for best practice pathways as focus for change Comprehensive understanding of current supply across pathways, including cost and clinical effectiveness Early and full clinical and co-commissioner engagement Clear understanding of service user needs and views The right staff with the right skills in the right place Robust governance arrangements in place Services able to offer functional rather than age specific model of care Development of Rehabilitation Model

Since October 2012, there has been a review of rehabilitation and reablement across Bristol, North Somerset and South Gloucestershire (BNSSG). As part of this review, a new model of care has been described which reduces the amount of rehabilitation happening in acute hospitals and increases the rehabilitation and reablement in the community. The development of this model has also taken into account work undertaken to review the clinical services provided from Clevedon Community Hospital, which included co-production of options for inpatient, outpatient and diagnostic services. At the heart of the review of options for rehabilitation services are

A focus on facilitating earlier discharge from hospital for appropriate rehabilitation patients

Improving the overall quality and effectiveness of the treatment patients receive.

Embedding support to self-care and self-manage and the reablement ethos to maximise the independence of these patients.

Providing a more homelike care setting tailored to individual’s needs.

Increase the proportion of people returning to their own home following hospital discharge by taking an enabling approach from an earlier stage in the care pathway

Create a seamless interface between health and social care services by linking up existing pathways from hospital to rehabilitation, enablement and reablement services.

The following milestones have been agreed for this work:

Develop the business case for agreed model of care. April 2014

Develop the rehabilitation pathway and service specification Sept 2014

Commence procurement exercise and award contract - TBC dependant on JCG decision in July 2014

Commission service, review and evaluate - April 2015

Primary Care Development

In line with National Guidance, we have identified additional funding to support practices in transforming the care of patients aged 75 or older and reducing avoidable admissions to hospital.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 41 Practices have agreed that 50% of this funding is used to commission three key schemes which will integrate with practices. These are:

Community Geriatrician led team Care Home Support Team Nursing Home Local Enhanced Scheme

The remainder of the funding will be made available to practices (based on practice population) through the locality groups. The locality groups will be responsible for working with practices and other service providers including those in the third sector to develop new ways of working which will reduce admissions to hospital. These interventions will be assessed through our Delivery and Performance Group to gain assurance that investment is likely to have a positive impact in admission avoidance for over 75s and appropriate benefits identified to enable recurrent funding if successful.

We have also redesigned our Commissioning Participation Scheme to enable primary care led service development. The funding for this scheme has now been made available to individual practices to work independently, in localities or in a broader coalition to develop interventions that reduce the need for hospital based care when primary care, community care or the voluntary secor could meet this need.

Children and Young People

Capacity review, planned major service re- commissioning and service reconfigurations.

We are working with Bristol and South Gloucestershire CCGs to review the provision of acute children’s services and have identified the following areas of change:-

Consider viability of Weston Area Health Trust as a provider trust to continue to deliver maternity services for the population of NS alongside the most optimum location of a birth centre to serve the needs of pregnant women in North Somerset

Given the significant concerns relating to paediatric provision at Weston Area Health Trust in relation to safety and service continuity, commissioners will be reviewing the commissioning and provision arrangements for these services and may consider it necessary to make arrangements for these services to be delivered by another provider

The opening of the new Southmead Hospital may have implications for the provision of services. There is a particular issue relating to access to ED for children and young people as it is proposed that all under 16s will be diverted to Bristol Children’s Hospital. We need to examine what impact if any there will be for North Somerset residents.

The transfer of specialist paediatrics services from North Bristol Trust to Bristol Children’s Hospital is an important service development and will have an impact upon patient flows across providers. In some areas changes to patient flow may need to be supported by clinical protocols.

We are working with BNSSG colleagues to :-

Improving continuity of antenatal care Improving access to support for peri-natal mental health

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 42 Linking with Public Health on flu vaccinations Monitor services regularly to ensure safe practices Regularly use information from the Friends and Family Test to monitor patient experience Continue to implement new maternity pathway to provide improved access to relevant services provided by WAHT, NBT, UHB through collaborative commissioning across BNSSG and close working with North Somerset Council (public health and people’s directorate) Inclusion of a service improvement CQUIN relating to ante-natal / postnatal period, to be agreed across BNSSG Operate an effective and efficient birth centre in the North Somerset area for ‘low risk’ women Integrated teams of midwives to provide ante-natal and postnatal care, through one-to-one midwife care to improve continuity of care Increase choice through the promotion of home births Engage users and voluntary sector through Maternity Liaison Committee

