CCG Operational Plan 2019/20 and Stoke-On-Trent Version: V.1 Final

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Contents 1. Introduction ...... 4 2. Context ...... 4 3. Our priorities and deliverables ...... 6 4. Urgent and Emergency care (UEC) and Enhanced Primary and Community Care (EPCC) ...... 8 Integrated Care Teams and Hubs ...... 8 Integrated Urgent Care ...... 9 Ambulance services ...... 10 Model of same day emergency care (SDEC) ...... 11 Care Homes ...... 11 Delayed transfers of care (DToC) ...... 12 Long term conditions (LTCs) ...... 12 Respiratory ...... 13 Diabetes ...... 14 Frailty ...... 15 5. Quality, safety assurance and improvement ...... 16 6. Primary care...... 17 Primary care networks (PCN) ...... 17 Quality in primary care ...... 18 Primary care digital work stream ...... 19 7. Planned care and cancer ...... 19 Outpatient follow up reduction ...... 20 System Speciality Reviews ...... 21 Musculoskeletal (MSK) ...... 21 Gastroenterology ...... 22 CCG Pathway reviews ...... 23 Ophthalmology ...... 23 Dermatology ...... 23 Cardiovascular Disease (CVD) ...... 24 Cancer ...... 24 8. Mental health and learning disabilities ...... 29 Out of area ...... 29 High volume and intensity users ...... 30 CAMHS (Child and Adolescent Mental Health Services) ...... 32 Special Educational Needs and disabilities (SEND) ...... 33 Learning disabilities and autism ...... 34 2 | P a g e

Learning from deaths report (LeDeR) ...... 35 9. Maternity and neonatal ...... 36 10. End of Life ...... 37 11. Personalised care ...... 38 Continuing healthcare (CHC) ...... 38 Personal health budgets ...... 38 12. Estates ...... 39 13. Specialised Commissioning ...... 39 14. Workforce ...... 39 15. Data and technology ...... 40 16. Finance...... 41 17. Public involvement ...... 43 18. Summary ...... 44 Appendix 1 – North Staffordshire and Stoke-on-Trent CCG locality focus ...... 45 Appendix 2 – Chase CCG, and Surrounds CCG and South and Peninsula CCG locality focus ...... 48 Appendix 3 – East Staffordshire CCG locality focus ...... 51 Appendix 4 - Supporting primary care ...... 52 Appendix 5 – Further detail on 2019/20 deliverables ...... 55 Appendix 6 – Regional Assurance Statements ...... 60

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1. Introduction

NHS published planning guidance for 19/20 operational planning along with a ten year plan that places emphasis on significant transformation of healthcare systems, building on the requirements of the five year forward view.

The long term plan is clear on the importance of integrated working and the development of Integrated Care Systems. Along with equivalent provision mechanisms it essentially suggests a shift for local areas from focusing redesign initiatives on predominantly curative and episodic care interventions, to looking at prevention focused pathway and whole system transformation in line with a population health management and outcomes approach to care delivery.

This plan outlines our ambition for healthcare delivery in Staffordshire and Stoke-on-Trent and sets out our priorities building on commissioning intentions and local priorities set out in September 2018, whilst fulfilling the expectations placed upon us through the national planning cycle. It reflects across the 6 CCGs where things should be done once but also reflects some locality based differences which are outlined in Appendix 1, 2 and 3.

2. Context

There are real demographic and health delivery challenges locally. Recognising these challenges to deliver health care that meets the needs of an ageing population with significant burden of multiple long term conditions necessitates a left shift towards care at home or within the community. This requires significant changes to our care delivery infrastructure, with greater integration of our services, from primary care networks and locality integrated care teams through to the development of integrated care partnerships. At the same time we need to reduce unplanned entry into secondary care and work collectively as a system to deliver effective utilisation of our resources, including estates and workforce.

Local population Staffordshire and Stoke-on-Trent has a combined population of 1.1m, with approximately 850, 000 people living in Staffordshire and around 250, 000 in Stoke-on-Trent.

The population is expected to grow by approximately 6% over the next 25 years with our complex and frail elderly population growing faster than the national average (as highlighted by the growing gap between healthy life expectancy and life expectancy we are seeing in Stoke-on-Trent). This will mean a greater burden of chronic ill health in our older population even though our older population is, overall growing less than the national average (16% growth rate in the 65+ population by 2021) equating to 8,570 additional residents aged 85 and over by 2027; for Stoke-on-Trent this equates to 740 additional residents.

This greater burden of ill health is linked to higher levels of obesity, poor smoking cessation rates, increasing alcohol related admissions and high levels of deprivation in some parts of Staffordshire and Stoke-on-Trent. The graph below shows the population forecasts for Staffordshire and Stoke-on-Trent.

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Graph 1

Deprivation Levels of deprivation vary significantly across Staffordshire and Stoke-on-Trent shown in the map below. Stoke-on-Trent is ranked as the 16th most deprived local authority area in England, whereas Staffordshire is relatively affluent with pockets of high deprivation in some urban areas1. Over 30% of the population of Stoke-on-Trent lives in the 10% most deprived areas in England, and only 16.5% live in areas classified as ‘better than the English average’. Stoke-on-Trent is also ranked as the 12th most deprived area for health- related deprivation2.

PGMJ (2005) Access to health care for ethnic minority populations. 1 Gov, Index of multiple deprivation, 2015 1 JSNA outcomes report (2015)

Along with the demographic and health consumption challenges outlined, our local system has considerable financial challenges in delivering a break even system control total by March 2024. The CCGs are predicting a £73M deficit position in 2018/19 with a control total of £20.14M deficit. The control total for the CCGs is £54M deficit in 2019/20. Given that the underlying system deficit has been independently assessed as

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approximately £220m this will represent a significant challenge to deliver efficiency and saving requirements of over 3.6% of current expenditure before even considering the implications of the 2019/20 allocations and associated expenditure requirements.

Given this challenging context, this planning round is an opportunity to accelerate our collaborative work as a single health and care system during 2019/20 and collectively agree and deliver significant transformational and financial change, which builds the system approach and set the basis for our strategic plan in summer 2019. Our operational plan is designed to:  develop a single set of operational delivery objectives for 2019/20 that are agreed by our membership and sets the basis for strategic commissioning 19/20 and beyond  accelerate greater integration of health and care across Staffordshire and Stoke-On-Trent by delivering system owned operational solutions to our challenges in 2019/20 that will move us towards an Integrated Care System (ICS) that includes a single strategic commissioner, effective Integrated Care Providers (ICPs) and strong Primary Care Networks (PCNs) based on the work we have already started  build system resilience by developing a collective response to significant demographic, health consumption and financial challenges over the next year, which will be projected further in our strategic plan and as part of a wider system planning approach

Population Health Management Key to improving both the health outcomes for patients and the population’s ability to live well, is to have effectively linked information about people so as to be in a position to proactively manage their health and social care interventions at a range of risk levels. There is a requirement as a system to develop our approach to population health management and we are currently working with our local authority partners and university colleagues about what this offer may look like.

3. Our priorities and deliverables

We will work better to understand our current position and identify our strengths, as well as what we need to put in place to deliver the ambitions set out in the plan. We will evolve the integrated care system and develop into a strategic commissioner, as well as developing a case for change for a potential merger of the six CCGs.

During 2019/20 we will continue to streamline our governance and working arrangements, whether it is through merger or working together more closely. If the membership, governing bodies and NHS England were to decide on the CCGs merging, this will take effect from April 2020.

Working with our voluntary and community sector partners in 19/20 we are co-developing a strategy which predicates operational delivery of specific voluntary sector led priorities that enable some of our other key and longer term system priorities. Working with the sector, for example in Social Prescribing, enables us to address some of the issues we have regarding access to services and improving employability of patients living with mental health challenges, including those with low level mental health issues. We believe this will build community resilience and the sustainability of our communities.

The operational plan is designed to meet the shared ambitions and priorities detailed in the Staffordshire and Stoke-on-Trent system plan. As a Sustainability and Transformation Partnership (STP), we will continue to develop plans across our wider services to address a broad range of issues and opportunities including: continued development of maternity services, cancer service, prevention, children’s services, the

6 | P a g e development of Integrated Care Systems (ICS’s), and use of digital technology. While these services are central to the delivery of our health and care services, plans to address these issues and opportunities are described within our sustainability and transformation programme plans and are not focused on in depth in this plan.

Following the Staffordshire and Stoke on Trent system planning summit on 11th and 12th February 2019, a number of priority transformation programmes were identified for rapid development within a six week timetable.

The priority transformation programmes for 2019/20 and associated schemes are focused around UEC and EPCC; Planned Care and Mental Health as outlined in the diagram below and described further in the relevant sections within this document

The operational plan also sets out how we will deliver the CCGs commissioning intentions for 2019/20. There is a focus on older people including frailty, end of life and care homes.

Building on existing relationships with partners and established integrated services key areas are:  further development and delivery of the frailty pathway with the aim of delivering seamless care  commissioning an expanded community assessment model for proactive management of frailty and long term conditions with the aim of supporting people to live independently for longer  development of an end of life model so individuals in the last phase of life can make decisions about their care and support their choices to reduce the number of non-elective admissions in their last 12 months of life  developing a consistent approach to services for patients in nursing or residential care to reduce the number of ambulance conveyancing and non-elective admissions. Working with local authorities to make sure the care home market meets the needs of the population, ensuring that primary care, community and voluntary sector organisations work together to provide the appropriate clinical services NHS England will monitor our progress against the NHS planning guidance and long term plan by requesting assessment of delivery against a range of assurance statements, set nationally, these are set out in Appendix

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6 and CCG plans will be monitored as part of the planning round to ensure we are able to demonstrate compliance.

4. Urgent and Emergency care (UEC) and Enhanced Primary and Community Care (EPCC)

The NHS 5 Year Forward View and the subsequent Long Term Plan describes the need for a redesign of urgent and emergency care services for people of all ages with physical and mental health problems to simplify access and to support the delivery of urgent care in alternative settings to the emergency department. It is expected that this will be delivered through service redesign as well as longer term planned transformation and implementing new models of care. For Staffordshire this will mean a change in the way that our urgent and emergency care services are provided to our local population; with more care being delivered closer to home and a reduced number of hospital attendances and admissions.

The National UEC Delivery Plan accompanies the “Next Steps on the NHS Five Year Forward View (5YFV)” publication, articulating in more detail the offer, specification, delivery plan, expected costs and benefits, which will deliver transformation of urgent & emergency care. The key elements of this plan are to simplify access through integration of urgent care and to develop a standardised urgent treatment offer across Staffordshire and Stoke-on-Trent which is responsive and easy to access as an alternative to the Emergency Department.

Transforming the Urgent and Emergency Care system has a clear interdependency with the work being undertaken through Enhanced Primary and Community Care (EPCC). The national and strategic direction of both programmes gives clear indication that there are many opportunities to integrate wider primary care with urgent care, reduce duplication and flex the workforce to provide urgent and primary care services which meet the needs of the local population.

The NHS Plan outlines new models of care which will see community, primary care and specialist services integrate in order to provide proactive care which wraps services around individual needs. The CCGs with system partners have developed a new approach to the provision of care which recognises the effective management of patients with long term conditions and frailty as pivotal to supporting whole system change which will support individuals to retain their independence, receive care at home where appropriate and for as long as possible.

Integrated Care Teams and Hubs

Through Integrated Care Teams (ICTs) and Hubs we will support:

 adults with high clinical needs such as significant frailty, who are at risk of prolonged stays in acute hospital  adults with multiple long-term conditions and complex needs who require proactive multidisciplinary input to keep them safe and independent in their usual place of residence

The table below outlines our consolidated Sustainability and Transformation Partnership (STP) system programme, underpinning projects, objectives and the proposed financial impact which will be further scoped and refined. Each deliverable is described further in the following sections.

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Deliverables Objectives Integrated Urgent Care Intermediate model ahead of the implementation of an integrated urgent treatment system in 20/21

Care Homes Reduce urgent activity and A&E attendances from care home patients

LTC Reduce Urgent and NEL activity relating to patients with LTCs

Frailty Reduce Urgent and NEL activity relating to frail elderly patients

Integrated Urgent Care

Within Staffordshire and Stoke-on-Trent there are currently many services which offer alternatives to A&E departments, however, understanding what services are available, what each service does and how to access it remains complicated for service users and health care professionals. For many service users this confusion and lack of access to urgent care appointments leads to an over reliance on hard pressed A&E services.

The opportunity to improve the patient’s experience of, and clinical outcomes from, urgent care is significant. NHS England developed a new national service specification for the provision of an integrated 24/7 urgent care access, clinical advice and treatment service which incorporates NHS 111 call-handling and former GP out-of-hours services. This new specification is the starting point to revolutionise the way in which urgent care services are provided and accessed.

Where NHS 111 and GP OOH services are currently integrated, or closely aligned, data shows that some patients are receiving quicker response times and there is less impact on higher acuity ‘downstream services’. The new Integrated Urgent Care Specification supersedes previous commissioning standards, moving from an advisory set of recommendations to mandatory requirements in order to ensure a consistent service across the country. The integrated Urgent Care (IUC) Service Specification outlines the provision of an integrated 24/7 urgent care access, clinical advice and treatment service, which incorporates NHS111 and GP Out of Hours (GPOOH).

The IUC specification must be implemented by March 2019. In order to meet this deadline in Staffordshire and Stoke-on-Trent the national requirements will be contract varied into existing contracts for March 2019 with a commitment that a full procurement will conclude by March 2020.

The key deliverables for April 2019 within the IUC are:

Deliverable CCGs current position Clinical Assessment Service (CAS) – The service will Staffordshire delivered a base CAS from 17th reduce onward referrals and signposting by December 2018. Implementation of elements of the increasing the availability of telephone CAS service including, extra validation of ED cases consultations by clinicians. The specification and ambulance cat 3 & 4 cases, EMDs, GPs and ANP stipulates 24/7 coverage from a GP, however the and also prescribing Nurse practioners representing model can be determined locally to include ANPs the senior clinical workforce required. Funding will etc. as long as the needs of the population are met cover Monday to Friday 08:00 – 18:00; this reflects where Vocare have the most ambulance and ED dispositions. This is where paramedics have indicated that they would like targeting following stakeholder engagement. Mix of clinical skills, equivalent to 2.6 WTE a week or 97.5 hours 9 | P a g e

Direct Booking – Post clinical assessment patients Interoperability solution expected to be in place by will be directly booked into an appropriate service, the end of January 19 to allow NHS111 to book in to this includes GP OOH, patients own GP, extended extended access. This has faced continued delays. access services, urgent treatment centres, services co-located with A&E and other services as specified There is no primary care appetite at this current time locally e.g. hospice services to allow NHS111 the ability to direct book in to ‘in hours’ primary care services

NHS111 Online – implement a solution that allows NHS111 online phase 3 went live in Staffordshire on patients to access the IUC offer via an online the 22nd October 18. This means that our patients solution are able to get a clinical call back from 111 if their online disposition says they need to speak to a clinician

Integration with the Ambulance – support The CAS would support the implementation of *5 paramedics with access to the IUC service whilst on which allows WMAS direct access to a clinician via scene NHS111 when on scene with a view to transferring the patient to the CAS for ongoing management as opposed to A&E conveyance

*5 mobilisation is being worked on now that the base CAS is operational

In addition to specified GP out of hours services, there is an opportunity to include a wider range of primary care services in to the IUC procurement and therefore the scope of what will be included within the IUC procurement is to be decided locally.

Ambulance services Ambulance provision for Staffordshire and Stoke-on-Trent is provided by West Ambulance Service (WMAS), they provide the provision on a regional footprint across the covering the population of 22 CCGs. The contract is hosted by and West CCG, the national ambulance response time standards are held at a regional level and the Key Performance Indicator (KPI) targets are consistently met. Locally, the south of Staffordshire does not meet the category 1 performance, although it is close. As the KPIs are held at a regional level, and perform, there are no contractual levers that can be put in place to support Staffordshire specifically, therefore the Staffordshire commissioners work closely with the hosts to highlight these issues through the contract and commissioner forums.

The recent Carter review on ambulance performance addresses the need nationally to convey fewer patients to A&E departments, the report is clear that this will require system wide support whereby ambulance trusts have alternative pathways to access and divert patients to. Through the integrated urgent care agenda locally, the system is working together, alongside the enhanced primary and community care work programme, to design and provide alternative pathways that support patients to remain safely at home; such services will be available to paramedics through the integrated urgent care service. A recent local ‘test of change’ pilot that was supported by WMAS, our community provider, Midlands Partnership NHS Foundation Trust, (MPFT) and University Hospital North Midlands (UHNM) demonstrated that there is a clear opportunity to reduce ambulance conveyance to Royal Stoke hospital. The pilot demonstrated that 64% of the patients referred to the pilot remained at home after a 7 day period. A further pilot throughout the month of April 2019 has been planned and is currently underway. Findings of the pilot will be utilised in system plans going forward to improve and enhance patient’s experience of care and access to urgent care services. 10 | P a g e

Model of same day emergency care (SDEC) Through the STP urgent and emergency care (UEC) board the CCGs will continue to work with acute providers to implement ambulatory emergency care that aim to deliver the model of SDEC and reduce unnecessary admissions. The implementation of the Ambulatory Medical Receiving Unit (AMRU) within the emergency floor model at Royal Stoke Hospital has proved to be a significant success whereby patients are treated in a timely manner and discharged. This has contributed to improved flow within the emergency departments and subsequent improved flow in the UEC system. For 2019/20 we will  continue to review the management of patients within the emergency departments across the STP ensuring that patients receive good quality care during their stay, and that they do not stay in hospital for longer than is necessary  work with the trusts and CCGs during 2019/20 to understand their plans on implementing units that support SDEC, where our patients attend emergency departments out of Staffordshire and Stoke- on-Trent

Care Homes During 2019/20 we will embed the CCGs care home strategy across Staffordshire and Stoke-on-Trent. We will work with primary and community care providers to reduce variation across Staffordshire and Stoke-on- Trent in access to health services for residents in care homes. See Appendix 4 for further detail on how we will support general practice to implement the framework for enhancing health in care homes and how we will drive and monitor improvements.

