Ealing CCG Draft Commissioning Intentions for 2013-14 Presentation to Health and Well Being Board Reference Group 27

th

September

1

1. AIM OF THE COMMISSIONING INTENTIONS 2. EALING HEALTH COMMISSIONING LANDSCAPE 3. EALING HEALTH NEEDS 4. FINANCIAL IMPLICATIONS 5. COMMISSIONING INTENTIONS 6. OTHER CONSIDATIONS

 To provide an overview of our plans to commission high quality health care to improve health outcomes for Ealing registered patients for 2013/14 and beyond and to set the scene for how we envisage services developing over the next 3 years;  To engage partners, patients and the wider public in shaping the way by which we respond to the health needs of Ealing residents and the way we commission the appropriate services to meet local needs;  To engage with our member practices in commissioning a model of high quality health care for the residents of Ealing; • • • • •

To support our work we will be seeking to:

Improve patient outcomes and reduce health inequalities for Ealing residents Strengthen our engagement with LINKs (Healthwatch) in all aspects of commissioning and development Develop, ratify and implement our Patient and Public Engagement Strategy Consolidate our working relations with the Local Authority as joint commissioners of services and identify further opportunities for joint working and strengthen current work arrangements around safeguarding Work with commissioners in the National Commissioning Board, NW London Commissioning Support Unit and the Local Authority to ensure that we have a seamless approach to the commissioning of services for Ealing residents

What will be different in 2013/14?

 Ealing Clinical Commissioning Consortium (ECCG) will be a statutory organisation, taking over commissioning responsibility from NHS Ealing as of 1 st April 2013  NW London Commissioning Support Unit will commission a wide range of services on behalf of ECCG (e.g. acute, community, mental health etc.), the CCG will need to develop its skills as an ‘intelligent customer’  Implementation of the NW London/Ealing Out-Of-Hospital Strategy will be underway  Strengthened role of the Health and Wellbeing Board  Change in the range of services commissioned by ECG with more services to be commissioned either by NCB or by LBE(PH)  More focused drive to commission evidence based services which offer best value for money and meet the changing local healthcare needs  Very challenging environment to achieve longer-term financial sustainability

1. DEPRIVATION:

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Ealing is 61 st most deprived Local Authority area and among top 20% nationally Dormers Wells ward is among the 1% most deprived areas nationally Perivale, South Acton, Southall Broadway and Greenford Green have become more deprived in recent years

2. LIFE EXPECTANCY:

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Overall higher life expectancy in Ealing compared to England average Differences in life expectancy across Ealing with Southall having the lowest at 76.3 for men and 80.9 for women

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Life expectancy inequalities have been increasing gradually for females in Ealing and reducing slightly for men but the gap remains large for men at 10.7 years and 3.9 years for women.

3. LIFESTYLE

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21% of adult in Ealing are smokers, which whilst not significantly different from the London (19.7%) or England average (20.5%) is the single biggest preventable cause of death

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Adult participation in 5x30 minutes of sport and active recreation per week decreased from 10.7% in 2005/06 to 8.1% in 2009/10

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It is estimated that 18.1% of the adult population in Ealing are obese and 16% of children

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aged 11 are obese Alcohol related admissions are the 5th highest in London Ealing has the 7th highest estimated prevalence of opiate and/or crack use in London.

4. What does the Joint Strategic Needs Assessment for 2012/13 tells us and how are we responding to it?

HEALTH NEED WHAT DOES JSNA TELLS US?

WHAT ARE WE GOING TO DO ABOUT IT?

2011 Consensus

: 338,400 people are residents of the LB Ealing. In contrast, over 370,000 are registered with an Ealing GP

Poverty, child poverty and unemployment Although relatively prosperous, Ealing has: - 8% of residents out-of-work benefits - 2,000 people unemployed for over 12 months - 9,290 workless households in Ealing - 18,900 children aged 0-18 living in poverty - Review joint working arrangements with local authority - Link into Local Authority strategies to tackle poverty and unemployment - Continued support for the IAPT (improving access to psychological therapies) Disability Physical activity & Obesity - 4% of residents are on incapacity benefit or employment support allowance - 1,580 on disability benefit - There are a further 1,980 people on carers allowance - 5,524 adults with physical disability known to the Ealing Council (2011/12) - Levels of physical activity amongst adults are significantly worse in Ealing compared to England average - An estimated 18.1 % of the adult and child population in Ealing are obese - Implement new carers strategy - Increase funding for equipment and adaptations budget - Strengthen public health programmes to promote physical activity - Focus on actions to address childhood obesity Early years and young people (0 17) Older People - total number people aged 0 to 14 will grow by 17.2% between 2012 to 2035 to 71,600 - Number of over 65s expected to grow by 14,900 between 2012 and 2030 - Prevalence of dementia expected to increase by 40% in over 65s between 2011 and 2030 - Continue plans to implement new community children’s nursing service - Drive up quality of maternity services - Continue with roll-out of Integrated Care Pilot - Extend MSK and falls services - Commission new enhanced dementia service

4. What does the Joint Strategic Needs Assessment for 2012/13 tells us and how are we responding to it?

HEALTH NEED

Smoking Alcohol & Drug abuse Cardiovascular Disease (CVD) – includes coronary heart disease stroke, and peripheral vascular disease Diabetes Respiratory Disease (Asthma, COPD) Cancer

WHAT DOES JSNA TELLS US?