We are working with Public Health to reduce health inequalities and reduce morbidity and mortality in the child population by:-

Reducing smoking and alcohol use in pregnancy Increasing breastfeeding Increasing immunisation rates Reducing injuries Increasing uptake of healthy start vitamins Continue to pilot the maternal weight management programme Increase take-up of all antenatal and newborn screening programmes Oversee all aspects of health service contribution to safeguarding

We are working with local authority to :-

Develop integrated information systems to support the development of multiagency care pathways Improve children and young people’s experience of healthcare through the accreditation of services under the Young People Friendly Ensure all services comply with the highest standards of practices for safeguarding Deliver early help and targeted support for vulnerable families (including Looked After children, teenage parents and those living with domestic abuse. Improve transitions pathway, particularly for 16-18 year olds in crisis Enhance quality of life for young carers Reduce time spent in hospital for asthma, diabetes and epilepsy for under 19’s Prevent lower respiratory tract infections in children from becoming serious Review packages of home care tailored to individual needs to ensure that they continue to meet needs

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 43 Mental Health Services

A key component of our continuum of care is the provision of services for people of all ages with mental health problems including those with dementia. The mental health programme of work will not involve managing existing contracts against quality and performance indicators, but will include a programme of service improvement, in partnership with NSC, providers and voluntary and 3rd sector agencies to ensure that the mental health needs of the North Somerset Population are met in accordance with national best practice and legislation, in a cost-effective way. Work delivery plans are developed in conjunction with our partners, including providers and service users. In additional to a planned programme of work, the programme will respond to in year demands for service review or redesign.

The key outcomes we are commissioning for in the next 2 years include:

Smooth transition between Children’s and Adult Mental Health Services Collaboration between services is critical for good clinical, educational and social outcomes for young people. A good transition pathway will involve adequate consultation between professionals and users; flexibility in the timing of transition; a period of preparation for the young person and family; information transfer and monitoring of attendance until the young person is established in the appropriate adult oriented service.

Meeting the mental health needs of patients in physical healthcare settings and services There is a strong evidence base for health, social and economic benefits deriving from provision of psychiatric liaison services in hospital settings. North Somerset CCG will continue to commission mental health services that can recognise and work in partnership with health care providers to meet the physical health care needs of their service users. Similarly we will expect our physical health care providers to work in collaboration with mental health providers to ensure the mental health needs of patients under their care are optimally met. In particular in 14/15 North Somerset will be focussing on dementia liaison for patients in Weston General Hospital and on opportunities to extend the operating hours and scope of the existing psychiatric liaison service.

Provision of high standard, cost-effective individual mental health placements that meet the needs of service users with appropriate step up and step down arrangements Key to achieving this outcome is to ensure that there is an integrated approach with North Somerset council, to quality and outcome assurance. It will also include a review of all out of area placements across CCGs that we co-commission with to identify any gaps in local service provision. To ensure we are using our resources to best effect, work around section 117 responsible commissioner guidance will be undertaken with other local CCGs to ensure a consistent approach to application of the guidance. A protocol will be developed to ensure fair, equitable and transparent decision making processes are achieved.

Improving outcomes for people with Dementia In addition to increasing capacity in the Memory Assessment Service, work is underway to revise the current pathway to ensure patients are seen in a timelier manner, with better post-diagnostic support and improved collaboration between specialist services and primary care. Specifically, we will: Ensure access to timely diagnosis, including meeting a locally agreed referral to assessment timescale of 4 weeks (and a referral to diagnosis timescale of 8 weeks). Work with the Specialist Memory Assessment Service and Primary Care to ensure there is sustainable capacity across the dementia diagnostic pathway, which will support efforts to achieve the NHS Outcomes Framework requirement of a dementia diagnosis rate of 67% by March 2015. Promote increased interaction between the Specialist Memory Assessment Service and Primary Care. Develop a ‘Dementia Roadmap’ web tool for health professionals to detail the local dementia pathway, signpost to support services and guidance. Continue to offer a stepped model of education for staff in caring roles across North Somerset and progressing work to ensure there is an informed and effective workforce. North Somerset CCG Operational Plan for 2014/15 – 2015/16) 44 Monitor the implementation of the North Somerset Dementia Action Plan via the North Somerset Dementia Strategy Group. Review the North Somerset Dementia Pathway, which has been produced and endorsed by all the stakeholders involved in the delivery and receipt of services for people with dementia, their family and carers. The pathway details all the services and support in North Somerset following a diagnosis of dementia. Increase awareness of services that support people with dementia to continue to live in their own homes for as long as possible.