Our vision for care homes is that residents have access to safe, good quality care in an environment appropriate to their needs.

To achieve our vision we will focus on three objectives which will underpin a new model of care for care homes:

1. consistent core community, mental health and enhanced primary care services available for everyone resident in a care home 2. good quality end of life care available for everyone resident in a care home 3. joined up commissioning and collaboration between health and social care

In order to achieve these objectives we will:

 develop a joint commissioning framework with local authorities to implement a single procurement and brokerage model that sets core minimum standards for staffing levels, procedures for managing risk and a core framework for competencies and skills  review existing community services provision to ensure the necessary skills and capacity are in place to deliver the new model of care for people with long term conditions (LTCs) and those living in care homes and agree a plan to close the gaps in core community provision  commission core community health care services across the STP footprint  commission a community rapid intervention service see long term conditions section  implement the *6 direct access to the clinical assessment service (CAS) for all care homes  commission an enhanced health in care home service through the emerging primary care networks  implement the red bag scheme see below

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The CCG has already commenced work on the red bag scheme to develop effective and efficient arrangements for hospital transfer pathways. This scheme aims to provide a better care experience for care home residents by improving communication between care homes and hospital. During 2019/20 we will:

 review the effectiveness of the use of red bag scheme (including any reductions in length of stay) and learn from other areas where this scheme has been fully implemented  identify options for the ongoing delivery model of the red bag scheme. This will form part of the CCG strategic approach to improving outcomes for patients in care homes

The table below provides an overview timeline of the project to deliver the objectives above:

Care homes mobilisation plan Timeline Develop a joint commissioning approach with the local authorities End of 2019/20 Commission a core community service offer for care home residents End of 2019/20 Develop an implementation plan for the roll out of the Red Bag Scheme June 2019 Commission an enhanced primary care service offer for care home residents August 2019 Commission a community-based rapid response service August 2019 Implement the *6 function to provide Care Hoes with Direct access to the 111 August 2019 Clinical Assessment Service (CAS)

Delayed transfers of care (DToC) Delayed transfer of care (DTOC) occurs when patients who are ready to be discharged or transferred to another care setting are unable to do so. Both the NHS and Social Care (Local Authorities) are responsible for the delivery of the reduction in DTOC levels through the Better Care Fund.

The CCG, collaboratively with system partners such as the Local Authority and community providers have developed a number of key actions and implementation of commissioning proposals to support a reduction in DTOCs across the Staffordshire and Stoke-on-Trent CCG footprint, these are described in appendix 1, 2 and 3.

See Appendix 4 for further detail on deliverables for 2019/20 across Staffordshire and Stoke-on-Trent.

Long term conditions (LTCs) Integrated Care Teams (ICTs) will support and integrate with wider community services in the timely and effective management of patients with long term conditions. This will include district nursing, specialist nursing, specialist therapies, community matrons and social care provision.

Our vision for long term conditions (LTCs) is to help people manage their conditions better and reduce non elective admissions by keeping people out of hospital.

To deliver our vision we will deliver three objectives which will underpin a new model of care for LTCs, with a focus on diabetes, heart failure, pneumonia and COPD: 1. rapid access to community services which will provide a two hour rapid response to patients, characterised by multi-morbidities, who are experiencing an exacerbation in their condition 2. develop a proactive approach to managing LTC which will increase the number of patients with co- ordinated care plans who feel involved in their care plan managed through Primary Care Networks (PCNs)

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3. joined up commissioning and integration between primary, community and acute services

In order to achieve the objectives described above, we will do the following:  commission a community rapid intervention service to start roll out by 1st June 2019. This will deliver a co-ordinated step-up to the intensity of care that is provided to enable the patient to remain in their normal place of residence and stop inappropriate admissions to hospital  commission a LTC outcome framework through the emerging PCNs  review existing community and primary care services and investments by April 2019, to ensure the necessary skills and capacity are in place to deliver the new model of care for people with LTCs and those living in care homes  undertake a gap analysis to identify the level of inequity of access to core healthcare services by the end of April 2019  develop a plan to close the gaps in core community provision by the end of May 2019

The table below provides an overview timeline of the project to deliver the above:

Long term conditions mobilisation plan Start date End date Project governance 1.3.19 30.6.19 Data modelling 25.2.19 30.4.19 Design phase 25.2.19 30.6.19 Transaction requirements i.e. contractual, costed model 1.3.19 30.6.19 Community Rapid intervention service 1.3.19 12.5.19 LTC system pathway review 1.3.19 30.6.19 Consultation and engagement 1.4.19 30.4.19 PCN proposal developed 1.4.19 30.6.19 Formal approval 1.4.19 30.4.19 Mobilisation 13.5.19 30.9.19

Respiratory Respiratory has been identified as one of our largest areas of spend, in order to address some of the variation this has been incorporated into the project described above. Pulmonary rehabilitation offers a structured exercise and education programme designed for those with lung disease or breathlessness. Pulmonary Rehab is currently commissioned as part of the long term conditions service; services adhere to the national service specification. We will build on the existing RightCare programme to reduce variation in the quality of spirometry testing.

Key deliverable Action Timeline Support the Develop a diagnostic spirometry specification meeting the October 2019 delivery of the accreditation requirements of the Association Respiratory respiratory Technology and Physiology (ARTP) to provide a service across RightCare Staffordshire and Stoke-on-Trent opportunities

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Diabetes Although roll out of the National Diabetes Prevention Programme, Pan Staffordshire scheme has commenced, this has not taken place at the pace initially thought due to the change in GDPR rules earlier in the year. The programme was initially set up whereby patients had to opt-in to a referral onto the programme however as this relates to direct patient care an opt-out process can be adopted. Initially it was anticipated that all practices would be referring into the programme from April 2019, the CCG will continue to work with membership practices to increase uptake and patient utilisation of the service. A series of engagement events were scheduled in January / February highlighting the changes to the referral process.

The key deliverables are shown in the table below. See Appendix 5 for further detail on how we will meet deliverables during 2019/20

Key deliverable Action Timeline Patient education Promote diabetes bitesize education sessions 2019/20 Advice and Implemented through the LTC Integrated Care Team Transformation 2019/20 guidance Programme NICE Undertake practice visits offering advice and support where required 2019/20 recommended ensure findings from practice visits will form training for the treatment targets Protected Learning Time sessions undertake an annual review of Quality Improvement Framework (QIF) indicators to ensure they are still appropriate Double Increased practice sign up to the programme across Staffordshire July 2019 enrolment in the (practices have to agree to sign up and sign a data sharing NHS Diabetes agreement) Prevention All practices wishing to participate will have signed up and be able to July 2019 Programme refer patients to the programme.

The Integrated Care Record (ICR) will enable improved continuity and effectiveness of care for patients with long term conditions by offering an integrated view of the patient record to all involved health and care professionals and enable the creation of single care plans where required. The ICR will support improving the experience of patients living with one or many long-term conditions and deliver tools to pro-actively promote and support self-care. The procurement exercise will be concluded by the end of March 2019 moving to the phase 3 (contract award) and phase 4 (deployment) during the first quarter of 2019/20.

The CCGs have been liaising with People Plus around a specific health engagement plan to understand the proportion of carers with a long term condition who feel supported to manage their condition. This is building on the work that has been done at University Hospital North Midlands (UHNM) and the Stoke-on- Trent GP practices. This targets carer support and awareness in a number of health locations including pharmacies, GP surgeries, hospitals and community teams. People Plus is delivering the service until September 2019.

Staffordshire County Council is in the process of developing a ‘Carers Strategy’, further discussions are to be held in the coming months. Stoke-on-Trent County Council will shortly be commencing an engagement exercise to refresh their existing policy.

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Frailty We are working to develop patient centered services that enable people to age well. This means starting with prevention and early identification of frailty and supporting people appropriately on the basis of their needs through to the end of their life. During 2019/20 we will continue to develop and implement the older people’s strategy for Staffordshire and Stoke-on-Trent and work towards the new models of care set out in the NHS long term plan.

In Staffordshire 2017/18 spend in non-elective admissions (NELs) for people over 55 years was c. £117.2m. It is widely accepted that many of these admissions are avoidable. The objective of the staying well – frailty pathway project is to continue the roll out of the staying well pathway across Staffordshire and Stoke-on- Trent with a proactive approach to the management of mild to moderate frailty. Providing care and interventions in a coordinated way to prevent hospital admission and attendance, improve patient outcomes and an aim for patients to stay well for longer.

The objectives of the staying well- frailty pathway project are:

 accurately identify 10,110 (FYE) patients with mild-moderate frailty, through risk stratification and pro-active triage and assessment  system savings – reduction of non-elective admissions and A&E attendances 8089 (FYE) Pan Staffordshire  option to refer appropriate patients to a multi-disciplinary staffed hub, leading to the creation of a co-produced care plan to further support any unmet complex needs

The table below provides a high level overview of the staying well – frailty pathway project timeline to deliver the frailty pathway model across Stafford and Stoke-on-Trent

Frailty mobilisation plan Start date End date Project governance 2.7.18 1.2.19 Service development/proof of concept 2.7.18 1.2.19 Clinical engagement 1.7.18 1.12.19 Decision making i.e. approval of frailty models and investment 1.7.18 20.3.19 Transaction requirements i.e. contractual, costed model 22.12.18 4.9.19 Communications and IT i.e. patient council engagement, full comms plan and 1.9.18 1.4.19 EMIS consultation Mobilisation across Staffordshire 4.7.18 1.9.19

RightCare has highlighted an opportunity to reduce acute spend in falls across the 6 CCGs. A quality, innovation, productivity and prevention (QIPP) scheme has been approved which will enable us to work with the provider(s) to align the Community Specialist Falls Service across all 6 CCGs ensuring there is parity of service including the same criteria and provision of service in line with best practice.

As part of the falls prevention service, during 2019 we will review the commissioned falls prevention service across Staffordshire and Stoke-on-Trent to reduce variation in service provision.

Key deliverables are:

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 work collaboratively with community providers to align service provision across Staffordshire for specialist falls in line with best practice as identified in the falls and fragility statement and set out in the service specification that has been written  ensure the criteria for accessing the falls service is consistent across Staffordshire and Stoke-on- Trent  align services across Staffordshire where possible i.e. low level exercise classes, falls responder and revival services on discharge from hospital  agree best practice service specification across all CCGs and agree a contract variation with providers

We will review of the elderly care facilitator local improvement scheme (LIS) with a view to enhance and continue the service in 2019/20.

5. Quality, safety assurance and improvement

The CCGs have a statutory duty to improve quality and ensuring the delivery of compassionate, high quality care focused on outcomes is at the very heart of our values. By establishing a shared understanding of quality and a commitment to place it at the centre of everything we do the CCGs have a unique and important opportunity to continually improve and safeguard the quality and safety of local NHS services for everyone, now and in the future.

During 2019/20 we will continue to work closely with regulatory bodies such as the Care Quality Commission (CQC) to ensure that any quality and safety assurance issues highlighted are reported internally to the Quality and Safety Committees in Common (QSCC) as part of the assurance process within the CCG. The detail on how we plan to continue to deliver this is outlined below.

To drive up quality, identify emerging safety concerns at the earliest possible opportunity and to embed improvements and standardise processes across Staffordshire and Stoke-on-Trent we will:

 lead monthly QSCC meetings in the CCG and hold clinical quality review meetings (CQRM) with providers escalating concerns through to all governing bodies as appropriate. This will include reviewing provider action plans following CCG visits and CQC inspections. These action plans will be monitored to ensure recommendations are captured within them and the outcomes demonstrate quality improvement.  work towards embedding CQUINs into the contract as part of ‘business as usual’. We will attempt to reduce the option of localisation to deliver a consistent approach whilst improving quality overall.  ensure that the Quality Impact Assessment (QIA) processes put in place during 2018/19 for the 6 Staffordshire CCGs are followed and continuously reviewed to ensure they are purposeful and not bureaucratic and supports delivery of the CCG key priorities. All commissioners and primary care managers are required to undertake a full QIA for any proposed service change, renewal or in relation to decisions to decommission services to ensure that any impact on patient safety and quality is fully understood and the CCG can demonstrate improvements.  continue to enhance the quality schedule of the NHS contract using evaluation from previously commissioned services to improve service provision and overall quality. The quality schedule will incorporate national requirements in relation to the quality and safety of services such as those from NHSE, the National Quality Board, NICE, CQC and professional bodies. We will continue to update the quality schedule in provider contracts and where appropriate contract variations will be made in year so the CCGs can respond quickly to changing priorities or concerns

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 align the Staffordshire and Stoke-on-Trent quality strategies to ensure consistency across the 6 CCGs. The aligned strategy and associated improvement plan will be approved and monitored by the quality and safety committee in common (QSCC)  attend and support both the Adult and Children’s Safeguarding Boards to meet statutory duties and ensure commissioned services are meeting their safeguarding duties. During 2019 the CCG will be one of the key partners in the establishment of new arrangements for Safeguarding Children’s Boards as part of a national early adopter programme  work in collaboration with the local authority to monitor and support the independent nursing home sector to drive up standards of care, improve quality and support informed decision making in relation to commissioning intentions  ensuring the health and wellbeing needs of Looked After Children (LAC) is being effectively commissioned

Key deliverable Action plan Timeline Quality strategy Produce a revised and aligned quality strategy for the six Clinical Oct 2019 Commissioning Groups Oct 2019 Ensure delivery of the above through revised and aligned improvement Dec 2019 plans aligned to the quality strategy Ensure prompt approval of aligned quality strategy via appropriate Ongoing governance processes Monitor of improvement plans via Quality and Safety Committee in Common (QSCC) CCG priority frail Quality in care homes September elderly and care Complete and agree systems and processes for monitoring the quality 2019 homes and safety of care in nursing homes CCG priority frail Provider improvement and response team (PIRT) elderly and care Complete the mobilisation of the Provider Improvement & Response July 2019 homes Team (PIRT) September Agree and put in place key quality performance indicators to ensure 2019 quality improvement outcomes are measured QIA process Review current systems and processes for QIA across the system and June 2019 streamline to ensure clarity and consistency across all areas of the local health system Continue to undertake QIA process for all CCG decisions ensuring prompt and thorough reviews are completed and reported in line with Ongoing policy requirements

6. Primary care

Primary care networks (PCN) We will develop a commissioning framework to invest in primary care networks to deliver the STP ambition that more patients are seen out of hospital and closer to their own homes. The primary care team will continue to engage with the STP work streams. The executive director of primary care and medicines optimisation for Staffordshire CCG and Stoke-on-Trent CCG leads on the Enhanced Primary and Community Care (EPCC) work stream and will be actively involved in the work programme for the sustainability and transformation plan.

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The CCGs will engage with practices to establish 100% coverage of PCNs by July 2019 and ensuring a network agreement and the 2019/20 Network Contract Directed Enhances Services (DES) is in place. We will work with the locality networks to register formally as PCNs and support these PCNs to prepare to meet the Network Contract DES registration requirements. Work to meet the network contract DES registration requirements. To be eligible for the Network Contract DES, a PCN needs to submit a completed registration form to its CCG by no later than 15 May 2019, and have all member practices signed-up to the DES. CCGs are responsible for confirming that the registration requirements have been met by no later than Friday 31 May 2019. We will work with the commissioning support unit (CSU) and NHS England to develop and support an organisational development programme for primary care particularly focusing on development of PCNs.

The table below outlines the deliverables within primary care across Staffordshire and Stoke-on-Trent during 2019/20, for additional detail on how this will be implemented see Appendix 4.

Key deliverable Action Timeline Develop and implement primary Standardise across Staffordshire and Stoke-on-Trent Ongoing care strategy 2019/20 Primary care networks Ensure 100% coverage recruitment and retention capacity Develop and implement workforce plans in primary care Primary care investment review Review of Local Enhanced Services (LES) and Local Improvement Schemes (LIS) Delivery of 10 high impact actions Continue to build on progress already made High cost drugs – biosimilar uptake Support uptake of biosimilar uptake Primary care prescribing Reduce levels of inappropriate prescribing

Quality in primary care We place a high priority on the development and sustainability of high quality primary care. Systems and processes are in place to ensure regular reporting to the CCGs’ Primary Care Commissioning Committee and the Quality & Safety Committee in Common. There is an identified lead within the quality team who works with primary care colleagues in strengthening the quality monitoring process and adding additional specialist input into their quality assurance systems and processes.

During 2019/20 we will continue to develop processes for improving and monitoring quality in general practice, building on the quality assurance framework and working closely with NHSE, CQC and other stakeholders.

Key deliverable Action Timeline Data quality Develop electronic quality data set to monitor and Ongoing assess quality in primary care and enable practices to 2019/20 measure themselves against regional benchmarks Incident reporting Agree processes for reporting and recording of March 2020 serious incidents. Including how learning from incidents will be shared across the CCGs Quality and engagement visits Commence an annual schedule of standardised Ongoing quality and engagement visits across the 6 CCGs 2019/20 Patient survey Work with practices to improve results from the Ongoing national GP patient survey. Outcomes from the 2019/20 survey discussed during quality visits

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Monitor completion of surveys and support practices to encourage uptake by patients

Primary care digital work stream During 2019/20 we will continue to implement the development of an integrated care record through the ‘Your Care Connected’ programme. This will enable patient records to be shared between GP practices, acute, mental health and community trusts. It will deliver one of the core programmes designed through the local digital roadmap. After the success of the national paper switch-off programme NHS England are now proposing, as part of the draft guidance for 19/20 Standard Contract, to encourage mental health services to follow suit.