- 21% of adults aged 18 and over in Ealing were smokers not significantly different from London 19.7% and the England average (20.5%) - Ealing alcohol admission rate 2010/11 is still above London and the England average - 7th highest estimated prevalence of opiate and/or crack use (OCU) in London (2,918) in 2010/11 - most common cause of deaths in Ealing and contributed to 1/3rd of all deaths in 2010. In 2010 the CVD mortality rate in Ealing for persons under 75 years was 83.8 per 100,000 population, a decrease of 49.3% from 1995 - 6.5% population are known to have diabetes vs. predicted prevalence of 8.6% By 2030 this is expected to increase to 10% (30,000 people) - Only 0.8% of Ealing patients diagnosed with COPD vs. estimated prevalence of 3.7% (6,200 undiagnosed) - Cancer is the second major cause of all premature deaths (>75 years) in Ealing in 2010

WHAT ARE WE GOING TO DO ABOUT IT?

- We will continue to commission our smoking cessation service

CONTINUED

- We are re-commissioning community drug and alcohol treatment services in line with best practice - Continue to fund vascular risk assessments in primary care - Review use of Grasp-AF diagnostics tool for Atrial Fibrillation in primary care - Roll out new community Anticoagulation service - Fully roll out Integrated Care Pilot (ICP) - Continue shift of diabetes activity into primary care and community clinics - Further support Diabetic Eye Screening programme - Bed in the Pulmonary Rehab Service commissioned in 2011/12 - Extend ICP to cover respiratory disease - Continue to work as part of NW London Cardiac network to commission rapid diagnostics and good outcomes from acute hospital - Fully implement the 2011/12 McMillan project

HEALTH NEED

Musculoskeletal Disorders Mental health disorders

WHAT DOES JSNA TELLS US?

- estimated that up to 30% of all GP consultations are about musculoskeletal complaints and GPs have reported that it is the top clinical reason for visits - Single largest cause for disability in Ealing and UK - 19,581 adults in Ealing were on depression GP registers in 2011 - 3,884 adults on psychoses registers - 1,214 adults on dementia registers - 1418 mental health hospital admissions (all ages) in 2010/11

WHAT ARE WE GOING TO DO ABOUT IT?

- Extend the See-and-Treat community MSK service - Shift additional MSK diagnostics activity from secondary care in community setting - We are continuing the process of re commissioning community mental health services to reduce reliance on inpatient mental health facilities through improved prevention and proactive management - Bedding in the acute psychiatric liaison service at Ealing Hospital

Spend and Outcome relative to other PCTs in England Lower Spend, Better Outcome

0,0 -0,5 -1,0 -1,5 2,5 2,0 1,5 1,0 0,5 -2,0 -2,5 -2,5 -2,0

Lower Spend, Worse Outcome

Hlth -1,5 LD Trauma Musc Neuro Neo Hear,Soc GU Canc,Resp,Dent End,Vision Pois MH,Gastro Blood,Skin,Mat Circ Inf -1,0 -0,5 0,0 0,5 1,0

Higher Spend, Better Outcome

1,5 2,0 2,5

Higher Spend, Worse Outcome Spend per head Z Score

• Very challenging financial environment

£m 2012/13 2013/14 2014/15 Total QIPP Targets

18.7

22.0

9.7

50.4

• Expected QIPP under-delivery in 2012/13 which will increase pressure on 2013/14 • The expected impact on acute hospitals as a result of implementing our QIPP Schemes is :

Cumulative Incremental Total by provider (£000) Total for all hospitals 2012/13 2013/14 2014/15 2012/13 2013/14 2014/15

14,201 34,610 52,071 14,201 20,409 17,461

PRINCIPLE

Closer to home

WHAT WILL IT INVOLVE?

WHAT WILL BE THE IMPACT?

• Self-managed • Domiciliary • Primary care • Ambulatory care • Specialist care 1. Improved independence for patients 2. Improved access to services 3. Better value for money

Effective joined up system Patient focussed intervention & service design

• Appropriate access.

• Consistent response to need.

• Shorter, more effective pathways.

• Right care, first time • Anticipating care needs.