With a high number of care homes in North Somerset catering for an increasingly elderly population, there is an increasing need to ensure that the mental and physical health care needs of people with dementia are being met. We are also working in partnership with NSC to develop additional in county facilities for people with Dementia (Ebdon Court).

What Dementia Diagnosis rate are you aiming for in 2014/15 and 2015/16?

Number of people Prevalence % diagnosis diagnosed of dementia rate 2014/15 2665 3977 67

The planning guidance states that an increase in the dementia diagnosis rate to 67 per cent should be achieved by March 2015.

Supporting patients with mental health problems to achieve a good quality of life and recover from mental health problems To ensure patients are supported to achieve a good quality of life and good recovery from episodes of mental ill-health it is crucial they can easily access appropriate services that can meet their needs in a timely manner. This includes a spectrum of services from psychological therapies through to acute inpatient services.

There will be continued focus on Improving Access to Psychological Therapies (IAPT) services to improve access and recovery rates in line with national targets, which we currently fall slightly below. There are some specific in year CQUINS in the providers contract, which include:

Strengthening the Long Term Conditions service, which aims to deliver a service tailored to patients with a co-morbid long term condition, and develop this service to include additional long term conditions such as patients with chronic pain. Evaluation of current PositiveStep service to identify opportunities for service development, particularly with regard to access and recovery rates. This will include an external review. Reviewing arrangements for patients aged 16-18 to ensure their needs can be met by services for adults or children - whichever is appropriate. To build on progress to date with the BPD pathway and services, with the providers working on developing a gap analysis, action plan and delivery plan for 14/15

The performance of the service is closely monitored with monthly performance meetings.

The providers will continue to promote their service by:

Production of an annual GP report to ensure GPs have service updates Ensure information on the service is widely available in community settings including GP practices, opticians, pharmacists, churches etc Sending out newsletters to stakeholders in health, social and 3rd sector agencies Adverts in local papers/magazines, medi-screens in GP practices and Weston hospital maps

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 45 The newly implemented Primary Care Liaison Service will be evaluated to ensure it meets the needs of the population it serves. The newly commissioned S136 Suite at Southmead will also be evaluated in year.

For IAPT, what proportion of people that enter treatment against the level of need in the general population are planned in 2014/15 and 2015/16?

The number of people who The number of people who Proportion receive psychological therapies have depression and or anxiety disorders Q1 2014/15 940 6268 3.18% Q2 2014/15 940 6268 3.18% Q3 2014/15 940 6268 3.18% Q4 2014/15 940 6268 3.18% 2015/16 3761 25072 15%

What level of IAPT recovery are you aiming for in 2014/15 and 2015/16?

The number of people who (The number of people who have % have completed treatment completed treatment within the recovery having attended at least 2 reporting quarter, having attended at rate treatment contacts and are least 2 treatment contacts) minus (the moving to recovery (those who number of people who have at initial assessment achieved completed treatment not at clinical “caseness” and at final session caseness at initial assessment did not 2014/15 750 1494 50% 2015/16 775 1550 50%

The national mandate anticipates the completion of the full roll-out of the access to psychological therapies programme by 2014/15, with at least 15% of adults with relevant disorders having timely access to services, with and the recovery rate to reach 50%. Both of these indicators will be monitored via the IAPT minimum dataset.

Think family

Mental health services, as with all services offered by North Somerset CCG will fall under the ‘Think Family’ Philosophy, to improve the support offered to vulnerable children and adults within the same family. A system that ‘thinks family’ has no ‘wrong door’. Contact with any one service will give access to a wider system of support. Individual needs are looked at in the context of the whole family, so clients are seen not just as individuals but as parents or other family members. Services build on the strengths of families, increasing their resilience and aspirations. Support is tailored to meet need so that families with the most complex needs receive the most intensive support. We expect Avon and Wiltshire Partnership Trust as a partner to work closely with North Somerset on this key agenda.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 46 Delivery Risk Analysis

Risk/Barriers Mitigation/ Enablers Engagement Lack of ownership by primary care Work through the CCLG and GP Forum clinicians to ensure plans are clinically led Develop innovative approaches to clinical leadership of workstreams Robust mechanisms to manage conflict of interest.