Key deliverable Action Timeline On-line consultation capability Following an initial pilot of 24 sites being evaluated April 2020 across all practices in Staffordshire and lessons learnt the area will aspire to fully roll out of the on-line consultation capability Moving GP referrals to acute Elective mental health services listed on eRS. October services fully onto eRS – elective 2019 mental health services Increase the amount of patients Work with practices to ensure DCR is viewed as an Ongoing with access to their Detailed Coded important part of the NHS England Empower the through Record (DCR) to support citizens to Patient work stream and the CCGs focus is to provide 2019/20 better use technology to manage software and best practice guides to support patient their health needs sign up

7. Planned care and cancer

Across Staffordshire and Stoke-on-Trent we will commission high quality and effective elective care services safely which are both clinically and financially sustainable with coordinated and collaborative alliances of local providers working across organisational boundaries. We will ensure efficiency across speciality pathways, develop co-ordinated seven-day elective (non-emergency) services and a sustainable model for outpatient and day case provision, all underpinned by efficient diagnostics services. We are also focussing on increasing self-care and cancer screening uptake, early access and intervention.

During 19/20 we will conduct specialty reviews specifically for MSK and Gastroenterology focusing on delivering three specific outcome objectives:

 reducing variation  improving efficiency and  delivering care in appropriate alternative settings

The table below shows our focus on the priorities:

Key deliverable Objectives Timeline

Outpatient follow up To remove costs from system relating to unnecessary patient follow 19/20 - 2024 reduction ups commencing in 2019/20

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Specialty reviews Establish a rolling programme of specialty reviews, focussed on 19/20 - 2024 (MSK and Gastro) three key pillars, (i) reducing variation, (ii) improving efficiency and (iii) delivering care in alternative settings commencing in 2019/20

Outpatient follow up reduction Outpatients departments continue to follow traditional models, calling patients back into hospital to follow up their care, often to provide reassurance rather than treatment. This is a costly model, the total commissioner expenditure on all outpatient appointments in the Staffordshire footprint is £144m, split across 224 providers. The main three providers deliver over 70% of the total commissioner expenditure, University Hospital North Midlands (UHNM): £63m, Royal Trust (RWT): £19m and University Hospital Derby and Burton (UHDB): £20m with the remainder split between 221 further providers. Peer comparison has identified a high level cost reduction opportunity of £1m for UHNM.

The Outpatient Productivity project aims to offer patients an outpatient service that is sustainable and appropriate to their health needs whilst reducing costs across the system by:  reducing demand into hospital setting and ensuring that only those patients who need to be seen in specialty clinics are offered face to face appointments  optimising the pre-assessment model to minimise disruption for patients due to avoidable appointments and tests  ensuring that patients only attend a hospital based follow-up appointment where necessary and offering patient initiated appointments for routine follow-ups  offering cost effective alternatives to face-to-face appointments, minimising disruption to patients’ and carers’ lives  offering services in alternative settings and by alternative methods, where possible avoiding acute trust attendance  identifying system-wide capacity that can be released to reduce costs and/or re-invested to improve waiting times  developing a system to balance demand and capacity throughout the STP footprint

The table below shows the high level milestones for the outpatient productivity project:

Key Milestone Description Date (w/c) Priority areas of work agreed based on: 25 March 2019 a) Evidence from benchmarking data that specialties are providing excessive patient contact compared to peers b) Evidence of excessive waiting times and/or high numbers of patients on waiting lists c) Evidence of higher than average costs incurred in delivery of service d) Perceived delivery capability Baseline data and performance measures agreed 25 March 2019 Project teams based on focus areas formed 1 April 2019 Potential costs and resource requirements identified and agreed 1 April 2019 Stakeholder plan and communications plan developed 29 April 2019 Benefits Realisation Plan agreed 29 April 2019 Detailed project plan developed 29 April 2019 Pathways agreed through series of workshops and other methods (phase 1 6 May 2019 followed at 2 weekly intervals by subsequent phases)

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Supporting systems and resources identified and agreed 20 May 2019 Testing period and minimum criteria for implementation established 10 June 2019 Detailed implementation plan developed and agreed 10 June 2019 Procurement and contracting terms developed and agreed 5 August 2019 Approval to proceed 26 August 2019 Implementation (phase 1) 1 September 2019 Benefits measured, key performance indicators (KPIs) established 15 October 2019 Approval to transfer to business as usual and standard trust governance 31 October 2019 (phase 1)

System Speciality Reviews

Musculoskeletal (MSK) During 2019/20 as part of the STP planned care MSK programme we will work to improve MSK services. See Appendix 5 for further detail on the deliverables during 2019/20.

Key deliverable Action Timeline Reduction in onward referrals from Community MSK services to onward refer <25% - Ongoing 2019/20 MSK services <30% to be adjusted in the current contract as currently at 30% Reduction in unnecessary follow ups Introduce a pathway cost model Ongoing 2019/20 Pathways and MSK policy contracted with providers Adherence to the MSK commissioning policy (PoLCV)

Reduction in associated surgical Maximise non-invasive treatment Ongoing 2019/20 procedures

Pain management services across Staffordshire are fragmented and this is likely to result in pain management procedures, generally joint and facet nerve injections, being undertaken in the acute sector. The 2017/18 RightCare data suggests an opportunity value of £1.1 million in relation to these procedures.

The MSK project predicts a total system wide opportunity (knees and hips) based on 30% reduction of outpatient appointment follow ups of £171,306.00.

The MSK project aims to:  ensure all MSK pathways are as lean, efficient as possible and are evidence based. These will be delivered by managing demand into the acute sector by a redesign of primary care and community MSK pathways  consolidate the existing four service specifications across Staffordshire into a single specification with key outcome measures and revised key performance indicators (KPIs) that ensure flow into the acute sector is appropriately managed  ensure that the STP plan to roll out of first contact practitioner services is included as part of the funding included in the recently announced GP contract through primary care networks

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 develop a pilot project to allow ‘direct listing’ of patients deemed eligible and needing joint replacement by the MSK service. This will allow the patient to be seen in a one-stop pre-op assessment prior to being listed for surgery, in turn reducing the first outpatient appointment numbers and associated costs, along with an improved pathway for patients

Gastroenterology Our local transformation plans reflect the recommendations in the elective care specialty handbooks. The long term conditions integrated transformation programme will roll out initiatives through 2019/20 around advice and guidance and education for patients in self-management of their gastroenterology condition.

NHS RightCare data has highlighted opportunities both financially and in patient experience across initiatives shown below:

Initiative FYE opportunity (gross savings) Clinical Assessment Service (CAS) at University Hospital North £160k Midlands (UHNM )(including speciality pathways) Gall bladder disease £1.3m Reducing spend on consumables (e.g. Stoma) £600k

The aim of the Gastroenterology Efficiency project is to:  introduce a Clinical Assessment Service (CAS) model into UHNM (potentially University Hospital Derby and Burton) to ensure inappropriate referrals are triaged out and advice and guidance to GPs is maximised  introduce a series of speciality pathways that will expedite the patient journey, reduce 18 week RTT and increase the capacity of the gastro service over Staffordshire  ensure primary care and emerging care networks maximise the use of available tests to inform referral e.g. H.pylori, faecal calprotectin and utilise any new tests that could benefit the patient journey as well as reducing demand on the service  address the high cost prescribing in gastro related consumable areas (e.g. Stoma)  work with local authorities to prevent gastrointestinal problems through healthier lifestyle interventions including weight management, diet and exercise and reducing alcohol misuse  detailed analysis will be undertaken of acute sector expenditure to identify areas of service that might be subject to effective demand management or self-care including diagnostics that might be more clinically sustainable and cost effective if delivered in community or primary care services.  introduce new pathways of care for specific conditions which will reduce unnecessary admissions / multiple attendances

The table below shows the Gastroenterology Efficiency project timelines:

Gastroenterology CAS Timeline Business case developed April 2019 Business case approved May 2019 Communications plan July 2019 Implementation phase May to July 2019 Go live August 2019

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Gall bladder disease Timeline Data analysis April 2019 Clinical model agreed May to June 2019 Submit business case July 2019 Governance – approval August to September 2019 Implementation phase September to October 2019 Go live December 2019

Stoma prescribing Timeline GP practice audit April to June 2019 Develop Stoma prescribing policy June-July 2019 Patient engagement May to July 2019 Governance – approval of policy August 2019 Implementation phase October – November 2019 Go live December 2019

CCG Pathway reviews

Ophthalmology An ophthalmology service specification has been developed across the 5 Staffordshire CCGs (excluding East); this has utilised NHS RightCare intelligence and aligned the services at pan Staffordshire level along with introducing a Tier 3 consultant lead triage and treat service and expanding the patient pathways to include Paediatrics. Ophthalmology has been identified as one of the main specialty areas contributing to large patient backlogs; in addition NHS RightCare has identified areas of ophthalmology that are outliers in terms of spend when comparing to ‘Like CCGs’. The implementation of the Tier 3 service, along with expanding the patient pathways so follow ups can be carried out within the community, should help address this.

Key deliverable Action Timeline Tier 3 ophthalmology service to Implementation of the enhanced ophthalmology September 2019 triage and treat within the service (subject to procurement rules) community, alleviating pressure on Joint work with primary care to expand acute from the front end allowing awareness of the community ophthalmology 2019/20 them to address their backlog clinics and this work will continue in 2019 Developing further community Demand and Capacity model to understand the September 2019 pathways within ophthalmology Staffordshire activity along with condition types including paediatric shared care Review of the High Impact Interventions including 2019/20 which will ensure rapid access and fail safe prioritisation recommendations and reduced waiting times and waiting agreed actions delivered throughout 19/20 2019/20 lists at acute provider Alternative approach to follow ups utilising Review of the demands for and technology will be explored throughout 19/20 eye health requirements of the including virtual clinics local population and future provision i.e. increase in patients with glaucoma

Dermatology Dermatology is currently an area of focus as a number of local acute trusts have suspended dermatology services. It is therefore an important focus specialty where there is a need to deliver further dermatological services within the community. A draft dermatology service specification has been developed across the 5

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Staffordshire CCGs (excluding East); this has utilised NHS RightCare intelligence and aligned the services at pan Staffordshire level. A review has been carried out of the conditions that are clinically appropriate to be carried out within the community and these conditions have been included within the service specification.

Key deliverable Action Timeline Dermatology Service specification signed off and agreed April 2019 service Procurement of the redesigned service (subject to procurement December 2019 specification and rules) and service commencement delivery of re- Through 2019/20 commissioners will explore the development of Ongoing through designed services tele dermatology to assist in ensuring patients receive the right 2019/20 care, right place at the right time Introduction of advice and guidance services to enable diagnosis April 2019 and treatment of dermatology conditions within primary care where possible and assist the patient in managing their condition December 2019 Explore introduction of mole clinics within the tier 3 service to December 2019 avoid unnecessary referrals on the 2 week wait pathway Implement shared decision making within appointments utilising NHS RightCare decision making tools

Cardiovascular Disease (CVD) Hypertension, atrial fibrillation, high cholesterol, diabetes, non-diabetic hyper glycaemia and chronic kidney disease are high risk cardiovascular conditions. Late diagnosis and under-treatment of these high risk conditions is common, and this substantially increases the incidence of stroke and heart attack. We will work with NHS RightCare programme to implement national priority initiatives for cardiovascular conditions in 2019/20.

Cancer As a member of the West Midlands cancer alliance, during 2019/20 we will use transformational funding to support implementation of best practice pathways for lung, upper gastrointestinal (GI), lower GI and prostate cancer to ensure consistency and sustainability of services to deliver the 62 day NHS constitution target. We will implement and embed pathways by March 2020. During 2019/20 across Staffordshire and Stoke-on-Trent we will:  increase the proportion of patients living with and beyond cancer who benefit from a post cancer recovery package and risk stratification pathways  work with acute and community providers so patients with cancer access more services, particularly lower risk supportive therapies and procedures in community settings whilst under the care of hospital specialists  increase awareness of cancer warning signs across Staffordshire, alongside national and regional campaigns  support primary care to implement best practice in recognising and referring suspected cancer cases promptly to increase the proportion of stage 1 and stage 2 diagnoses and reduce the proportion of cancer cases diagnosed following emergency presentation  commission a pilot to target people at high risk of lung cancer to be offered a low dose CT screening to support earlier detection and provide opportunities for curative treatment  we will ensure that the key constitutional targets for cancer are met and extend this further to implement human papillomavirus (HPV) primary screening for cervical cancer across England by 2020  during 2019/20 we will ensure that the key deliverables for cancer are met.

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Following a successful bid to the National Cancer Transformation Board (NCTB) West Midlands Cancer Alliance (WMCA) has received and allocated funding to the West Midlands STPs.

The Transforming Cancer Services project sets out how the Staffordshire and Stoke-on-Trent will utilise its allocation to deliver the WMCA transformation programme over the next two years. The project also pulls together Staffordshire and Stoke-on-Trent specific ambitions for transforming cancer services and ensures that these are fully aligned with the WMCA objectives.

The table below shows the timelines of the project:

Deliverable Action Timeline Cancer Overall cancer transformation steering group schedule through to June 28.2.2019 transformation confirmed – overall Detailed breakdown of use of transformation funding allocated to 31.3.2019 project digitisation of pathology networks confirmed management Complete summary report on radiography network development and 30.4.2019 arrangements in place with Staffordshire and Stoke-on-Trent STP Workforce issues and impact of increased demand, this will be included 1.3.2019 in updates to the cancer planned care and cancer board in future Quarterly review of workforce issues and escalate any risks to STP and From 1.3.2019 cancer board Early detection Adopt Faecal immunochemical Test (FIT) for national bowel screening 31.3.2019 of cancer and programme reduction in Provide information to GP practices to enable staff to present benefits 31.12.2019 emergency of FIT and support patients to choose to accept bowel screening presentation Provide targeted support to practices with lower rates of bowel 31.12.2019 screening uptake Enable GPs to order bowel screening tests at appointment 31.3.2019 Bowel screening uptake to increase by 6% (from 17/18 baseline) 31.12.2020 Provide targeted support to practices with lower rates of cervical 31.12.2019 screening uptake Provide targeted support to practices with lower rates of breast 31.12.2019 screening uptake Ensure all women at moderate risk of familial breast cancer are 31.3.2019 automatically recalled for surveillance Develop vague symptom cancer diagnostic pathway 31.3.2020 Provide GPs with clear guidelines for referring patients where cancer is Throughout suspected via protected learning time events (links to best practice 2019/2020 pathways implementation) Request for providers to deliver immunohistochemistry tests for 31.10.2019 potential lynch syndrome markers via 2019/20 SDIP 4% increase in proportion of cancer diagnosed at stage 1 or 2 by Q4 2020/21 (compared with 2016 benchmarked) 3% fewer cancer diagnosed followed emergency presentation by Q4 Q4 2020/21 2020/21 (compared with 2016 benchmark) STP / CCG communications and engagement campaign improving 1.3.2019 awareness of ovarian cancer and providing encouragement for uptake of cervical screening in line with national Public Health England (PHE) campaign STP / CCG communications and engagement campaign supporting 1.4.2019 bowel cancer awareness month Develop targeted information and support relating to cancer awareness 31.3.2019 25 | P a g e

and improving screening uptake during 19/20. Programme for remainder of year to be planned Implement best Complete development work for implementation of NOLCP within each 31.3.2019 practice provider pathway for Embed NOLCP into the daily and weekly cancer waiting time meetings, 30.6.2019 lung cancer review of potential breaches etc and care navigation National Implement diagnostic pathway which ensures patients referred by GP 31.3.2020 Optimal Lung where lung cancer is suspected whether referred for CXR or direct to Cancer Pathway CT are offered CT scan if clinically appropriate within 72 hours of (NOLCP) referral 95% of patients where lung cancer is suspected receive confirmed From Q1 diagnosis of all clear with 28 days 2020/21 (or in line with national target once confirmed) Benchmark key indicators for lung cancer treatment – surgical 31.10.2019 resection rates, curative intent treatment rates etc Audit implementation of NOLCP Q4 2019/2020 Lung cancer patients sustainably meet 62 day and 31 day cancer Q4 2019/2020 waiting time targets Summary of sustainability plan and future developments to build on 31 March 2020 NOLCP Implement best Complete development work for implementation of national best 31 March 2019 practice practice pathway for prostate cancer within each provider pathway for Embed best practice pathway for prostate cancer into the daily and 30 June 2019 prostate cancer weekly cancer waiting time meetings, review of potential breaches etc and care navigation Implement diagnostic pathway which ensures patients referred by GP 31 March 2020 are triaged and requirement for pre-biopsy mpMRI considered within 3 days 95% of patients where prostate cancer is suspected receive confirmed From Q1 diagnosis of all clear with 28 days 2020/2021 (or in line with national target once confirmed) Benchmark key indicators for prostate cancer treatment – including 31 October access to and use of the different treatment options 2019 Audit implementation of best practice pathway for prostate cancer Q4 2019/2020 Prostate cancer patients sustainably meet 62 day and 31 day cancer Q4 2019/2020 waiting time targets Summary of sustainability plan and future developments to build on 31 March 2020 best practice pathway for lung cancer Implement best Complete development work for implementation of national best 31 March 2019 practice practice pathway for Lower GI cancer within UHNM pathway for Embed best practice pathway for lower GI cancer into the daily and 30 June 2019 lower weekly cancer waiting time meetings, review of potential breaches etc gastrointestinal and care navigation (GI) cancer Implement diagnostic pathway which ensures patients referred by GP 31 March 2020 are triaged within 3 days and unless contraindicated, offered “straight to test” first appointment without outpatient consultation

