Agenda item

Ian Atkinson, Deputy Chief Officer RCCG, to present

 

Ian Atkinson, Deputy Chief Officer, Rotherham Clinical Commissioning Group gave a presentation on the review of the CCG’s Commissioning Plan for 2018-19.  Extensive consultation had been undertaken when the 2015-20 plan had been developed but the CCG had a statutory duty to update its plan.

 

After earlier discussion of the strategic priorities across the Rotherham health and care system with the HWBS and the IHSCP, this focused on the CCG’s plans and how Members would see joined up working on how the CCG planned to prioritise spending the healthcare pound across the borough. 

 

Presentation Overview

1)     Where we are now:

–             Financial position

–             Demographic Challenge.

–             Our Current Priorities, Delivery and Performance

2)     The plan, and how we put it together

3)     Review of priority areas

4)     PPG Feedback

 

Finance Allocation

•        17-18 £399 million

•        Savings of £75million over 5 years 2015-20

•        17-18 savings of £15.9million

•        18-19 and beyond awaiting settlement following Autumn statement

 

There was an efficiency challenge but no cuts in allocation and the CCG expected a small uplift for next year, although final confirmation would be in the new year.

 

Where we spend our money

48% Acute Care – hospital based, planned or urgent

12% Prescribing - nearly £30m p.a.

10% Primary Care

9% Mental Health

9% Community – district nursing, physiotherapy and occupational therapy

9% Joint commissioning including the LA and CHC

2% Corporate

1% Central Budgets

 

The CCG were seeing a reduction in spending on acute care which had previously been around 51% and was in line with the strategy to provide more care in a community based setting.  Spending on mental health had increased around national requirements linked to the parity of esteem agenda. 

 

System efficiency

Graph showing 2017-18 efficiency schemes

£75m over 5 years, £15m 17-18

2017-18 efficiency schemes were:

·           Corporate savings

·           Planned care - reducing unnecessary referrals to hospital and improving pathways and guidelines through GP colleagues. Introduction of clinical thresholds.  Reducing unnecessary follow up activity where best practice suggests it was not needed.

·           Urgent care - wrapping care around the person, reducing urgent admissions and where possible supporting people in the community.

·           Mental health

·           Medicine management – waste management and repeat prescribing schemes, but challenged by drug costs which were volatile.

·           Continuing healthcare

·           Hospital payment system – national tariffs were set for each hospital episode with inflation included and then the efficiencies taken out that the hospital had to make.

 

The efficiencies were on track so the CCG expected to deliver a balanced position.

 

Changing demographics

·           Rotherham is the 52nd most deprived out of 326 districts

·           50,370 Rotherham residents (19.5%) live in the most deprived 10% of England (this has increased)

·           Rotherham has 8,640 residents (3.3%) in Ferham, Eastwood, East Herringthorpe and Canklow living in the most deprived 1% of England.

 

2015-20 Priority Areas

Strategic aims – The CCG strategic aims seek to address all five Health and Wellbeing Board Strategic Aims across all life stages and for all communities, both geographical and communities of interest.

 

1 Primary Care

2 Unscheduled Care

3 Transforming Community Services

4 Ambulance and Patient Transport

5 Clinical Referrals

6 Medicines Management

7 Mental Health

8 Learning Disabilities

9 Maternity and Children’s Services

10 Continuing Health and Funded Nursing Care

11 Palliative Care

12 Specialised Services

13 Joint working – local and regional

14 Child Sexual Exploitation

15 Cancer

 

Most priorities fed directly into the IHSCP although the CCG also had a wider remit, like other statutory organisations, on other areas that were less closely linked to the place plan such as palliative care, cancer targets, and continuing health and funded nursing care.  A delivery plan and key performance indicators sat below and were monitored quarterly.

 

Strategy delivery

·           Planned Care - contained growth in referrals and our system is in the top 10% nationally for 18 week performance.

·           Urgent Care - New Urgent and Emergency Care Centre now open and now refining the model and ways of working. Focus on improving performance

·           Primary Care - 31 practices now inspected by CQC, 27 rated good four require improvement.  Primary Care access data suggests best in South Yorkshire.  Update due to HSC in March.

·           Mental Health – Talking Therapies (referred to as IAPT) high performing in access, treatment and outcomes, having moved into top quartile.  Dementia diagnosis rates highest in Yorkshire & Humber and now it was a focus on onward care and care in the community as Rotherham still had rather a historic model.

·           Child and Adolescent Mental Health – CQC rated as good. Improved access times, ongoing journey of improvement with HSC having a good oversight and recommendations progressing.

·           Delayed Transfer of Care – System wide success, although it had been a challenge and performance was currently 1.8% (national target below 3.5%).  IBCF monies have supported some real transformational work.