Lack of public support for plans Communications strategy particularly focused on five year strategic plan and significant changes

Lack of political support for plans Increased engagement with the People and Communities Group

Lack of engagement with other BNSSSG group and work with Somerset commissioners CCG used to co-ordinate planning and implementation.

Lack of support from providers Develop stronger mechanisms for working with providers on service development Identify clinical champions in secondary care.

Workforce Lack of capacity within the CCG Review staffing structures and commissioning support arrangements. Identify potential opportunities for joint working with other CCGs. Prioritisation of workload

Lack of capacity/skills within the CCG Ongoing appraisal and development Organisational Development Plan

Lack of motivation and enthusiasm Ongoing review of workplans/ objectives Ongoing appraisal and development Organisational Delivery Plan Promotion of “Can Do” attitude by leadership team

Insufficient/ inappropriate Review arrangements with CSU commissioning support Develop intelligent customers

Information Information from providers is not of Ongoing discussion with providers to sufficient quality to support decision improve data quality making Triangulation of data

Data is not timely enough to support Adapt decision making structures and decision making processes to utilise available information

Benchmarking data has discrepancies Triangulation of data Development of Business Intelligence function to consider data in local context.

Finance Insufficient funding to support service Ensure plans for delivery clearly identify North Somerset CCG Operational Plan for 2014/15 – 2015/16) 47 development resources required. Phased implementation of delivery

Insufficient running costs to manage Review staffing structures and organisation commissioning support arrangements. Identify potential opportunities for joint working with other CCGs.

Systems and Mechanisms for monitoring delivery and Development of new Delivery and processes performance are not sufficiently robust Performance system to be embedded throughout organisation

Contracting arrangements are not Review support from CSU sufficiently robust Develop new contracting processes to ensure connections across the organisation and links to all programmes of work Relatively new organisation still working Development of new Delivery and in silos Performance system to be embedded throughout organisation Focus work on delivery of 2 and 5 year plan.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 48 Enabling Workstreams

Partnership Working Arrangements

We are committed to: working in partnership with patients and the local community to secure the best care for them delivering real improvements in health and well being and reduce health inequalities for the people of North Somerset, by working in partnership with statutory and non-statutory bodies including NHS organisations, the local authority,and a wide range of voluntary and private sector partners. working in partnership with other Clinical Commissioning Groups, stakeholders and local providers to introduce evidence-based pathways and undertake major service redesign

We have a range of partnership arrangements in place to support this commitment. Of note are the following:

Collaboration with other CCGs Bristol, North Somerset and South Gloucestershire commissioners have a long-standing partnership built on collaboration and this has been formalised with all three CCGs agreeing a Memorandum of Understanding (MOU) that ensure that the best use of resources will be achieved by working collaboratively to commission a range of health services across the whole health economy and through effective collaboration for relevant commissioning activity. Working collaboratively our aim is to achieve a number of benefits to improve the quality of services for the patient. For example, Develop a strength in a common voice to increase their ability to negotiate and influence existing and new providers Align strategy and resources as well as share scarce skills, knowledge and resources/expertise to increase the resilience of the collective and individual CCG Realise savings from increase economies of scale Reduce the number of gaps in service provision across BNSSG and increase the clarity of services for patients and stakeholders Improve the working environment of their staff

We also work closely with Somerset CCG particularly when considering the development of services at Weston Hospital.

North Somerset Partnership Along with North Somerset Council, the emergency services organisations, community and voluntary groups as well as local businesses, we have formed the North Somerset Partnership to deliver a Sustainable Community Strategy for North Somerset. The People and Communities Board, bringing together work around children and families, community safety, health, housing, social care and safer, stronger communities reports to this partnership. For North Somerset the People and Communities Board also undertakes the role of the Health and Wellbeing Board.

A sub-structure under the People and Communities Board provides the framework for close partnership working and joint commissioning of a wide range of health and social care services. We have been working together with the Local Authority on Integration of services for some time and the Better Care Fund will be managed through these well established governance arrangements.