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Review Nottingham, Derby, models for use of FIT for 31 October symptomatic patients both as a diagnostic marker for symptomatic 2019 patients who are low but not nil risk and who do not meet 2 week wait criteria and to exclude cancer and avoid invasive diagnostic tests for symptomatic patients where FIT is negative. If clinically supported develop Staffordshire implementation programme 95% of patients where lower GI cancer is suspected receive confirmed From Q1 diagnosis of all clear with 28 days 2020/2021 (or in line with national target once confirmed) Benchmark key indicators for lower GI cancer treatment – including 31 October access to and use of the different treatment options 2019 Audit implementation of best practice pathway for lower GI cancer Q4 2019/2020 Lower GI cancer patients sustainably meet 62 day and 31 day cancer Q4 2019/2020 waiting time targets Summary of sustainability plan and future developments to build on 31 March 2020 best practice pathway for lower GI cancer Implement Complete development work for implementation of national best 31 March 2019 WMCA Best practice pathway for upper GI cancer within each provider Practice Embed best practice pathway for upper GI cancer into the daily and 30 June 2019 Pathway for weekly cancer waiting time meetings, review of potential breaches etc Upper GI and care navigation Cancer Implement diagnostic pathway which ensures patients referred by GP 31 March 2020 who meet the NICE clinical criteria are offered “straight to test” first appointment without outpatient consultation within 7 days 95% of patients where upper GI cancer is suspected receive confirmed From Q1 diagnosis of all clear with 28 days 2020/2021 (or in line with national target once confirmed) Benchmark key indicators for upper GI cancer treatment – including 31 October access to and use of the different treatment options 2019 Audit implementation of best practice pathway for upper GI cancer Q4 2019/2020 Upper GI cancer patients sustainably meet 62 day and 31 day cancer Q4 2019/2020 waiting time targets Summary of sustainability plan and future developments to build on 31 March 2020 best practice pathway for upper GI cancer Respiratory Phase 1 commences – phase 1 aim will be to see 200 patients in risk 31 March 2019 health clinics targeted respiratory health clinics over a 3 month period with patients and use of Low who meet agreed criteria invited Dose CT for Develop model for phase 2 (option to include community based CT Q2 2019/2020 lung cancer scanning but this will be dependent upon cost to benefit compared screening with hospital based CT) Evaluation of phase 1 completed 31 August 2019 Final plans for phase 2 complete 30 September 2019 Phase 2 commences. Phase 2 will reflect lessons learned from phase 1 01 November and any experience gained from other national lung cancer screening 2019 pilots

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Evaluation of pilot to be completed 30 June 2020 Develop options for roll out of lung cancer screening across 31July 2020 Staffordshire Lessons learned log shared with WMCA after phase 1 31 August 2019 Lessons learned log shared with WMCA after phase 2 31 January 2020 Lessons learned log shared with WMCA after pilot complete 30 June 2020 Living with and Pathway for risk stratification of need for follow up for breast cancer 31 March 2019 beyond cancer patients is agreed Implementation Implementation of risk stratified follow up and self-management for During of risk stratified breast cancer patients to be rolled out 2019/2020 follow up 70% of breast cancer patients whose treatment is completed during or 31 March 2021 pathways after Q4 2020/21 to benefit from self-management follow up pathway Pathway for risk stratification of need for follow up for prostate cancer 30 June 2019 patients is agreed Implementation of risk stratified follow up and self-management for July 2019 – prostate cancer patients to be rolled out March 2021 40% of prostate cancer patients whose treatment is completed during 31 March 2021 or after Q4 2020/21 to benefit from self-management follow up pathway Engagement with colorectal cancer stakeholders (secondary care, 28 February primary care) 2019 Devise OAFU pathway for colorectal cancer including treatment 30 April 2019 summary Clinical team agreement and executive approval for change 30 June 2019 Pathway for risk stratification of need for follow up for colorectal 30 November cancer patients is agreed 2019 Implementation of risk stratified follow up and self-management for December colorectal cancer patients to be rolled out 2019 – March 2021 30% of colorectal cancer patients whose treatment is completed during 31 March 2021 or after Q4 2020/21 to benefit from self-management follow up pathway Summary of sustainability plan and future developments to build on 31 March 2020 risk stratified follow up pathways Living with and Participation in Burton active recovery programme. This will be offered Q3 and Q4 beyond cancer to all cancer patients in East Staffordshire 2018/2019 – use of Develop proposal to roll out active recovery programme across the 30 April 2019 recovery whole of Staffordshire and Stoke on Trent. (Note that funding for this is package and not available within existing WMCA transformation funding allocation) support in the Completion of holistic needs assessment for 80% of cancer patients 31 March 2019 community diagnosed with cancer in Q4 18/19 Breast cancer roll out of treatment summaries in line with risk stratified From April follow up 2019 Prostate cancer roll out of treatment summaries in line with risk From July 2019 stratified follow up Colorectal cancer roll out of treatment summaries in line with risk From stratified follow up December 2019 40% of cancer patients will receive a treatment summary. (Treatment 31 March 2021 completed in Q4 20/21) Cancer care reviews completed within 12 months of diagnosis for 20% 31 March 2021 28 | P a g e

of patients diagnosed with cancer in Q4 19/20

8. Mental health and learning disabilities

In Staffordshire and Stoke-on-Trent there is an ambition to deliver integrated physical and mental health provision. This recognises that physical and mental health is closely connected. We will ensure that older people, adults, young people and children are supported 24/7 when experiencing mental health crisis or when their day-to-day mental health and wellbeing is affected. We will ensure that mental health and physical health care is integrated and care is delivered closer to home and family, leading to a reduction in out of area placements. Children and young people will not be unnecessarily admitted to hospital and children with an eating disorder will receive a responsive service. We have also signed-up to an ambition of zero suicides.

Priorities aligned to the long-term plan have been outlined by our providers in their operational plans including a range of local service developments such as children’s eating disorders, adult Eating Disorders, Zero Suicide ambition and IAPT LTC growth. In addition providers are also part of a range of national transformation developments including a CAMHS Trailblazer pilot site.

The table below shows the consolidated programme across the system, underpinning projects, objectives and the proposed financial impact which will be further scoped and refined over the coming weeks.

Priority Deliverables Objectives

Mental Health Out of Area Programme to identify the sub specialties and subsequently the & Learning priority work-streams to repatriate a proportion of the current Disabilities £43m that is spent on out of county placements. High volume and Enhance programmes across the county to demonstrate clear intensity users cohort and critical volume, supporting alternative use to urgent care portals.

Out of area The intention of the PICU and acute adult out of area pathway project is to reduce the financial challenges created by service users being sent out of area into a psychiatric intensive care unit (PICU) and acute care. This will improve patient and family/carer experience and reduce the length of stay for the patient.

The key project deliverables are to offer a service that:

 provides local provision at a reduced cost to commissioners  reduces length of stay and improved outcomes for service users (nationally exceeding 15 days)  improves experience for families and carers by providing local care

The PICU and acute care pathway is expected to realise the following benefits:

 an integrated pathway for the whole population of Staffordshire and Stoke-on-Trent who require PICU and acute provision  eliminate in appropriate out of area PICU and acute bed usage for the residents of Staffordshire and Stoke-on-Trent  reduce lengths of stay within PICU and adult acute in-patient services  improve quality and experience of service users and their families

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 reduce overall costs to the system of PICU patients

In order to calculate savings that could be generated by bringing these patients in area at a reduced length of stay, an allowance will need to be made where there have been peaks and troughs in activity. Evidence suggests there have been periods where more than 12 patients at a time have required beds which would need to be managed through out of area placements. We will also need to consider making an allowance for the new models of care and potential delays to discharge as a result of this, an adjustment of 20% has been included as a contingency. The table below shows the STP savings:

Moving OOA to “in area” OOA bed Assumed In area bed Estimated days average OOA day cost savings (£000) bed day cost Total OOA bed days 2963 700 2074 Equivalent in area bed days (54%) 1600 643 1029 Adjustment for peaks and troughs in 593 700 415 activity and new models of care (delayed discharges) Estimated saving 630

The table below shows the PICU and acute adult out of area pathway project timelines

Project Milestones Start Date Estimated Completion Date

Engagement and agreement in principle from system 21 February 2019 Complete partners to deliver PICU and Acute service through integration and from existing bed capacity (with additional commissioned capacity) Providers working within the agreed protocol and 21 February 2019 Complete procedures to deliver immediate benefits to the wider system by not sending patients out of area (OOA) Data analysis completed on OOA placements and actual 11/3/2019 20/3/2019 activity identified by male and female Additional bed capacity commissioned 11/3/2019 01/07/2019 Equity on bed costs across the two providers 11/03/2019 01/04/2019 Recruitment commences 01/04/2019 30/09/2019 Gatekeeping process and monitoring of inappropriate 11/03/2019 01/04/2019 OOA placements. Seclusion business case approved 11/03/2019 30/03/2019 Dashboard and KPIs identified 01/04/2019 28/06/2019 Integrated Pathway Development 01/04/2019 20/07/2019

High volume and intensity users Across Staffordshire and Stoke-on-Trent there are a number of schemes in place to address high volume users (HVU) and high intensity users (HIU). During 2019/20 we will implement the High Volume User Service project with the intention to remove fragmentation and align current services schemes into a single co- ordinated response to the challenge of significant frequent West Midlands Ambulance Service (WMAS) calls, attendances and admissions concentrated in a small number of patients.

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The aim of the project is to offer a service that:  provides proactive telephone/contact support using a health coaching approach at first point of contact where service users make frequent calls for ambulance or attend A&E on numerous occasions when alternative support can be offered  provides health and social work interventions in support of staff within A&E departments. Working collaboratively and in an integrated approach with secondary care clinicians and WMAS to identify high intensity users and provide assistance to de-escalate the patients dependency on frequent and crisis support

The key project deliverables are:  establish integrated partnership working and increase capacity in the Staffordshire Mental Health Helpline to support those patients who would benefit from proactive support.  increase capacity within the HVU and HVU teams to support warm transfers for people considered to be higher risk and not suitable for low level mental health helpline support.  establish protocols/pathways (and communication plan) for WMAS colleagues to identify patients appropriate for this alternative approach and local A&E Departments.  data inputting and analyst support to ensure sharing of information between provider partners  integration and alignment of current services for a Pan Staffordshire offer providing equitable care to our patients.

The opportunity assessment identified by NHS RightCare for the CCGs commissioning of a high volume user service targeting the top 50 attending patients at A&E would net savings of £1.05m.

We expect the high volume user (HVU) element of the services within A&E to reduce attendance by 40 % (Please note that this is based on the residual activity after WMAS service intervention).

• the current service supports 220 patients at an annual cost of £1522 per patient • initial extrapolation of opportunity would require an additional £324k for an additional 290 patients • potential reduction in A&E attendances of 1554 at a current cost of £182k • potential to reduce NEL admissions by 415 based on a 26.7% conversion rate (Av. spell price £1876 cohort 11-19 attends cohort) would save £778k and potentially 15 beds

On a pure tariff the savings would be a net £1.08m (including reduction for WMAS conveyance) excluding costs with other elements of the health and care system, including general practice, ambulance, police costs

The table below shows the high level timeline of the high volume user service project

Activity End date Engagement and agreement in principle from system partners to align HVU and HIU 21.2.19 service Clinical and operational engagement – high volume user workshop 28.2.19 Mental health/learning disabilities working group – confirm and challenge 13.3.19 Clinical sign off on model across six CCGs 20.3.19 Evaluation framework agreed with providers and clinical leads 20.3.19 Approval of service specification across six CCGs 30.4.19 Expanded service mobilisation 30.6.19

We will continue to deliver mental health projects that reflect the CCG and STP ambitions set out based on the FYFV for mental health, the table below shows what will be delivered for 2019/20. See Appendix 5 on how the CCGs will meet key deliverables in mental health set out in the NHS guidance. 31 | P a g e

Key deliverable Action Timeline Supporting the Map whether STP is offering people with long term physical April 2019 mental health of health conditions support for the psychological aspects of their people with long- condition as a standard part of care term conditions Active case-finding system wide to identify people at greater risk April 2020 in line with guidelines from the national institute for health care excellence Supporting mental Ensure hospital professionals have necessary skills and April 2020 health in acute confidence to manage mental health appropriately hospitals Supporting the The physical and mental health of carers and family members are April 2020 mental health and assessed as routine part of care provided to people with long- wellbeing of carers term conditions or people with a terminal illness Carer support is assessed during the carer’s journey. Those providing substantial levels of informal care have their own written care plan updated on an annual basis

CAMHS (Child and Adolescent Mental Health Services) The CCGs are working in partnership with Staffordshire and Stoke-on-Trent local authority colleagues to deliver the Integrated Children and Young People’s Emotional Well-being and Mental Health Strategy 2018- 2023. This strategy supports the delivery of a number of objectives set out in related local strategic documents which have been informed by engagement with key stakeholders and communities. The strategy takes account of the findings and recommendations in the Children’s Joint Strategic Needs Assessment (April 2017) and the Children and Young People’s Emotional Wellbeing Joint Strategic Needs Analysis (May 2018).

The strategy sets out the intentions to align to the principles of Thrive model, this will be delivered by:  a better understanding of the needs of children and young people across Staffordshire and Stoke-on- Trent  a focus on prevention and early intervention without navigating through tiers of interventions  provide greater challenge to the current operating model and explore a single model of delivery and point of access  focus on putting children and young people (CYP) and parents/carers at the heart of decision making  provide clarity on crisis support requirement and model  provide joined up and integrated working across the ‘whole system’ including focus on transition services

North Staffordshire CCG and Stoke-on-Trent CCG have been invited to apply to be a Wave 1 CYP Trailblazer site alongside East Staffordshire CCG and South East Staffordshire and Seisdon Peninsular CCG. The trailblazers will be the first to implement and test the delivery model for the Mental Health Support Teams (MHSTs), and the 4-week pilot sites, and learning from the trailblazers will inform future roll-out of the proposals. The Implementation process and timescales are below:

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Implementation MHST sites consult with schools and colleges to agree detailed set October to January, 2019 up & location of teams Sites finalise trainee recruitment with Higher Education Institute November, 2018 (HEI) MHST trainees commence training, placements start January 2019 National monitoring of waiting time pilot performance commences 1st April 2019 Full MHST service operational no later than End of December 2019

Special Educational Needs and disabilities (SEND) In November 2018, Ofsted and the Care Quality Commission (CQC) conducted a joint inspection of the local area of Staffordshire to judge the effectiveness of the area in implementing the special educational needs and disability (SEND) reforms as set out in the Children and Families Act 2014. Across Staffordshire the system of support for children with SEND is under significant pressure. Locally, the number of children who have a special educational need or disability has increased by a third in the last five years.

The inspection identified a number of areas of concern, particularly with the way different parts of the system of support, namely education, health and care, work together with families to ensure they receive timely, joined up support that meets their needs. Ofsted and CQC now require Staffordshire to submit a Written Statement of Action (WSOA) detailing how they will address these concerns.

Staffordshire County Council and the five Staffordshire clinical commissioning groups are jointly responsible for submitting the WSOA.

Work is underway with senior leaders from all partner agencies to develop a robust action plan to address areas of concern. The subsequent plan will address required improvements for children and young people in Staffordshire who have special educational needs and disabilities across 3 key areas:  how effectively the local area identify children and young people who have special educational needs and/ or disabilities  how effectively the local area assesses and meets the needs of children and young people who have special educational needs and/ or disabilities  how effectively the local area improve outcomes for children and young people who have special educational needs and/ or disabilities

Stoke-on-Trent CCG will contribute to the role out of the Stoke-on-Trent Education and Health Care Hub, an electronic portal to improve efficacy of Education, Health and Care Plans (EHCPs); to streamline the process and improve quality of education health and care plans.

The CCG will attend the re-established Children Young People and Families Commissioning Group in order to:

• develop a strategic approach across services for children and young people • share good practice • optimise opportunities to improve outcomes by creating innovative solutions • ensure commissioned services include early identification, prevention and intervention approaches ensuring children have the best start in life • promote the development of an integrated and streamlined approach to the commissioning of services for children and young people; this includes health and social care, prevention and treatment

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The executive director of nursing and quality has overall responsibility for SEND at board level. The CCGs have two designated clinical officers (DCOs) in post who work collaboratively with partner agencies and health provider services.

Learning disabilities and autism The Transforming Care Programme (TCP) is an NHS England programme, set up in response to the crises at Winterbourne View and other inpatient units for people with learning disabilities or autism. The CCGs have led the Staffordshire TCP since it was launched in 2016. As leads for the transforming care partnership (TCP) the CCGs are committed to improving the lives of people with learning disabilities (LD). As the TCP programme ends in March 2019, the CCGs will continue to develop alternative services to reduce long-term hospitalisation of people with a learning disability, autism or both. The aim is to reduce premature mortality, by improving access to health services, education and the training of staff, and by making necessary reasonable adjustments for people with a learning disability and/or autism.

The current learning disability (LD) and autism system across Staffordshire and Stoke-on-Trent is fragmented and reactive in nature, often resulting in poor user experience, duplicated activity and high cost. The delivery of a properly coordinated system can make a huge difference to people’s lives and also gives people the best possible chance of staying out of hospital, residential or nursing care altogether. For people who do need to be admitted to hospital, integrated care would give them the best possible chance of being discharged sooner to a bespoke placement.

The learning disability adult population of Staffordshire and Stoke-on-Trent known to statutory services is approximately 3,200. Of this group the CCGs spend is focussed on 416 people who are the most complex, vulnerable and high cost. Currently there is no single commissioning approach or plan. The service is reactive in nature usually based on crisis, this has led to high cost packages without any consistent approach to review. The user experience is varied and support is often only available too late in the process. This consistently leads to admission, often out the area as there is a lack of a consistent pathway to support service users which leads to greater reliance on inpatient beds, leading to long stays and high costs.

The out of area learning disabilities project will initially focus on the 416 people with spend of approximately £27.2 million. The project will allow us to review duplication, price variation, excess observation costs not utilised and commissioning that is outside of Staffordshire and Stoke-on-Trent. In the shorter term we expect to achieve efficiencies through removing the duplication in the current system.

The key project deliverables are:  ensure that care is being delivered in the right place, meets the needs of the individual, consistently high quality and is cost effective  a consistent and regular review process conducted by appropriately skilled staff is put in place  all agencies work together in the best interests of the person, information and learning is shared  cut out waste and duplication to realise efficiencies and where appropriate reinvest in service development to ensure people remain in their communities

The project will take a phased approach:

Phase 1 (Health spend): analysis of the current cohort of people Phase 2a: analysis of the needs of the cohort following the review (phase1) Phase 2b (local authority spend): analysis of local authority spend 34 | P a g e

Phase3: system wide analysis and development of integrated model (all age)

The financial impact will be part year effect for 2019/2020, full year effect 2020/21. We anticipate a 5% return of circa £1.1m; however some of this will need to be invested into community teams to enhance capacity.