• Patients involved in the design of the services.

• Patients and carers involved in the design of the care package 1. Better information flow leading to more effective triage and better hand-offs and discharges, leading to improved outcomes and better patient satisfaction with their healthcare journey 1. Better outcomes through greater adherence to treatment regimes by patients 2. Reduced reliance on emergency care 3. Improved patient satisfaction with the care they receive

Commissioning Intention Rapid Response Description

Providing effective urgent care response (as an alternative to acute care)

i.

Intermediate Care – Rapid Response (ICE)

– expand schemes to manage a wider range of patients who can be safely cared for outside of hospital

ii.

Work with London Ambulance Service (LAS) on new pathways

glycaemic attacks) e.g. hear and treat, reducing LAS conveyances, improved management of LTC e.g. diabetes (hypos and hyper

Effective discharge

Effective discharge when acute care is no longer clinically necessary • New schemes:

i.

ii.

Reduce very short stay admissions i.e. those of 1 day or less Reduce number of delayed transfers of care Clayponds

We are seeking views on the relocation of Clayponds wards to the EHT site; We will also seek to agree with ICO how some of the services provided on the wards e.g. stroke rehab are re-provided on the Ealing Hospital site or become more community based

Commissioning Intention Better Referrals Elective or Planned Care Pathway redesign Description

We intend to make sure our newly established Referral Facilitation Service (RFS)is expanded to provide a clinical triage of the following specialties:

Cardiology, ENT, Dermatology, Gastro, Paediatrics, Gynaecology, Urology, Orthopaedics

- We expect to see a reduction in referrals and more use of appropriate community services • •

CURRENT SCHEMES: Anticoagulation:

fully roll out the

community anticoagulation service

– we expect 85% of people needing to start taking warfarin and continue taking it will be managed within their local network

MSK:

we expect to bed in the See-and-Treat service commissioned in 2012. Following service impact assessment in July 2013, we will seek to scale up the service further increased reduction in outpatient T&O activity.

– thereby leading to • • •

NEW SCHEMES:

• For the following new pathways we will be seeking to re-commission a significant proportion of acute based activity in a community setting: Specific commissioning intentions and plans will be made available during October/November, however high level intentions are as follows:

Cardiology:

Develop new pathways for people with heart failure . Commission a cardiac rehabilitation service in the community

Dermatology

,

Gastro

,

Gynaecology, ENT :

Develop new pathways for these conditions. Adult audiology will be offered on a ‘Any Qualified Provider’ basis from October 2012

Respiratory:

During 2012/13 we have commissioned a community Pulmonary Rehabilitation service. We expect this to be fully in place for 13/14 and therefore see a reduction in acute admissions for COPD etc.

Commissioning Intention Case Management Schemes Description

• Existing schemes:

Enhanced medical care for nursing home residents

– we will be bedding in the service commissioned in 2012/13 and commissioning Ealing ICO to provide the training and skills development component to work alongside this service. This service should be in place later in the year . We are currently starting the tender process.

• • • New schemes:

End of Life Care

–we will review End of Life Care services with the aim of ensuring that we commission a best practice range of support services for the local population.

Falls

– we will be seeking to negotiate a local tariff for the whole fragility fractures and hip fractures, which spans acute and community services

McMillan project

– we will seek to implement the findings arising from the 6 months review of the McMillan project

Commissioning Intention Productivity improvement Description

• We will be seeking to review the productivity of all community services. This is to ensure that the services provide a level of activity which represents good value for money for commissioners and the population of Ealing. This exercise will allow us to identify the service areas which we will seek to focus development or redevelopment on. • For each service we will look at current performance levels of the Integrated Care Organisation and compare these to other services throughout the country. We will ask the ICO as a very minimum to achieve national average levels of productivity. We know that some services currently appear not to be giving value for money .

• AQP - will be seeking to extend the range of services offered by Any Qualified Provider (AQP). Potentially we will be looking to open Tissue Viability Services and Children’s Wheelchairs Services to AQP. • We will want to work with the ICO to ensure we are commissioning community services to better support our out of hospital plans e.g. for care of people with heart failures, diabetes etc.

Diabetes

• By Dec 2013 we will have a link Diabetes Specialist Nurse for each of the 7 emerging health networks, supported by a Nurse Consultant who will provide leadership to our community based diabetic services • We will have in place a third community clinic to support diabetic care in the community , to compliment existing clinics at Grand Union Village and Featherstone Road • We will focus on increasing the skills of staff both community and primary care to manage diabetes and our intention into work closely with the ICO to achieve this goal

Commiss ioning Intention

Mental Health

Description

Adult Mental Health Services CAMHS We will work with other commissioners in NW London to implement the NW London mental health strategy. This includes 3 specific pathways: • Psychiatric Liaison Series in all Acute Trusts; The pilot is being audited and we anticipate that this service will be formally commissioned in 2013/4 • Long Term Conditions; We will commission WLMHT to work more closely with local Acute services e.g. through the ICP to ensure better support for this people with a LTC such as diabetes as well as depression etc.