North Somerset Council We have formal arrangements in place with North Somerset Council for Joint Commissioning arrangements for a wide range of community services including contracting arrangements with the independent sector for continuing health care and funded nursing care, integrated community equipment services, a jointly commissioned single point of access to health and social care, integrated teams, reablement and enablement placements. These arrangements are managed through formal section 256 agreement approved by the Governing Body.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 49 Partnership Working with Others We work with providers through formal contractual arrangements as well as informal forums. This includes primary, secondary and community care. Of note are: The arrangements for working with our CCG membership through a monthly GP Forum where every practice is represented and through which we work on delivery of our plan and planning for the future. Both contractual and strategic meetings with North Somerset Community Partnership Regular meetings and close working with Voluntary Action North Somerset, the infrastructure provider for voluntary sector providers throughout North Somerset Regular meetings with MPs and councillors, senior community leaders and local voluntary groups concerned about local issues. Work we do with Patient Participation Groups to support the development of leaders and specific activities they undertake with the populations they serve.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 50

Research and Innovation

The Avon Primary Care Research Collaborative (APCRC) Research and Development team provide our research and development function and have developed a 3 year Research and Development strategy (2013 – 16) on our behalf. This strategy will ensure that we are able meet the obligations around using and promoting research and evidence. The strategy is comprised of four strategic aims:

1. To increase the value, breadth and range of the research portfolio and embed its management into the core business of the CCG 2. To embed research, robust evaluation and the use of evidence into the core business of the CCG 3. To ensure that the APCRC creates the best use of all available evidence and expertise through collaboration and networking partnerships 4. Maintain and promote APCRC as a highly effective, efficient, innovative and user-responsive organisation for research governance and to lead the field nationally in all work streams on our behalf.

By operationalising these aims, the R&D team will ensure that Research and Evidence is at the heart of CCG work.

The APCRC are working towards developing a culture of evidence informed commissioning and meeting the requirements of the Association of Medical Research Councils (AMRC) research charter for CCGs, these are:

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 51 The R&D strategy is supported by a comprehensive action plan which includes a range of activities that will support this work including:

Development of a service specification template for inclusion in the NHS standard contract service specifications focusing research participation and service evaluation Development of a research utilisation tool to support commissioners in accessing, analysing and applying research/evidence to their work Access to advice, guidance and training around service evaluation Access to a ‘Research Aware’ questionnaire which assesses current staff use and application of research and evidence (currently being piloted in Bristol CCG as part of Management Fellowship, and will be made available in North Somerset CCG) Opportunity for staff secondment to the APCRC NHS Management Fellowship scheme in 2014 15. This scheme is aimed at creating stronger links between academic and research communities Opportunity to apply for a ‘researcher in residence’ who will be embedded within the CCG. This is a new initiative being developed by APCRC in 2014/2015, and details will follow.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 52 Innovative Commissioning and Contracting Arrangements

There is growing recognition that the way in which care and services are commissioned needs to change in order to address the challenges we face, including the nature of health needs and growth in demand, change required to improve quality and safety and patient experience, step change in efficiency, the financial environment, clinical and organisational sustainability. As we implement 2 and 5 years plans there will be a need to:

Shift from transactional to transformational working that changes the way in which we address the challenges we face;

Change focus from inputs to outcomes for patients, commissioners and partners within the system;

Develop commissioning and contracting designed to operate across potential service, organisational and system boundaries; this includes alignment of objectives and joint delivery plans across providers;

Enable patients and their carers and their communities to be engaged, involved and lead as full partners in shaping development and delivery of health care;

Develop proactive market development and management that facilitates innovation and new market entrants that can work with existing service providers to help deliver the transformation needed;

Develop a longer term focus, moving from annual to 2 – 5 years which will also support deliver of the other elements above;

As part of this process the CCG together with its Commissioning Support Unit is working to develop innovative commissioning and contracting arrangements that can support the new ways of working. A number of models are in development across the wider commissioning system including:

SIBs (Social Impact Bond) - Upfront funding provided by investors for outcomes based contracts, which produce social impact and financial returns. Typical investors include Big Issue, charitable grants or the Government. SIBs are typically used to invest in early interventions and allow for a more diverse range of providers to bid to provide services. For example in the Midlands a CCG has commissioned a third sector provider to provide end of life care support at home and payment is made on a reduction in demand for acute care. LIST (Local Integrated Services Trust) - Have 3 core purposes, to integrate budgets at scale, to foster Community engagement and as a conduit .

Alliance Commissioning Alliance Commissioning is where there is one contract between the commissioners and an alliance of parties who will deliver the service. This means there is one service specification, one contract and one performance framework.

Prime Contractor or Accountable lead provider Once the commissioners have agreed an integrated model of care, they have a single contract with one of the providers who is responsible for sub-contracting with all the others. That lead provider is accountable to the commissioners for delivery of a fully integrated service where the patient does not experience the current fragmentation of service. The other providers become sub- contractors to the lead provider.