Phase Project milestone Planned date Estimated completion date Phase 1 Health spend – completion of identification and 1.4.2019 01.5.2019 evaluation of current reviewing arrangements and health spend Create and design and launch a benchmarking/ 1.4.2019 31.5.2019 standards for review in consultation – consistent approach across the system Establish current reviewing provision and 1.5.2019 31.5.2019 identify gaps/duplication If required recruit additional capacity 31.5.2019 31.7.2019 Phased review schedule to focus on high cost 1.4.2019 1.5.2019 provision and potential quick wins Market engagement 1.4.2019 1.6.2019 Phase 2 Greater understanding of service development 1.9.2019 1.12.2019 needed to support the prevention agenda and identify gaps in service provision, this may become evident following first phase reviews Phase 3 Information gained from phases 1 and 2 to 1.4.2020 inform design of an integrated learning disability system/ commissioning strategy which focuses on early intervention and prevention in Staffordshire and Stoke-on-Trent Evaluation Agreement of measures to evaluate outcomes 1.5.2020 31.5.2020 and effectiveness

Learning from deaths report (LeDeR) The CCGs are members of the learning from deaths report (LeDeR) steering group and have a named person with lead responsibility for overseeing this process. Staffordshire LeDeR Steering Group has been active since October 2017. The CCGs have systems in place to analyse and address the themes and recommendations from completed LeDeR reviews. Themes and recommendations from completed reviews are considered in a structured way by the Staffordshire LeDeR steering group. An annual report is submitted to the appropriate board/committee for all statutory partners, demonstrating action taken and outcomes from LeDeR reviews. Quarterly reports are submitted to the CCGs’ quality committee, reports include a summary of outcomes from reviews and actions taken.

Priorities aligned to the long-term plan have been outlined by our providers in their operational plans including a range of local service developments to work jointly in a review of community services to reduce the variation in service provision for adults with autism.

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Across Staffordshire and Stoke-on-Trent we will:  continue to work with partners to redesign how and where services are provided to ensure there is an enhanced community service offer for people with learning disabilities and/or autism  work to reduce variation in the provision of learning disability liaison nurses across Staffordshire and Stoke-on-Trent  review community services with our partners, with a view to reducing or preventing acute admissions for people with a learning disability and/or autism. This will ensure a sustainable service for those already discharged as part of the TCP partnership  work to reduce the variation in service provision for adults with autism across Staffordshire and Stoke-on-Trent. A system wide review will ensure the needs of the cohort are met  increase the uptake of annual health checks undertaken in primary care and improve completeness of the GP learning disability register

See Appendix 5 on how the CCGs will meet key deliverables for learning disabilities and autism set out in the NHS guidance.

9. Maternity and neonatal

Staffordshire and Stoke on Trent have an established and highly effective local maternity system (LMS) board which has met since early 2017 and where the current maternity transformation plans was developed and approved. We will continue to implement the agreed delivery plan based on the recommendations and gap analysis of the better births national maternity review across Staffordshire and Stoke-on-Trent.

The CCGs will agree and deliver an action plan following a regional NHSE deep dive review of the saving babies lives care bundle during 2019. We will deliver:

 the improvements in safety towards the 2020 ambition to reduce still births, neonatal deaths, maternal deaths and brain injuries by 20% and by 50% in 2025  and reduce the number of intrapartum brain injuries to achieve a reduction of 20% by 2021 and 50% by 2021

All trusts in Staffordshire are part of the National Maternal and Neonatal Health Safety Collaborative and all maternity services are part of an accredited, evidence based infant feeding programme

We will continue against the trajectory to deliver improvements in choice and personalisation through the LMS so that by March 2021 all women have a personalised care plan. Following a survey in 2018/19 an action plan has been put in place with providers in the LMS and key lines of enquiry (KLOEs) agreed with NHS England the table below shows the trajectory agreed.

Local baseline Trajectory March 2019 Trajectory March 2020 Trajectory March 2021

18% 18% 25% 50%

2183 2197 3053 6097

The table below shows what actions we will be taking across Staffordshire and Stoke-on-Trent during 2019/20

Action Timeline Explore implementing a single point of access for women to call across Ongoing 2019/20 Staffordshire for booking, advice and guidance 36 | P a g e

Increase the number of women who give birth in midwifery led settings across Ongoing 2019/20 Staffordshire. The trajectory agreed with heads of midwifery for an increase of 5% annually over the next three years Continue with the plan in place to increase the membership of maternity Ongoing 2019/20 ambassadors/ women who use the services to form part of the maternity voices partnership (MVP) Continue to influence the development of formal clinical peer review networks to Ongoing 2019/20 share issues, good practice and learning from incidents across the local maternity system Support UHNM to work with NHS digital to launch a ‘2-way noting system’ which Ongoing 2019/20 builds on the current ability for women to access their digital maternity records online. It enables the mother to add to certain parts of their own notes Pilot a 36 week antenatal review to re-assess for the best place of delivery Ongoing 2019/20 Review and agree a trajectory for fewer readmissions for women and babies to Ongoing 2019/20 hospital Develop and implement a communication and engagement plan to focus the by 2021 promotion of choices with an ambition of 90% Agree and establish data requirements with maternity services to support referral Ongoing 2019/20 rates for pregnant women who want to stop smoking Continue to increase access to specialist perinatal mental health services ensuring Ongoing 2019/20 an additional 136 women in Staffordshire access the service. There will be a staged increase in activity through 2019 and will be monitored via the Staffordshire and Stoke-on-Trent maternity transformation programme board Roll out the commissioned validated cardiotocograph training package to all By 2021 midwives and obstetricians across Staffordshire Continue with the current pilot in place for the continuity of carer for a small group Ongoing 2019/20 of vulnerable women so they are seen by a team of four to six midwives. The projection of 20% of women to be on this pathway by March 2019 has been challenging and current predictions indicate around 12 to 14% will be achieved by March 2019. Providers are working towards the 20% target; they have been requested by the CCG to add ‘not meeting the target’ to their trust risk registers

10. End of Life

The Ambitions for Palliative and End of Life Care Framework establishes the importance of offering everyone the chance to create a personalised care plan including the possibility of recording preferences that might guide others if the person were to lose capacity to make their own decisions. The CCG’s will commission palliative and end of life care coordination across Staffordshire to ensure patients and professionals can access the appropriate proactive and responsive services accordingly. We will develop the public health model of care using development workers to help build social connectedness and supportive communities for people at the end of their life. The tables below show what we will deliver during 2019/20 for end of life and advance care plans

Key deliverable Action Timeline Personalise care, Implement the end of life template within the integrated care Ongoing through to improve end of record 2019/20 life care Embed the standard operational policy for DNARCPR across all April 2019 organisations and care homes. This will be monitored via the care onwards home strategy group and EOL programme board From Q2 2019/20 Work with local authority colleagues to implement any actions

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highlighted following the CQC local area reviews held in November 2018 Develop a local incentive scheme for identification of end of life (EOL) and frail elderly patients in line with CCGs integrated care team (ICT) specification Commission 24/7 advice, triage, rapid response (care coordination) A revised specification will be developed in Q4 2018/19. Action plans will be in line with the development of the ICT’s at a local level Advance care In light of recent guidance on the GP contract the CCG will support Ongoing 2019/20 plans practices to implement the end of life quality improvement module. This will support the continued increase in the number of patients on the GP register to ensure that all patients are offered May 2019 the opportunity to develop an advance care plan Increase public awareness of death and dying and the importance of care planning by building on the public engagement campaign December 2019 ‘dying matters-Staffordshire’ Implement actions from the NHSE transformation funds care home scheme. We will continue to develop a training and education scheme for care home staff in advance care planning (see care homes)

11. Personalised care

Continuing healthcare (CHC) The CCGs recognise the national focus on CHC services through both the national strategic improvement programme and the introduction of the new CHC adults’ framework.

Key deliverable Action Timeline Continuing Continue to focus on sustained delivery of the two national Ongoing healthcare fund metrics, timeliness of assessment and care setting of assessment so patients who may be eligible for CHC are assessed in a timely manner and in a setting which reflects their care needs We will bring forward proposals to further integrate CHC services to support the development of excellence in assessment and 2019/20 brokerage of CHC funded packages of care

Personal health budgets The CCG will ensure that the approach to personal health budgets will enable a person-centred approach and more choice and control. The CCG will continue to accelerate the roll out of personal health budgets to give people greater choice and control over how care is planned and delivered by. This will develop further to include people with a learning disability or autism or both.

Key deliverable Action Timeline Accelerate the roll Work towards the NHSE guidance; domiciliary care April 2020 out of Personal packages ‘PHB by default’ Health Budgets Finalise the CCG PHB draft strategy April 2019 Explore an appropriate system for managing and auditing PHB September 2019 payments, currently undertaken by a clinician

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12. Estates

Our priorities are to deliver real change in how services are provided within our collective estate, by using our estate efficiently to support the new models of care and disposing of unneeded estate. Through our commitment to ‘one public estate’ we will work with wider partners across Staffordshire and Stoke-on-Trent to maximise this approach across the whole of the public sector. We will support the systems capital priority projects, creating new multi-use and flexible health and care hubs and health villages and identifying surplus land and housing opportunities.

Over 19/20 we expect:  to reduce non-clinical space of estate by a further 1% through system wide utilisation review and rationalisation  STP energy group will deliver opportunities to make efficiencies through different ways of working and bringing in grant opportunities to the system  support regional NHSE colleagues with identifying transactional process to receive funding for Greenwood House  support Longton South and Outwoods project boards to deliver on time and on budget

13. Specialised Commissioning

Working with colleagues from specialised commissioning we expect to continue to deliver innovative, specialised cancer treatments ensuring continued adherence to NICE guidelines and maximising on opportunities for further improvement, along with an improved and adequately funded mental health service. This work will seek to ensure that that plans are based on the specific requirements of the local population. We will work with the NHS England-led specialised services planning boards to decide on the services to prioritise especially those that overlap with locally-commissioned services We will therefore be ensuring:  strong engagement in the implementation of the national strategy for specialised services  identification of opportunities for joint planning and development of care across the whole patient pathway within local plans  supporting the need for change within an agreed case for change

14. Workforce

During 2019/20 the STP will continue to deliver the STP workforce programme strategy project. Project objectives and deliverables are listed below:

Objectives Deliverables Timeline Maintain a cost Support the clinical workforce planning for STP work streams Ongoing during effective Support the development of the integrated care teams 2019/20 workforce Support the development of the primary care workforce strategy (in partnership with relevant partners) Maintain and Work with commissioning bodies to challenge how services are increase commissioned if there is a possible impact on workforce workforce supply availability

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15. Data and technology

Underpinning transformational work is digital technology and we are working to establish a robust, future proof and state-of-the-art information technology infrastructure to support delivery of the new models of health and care. During 2019/20 activity across Staffordshire and Stoke-on-Trent will focus on the areas below:

Refreshed Local Digital Roadmap (LDR) and Associated Digital Delivery Programme - A critical activity towards the end of 2018/19 and delivering early into 19/20 will be to refresh the Local Digital Roadmap to:  Review progress against existing areas and remove any completed elements  Revise/remove any elements that are not completed and are deemed no longer relevant or are only relevant on a revised basis  Assess the LDR against revised NHS strategy and policy including (but not limited to) the 5 year forward view series of documents, NHS long term plan and updated STP programme priorities

The revised LDR will subsequently result in revisions to the structure of and deliverables within the Digital Programme resulting in revised work streams, plans and delivery milestones especially in areas where insufficient progress has been made

Integrated Care Record - 2019/20 will focus on finalising the procurement and agreeing a contract for the provision of the technology to deliver integrated care records.

Whilst it is difficult to put specific achievements against 19/20 due to these needing to be agreed it is likely to be based around the following:  Complete procurement and award contract  Agree the deployment and benefits plan  Connect health & care provider organisations including General Practice to the ICR  Centralised end of life care plan agreed and live  Centralised maternity care plan agreed

Population health management- Population health management in terms of outcomes, processes and tools/technology has yet to be defined and therefore the key deliverables within population health management for 19/20 will focus on:  Establish and consolidate an approach to delivering population health management including the definition of: . Purpose/intended outcomes . Operating model . Data management . Information sharing . Tools and technologies  Implement a series of ring-fenced population health management based pilots/case studies to inform the development of a business case for the wider adoption of public health management tools and processes  Define and agree a business case (if applicable) for the “implementation” of population health management

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Information Sharing Agreements (ISAs) - The information sharing agreements work stream will deliver the ISA’s to support the implement both of ICR2 and any necessary ISA’s to support the PHM pilots.

Technology Enabled Care Services (TECS) - Currently approved TECS will continue to be deployed to interested parties whilst a structured approach is agreed to industrialise the use of preferred technologies such that all practices can move towards “Exemplar” status.

Review and re-establish work streams - The following work streams will be reviewed as part of the Digital Programme refresh early in 2019 and will either be removed and replaced with alternate work streams or will have an established revised set of milestones and deliverables.

 Staffordshire Informatics Network  Model Architecture  Technology Enabled Care Services

Health System Led Investments (HSLI) - Whilst not formally part of the Digital Programme the projects resulting from the HSLI funding will be continued specifically eAppointment letters, eReferral Advice and Guidance, speech recognition and process automation. Further work will be undertaken to plan, seek funding for and implement additional initiatives during 2019/20 in line with the initial overview plans.

16. Finance

Allocations Staffordshire CCGs have received a combined allocation uplift of 5.35% against a national uplift of 5.73%. The closing distance from target for the group is 1.85% below target for the core allocation which represents c£28m shortfall in funding, and 2.58% over target for primary care which represents c£4m of excess funding.

STP System wide contracting approach Work has progressed via the STP on an Intelligent Fixed Payment System (IFPS) which is a different contractual approach to 2019/20 that shares risk across the system and seeks to minimise investment expectations against the growth allocation. It is based on collaboration not competition with the NHS National Tariff arrangements being set aside between the intra STP partners in 2019-20 enabling the system to concentrate on the cost of providing healthcare within the county, and in bringing the whole health system back to clinical, operational and financial balance. A transformation programme is in development supported by Deloitte to identify opportunities to remove capacity and the resultant cost to the system. This is backed up by work on major programmes including frailty, end of life care, population health management and alignment of incentives and removal of financial barriers to integrated care.

This approach is not without risk but the IFPS, by nature of fixing payments to STP based providers attracts a lower degree of financial risk by facing challenges together on a collaborative basis whilst supporting delivery in a safe and operationally balanced environment built on jointly owned transformational schemes with STP partners.

Overall CCG summary Financial Plan The CCG group presently has a combined control total of £54m deficit and subject to approval by governing bodies will submit a combined planned deficit of £74.4m based on implementing the Intelligent Fixed Payment System (IFPS) contract with Staffordshire STP providers.

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The group has a combined underlying budget deficit position brought forward from 2018/19 of £104.7m (6.4%) largely driven by over performance on provider contracts as a result of failure to identify and manage QIPP into provider contracts.

A total allocation of £1,722.8m including growth of £87.4m (5.35%) has been received in 2019/20 by the 6 CCGs and includes uplifts for core allocation of 5.55% and 2.56% for delegated primary care (after central allocation reductions to pay for the national GP Contract agreement on Professional Indemnity Insurance). In addition £25.3m (7.7%) growth for specialised commissioning has been received and subject to some minor adjustments to contracts relating to provider eligibility this budget is managed directly by NHSE and is therefore assumed to be net neutral in the plan which would be consistent with the projected 2018/19 performance.

The key assumptions contained within this plan  STP Provider contracts will be agreed under a Fixed Price Contract (IFPS)  Non STP provider contracts can be maintained within the envelope identified which includes a net QIPP requirement of 3.5%.  A cash releasing QIPP of £46.4m is delivered (from both non STP provider contracts and from CCG direct expenditure)  STP cash releasing Transformation savings of £9m are achieved  A 0.5% contingency will be sufficient to cover all risks  Resources are ring fenced within the confines of the IFPS agreement for o Mental health that requires mental health trusts to spend funds to deliver the MHIS o Community provision to support transformation programmes o Delegated primary care in line with allocations  Provider inflationary and tariff funding in line with national expectations  £1.50 per/head investment in primary care per the GP Forward View  Minimum contribution to the Better Care Fund (1.79%)  CQUIN is reduced from 2.5% to 1.25% (1.25% moved to tariff)  Increase in employer pension contributions have been excluded in line with national guidance on the understanding that funding will be made available in year

Key risks identified with delivery of the plan  Failure to achieve the planned levels of QIPP & transformational savings. The £17m of stretch savings over and above the 28th March submission are shown as unmitigated risks as these schemes remain high risk until the schemes are developed fully  The plan assumes that the ring fenced funding for delegated primary care will be sufficient to cover all nationally driven GPFV initiatives including the £1.9m shortfall in the recently announced GP Clinical Negligence Indemnity scheme, or that any resultant shortfall will be offset by additional central funding. As guidance in this respect is still awaited, the £1.9m is currently highlighted as an unmitigated risk in the plan  Specific service provisions exceeding the planned allocations, notably o Acute care where PbR contracts exist o Pressures associated with financial contribution to shared care arrangements including . Funded Nursing Care . Continuing Health Care . Out of county mental health placements o System wide risks as transition to IFPS collaborative cost reduction programmes develop further

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Methodology for the activity submission  The CCGs have used Month 7 (October) as the baseline. Forecast projection has been based on calendar days for emergency point of deliveries (PODs) and working days for elective PODs. The appropriate adjustments to forecasts have been made including:  Anticipated QIPP delivery in Months 8-12 (November to March)  Reduction in A&E Type 1 activity at UHNM due to changes in UCC in year  Increase in A&E Type 3 projection due to inclusion of Haywood and Leek attendances part year  We have used the adjusted CCG 2018/19 forecast  Counting and coding amendments have been included such as the full year impact of A&E type 3 attendances  Non demographic growth has been included based on variance from 2017/18 to 2018/19 forecast out turn and amended in the following PODs:  GP referrals growth set to zero due to negative growth seen in last 12 months  NEL 0 LoS and NEL 1+ LoS stripped of in year operational changes such as CDU capacity increase, AMRA etc for inclusion of real growth  A&E growth set to NEL growth (problems with inclusion of UCC attendances clouding genuine growth)  We have included demographic growth based on ONS and activity projections at UHNM and transformational adjustments were applied including:  Implementation of outpatient follow up reduction  Full year impact of operational changes in NEL 0 LoS activity (CDU, AMRA, MRU)  Reduction in A&E Type 1 attendances due to UCC activity within M7 (October) year to date  This is reflected in the final 19/20 Activity Plan.