 

The plan and how we put it together

·           RCCG has to have an up to date commissioning plan

·           Our GP Members, the 31 practices, recommend the plan for approval by our Governing Body

·           This year we are aligning the Rotherham Place Plan & Health and Well Being Strategy.

·           In the process, we include: CCG member practices & stakeholders, patients and the public

·           Our Governing Body and Clinical Executive have already reviewed the existing Plan and have endorsed the continuation of existing priority areas 

 

The review did highlight support for care homes to prevent hospital admissions and a need for better coordination between the various services commissioned that supported care homes.

 

Refreshing our plan

To date GP Members, Patients groups and the PPG forums have supported the CCG in giving feedback around many of the 15 priority commissioning areas;

 

In particular we would welcome further views regarding our proposed approach for the following strategic priority areas:

 

·           Urgent care – National drive to integrate, linking 111/Out of Hours and urgent access to Primary Care – Urgent Care Model for centre by 2020.

·           Primary care – 7 day Access – big push for 7:7 and evenings.Capital development at Waverley and new GP.  Workforce - issues with GPs and a need to utilise the wider skill mix.

·           Mental health

- Talking Therapies

- Crisis care, known as Core 24, in the urgent care centre and community crisis care. 

- Dementia - community diagnosis by GPs is positive.  The follow up is through the memory service provided by RDaSH but it could be GPs for ongoing care if trained appropriately.  Support for carers of people with dementia.

·           End of life care – Care in Community.  Work with hospice, hospice at home services across the borough and into care homes to keep people in the community setting as far as possible.

·           Maternity and children – Better Births national strategy, probably consultation in next year or so across SY&B.

·           Care homes – Support to prevent admission

 

Things had moved on in the last two years with the publication of the Five Year Forward View for Primary Care and the Five Year Forward for mental health plus the system changes at local level.  These were the main proposed changes with a detailed consultation document underpinning these that could be circulated so the HSC could go into the 15 priorities in more depth.  It covered what the CCG had said it would do, what it had done and what it planned to do.

 

Other sections in the plan

The following list are areas not covered in the presentation but are very important to the CCG, feedback is welcome:

•        Health & Wellbeing Strategy

•        Joint Strategic Needs Assessment

•        Medicines Management

•        Continuing Care & Funded Nursing Care

•        End of Life Care

•        Ambulance & Patient Transport Services

•        Specialised Commissioning

•        Public Involvement & Promotion of Choice

•        Health Inequalities

•        Statutory Responsibilities

•        Efficiency

•        Finance

•        Information Management & Technology

•        Communication

•        Performance & Assurance

•        Risk 

•        The prevention of Child Sexual Exploitation will remain a priority

 

What does this all mean?

•        Increasing and significant financial challenge for local health and social care economy.

•        RCCG will work with partners across the Rotherham Place, to best meet the needs of the Rotherham population.

•        Generally, and where this is better  for patients, RCCG wants to move services from Secondary (hospital) to Community/Primary Care.

•        CCG wants to commission services in Rotherham.

•        Where patient quality and outcomes can be improved, we will consider commissioning on a geographical area

 

Feedback from stakeholders

The CCG welcomes all feedback and any comments can be sent via the CCG email address Rotherhamccg@rotherham.nhs.uk

 

The current 2016/17 Commissioning Plan is available at http://www.rotherhamccg.nhs.uk/our-plan.htm

 

The first draft version of the 2018/19 Commissioning Plan will be circulated to stakeholders for comment mid-January.

 

CCG transformation capacity is finite so it is important that if new initiatives are prioritised some exiting initiatives are stopped.

 

The following questions were raised by Members following the presentation:

 

Could you update us on how we are performing against the 4-hour A&E target even though it is still early days for the new centre? And if we are not meeting the target what were the problems associated with it?

-        It had been a challenge to meet the 95% target as under the previous configuration before the new centre opened they had worked for the last two winters out of a decanted ward.  Although the new centre opened in July they were still challenged, averaging around 85% year to date but the focus was there to get performance up.  They had seen improvements in the last couple of weeks, averaging 90% in line with other hospitals in South Yorkshire and nationally. 

 

-        Key challenges were bedding in a new facility and new ways of working with triage and flow through of patients.  Flow in and out of the hospital was closely scrutinised.  The A&E Delivery Board met monthly and had significant focus and support across the system to improve performance.

 

Would it be possible to have information on the CQC ratings for the 31 GP practices so that Members could look at the surgeries in their own wards and see how they were doing?

-        All the information was in the public domain and a summary for the 31 practices would be provided.

 

With regard to DTOC, could savings from one area go elsewhere in the system, for example to mental health, or were they ringfenced?

-        What they were trying to do was improve the flow of patients through the hospital so that as soon as they were well they would go home to their normal place of residence or to other supported care if required. 