Commissioning Outcomes Based Incentivised Contracts (COBIC)

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 53 Focussing on local priorities to improve outcomes and quality and reduce inequalities, this model seeks to eliminate perverse incentives in the system and to promote accountability for delivery across a health system. It requires robust engagement and procurement processes, works best with longer term (5 years) contracts and assumes a departure from tariff. COBIC commissioning models aim to reduce the number of failed handovers which contribute to inefficiencies and less than optimum outcomes. COBIC seeks to remove fragmentation of the delivery system, improve use of data and evidence, to better involve clinicians, and to better involve the public.

Development of these models within our wider system is beginning with a 3 months scoping exercise across Muskulo Skeletal Services, including referral, interface and acute services. The scoping project will be delivered by SWCSU in partnership with COBIC and will report in time for the outputs to be included within commissioning intentions for 2015/16, although implementation may take up to two years to achieve in full.

SWCSU is also working with Alliance contract experts to develop and offer for piloting the development of this offer within local systems; plans being developed within North Somerset may provide a good fit with this approach and we will further explore this in 2014-15.

The use of advanced information systems to support this working, drawing upon international best practice will be vital in supporting an outcomes focus, sensitive to personal needs, suitable for use with people with multiple and complex needs, enabling efficient, service delivery providing the outcomes required and value for money.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 54 Developing CCG Capacity (Workforce and OD)

We recognise that delivery of both the 5 year strategic plan and 2 year operational plan is dependent on having sufficient capacity and capability within our workforce. We are pleased to have established a team which is now functioning well and starting to deliver real change. However our staff have been through a period of significant organisational change and insecurity and this has been reflected in the staff survey which was completed last year. As a result of this feedback we have identified a number of short term actions which will increase staff satisfaction and productivity. These include:

Fully embedding the appraisal system Training Needs Analysis Formalising clinical advisors arrangement Strengthening Training and Development arrangements including impact monitoring Consideration of Staff Recognition/Award scheme Arrangements for self-management and stress management support

We are also refreshing our organisational development plan in order to develop longer term capacity and capability within the organisation. The outline plan is set out below:

A constant clinical focus on Further development of quality improvement improving quality and health mechanisms outcomes and reducing health Utilisation of Public Health information to inequalities support outcome improvement.

Significant engagement of Develop role of Membership Forum

ngagement e constituent member practices to Primary Care Development Strategy increase the focus and delivery Practice visits of service redesign Mechanisms for peer review/buddying Increase and improve info for practices Strong involvement of the wider Increased involvement of Practice Nurses multi-professional clinical Clinical Pathway development

community in commissioning to Provider development strategy

multiprofessional focuswith significantmember A strong A clinical and deliver transformational change The public and patient voice at Consultation and engagement strategy the heart of every decision taken An understanding of the assets Consultation and engagement strategy and needs of the population at Increased Public Health input locality level Patients and carers participate Consultation and engagement strategy in planning, managing and making decisions about their care and treatment Effective mechanisms to capture Consultation and engagement strategy patient and public insight so it Engagement in objectives for all staff and underpins and informs CCG clinical leaders. decision making processes A reputation for being a Website transparent and open Board feedback organisation which is trusted by Newsletters

the local population You said we did and the public the and Meaningful involvement of patients carers carers of patients involvement Meaningful What we’ve heard

Strategic plans which are Develop People and Communities Board

aligned with joint health and

and and credi ble plans Clear Clear wellbeing strategies North Somerset CCG Operational Plan for 2014/15 – 2015/16) 55 Clear and credible operational IT Strategy plans which are evidence Constant challenge to bureaucracy based, measurable and affordable Outcomes based contracts with Develop robust approach to contracting all providers which is integrated with commissioning and service redesign.

A strong track record of Stat Man training all staff and members delivering changes that improve All staff have up to date objectives quality and productivity, whilst All staff have PDPs delivering financial savings to Robust appraisal and development process ensure the sustainability of future services Robust governance Develop Clinical Commissioning Leadership

arrangements, rigorous enough Group to withstand challenge but Information governance flexible enough to enable local Risk Management process ownership from the clinical community A system of strong internal Implement Delivery and Performance controls which enables clinicians system to focus their time and effort on driving improvements in services and outcomes An innovative commissioning Review arrangements with CSU to ensure support provider which they meet ongoing support needs

anticipates its needs Robust governance arrangements governance Robust Strong collaborative ties to Develop role at People and Communities

health and wellbeing boards Board. with the CCG being a Implementation of Better Care Fund Plan recognised system leader Strong and productive Primary Care Development Strategy partnerships with its area team which lead to measurable improvements in the quality of primary care Effective partnerships with other BNSSG CCG Partnership CCGs to co-commission services where this will improve