17. Public involvement

During 2014-18 we undertook a significant pre-consultation exercise with key stakeholders to involve them in developing the options for change for local health services in Northern Staffordshire to meet the population’s changing health needs. The process was signed off following the rigorous assurance process by NHS England and was quality assured by the Consultation Institute as best practice. A formal consultation process began in December 2018 and is set to conclude in March 2019. In the months after consultation, we will have the feedback independently analysed and the information will be given conscientious consideration by the Governing Bodies in summer 2019. This will inform a Decision Making Business Case (DMBC) which will undergo NHS England assurance.

In addition to the consultation on the future of local health services in northern Staffordshire, which is underway at the time of writing this plan, the CCGs continue to involve patients and the public when considering any service change. Commissioners have been supported with training to better understand their statutory duties to ensure that patient and public feedback is actively sought and used to inform decision making processes Particular emphasis on understanding population health needs and reducing health inequalities as well as mitigating any unintended consequences for protected groups will be afforded going forwards. We will continue to actively involve patients through our CCG Patient Groups and Primary Care Patient Participation Groups and we will be expanding our Northern Local Equality Advisory Forum (LEAF) to cover the whole of the county. Our patient and public involvement (PPI) Lay members chair key meetings at which we listen to patient views and provide feedback through our expanding communication channels. We will continue to implement our Digital Communication Strategy which was informed by young

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people. This strategy sits hand in glove with our Communication and Engagement Strategy. Whilst patient feedback is the bedrock for us to understand and improve quality and patient experience, clinical engagement through our membership will be a continued focus. We have also worked hard during the last 12 months to better involve our workforce and having developed a staff engagement group, implemented an intranet and improved our briefing system, we will continue to implement our organisational development plans. We know that employing the right people with the right skills in the right place is the key to unlocking transformational system change.

The Together We’re Better’ (STP) which includes commissioners, clinicians, health service providers, local authorities and voluntary organisations, continue to develop proposals for transformational change which seek to address how local health and care services could be delivered differently to meet local needs against the backdrop of significant challenges faced by the local health economy. Work is in progress to develop the case for change and the clinical models of care which will form the basis of the ‘Pre-consultation Businesses Case (PCBC). During 2019/20 the CCGs, with the statutory responsibility, will work with stakeholders to finalise the case for change develop clinical models and the proposals for change, and commence the NHS England assurance process including the West-Midlands Clinical Senate.

18. Summary

This plan outlines the actions and timelines for healthcare delivery in Staffordshire and Stoke-on-Trent whilst fulfilling the expectations placed upon us through the national planning cycle and the NHS long term plan.

This plan has been approved by the CCG governing bodies and is a working document. It will be monitored by the Strategy and Planning Directorate using a planning delivery matrix. The excel spreadsheet below provides an overview of the proposed governance structure and process that will monitor the actions and deadlines presented in the operational plan.

Planning delivery matrix.xlsx

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Appendix 1 – North Staffordshire and Stoke-on-Trent CCG locality focus

It is recognised that during 2019/20 there will be variance in some of the service delivery/service improvements within localities and this section highlights the local plans for North Staffordshire and Stoke- on-Trent CCG. This section sets out priorities for the locality building on commissioning intentions approved in September 2018 and national requirements outlined in the long-term plan/planning guidance.

Service Transformation Health and social care services in North Staffordshire and Stoke-on-Trent face a number of significant challenges. The Pre-Consultation Business Case (PCBC) sets out our journey so far in making the case for transforming the future of local community services.

We serve a population of 479,000 people, which is growing by 0.3% annually – somewhat lower than the English average of 0.8%. Our population is less active, smoke more and have higher rates of alcohol-related harm than the national average. Overall deprivation across our area is below the national average, but there are variations between locality and within localities. As an example, Stoke-on-Trent is one of the most deprived local authority areas in England. This is reflected in our population having slightly lower life expectancy than average.

To meet the changing demographic demands for care and make sure people’s outcomes continue to improve, we must transform the way in which care is provided to ensure people are cared for in the right place.

The community care system we currently operate faces various challenges that we need to address:  Health and wellbeing: There is an ageing population and increased prevalence of long term illnesses and complexity of conditions compared to national averages. Our community services were designed to cope with the burden of shorter term illnesses and for individuals who were in general, less frail when they sought help  Care and Quality: Health services across North Staffordshire and Stoke-on-Trent provide a range of care services that are safe and well-led. However, care has historically been too beds focused, impacting both patient outcomes and experience. We have a significant opportunity to provide care which is more appropriate to patient needs  Estates: The available estate across North Staffordshire and Stoke on Trent is in varying states of condition and suitability for delivery of bed based and non-bed based community services. To deliver the highest quality of care that is accessible, we need to assess the use of the five hospitals currently used to deliver services and ensure community services are delivered in appropriate locations and environments  Workforce: We had significant challenges staffing the full contingent of 264 beds (such as recruiting and retaining appropriate employees), which impacted the delivery of clinical services within the community. While the temporary closure of beds has helped, the current position shares similar challenges, though reduced in scale since moving towards Home First services. However, the impact of nationally recognised pressures, such as the ageing workforce and Brexit, are only starting to be felt locally, and staff surveys show that morale in local community services has been lower than in peer organisations  Financial: There are already significant financial sustainability challenges today. These are likely to grow as inflation and demand growth continue to outstrip increases to funding.

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The following narrative highlights the areas where 2019/20 plans are bespoke to North Staffordshire and Stoke-on-Trent CCGs.

D2A The North is operating a full D2A model across both home and bed based services, in line with modelling. Home First is now fully implemented and is beginning to turnaround the numbers of patients who are medically fit for discharge (MFFD) and helping to reduce DTOCs since April 2018. The availability and accessibility of Home First within the North has significantly improved over the year; in Feb 18 the average days waiting for patients within the acute hospital for Home First was 5 days and is now currently <1 day.

There has also been a positive improvement in the average length of stay within the community D2A bed base across the North supporting patients to their long term preferred place of care in a timely manner.

Musculoskeletal (MSK) In the North, the first contact practitioner (FCP) model is currently being piloted. The current service model varies and comprises of a series of three service models that have been developed in different localities, they are however all managed and provided by a single community services provider (MPFT) that support the clinical governance.

Supporting carers with a long term condition The CCGs have been liaising with People Plus around a specific health engagement plan, building on the work that has been done at UHNM and the Stoke-on-Trent GP practices. This targets carer support and awareness in a number of health locations including pharmacies, GP surgeries, hospitals and community teams. People Plus is delivering the service until September 2019.

Special Educational Needs and disabilities (SEND) Stoke-on-Trent will contribute to the role out of the Stoke-on-Trent Education and Health Care Hub, an electronic portal to improve efficacy of EHCPs; to streamline the process and improve quality of education health and care plans.

The CCG will attend the re-established Children Young People and Families Commissioning Group in order to: • develop a strategic approach across services for children and young people • share good practice • optimise opportunities to improve outcomes by creating innovative solutions • Ensure commissioned services include early identification, prevention and intervention approaches ensuring children have the best start in life. • Promote the development of an integrated and streamlined approach to the commissioning of services for children and young people; this includes health and social care, prevention and treatment.

Data and technology - Proposed Northern Staffordshire TECS Priorities and Programme 2019- 2020  Nursing/Care Homes – using TECS (Skype) to improve remote consultation between clinicians (practices/GP Federation led programmes/health professionals/any setting such as hospice) and patients/residents of Care/Nursing Homes. This will enhance access, provide good chronic disease management and enable regular medication reviews to improve compliance.  National vision: NHS Long Term Plan/GP Forward View – high impact focus including prevention; Online Consultation; GP/Patient Online; patient empowerment; workforce effectiveness and productivity; integrated care working. 46 | P a g e

 Support QIPP programmes, especially those relating to digital transformation in primary care e.g. focus on digital modes of delivery for care of LTCs (respiratory, cardiovascular, diabetes); align with end of life care delivery.  Work along other providers locally - with North Staffs GP Federation who is providing Care Home services, Combined Health Care, voluntary organisations to promote use of technology and innovation.  Upskilling citizens/patients to utilise TECS to enhance empowerment/self-care and support for family/social carers e.g. via apps/remote medicines use reviews with pharmacists – minimise likelihood of deterioration of health condition/reduce likelihood of hospital admission.  Continued rollout of learning around competence/confidence/capability/capacity of general practice teams and support succession of digital champions (clinicians/managers).  Continued rollout of TECS for video consultation and/or video consultation across all health settings e.g. Primary care, secondary care, mental health care, social care – interacting with Alliance Board.  Continue promotion of use of Facebook on practice sites for population-wide messaging to invite participation in STP/CCGs’ consultations with regard to services, boost uptake screening, post alerts (e.g. cyber security crisis) and closed Facebook sites for clinical supervision of peer support.

Social prescribing

VAST have been delivering a social prescribing project model since 2015, funded by the CCG. The service is within Care Navigation, GP referrals are increasing and many good working links have been formed throughout North Staffs. Any further developments of social prescribing will benefit from the ground work already carried out.

Funding awarded by PCC from delegated commissioning underspend for North Staffs. Operating model, evaluation process and early implementer localities have been proposed. North Staffordshire and Stoke-on- Trent CCGs to roll out social prescribing pilot across 20 GP practices initially.

Weekly meetings of the extensivist service are ongoing. There have been approximately 60 patients contacted so far. The team determines the level of support needed and all parties contribute where they can.

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Appendix 2 – Cannock Chase CCG, Stafford and Surrounds CCG and South East Staffordshire and Seisdon Peninsula CCG locality focus

It is recognised that during 2019/20 there will be variance in some of the service delivery/service improvements within localities and this section highlights the local plans for Cannock Chase CCG, Stafford and Surrounds CCG and South East Staffordshire and Seisdon Peninsula CCG. This section sets out priorities for the locality building on commissioning intentions approved in September 2018 and national requirements outlined in the long-term plan/planning guidance.

Anti-coagulation Development of a new end to end pathway and service for anti-coagulation in South Staffordshire –this will support the delivery of the circulatory right care opportunities.

PbR/High Cost Drugs Pilot a step-down pathway for rheumatoid arthritis patients receiving biologic drugs but are considered to be in remission. The protocol and pathway will be jointly produced with providers to develop a clinically effective service.

Autism Treatment Services The CCGs currently have different arrangements for adults with autism. There is a gap in the south of the county in respect of treatment once diagnosis has been obtained and this is emerging as a regular theme in patient complaints, particularly those from families with older adults with ASD related conditions. There is a long term support gap for adults, particularly where their parents are older and not able to provide the same level of care. A system-wide review will ensure the needs of this cohort will be met. We will re-procure the Children and Young Persons Autism service across South Staffordshire, ensuring that children and their families are involved in the development of the services through patient groups.

Referral to Treatment Times (RTT) South Staffordshire CCGs will ensure referrals are generated in line with agreed targets and local population need. This is being managed through the South West Alliance Board which consists of providers, commissioners and the local authority. The board are prioritising diabetes and Health Population management to ensure effective care for pre-diabetes and diabetes patients. The commissioners will ensure that local need is modelled and will work through this with membership boards to assess that the referrals generated are at the expected levels to meet the local needs.

Respiratory Respiratory has been identified as one of our largest areas of spend, in order to address some of the variation a series of workshops are being arranged to consider alternative approaches to service delivery through the Enhanced Primary Community Care (EPCC) work stream.

Key deliverable Action plan Timeline Support the delivery The roll out of the Mycopd app is on track to achieve march 2019 March 2019 of the respiratory roll out – the EQI , QIA & DPIA are 90 complete right care  A commission support manager has been tasked and set up as opportunities App license administrator  Engagement and awareness Training was commenced November 28th 2018 invites across the health economy were sent to sectors that represented the spectrum of potential providers

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 Training was provided in Stafford. Acute providers UHNM were offered the training and the use of the application, they however declined  Acute trust providers were reluctant to sign up to the offer and they felt this app would be better utilised in the community- we offered to facilitate a pathway that would support the acute providers in utilising the app for the benefit of the patients  If further training is required via Webex if update or reminder training is required for existing or new providers

Delivery of 10 high impact actions Continue to work towards delivering the 10 high impact actions in a phased approach building on the progress made by practices particularly around Active Signposting and Workflow optimisation

Delayed transfers of care (DTOC) Work up the provision of Home First in the South of the patch for the 19/20 contracts.

D2A in the south is less established which has impacted on the ability to sustain a reduced level of DTOCs across the patch; this is evident for patients waiting to return home and into a D2A bed.

The availability of Home First across the south is variable, which often leads to patients waiting in acute hospital beds unnecessarily. The CCGs, collaboratively with our community partners and Staffordshire County Council have developed re-commissioning proposals which include an anticipated implementation from 1st October 2019.

The CCGs are committed to improving the commissioned pathways to access D2A beds across the south, including East to ensure patients are transferred promptly to the most appropriate care setting for their needs. This includes working towards fewer than 15% of NHS continuing healthcare full assessments take place in an acute setting

End of Life The Ambitions for Palliative and End of Life Care Framework establishes the importance of offering everyone the chance to create a personalised care plan including the possibility of recording preferences that might guide others if the person were to lose capacity to make their own decisions.

Key deliverable Action Timeline Personalise care, to Develop a plan with providers to implement actions from the Ongoing improve end of life care South Staffordshire EOL voluntary sector alliance. through 2019/20

Social prescribing

Discussions taking place to ensure Cannock any work related to Social Potential options for social prescribing to include exploring the existing Prescribing is joined up between services CASP (support for patients with cancer or their carers) and the organisations Family Support Service (for children & young people up to 19 and parents/carers). An additional option is a social prescribing pilot by the library service.

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To be explored further on how to progress. Stafford Social Prescribing pilot ongoing in all three practices from the Stone & locality. Working with support Staffordshire - community navigator role in place who works with patients to direct them to appropriate services. Learning to inform future roll out. 1st quarter report awaited. Seisdon Social Prescribing pilot ongoing in the locality, led by Age UK. Learning and understanding of impact to inform future roll out and developments. Currently smaller pilots (as Discussions taking place with Staffordshire County Council to ensure detailed above) are in place, any work related to Social Prescribing is joined up between looking to share learning and organisations opportunities across the County.

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Appendix 3 – East Staffordshire CCG locality focus

It is recognised that during 2019/20 there will be variance in some of the service delivery/service improvements within localities and this section highlights the local plans for East Staffordshire CCG. This section sets out priorities for the locality building on commissioning intentions approved in September 2018 and national requirements outlined in the long-term plan/planning guidance.

East Staffordshire CCG will commission all acute, GP OoH and NHS111 services that formed part of the Improving Lives Contract with Virgin Care Services Limited directly from providers from May/June 2019. East Staffordshire CCG will agree this change with providers as part of dialogue for contracts commencing 1st April 2019.

Delayed transfers of care (DTOC) Widen community MADE (Home and Bed) rapid improvement cycle to include the East Staffordshire locality team.

The CCGs are committed to improving the commissioned pathways to access D2A beds across the south, including east to ensure patients are transferred promptly to the most appropriate care setting for their needs. This includes working towards fewer than 15% of NHS continuing healthcare full assessments take place in an acute setting

Social prescribing

Elements of social prescribing will be incorporated into the active signpost training. Some practices across East Staffs are already delivering social prescribing. These models will be looked at and discussions with practices on the best approach going forward.

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Appendix 4 - Supporting primary care

Primary Care Networks and networks Workforce plans that address recruitment and retention and capacity in primary care will be delivered by autumn 2020.

Deliverables for 2019/20:  Continue to implement the workforce development plan across Staffordshire. This includes various schemes to support recruitment and retention as well as building an alternative primary care workforce model utilising roles such as clinical pharmacists and Physicians Associates  Continue to implement the GP nursing ten point action plan to support the recruitment and retention of practice nursing workforce  Work with the locality networks to register formally as Primary Care Networks (PCNs) and support these PCNs prepare to meet the Network Contract DES registration requirements.  PCNs will require a GP Clinical Director role to be recruited by the networks so networks are clinically led  Engage with practices to establish 100% coverage of PCNs by July 2019 and ensuring a network agreement and the 2019/20 Network Contract DES is in place.  Develop the workforce delivery plan and strategy for Staffordshire  Engage with practices to minimise clinical variation through our Quality Improvement Framework (QIF) and membership schemes. The CCG will support associated learning and development by continuing to develop a clinical protected learning time (PLT) programme that will also be linked to STP clinical priorities.  Implement specification for prioritised investments including Local Enhanced Schemes (LES), Primary Medical Services (PMS) reinvestment  Provide primary care networks with primary care data analytics for population segmentation and risk stratification  Develop a primary care strategy as part of the system strategy to ensure sustainability and transformation of primary care and general practice.  Continue to provide extended access coverage across the population and work with NHS111 to enable direct booking into extended access services.  Work with NHS 111 to allow direct booking into GP Practice appointment booking systems.  Work with CSU strategy unit and NHSE to develop and support organisational development programme for primary care, particularly focusing on development of PCNs.