-        When patients were admitted to hospital there was a tariff for each admission of between £1000 and £2000 and the key was reducing the length of stay when someone was medically fit, prioritising patient health and the quality of care.  By that point the payment had already been made within the system so the focus was on the patient flow, both for the quality of care for the patient and for other patients who needed to come in to the hospital.  In terms of driving efficiency there were efficiencies if the length of stay could be reduced but taking out money directly around length of stay would certainly be a challenge.

 

What was the level of savings from actions taken on medicines management following the conference approximately 18 months ago?

-        The three areas involved were medicines waste, practice repeat prescribing and using the most cost appropriate drugs at any one time.  The £3m referred to was an aggregate of savings across all three and the breakdown was in the public domain as savings were reported to the governing body.

 

-        All three were considered successful including positive feedback from the public on the first two as many people had unwanted stocks of medicine due to unnecessary automated prescriptions.

 

Did the primary care budget include claims for compensation?

-        The budget was for the core GP contract and any additional enhanced services provided by GPs.  To discuss further following the meeting.

 

Following previous scrutiny work by HSC on improving access to GPs can you tell us if access has improved?

-        This had been a focus with extended hours and the three Saturday satellite hubs established in response to local need and the national direction.  The CCG’s primary care committee was considering how this could be extended to seven days to include Sundays and their work would conclude in the new year.

 

-        As mentioned earlier we are high performing and data could be provided on the availability of slots, although this will be covered in more depth in the March update.

 

Can you give an update on the new GP for Waverley as with increased houses going up this is creating additional pressure on the existing GP practice?

-        This is currently out to tender and the procurement process is due to close shortly.  Mobilisation would follow but the precise date would have to be confirmed as it linked in with the new building, but there would be a new practice within the next 12 months.

 

Ability to provide seven day cover if there were only two GPs in a practice.

-        The 2000 responses received for the recent CCG survey was positive in terms of engagement.  With the workforce challenges we could not expect all GPs to be 7:7, either locally or nationally.  Proposals would be more at scale in the system based around the hub model to ensure seven day population cover.  Plans are being developed and will be reported back in March.

 

With the reduction in nursing home places compared to residential care places, would patients be able to be placed appropriately in residential care homes if these did not have nurses on site?

-        This was a challenge within our system and the strategy for both nursing and residential care was about supporting people in the community and in the care setting as far as possible, working with the local authority. Pressures on nursing homes to have beds and available beds was significant. The challenge regarding nursing capacity in the system was acknowledged including for step up/down, to avoid hospital admissions and  support hospital discharge.

 

Would there be a need to keep revisiting capacity for dementia follow up post diagnosis?

-        With high diagnosis rates and population projections we would expect to diagnose more people with dementia, so part of the strategy is to work with primary care colleagues to do that, placing it at the heart of community care.  The existing resource for dementia follow up is not insignificant but we may need to change how families and carers are supported.  We probably would need to invest in post diagnostic support in the community, using GPs and community services to deliver that. For more complex needs central provision would still be needed to try and keep individuals within their community setting and their homes.  Dementia is central to mental health and is frequently discussed.

 

Did the RCCG plan support the aims of Public Health for prevention?

-        The Rotherham pound was finite but where the CCG could it would invest in and support on prevention.  It was very clear from the Place Board that prevention was at the heart of the place plan.

 

Could you give an update on the Rotherham Care Record?

-        This was a positive development and was a clinical system interface that would enable clinicians to have appropriate access to patient records.  For example if a patient came to the Urgent and Emergency Care Centre, with appropriate permissions, clinicians would be able to see some of the activity from primary care or mental health, providing a good understanding of the patient’s needs so they could offer the best support.

 

-        The information governance and IT behind developing the record was significant.  The right information governance for data sharing was in place, privacy impact assessments had been undertaken and the data sharing agreement developed, which had been endorsed by the Place Board in September.  The CCG, RMBC, TRFT and RDaSH were taking the agreement to enter into the RCR through their governance processes by the end of December 2017 with a view to  starting to flow data in February.

 

There had been a significant performance improvement on DTOC in the last few months, how had this been achieved so rapidly?

-        We had been at 6% earlier in the year making us an outlier in the Yorkshire and Humber.  RMBC commissioned an external review providing an independent view of our system which resulted in all partners signing up to a range of actions and recommendations.  The Council also committed a significant part of the IBCF to supporting DTOC, which was positive for the system as it was seen as new money.

 

-        Key things worked on were information sharing, looking at flows of patients and integration of discharge teams from care and health, which were bedding in well.  The issue was to sustain this position over winter, which would be a challenge.

 

Ian was thanked for his presentation.

 

As the commission had become inquorate during the meeting, Members agreed rather than resolved to:-

 

(1) Note the six strategic priority areas.

 

(2) Receive the final draft of the 2018-19 Rotherham Clinical Commissioning Group Commissioning Plan in January 2018.