Collaborative commissioning Collaborative quality and drive efficiencies Transformational leaders who Objectives for clinical leaders deliver measurable PDPs and appraisals for clinical leaders improvements in patient Multi-professional/organisational pathway experience and health outcomes development and deliver quantifiable Team Development for Officers reductions in health inequalities System leaders who influence Develop clinical networks the whole health economy Role on clinical senate council Role on Academic Health Science Network Board Bristol Health Partners

Distributed multi-professional Practice visits clinical leadership throughout Practice development plans (including

Clinical Leadership Clinical the CCG and member practices individual roles)

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 56 Vision and values demonstrable in all behaviours Strong succession planning and Succession plan leadership development

Medicines Optimisation/NICE Medicines are the second biggest spend in the NHS after staff costs. Ensuring cost effective use and that appropriate governance structures are in place to ensure safe, high quality prescribing, line with best practice, is a priority.

The Medicine Management work integrates across all care pathways and CCG work programmes, and requires working with CCG colleagues and stakeholders to ensure medicines are being used appropriately and cost effectively.

In particular:

Medicine optimisation – ensure patients, public and society more broadly get the best outcomes from medicines. From patients receiving insufficient information about their medicines to too many hospital admissions caused by the adverse effects of medicines which could have been prevented, professionals and patients need to work much closer together to improve the quality of medicines use. This can be achieved by ensuring that the four key principles of medicine optimisation are embedded across commissioned services - Aim to understand the patients experience - Evidence based choice of medicines; the most clinically appropriate and cost effective medicines are used to meet the needs of the patient, informed by the best available evidence base. - Ensure medicine use is as safe as possible - Make medicine optimisation part of routine practice Commissioning new services and pathways that the impact of medicines is considered and costed into all plans Advise the appropriate CCG members of the opportunities to commission or decommission existing services when new medicine innovations or any change in evidence that will allow a change in delivery of new or existing pathways / services Ensure the appropriate safe introduction and available funding of new NICE technology appraisals Continue to improve and develop policy, guidelines and processes in line to ensure best practice and monitor prescribing outcomes Ensuring a patient-centred approach to patient care for better patient safety and experience, to achieve optimal outcomes To promote better medicines governance arrangements across the primary/secondary/Local Authority care interface e.g. transfer of care Ensure that providers and contractors are implementing relevant medicine management/ prescribing guidelines and policy along with auditing their implementation To plan and drive forward potential QIPP cost saving opportunities to support the membership to ensure cost-effective, high quality prescribing and use of medicines across the healthcare community Work will focus on the 5 NHS domains and the wider North Somerset CCG strategic 2 year plan and support delivery of QIPP targets Receiving reports of medicine related incidents from all providers and agree any resulting action to share information and prevent re-occurrence

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 57 Specific medicines management interventions planned are:

Health area Aims/action Outcome Antibiotic Follow national & local guidelines to Reduced admissions; reduced C prescribing reduce inappropriate prescribing and diff rates; improved appropriate C diff rates antibiotic prescribing Dementia Ensure appropriate use and choice Improved and appropriate care of of dementia drugs in line with NICE; dementia patients to achieve the ensure patients regularly reviewed best outcome for this cohort of by appropriate practitioners and treat patients related co-morbidities Pain To reduce inappropriate prescribing Better pain management; reduced of strong opioid analgesics and risk of inappropriate use of high- promote local guidelines dose opioids. Improve patient self care Respiratory Reduce inappropriate prescribing of Improve patient education and self- high dose corticosteroid inhalers; care; reduce respiratory related maximise cost-effective use of new admissions and time-spent in medicines; review COPD and hospital; improved quality of life bronchiectasis patients for optimum care Diabetes Ensure cost-effective patient Reduce CVD complications.; regimes in line with NICE & local improved self-care for patients; pathways for optimal blood glucose reduced hospitalisation due to and cholesterol levels; review blood uncontrolled diabetes; slow disease glucose testing; review patients with progression micro-vascular damage Medicines Reviews of care home patients, Improve concordance; reduce optimisation mental health patients, housebound waste; reduce variation in patient patients, people with learning care; reduce admissions and/or difficulties, patients with multiple events; improve safety of morbidities, patients on high risk medicines; improve medication use; drugs; work with secondary care to improve quality of care; enable improve medicines optimisation at patients to live independently for discharge; review bisphosphonates longer; reduce out-patient and antidepressants appointments solely for monitoring of high risk drugs End of life care Rationalise medicines; ease of Ensure access to appropriate access to appropriate medicines in a medicines; ensure protocols are in timely manner place for safe and effective use of end of life medicines Cardiovascular Review use of statins and blood Ensure CV medicines are used at (CV) risk pressure medication especially in their maximum potential to improve prevention patients with multiple co-morbidities; health outcomes such as ensure medication regimes in heart cholesterol and blood pressure in failure optimised high risk patients so improving quality of life for people with long- term conditions; reduce admissions Stroke Ensure AF patients treated Reduce risk of stroke; ensure cost- prevention appropriately on anticoagulants. effective use of new medicines in Monitor use of new anticoagulation appropriate patients; increase medications to ensure following quality of life NICE and local pathways; target specific patients who may benefit Reduce Produce a safety dashboard, using a Reduce avoidable admissions; admissions / tool called Eclipse RADAR to Reduce complications due to complications highlight potential issues to inappropriate use of medicines and due to prescribers improve patient care North Somerset CCG Operational Plan for 2014/15 – 2015/16) 58 medicines Education of Training sessions for specific Improved patient care; improved Health Care conditions and/or medicines; peer use of cost-effective medicines Professionals support; expert opinion; increased including new medicines; joined up compliance from all HCP with local working across primary and and national guidelines secondary care

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 59 IT Strategy

Our strategic approach to the delivery of Informatics and IT can be demonstrated in our approach to the partnership with our supplier. We are committed to working closely with our technology partner, South West CSU (SWCS). In line with our IM&T strategy SWCS appointed Gartner to undertake a review of infrastructure, processes and people within their IT services division and have jointly developed a forward plan that will revolutionise the delivery of IT services and the infrastructure we rely upon. The roadmap is laid out under 3 categories, namely:

Technology – SWCS’s approach is taking us from a consolidation of locally hosted hardware, through a move to a co-located hosting partner for our existing hardware, to a cloud based fully- hosted technology platform in 3 years. NS CCG benefit from the increased flexibility and resilience this infrastructure platform can bring.

Processes – SWCS’s approach is ensuring they standardise processes across a broad geography and multiple customers and delivering efficiency in service delivery. NS CCG benefit through this approach by increased resilience and maximised VFM

People – SWCS’s approach is ensuring they have identified skills gaps and restructured to fill these gaps, implementation of level 3 ITIL for all IT services staff and implementation of a PDP process for all staff to underpin this approach. NS CCG benefit from increased performance from our technology partner

In all 3 areas the drivers for increased scale of operation, consistent process and people development underpin the ambition to create as efficient a service as possible and NS CCG seek to take advantage of that.

Clinical systems integration is a core part of the North Somerset IM&T strategy for the future. This includes integrating with local GP systems (over 90% EMIS) as a priority, but also includes social services (AIS), child health (McKesson) and others. All are partners are committed to the local ‘Connecting Care’ project that will deliver a clinical portal across Bristol, North Somerset and South Gloucestershire. A joint health and social care specification has now been completed , this specification identifies the expectation for one lead professional that develops a joint health and social care assessment and takes responsibility for the care of high risk patients. In response to the specification our current provider of community services is retendering their patient information system.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 60 Governance

We have mapped out the key decision dates for each programme. The Clinical Commissioning Leadership Group consisting of Senior Managers, Clinical Leaders and representatives from the Local Authority will be responsible for decisions relating to the programmes where these are within their delegated authority. Any decisions outside of the delegated level for the Clinical Commissioning Leadership Group will be considered by our Governing Body

Programme managers and clinical leads will hold the day to day responsibility for the delivery of the relevant programmes of care. We have recently established a new Delivery and Performance system which will ensure an organisation wide approach to ensuring that implementation of our plans achieves real changes for patients. This system will be based on a rigorous milestone monitoring programme for all projects. This will allow us to ensure that delivery is timely and that resources are targeted at those areas where they will have most influence.

In addition to monitoring our activity we will also use the Delivery and Performance Group to review our performance data to ensure that interventions are having their anticipated impact and remedial action is taken swiftly where required. This performance and delivery group will include all our senior management and clinical leaders to ensure a joined up approach.

North Somerset CCG Operational Plan for 2014/15 – 2015/16) 61