Commissioning in primary care A primary care investment review is underway; this includes a review of Local Enhanced Services (LES) and Local Improvement Schemes (LIS)  Develop a diagnostic spirometery service across Staffordshire and Stoke-on-Trent. This will support the delivery of the respiratory right care opportunities  Review the current wound care provision across Staffordshire with a view to reduce variation and provide continuity of care  Embed updated shared care agreements between primary care, community, acute and mental health services  Conduct a review of the phlebotomy provision and anticoagulation within primary care  Review the existing Elderly Facilitator LIS within North Staffordshire & Stoke-on-Trent to ensure it aligns as part of the Staying Well pathway

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Delivery of 10 high impact actions  Continue to work towards delivering the 10 high impact actions in a phased approach building on the progress made by practices particularly around Care Navigation (North)/Active Signposting (South) and Workflow optimisation  Focused support offered to practices not yet trained to encourage uptake  Utilise the dashboard designed to measure the impact of the scheme  Evaluation shared with practices to promote learning  Rollout of the programmes take place during 2019

High cost drugs – biosimilar uptake  Negotiate revised contract for 2019/20 with UHNM and MPFT to continue to support the uptake of biosimilar adalimumab

Primary care prescribing From April 2019 to March 2021  Continue to monitor practices on a monthly basis against the prescribing indicators set out within the quality premium guidance to reduce levels of inappropriate prescribing  Reviews by medicines optimisation team to include:  Chronic obstructive pulmonary disease (COPD) prescribing and clinical reviews  Palliative care prescribing and management of long term pain prescribing pathways and clinical reviews  Polypharmacy prescribing support and clinical reviews  Implementation of NHSE strategies on prescribing including drugs available over the counter, drugs of limited clinical value and optimisation of bio-similar medications  Transformation of prescription supply for products such as dressing, continence and stoma appliances, oral nutritional supplements and infant feeds with cow’s milk protein allergies to improve access to medications for patients and improve capacity within primary care  Review of the two medicines formulary with a view to agreeing one formulary in partnership with secondary care  Review local prescribing guidelines and update to support prescribing in primary care and enable reviews of good prescribing practice  Extend invoice reconciliation between acute providers against SUS data across the Staffordshire footprint

Care homes  Support general practice to implement the framework for enhancing health in care homes. Testing the model framework to enable people in care homes to have access to enhanced primary care. We will refine the current local incentive schemes and provide access to a named GP, wider services, medicine reviews and urgent out of hours care  Commission a medicines optimisation care home service from April 2019 for a select cohort of care homes. This will provide clinical pharmacy support, through pharmacists and pharmacy technicians, to support the CCG enhancing care in care homes agenda. The service will improve clinical pharmaceutical management of patients within care homes and improve the management of medication and appliances within care homes  Work closely with local authority colleagues to continually improve processes to monitor the quality and safety of care and make sure that nursing homes meet regulatory and local standards

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 Seek assurance and drive improvement through the recently reinstated CCG Nursing Home Quality, Information and Assurance Group  Continue to work with local authority colleagues to develop the jointly funded provider improvement response team (PIRT). The PIRT will focus on homes in the ‘requires improvement’ category in the CQC rating scale to reverse the CQC downward trend of homes within quality standards as well as reduce the number of homes that are outside of quality standards. Key performance indicators have been developed with local authority colleagues and will be used to measure outcomes  Continue to work with the LA in response to safeguarding concerns through support to LSE process, section 42 enquiries and safeguarding adult reviews  Continue to implement the hospice delivered care home scheme which will provide education and training to care home staff to support end of life patients (delivery of MDTs and advance care planning) Prepare for change in MCA Amendment Bill legislation for implementing Liberty Protection Safeguards which will require investment and system development for implementation from April 2020

Delayed transfers of care (DTOC)  Widen community MADE (Home and Bed) rapid improvement cycle to include the East Staffordshire locality team  Continue to work with NHS providers and Care Home Providers work together to develop a Trusted Assessor model that will work well in our health economy and that will be supported across Staffordshire and Stoke-on-Trent. The model will reflect lessons learned from the pilot in place in 2018  Work up the provision of Home First in the South of the patch for the 19/20 contracts  Speed up the assessment process and ensure that patients are sent home as soon as possible, and if home is not the best place for their immediate care, they will be transferred promptly to the most appropriate care setting for their needs. This includes working towards fewer than 15% of NHS continuing healthcare full assessments take place in an acute setting  Implement the high impact change model to reduce DToCs taking in to consideration the review that will conclude in early 2019, which will include clear requirements to continue to reduce DTOCs and improve the availability of care packages for patients ready to leave hospital

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Appendix 5 – Further detail on 2019/20 deliverables

Referral to Treatment Times (RTT) The CCGs will continue to work with providers around our constitutional targets in relation to:  18 weeks from referral to treatment (target 92%) this includes o Discussions in place regarding hip and knee schemes to reduce waiting times o Intention for a Pan Staffs Tier 3 gynae service ‘one stop shop’ developments to take place for 19/20. Aim for September 19/20 implementation o Innovation to appointments - Currently modelling ideas to reduce unnecessary referrals and appointments e.g. Telederm for Dermatology o Advice and Guidance - Implement advice and guidance into a number of specialties to assist in reducing unnecessary referrals to assist with addressing waiting lists o Self-Management and Shared Decision - This has been introduced across a number of specialties to educate patients in self-management of their condition, avoiding a referral o Work with clinicians through 19/20 to increase shared decision making so patients are fully informed before being referred  Deliver zero tolerance on 52 week waits with every patient waiting 6 months or longer to be contacted and offered the option of care at an alternative provider  The six weeks diagnostic test by continuing to work with providers on capacity plans and outsource diagnostics where there are capacity constraints  The CCGs will take into account any recommendations in relation to the National Medical Director’s Clinical Standards Review recommendations to be published in the spring that are relevant to RTT

Musculoskeletal (MSK) During 2019/20 as part of the STP planned care MSK programme we will work to improve MSK services. The key opportunities from the scheme are as follows: • Reduction in referrals into secondary care. The new model for 19/20 includes the outcome that no more than 30% of referrals to the triage service will then be sent to secondary care, to therefore improve conversion rates within secondary care for those referred • Introduce a pathway cost model to encourage reduction in unnecessary follow ups • Reduction in 1st outpatient attendance and therefore follow ups, with the development of the first contact practitioners within primary care and improving the triage and treat ‘one stop shop’ • Utilise capacity within County Hospital where possible • Reduction in onward referrals from MSK T&T services <30% • Reduction in associated surgical procedures, by maximising non-invasive treatment e.g. physiotherapy, pain management and exploring other alternatives to surgery throughout 2019/20 • Improved patient pathways in line with NICE Guidance • In the North, first contact practitioner (FCP) model is currently being piloted

We will be one of the early adopters for this opportunity which will incorporate: • Revised and agreed nationally integrated pathways across primary, intermediate and secondary care services, ensuring an effective and efficient service for patients where they are seen in the right place, receive right care at the right time • Improvements to the back pain pathways in line with the revised back pain pathway developed by NICE • A revision of the commissioned pathways based on best practice guidelines and improved patient outcomes including positive PROMs, reduction in referral to secondary care, low number of patients

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reporting back to the service within 6 months, improved wait times and accessibility for patients within the community • We will increase the collaborative and integrated engagement of clinicians and general practitioners as part of the review, development and implementation of new pathways for the Staffordshire population • Pathway mapping has been undertaken against current local provider pathways and these will commence with the new contract award in October 2019

The key actions • to follow pathways with regard to appropriate use of diagnostics and onward referral • to refer all patients through a Community MSK services as per pathways • acute providers not to accept referral unless it has been through a community MSK service • Community MSK services to onward refer <25% - to be adjusted in the current contract as currently at 30% • adherence to the MSK commissioning policy (PoLCV) • pathways and MSK policy contracted with providers • Completion of the FCP model pilot with evaluation through to an agreed contracted service being in place within 19/20

Diabetes Our local transformation plans reflect the recommendations in the elective care specialty handbooks: Patient education - Diabetes Bitesize education sessions have been promoted through bulletins and directly through membership boards to encourage patient attendance. Membership agreements included a focus on increased patient attendance at structured education course for patients newly diagnosed (less than one year) with a focus on Information on specific local sessions.

We will continue promotion with patients at My Diabetes sessions, local businesses and events. Year 2 funding has been secured via NHSE Treatment & Care Programme to increase attendance at structured education.

Advice and Guidance - Advice and guidance is being implemented through the LTC Integrated Care Team Transformation Programme.

Achievement of the NICE recommended treatment targets will continue to be measured via primary care as part of the Quality Improvement Framework. We will continue to:  undertake practice visits offering advice and support where required  ensure findings from practice visits will form training for the Protected Learning Time sessions  undertake an annual review of QIF indicators to ensure they are still appropriate

Mental health

Key deliverable Action plan Timescale By March 2020 IAPT services Increase access to psychological therapy (IAPT) services should be providing timely to 22% in 2019/20 and 25% in 2020/21. We will access to treatment for at achieve this by expanding integration with physical least 22% of those who health care pathways, primary care and the re- could benefit (people with procurement of IAPT services across Staffordshire and anxiety disorders and Stoke-on-Trent

56 | P a g e depression) At least 34% of children and We will increase access to NHS-funded community young people with a services to meet the needs of at least an extra 34% of diagnosable mental health children and young adults with diagnosable mental condition should receive health conditions treatment from an NHS- funded community mental health service By March 2021, at least 95% Work in partnership with Staffordshire and Stoke-on- of children and young Trent local authority colleagues to deliver the people with an eating integrated children and young people’s emotional well- disorder should be seen being and mental health strategy 2018-2023 within one week of an The mental health CYP project deliverables are: urgent referral Review the current eating disorder service provision to Jan 2019 to Jan By March 2021, at least 95% ensure compliance against national model of delivery 2021 of children and young Development of 7 day intensive outreach in North people with an eating Staffs to include support to young people with eating disorder should be seen disorders within four weeks of a routine referral Continued reduction in out Eliminate inappropriate out of area placements by of area placements for commissioning a Staffordshire and Stoke-on-Trent acute mental health care for psychiatric intensive care unit (PICU) pathway for adults, in line with agreed males and females with our two NHS providers to trajectories ensure seamless transition of care At least 60% people with a We will work with our mental health providers to April 2019 severe mental illness should implement NICE recommended screening and access receive a full annual to physical health checks for patients with a severe physical health check mental illness (SMI) across Staffordshire to meet the 60% national target. (50% of SMI register received in primary care, 10% of SMI register received in secondary care)

At least two thirds (66.7%) Work with the Memory Clinic and Alzheimer’s Society Commence – June of people with dementia, (whose contract will commence in May 19) to ensure 2019 Progress will aged 65 and over, should diagnosis rates are at least maintained and equity is be on going but receive a formal diagnosis achieved across Northern Staffordshire. Progress will changes will be be monitored monthly and shared with stakeholders expected by 31.12.19

Review of dementia specialist service specifications July 2019 and alignment with latest NICE guidance (To be complete by July 2019 for 19/20 financial year). Intention signalled via incorporation in to MPFT contract strategy

Development of strategic plan to align all March 2020 pathways/sectors to key outcomes/deliverables pathways Ensure alignment of older people’s and dementia strategy and that dementia is at forethought. Incorporation in to older people’s strategy as well. Improve post diagnostic Work with the Memory Clinic and Alzheimer’s Society Commence – June support and ensure care (whose contract will commence in May 19) to ensure 2019

57 | P a g e plans are recorded on the initial care plans from the memory clinic are recorded Progress will be on GP’s system and reviewed on the GP register and patients receive a minimum of a going but changes every 12 months 12 month face to face review of the care will be expected by plan. Progress will be monitored monthly and shared 31.01.10 with stakeholders. Perinatal mental health Continue to increase access to specialist perinatal Ongoing through mental health services ensuring an additional 136 2019 women in Staffordshire access the service. There will be a staged increase in activity through 2019 and will be monitored via the Staffordshire and Stoke-on-Trent maternity transformation programme board All age crisis and liaison We will deliver the 24/7 crisis care, mental health 2020/21 services programme project to ensure that regardless of age or locality patients are responded to and supported against national standards 50% of early intervention in Work with our NHS providers to achieve level 3 in the psychosis services graded at national audit of psychosis level 3 and reducing suicides Work with Staffordshire and Stoke-on-Trent public health teams to implement the Staffordshire and Stoke-on-Trent -on-Trent suicide action plan 2018- 2020 and deliver the ‘zero suicide’ ambition Work with providers to review and commission adult eating disorder services

Learning disabilities and autism

Key deliverable Action plan Timescale Reduction in reliance on Following the end of the Transforming Care Partnership April 2019 inpatient care for people (TCP) this work will need to be embedded in routine with a learning disability commissioning and monitoring of MH and LD services and/or autism (CCG- funded) to 18.5 inpatients Trajectories for the ongoing monitoring of this will be April 2019 per million adult population provided by March 2020 Consideration will be given to the future arrangements April 2019 for the management of this complex case load of patients, ensuring the successful aspects of the TCP are carried forward

Partnership working with the local authorities must Ongoing continue to ensure the continued success of this key transformation At least 75% of people on Part of Quality Improvement Framework in primary March 2020 the learning disability care TBC (North CCGs) (included in membership register should have had an agreement in the 3 south) annual health check CCGs are a member of Staffordshire LeDeR Steering Group has been active In place and Learning from Deaths since October 2017 and reports into the QSCC continuing report (LeDeR) steering group and have a named Local area contact for LeDeR as of 01/02/19 is the person with lead deputy director of nursing and quality. Associate local responsibility area contact is the quality improvement support manager There is a robust CCG plan A backlog of reviews does exist and this is reflective of April 2019 58 | P a g e in place to ensure that the status of LeDeR nationally. Work is ongoing to LeDeR reviews are address this and processes for allocating, monitoring undertaken within 6 and completing reviews are being strengthened. The months of the notification delivery of these plans will to some extent depend upon of death to the local area the allocation of anticipated funding for LeDeR for 2019/20 from NHS England, this funding has not yet been confirmed CCGs have systems in place Several individual actions have been taken to address Ongoing to analyse and address the specific recommendations and the steering group is themes and developing a wider action plan to address established recommendations from themes. completed LeDeR reviews The LeDeR steering group report to QSCC will be further April 2019 developed to ensure strong links between LeDeR, safeguarding and learning opportunities An annual report is Quarterly reports are submitted to the CCGs’ QSCC, Annually in line submitted to the reports include a summary of outcomes from reviews with reporting appropriate and actions taken requirements board/committee for all statutory partners, demonstrating action taken and outcomes from LeDeR reviews

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Appendix 6 – Regional Assurance Statements

Programme Next step deliverable Cancer All providers must start collecting mandatory data items for the 28-day faster diagnosis standard cohorts and, working through their Cancer Alliance, use the data to improve time to diagnosis, in particular for lung, prostate and colorectal cancers, before the standard is introduced in 2020. All Cancer Alliances should implement the national timed pathway for oesophago-gastric (OG) cancer by the end of 2019/20. Cancer Show improvement in the proportion of cancers diagnosed at stage 1 and 2, as progress towards the ambition of 75% cancers diagnosed at stage 1 and 2 by 2028/29, and reduces the proportion of cancers diagnosed following an emergency admission. All Alliances should work with the national programme to begin the roll out of Rapid Diagnostic Centres (RDCs) – starting with one RDC in each Alliance geography – and to transform diagnostic provision in their area. Where relevant, CCGs should participate in the national targeted lung health checks programme. Cancer Improve uptake of screening for bowel, cervical and breast cancers. Support the rollout of FIT in the bowel cancer screening programme and the implementation of HPV primary screening for cervical cancer [clarification to Annex B by Cancer Programme ] Cancer Implement the new radiotherapy service specification, including the establishment of Radiotherapy Networks. Cancer All providers should work with their designated Genomic Laboratory Hub to implement the national genomic test directory, the patient choice offer and fresh-frozen pathways. Cancer Ensure full implementation of breast cancer personalised (stratified) follow-up protocols by the end of 2019/20, so that from April 2020 approximately two-thirds of patients who finish treatment for breast cancer are on a supported self-management follow-up pathway. All Cancer Alliances should have in place clinically-agreed protocols for stratifying prostate and colorectal cancer patients and systems for remote monitoring by the end of 2019/20. Cancer Support delivery of regional plans for implementation of Phase 1 of the Cancer Workforce Plan.