• Shifting settings of care; We expect to work with WLMHT and Social Care to look at opportunities to move patients to less intensive care settings be that between acute services and forensic services, from inpatient to community MHT care, or from CMHT care to primary or voluntary sector care • Improving Access To Psychological therapies; Service consolidating in 2013/14 and refocus on supporting primary care. Tender IAPT service via AQP in 2014/5 . We need to review provision and expenditure on CAMHs ; our initial focus will be on commissioning a day care model for patients with an eating disorder Dementia services Our priorities are: • To

reduce unnecessary admissions to hospital and care home

s by remodelling existing • • specifications including voluntary sector contracts to support work with primary care teams including case finding, pre-diagnosis support and liaison with memory services; • Provision of

carer education and support

;

Profiling of memory

service to support community based dementia service;

Links with Intermediate Care Services and Integrated Care Pilot

; • Work steam with Acute providers starting with EHT and Imperial to

review discharge of patients

with dementia diagnosis and to reduce lengths of stay; • Further details will be set out in Dementia paper to be discussed at ECC in September;

Commissioning Intention Acute activity recording & counting Description

• For 2013/14 all acute providers are required to provide a Unique Booking Reference Number (UBRN) in their monthly data submissions against each outpatient first attendance originating from general practitioners • All providers shall provide patient level data allowing the CCGs to be able to identify the patient, the diagnosis, treatment and associated cost, following national and local standards on information provision. This is in addition to providing the UBRN.

Payment of outpatient activity Outpatient Advice and Guidance Prescribing Planned Procedures with Thresholds Data Quality

• In 2013/14 it is NHS Ealing’s intention that we will move toward only paying for those referrals that have been processed via the RFS and that, providing there is clinical agreement, the scope of referrals processed and managed by the RFS will be extended.

• Ealing CCG will be seeking to develop capacity in Advice and Guidance Services accessed by Choose and Book; The CCG will be seeking that an agreed proportion of activity for a set number of specialities is transferred to this type of service. The Advice and Guidance Service is expected to be delivered at a lower tariff than an outpatient consultation. • We expect all secondary care providers in NW London to adhere to the joint Primary and Secondary Care prescribing formulary developed during 2012/13. Ealing CCG will be seeking to withhold payment for all drugs not covered by the formulary.

• Our expectation is that a) Following the clinical audit that there may be adjustment to the clinical threshold for treatment b) New PPwTs will be added to the existing list.

• We will expect to see improved SUS submissions (acute) with key information e.g. OP clinic codes, OP appointment times, data appointment booked, admission time. Discharge time in an agreed format to an agreed timetable

Commissioning Intention Maternity Description

• We expect all acute providers to implement the decision of the NW London working group looking at standardizing outcome and performance reporting • We will be looking to ensure that Ealing Hospital Trust has fully implemented the actions arising from the External Review conducted in 2012 and those of the Action Plan on reducing Caesarean section rates. We expect to see the introduction of new maternity pathway tariffs for maternity

AQP

• We will be seeking to identify a further two services which will follow the AQP (Any Qualified Provider) route for tendering.

Discharge Cancer

• Discharge summaries/clinical correspondence will require that all discharges are accompanied by a discharge summaries containing all necessary information to manage the patient and support the validation of charges (acute services). We require that a full discharge summary including an agreed data set is sent out with 24 hours of discharge. Increasingly we expect this provision of information to be communicated electronically • Use learning from McMillian pilot to reshape at EHT how cancer follow up is provided • Review levels and quality of submission to TCR

PBR

• Review PbR changes and implications for contracting

• • • • • • • • Our intention is to; Discuss our 2013/14 Commissioning Intentions at our Ealing Wide Members meeting on 11 September th Discuss our Commissioning Plans with partners during September. We will be formally meeting LinKs/HealthWatch (2/10) and we will meet with Ealing Overview and Scrutiny Panel on 6 November th We will use other opportunities e.g. Mental Health Partnership Board and Older Peoples/LTC Partnership Board in September to talk partners about our plans We will offer to meet other interested groups to talk about our plans At the end of September we will issue DRAFT high level letters indicating our Commissioning Plans noting that they are subject to further discussion NWL Commissioning Board; lead by CCG chairs will start its work in September/October to oversee a coordinated approach to planning the 2013/4 contracting round Acute Commissioning Vehicle (now part of CSU) will start its planning for contracting round e.g.

start looking at financial base lines in September/October By October ; Commissioning Intentions to be signed off, having reflected stakeholder feedback, by member practices