Continuing Ensure that in more than 80% of cases with a positive NHS Continuing Healthcare (CHC) Checklist, the NHS CHC eligibility decision is made by Healthcare the CCG within 28 days from receipt of the Checklist (or other notification of potential eligibility). In addition, ensure there are no referrals breaching 28 days by more than 12 weeks in each reporting quarter, or by Q4 2019/20. Continuing Develop plans to incorporate Continuing Healthcare strategic improvement programme opportunities into QIPP for 2019/20 through Healthcare continued standardisation of process and adoption of best practice including the implementation of digital solutions, use of CHC SIP tools and guidance, and use of the CHAT assurance tools. All CHC QIPP plans greater than £500k or 5% of the total 2019/20 CCG Continuing Care budget must be signed off by the Chief Nurse at the CCG. Detailed QIPP plans outlining how the financial efficiencies will be achieved must be provided to NHSE regional teams by the end of quarter 1 and achievement against these plans should be reviewed at least on a quarterly basis. Continuing Ensure that less than 15% of all full assessments for NHS CHC funding take place in an acute hospital setting. Healthcare Personal Health Ensure the delivery of all new Continuing Healthcare home-based packages (excluding fast track), using the personal health budgets model as Budgets the default delivery process in all CCGs. 60 | P a g e

Elective Ensure all local transformation plans reflect the recommendations in the elective care specialty handbooks, where a relevant specialty has been identified as a priority. This includes development of endoscopy services as a High Impact Intervention along with other transformations such as transforming outpatients, which will be developed during 2019/20. Elective Continue to embed First Contact Practitioner (FCP) services, participate in the national evaluation process, and roll out FCP services more widely where opportunities are identified locally. Elective Maintain failsafe prioritisation processes and policies in all areas to manage the risk of harm to ophthalmology patients, and act on the outcomes from the eye health capacity reviews Elective Utilise capacity alerts on the NHS e-referral Service as a tool to support shifts in flows of activity identified in local commissioning plans and as a tool to support recovery where referral or activity plans are not being delivered in year. Maternity Continue against trajectory to deliver improvements in safety towards the 2020 ambition to reduce stillbirths, neonatal deaths, maternal death and brain injuries by 20% and by 50% in 2025. Maternity Deliver full implementation of the Saving Babies’ Lives Care Bundle (v2) by 31st March 2020. Maternity Increase the number of women receiving continuity of the person caring for them during pregnancy, birth and postnatally so that by March 2020, 35% of women are booked on to a continuity of carer pathway. All reasonable endeavours must be undertaken to ensure that continuity of carer is provided to groups that experience the poorest outcomes, such as women from ethnic minorities and the most deprived socio-economic groups. Continuity of carer should be delivered alongside ensuring high quality care maternity for all women. Maternity Continue against trajectory to deliver improvements in choice and personalisation through Local Maternity Systems so that by March 2021 all women have a personalised care plan. Maternity Continue against trajectory to deliver improvements in choice and personalisation through Local Maternity Systems so that by March 2021 more women can give birth in midwifery settings. Mental Health STP/ICS leaders, including an identified lead mental health provider, will review each CCG’s investment plan underpinning the MHIS to ensure it covers all of the priority areas for the programme and the related workforce requirements. Any outstanding concerns will be escalated to the NHS England/NHS Improvement regional teams. Mental Health Each CCG should work closely with their NHS and non-NHS provider partners and ALBs locally to deliver against workforce plans, including expansion and enabling of training and retention schemes. Workforce requirements should form part of finance and mental health investment plan discussions to ensure alignment with CCG financial submissions (as per process for above statement) Mental health Continue work to deliver expansion in the capacity and capability of the CYP workforce building towards 1,700 new staff and 3,400 existing staff trained to deliver evidence-based interventions by 2020/21. Mental health Continue to show evidence of local progress to transform children and young people’s mental health services through publication of refreshed joint agency Local Transformation Plans aligned to STPs - including recruit to train and 4 week waits where relevant

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Mental health Each CCG, as part of an STP footprint, should ensure increased access to NICE concordant community-based specialist perinatal mental health services (in secondary care settings) for at least 4.5% of their population birth rate, equating to an additional 20,000 women nationally. This means: •Ensuring effective use of additional CCG baseline investment for these services to continue and expand further following transformation funding in 2017/18 and 2018/19, as set out for 2019/20 in Chapter 3 of Implementing the Five Year Forward View for Mental Health •Ensuring this expansion includes timely access to psychological therapies as recommended in the published care pathway Mental health Ensure continued focus on improving access to psychology therapies (IAPT) services through meeting core IAPT offer requirements, all areas commissioning IAPT-LTC (psychological therapies for people with Long Term Conditions) services, and co-location of therapists in primary care. This requires CCGs to expand access, including for underrepresented groups like older people and BAME. For IAPT-LTC, this means CCGs should ensure they issue a contract variation to their local IAPT provider for the delivery of IAPT-LTC, and increase funding to the provider to achieve 22% access, whereby two thirds of the increase in access should be delivered within the IAPT-LTC service. Mental health Use additional 2019/20 baseline funding to stabilise and bolster core adult and older adult community mental health teams and services for people with the most complex needs, including people with diagnoses of personality disorder and eating disorders. Alongside this, undertake preparatory work for the mobilisation of a new integrated primary and community model as part of the Long Term Plan. This preparation should include strengthening local relationships between primary care, secondary care, local authorities and VCS services, developing understanding of local need through information and data (such as the NHS England and NHS Benchmarking Network community mental health services stocktake), and early workforce planning. Mental health All CCGs are encouraged to work with regional teams to develop plans to establish baselines and track access to PT-SMI (psychological therapies for people with severe mental illness, defined in the Five Year Forward View for Mental Health as Psychosis, Bipolar Disorder and Personality Disorder). For psychosis, this includes working with providers on delivering required training. Mental health For Crisis Resolution Home Treatment Teams (CRHTTs), CCGs must ensure that by the end of 2019/20 all populations have access to services for adults and older adults that are commissioned to meet the minimum functions of: (i) urgent and emergency community mental health assessment, and (ii) intensive home treatment as an alternative to inpatient admission, 24 hours a day, 7 days per week. This means that the services providing these functions can: •be accessed directly by telephone on a 24/7 basis, by new and known patients, with the contact details made clearly and publicly available to the local population; •be accessed 24/7 by all system partners (including police, ambulance, NHS111, GPs, members of the public); •visit people in their homes (or wherever they present in the community) on a 24/7 basis to conduct face to face assessments for people with urgent/emergency mental health needs; and •visit people under the care of the intensive home treatment function, as many times per day as needed, on a 24/7 basis. Commissioners should work with providers to assess local levels of demand and capacity in these functions, with a view to increasing capacity to achieve the above and further increasing capacity as necessary by 2020/21, to enable robust provision in line with the UCL CORE Crisis Resolution Team Fidelity Scale. Mental Health Deliver Core 24 mental health liaison standards for adults in 50% of acute hospitals subject to hospitals being able to successfully recruit (using transformation funding) 62 | P a g e

Mental Health 100% of areas should be progressing plans for their general acute hospitals to have mental health liaison services that can meet the specific needs of people of all ages, including children and young people and older adults by 2020/21. Mental health CCGs should ensure there is a crisis response that meets the needs of under 18 year olds. These should be staffed by practitioners who are trained and competent in meeting the specific mental health needs of children and young people. CCGs should then work towards delivering age-appropriate 24/7 crisis provision for children and young people (CYP) which combine crisis, liaison and intensive community support functions. This should apply whether or not the model selected by the CCG is a dedicated CYPMH service for 24/7 or extended hours, or a blended model that relies on Core24 to support CYP at some point during the 24 hours. Mental health As per the second part of the national standard for Early Intervention in Psychosis (EIP), CCGs are to ensure the 2018/19 commitment for NICE concordance for EIP from the implementation plan is met; then deliver against the further ambition for 50% of services to be graded at level 3 by the end of 2019/20. Mental health Ensure 60% national increase in access to Individual Placement and Support (IPS) services in 2019/20 through delivery against STP trajectories in line with best practice. Mental health Improve post-diagnostic dementia care in line with published guidance. Mental health Deliver against multi-agency suicide prevention plans, working towards a national 10% reduction in suicides by 2020/21. This includes working closely with mental health providers to ensure plans are in place for a zero-suicide ambition for mental health inpatients. Mental health Commissioners should ensure all providers, including third sector and independent sector providers, submit comprehensive data to the Mental Health Services Data Set (MHSDS) and Improving Access to Psychological Therapies Data set. Commissioners should work with providers to ensure data quality is proactively reviewed, national guidance is adhered to and the breadth of data submitted to the MHSDS accurately reflects local activity. Commissioners should routinely monitor MHSDS data and are encouraged to use MHSDS commissioner extracts to inform local discussions with providers. A mid-year review will be undertaken, and CCGs will be expected to ensure appropriate contract penalties are applied where providers have failed to meet data reporting and data quality standards. Mental health Evidence plans and preparation to partner with Provider Collaborative to manage care for patients from the area needing specialised services. Mental health Deliver liaison and diversion services to 100% of the population. Mental health Deliver against regional implementation plans to ensure that by 2020/21, inpatient stays for children and young people will only take place where clinically appropriate, will have the minimum possible length of stay, and will be as close to home as possible to avoid inappropriate out of area placements, within a context of 150-180 additional beds by 2020/21 Primary Care Actively support the establishment of Primary Care Networks (PCNs) within the geographical area to ensure that every practice in England is a part of a local PCN (serving populations of around 30,000 to 50,000) as soon as is possible, to achieve 100% coverage by 30 June 2019 at the latest. Primary Care Support the introduction of any nationally-agreed contract arrangements for PCNs, ensuring that community services are configured in line with PCN boundaries. Primary Care Provide a minimum of £1.50 per head of financial support to PCNs for their management and organisational development. This investment should start in 2019/20 and continue each year until 31 March 2024 Primary Care Support PCNs in their development and ensure they are practically supported to access the PCN Development Programme by 31 March 2020.

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Primary Care Ensure that PCNs are provided with primary care data analytics for population segmentation and risk stratification based on national data, complemented with local flows, to allow them to understand in depth their populations’ health and care needs for symptomatic and prevention programmes including screening and immunisation services by 1 July 2019 at the latest, and then on an ongoing basis at regular intervals as agreed locally. Primary Care Ensure that PCNs work together including at place level to ensure they play a full role in improving services commissioned and provided at that level, including urgent and emergency care services, and ensure every PCN is working to implement the comprehensive model for personalised care. Primary Care Ensure that the delegated budgets received are used to support the development of all practices in the context of PCN development, with a detailed local plan published by 1 July 2019 showing that every practice is actively engaged and all activity is completed by 31 March 2020 (ensuring delivery of at least two high-impact actions set out in the GPFV including Online consultations; Reception and clerical training; and Time for Care), to be determined through a diagnostic/evidence-based approach that enables deployment of targeted development offers in the most effective way to support, strengthen and transform services for the benefits of staff and patients locally. Primary Care Ensure that the local practice development plans continue to identify those practices who need more intensive and immediate support to stabilise, build their resilience and become sustainable. 75% of 2019/20 sustainability and resilience funding (allocated by NHS England) must be spent by 31 December 2019, with 100% of the allocation spent by 31 March 2020. Primary Care • Recruit the share of the additional 5000 doctors and maximise the impact of the over 5000 other health professionals already recruited since the GPFV was published as part of the multidisciplinary workforce, using all available channels and initiatives. This must include development of a detailed STP/ICS workforce plan with trajectories detailed by role type, taking into account local multi-disciplinary workforce needs (based on capacity and demand), and working with PCNs as they develop to recruit an expanded range of clinicians and other professionals. As part of this, plan specifically to retain as many GP trainees as possible at an STP/ICS level after completing specialist training; with as many of these as possible taking up substantive roles in the local primary care workforce by 31 March 2020. Primary Care Maximise retention of experienced, effective staff (doctors, nurses and other health professionals), with specific actions/focus in areas which have greatest workforce challenges and with roles where attrition is highest. This includes actions which are shown to have positive impact, (identified by the GP Retention Intensive Support Sites and wider retention programmes) and are tailored to local circumstances. The national GP Retention Scheme should also be offered to support all eligible GPs who cannot work a regular part-time position (up to 4 sessions per week) to remain in practice. Primary Care Continue planned investment in upgrading local primary care facilities, ensuring completion of the pipeline of Estates and Technology Transformation schemes and other STP primary care capital schemes (that support the interoperability with other clinical and administrative systems). Primary Care Ensure oversight of schemes within the geographical area and work closely to ensure these schemes are delivered as planned within the timescales and budget set out for each project so that the benefits of this investment are realised by the improved facilities being used to support multidisciplinary working and the expansion of the primary care workforce. Primary Care Ensure that all GP practices are technically enabled to provide all the functionality that will be offered through the NHS App, as part of the Digital Primary Care transformation plan to ensure it is available to 100% of the population by 31 July 2019. Primary Care Support connectivity by keeping in touch with all doctors in the locality, whether they are working on a sessional or substantive basis. 64 | P a g e

Primary Care Deliver the GP nursing plan including working with HEE and higher education institutions to support nurses to choose primary care as a first destination and to retain experienced nurses already working in primary care. Primary Care Continue with commissioning and deployment of 180 pharmacists and 60 pharmacy technician posts (funded by the Pharmacy Integration Fund, with support from NHS England Regional Independent Care Sector Programme Management Offices), to improve medicines optimisation for care home residents by 31 March 2020. Primary Care Ensure that clinical pharmacists are recruited into practices in line with approved applications for the clinical pharmacist programme. Primary Care Ensure all staff in primary care settings have access to the support of a training hub and capacity to participate in training programmes (e.g. e- learning resources held by HEE); and that there is a plan to develop the agreed set of required functions by 31 March 2020. Primary Care Work with HEE to ensure robust training programmes are in place to adequately support workforce plans. Primary Care Continue providing extended access to general practice services, including at evenings and weekends, for 100% of the population. This must include ensuring access is available during peak times of demand, including bank holidays and across the Easter, Christmas and New Year periods. Primary Care Integrate extended access with other services at scale to deliver value for money and efficiencies and support compliance with national core requirements to maximise capacity, availability and utilisation of appointments for 100% of the population. Seven Day Continue to rollout the seven-day services four priority clinical standards to five specialist services (major trauma, heart attack, paediatric Services intensive care, vascular and stroke) and the seven-day services four priority clinical standards in hospitals to meet the overall ambition of 100% population coverage by 2020/21. Transforming Care CCGs to work with local partners to plan for and invest in appropriate community provision to support people to live in their local communities, in line with the Building the right support service model. Transforming Care Ensure more children and young people with a learning disability, autism or both get a community Care, Education and Treatment Review (CETR), such that 90% of under-18s admitted to hospital have either had a community CETR or a CETR post-admission. Transforming Care CCGs to ensure that they are represented at CETRs for Children and Young People who are inpatients; and can demonstrate an increase in compliance and quality of CETRs in line with national policy. Transforming Care CCGs to have a dynamic risk stratification process in place with a clear function of identifying those at risk of admission and to ensure that this is reviewed and updated on a regular basis. Transforming Care CCGs are a member of a Learning from Deaths report (LeDeR) steering group and have a named person with lead responsibility. Transforming Care There is a robust CCG plan in place to ensure that LeDeR reviews are undertaken within 6 months of the notification of death to the local area.

Transforming Care CCGs have systems in place to analyse and address the themes and recommendations from completed LeDeR reviews. Transforming Care An annual report is submitted to the appropriate board/committee for all statutory partners, demonstrating action taken and outcomes from LeDeR reviews. Transforming Care There is a process in place to proactively identify children and young people and adults who are subject to regular and or prolonged restrictive practices including the use of seclusion/long term segregation and ensure that appropriate safeguarding and review measures are followed. UEC Maintain a 50%+ proportion of NHS 111 calls receiving clinical assessment.

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UEC Increase the percentage of people triaged by NHS 111 that are booked into a face-to-face appointment, where this is needed, to greater than 40% by 31st March 2020. UEC By 31st March 2020, reduce ‘A&E by default’ selections on the Directory of Services (DoS) to less than 1% by the commissioning of appropriate services that are accurately recorded on DoS. UEC Designate the majority of urgent treatment centres (UTC) by December 2019, with any exceptions to be agreed with the Regional Director. UEC Deliver a safe reduction in ambulance conveyance to EDs with trajectories to be agreed between services and their lead commissioners. UEC All ambulance services to meet, as a minimum, a baseline level of digital maturity including access to and usage of patient information at scene (e.g. Summary Care Record, Patient Demographic Service, Electronic Patient Record), access to service information at scene (e.g. DoS) and establishing Electronic Prescribing. UEC Ensure 100% of ambulance handovers occur within 30 minutes. UEC Ensure 100% of trusts are providing Same Day Emergency Care (12 hours day / 7 days week) by September 2019 with the aim of delivering 30% of non-elective admissions via SDEC by March 2020, UEC Ensure 100% of trusts are providing Same Day Emergency Care (12 hours day / 7 days week) by September 2019 with the aim of providing a frailty service (70 hours a week) by December 2019. UEC Nationally, deliver a 40% reduction in long stay patients (and long stay beds) from the March 2018 baseline by March 2020. UEC Continue to make progress on reducing delayed transfers of care (DTOC) to achieve and maintain a national average DTOC position of 4,000 or fewer daily delays, with local targets to be set for 2019/20 through Better Care Fund (BCF) plans. Further detail on these expectations as well as wider requirements for BCF plans will be published later in 2019. Diabetes Take action to reduce variation in achievement of the diabetes treatment targets (HbA1c, blood pressure and cholesterol for adults and HbA1c only for children) between GP practices in the CCG, particularly where the treatment target achievement in an individual GP practice is below the England average of 40.8%. Diabetes Ensure mechanisms are in place to refer individuals identified with Non-Diabetic Hyperglycaemia to the NHS Diabetes Prevention Programme to support them in reducing risk of Type 2 diabetes. Diabetes Ensure referrals are generated in line with agreed targets and local population need. Public Health For public health services the key aim is to support the commitments within the Cancer Strategy and the Section 7a public health functions agreement in relation to population screening and national immunisation programmes. For CCGs the focus will be on supporting NHS England to improve the quality and access to the diabetic eye and cancer screening programmes, the MMR immunisation programme, as well as the planning and delivery of an adequate cancer workforce covering symptomatic and screening services. To support this, CCGs must: • have a coherent plan to work with the local Public Health commissioning teams of NHS England to improve the quality, access to screening and immunisation programmes with a requirement to prioritise the public health service needs as part of PCN development and the sustainability and resilience of practices; and • work with PHE workforce planning team data, NHS England regions and local public health commissioning teams to develop plans supporting the prevention commitments for adequate workforce for the symptomatic and screening programme care pathways

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Public Health CCGs need to ensure they have capacity in place to deliver: •the additional colposcopies and cancer treatment that we expect to result from the conversion to HPV primary screening for cervical cancer in the short to medium term; and •the treatment of additional bowel cancer cases likely to follow the switch from FOBt to FIT 120ug/g. Public Health CCGs will support the implementation of the flu programme, with particular emphasis on: •·supporting improvement in uptake and reducing variation, and ensuring the recommended vaccines are used; •ensuring that there are clear arrangements in place to support oversight of the flu programme between October and March every year, which are broadly in line with the operating protocol developed for 2018/19; •supporting general practices to target at-risk population groups to improve uptake and coverage of the flu vaccination to achieve national uptake ambitions, also having a named flu lead in place whose role is to ensure that practices have ordered sufficient vaccine and that there are mechanisms in place to monitor supply and demand and to drive up uptake of flu vaccines; • supporting general practices (subject to national funding) to sustain and improve uptake and coverage of the routine childhood vaccination to achieve WHO targets for elimination and eradication of vaccine preventable diseases, improve cancer screening and immunisation uptake, flu vaccination uptake and other national screening and immunisation programmes; and • STPs/ICSs and NHS England public health commissioning teams working closely with their respective CCGs, taking a lead role in workforce planning and delivery across their geographical area.

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