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Achieving ExcellenceNHS Gloucestershire

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ceContentsSection Heading Page1 Executive Summary 32 NHS Gloucestershire Strategy 6

Vision & Values 6Strategic Principles 6Health Priorities & Health Outcomes 8Strategic Objectives 10How we developed our strategy 13

3 Health Need in Gloucestershire 16Demography of Gloucestershire 16Health need priorities for Gloucestershire 24Key priority health issues for districts identified in JSNA 24

4 A future model for service delivery 25Delivery model structure 26Tier 1 – Self-help and Preventive Services 26Tier 2 – Primary Care General Medical and Community Services, including Mental Health Services

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Tier 3 – Extended Primary Care Outpatient and Diagnostic Services and Community Inpatient services

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Tier 4 – Acute Sector Services 305 Delivering Excellence in Health – Commissioning a Comprehensive

Range of Services 32Introduction 33Staying Healthy 33Maternity & Newborn Care 35Children & Young People 42Long term Conditions 49Acute Care 51Planned Care 53Mental Health 58Learning Disabilities 60End of Life Care 62

6 Resourcing the Strategy 65Economic Climate 65Allocation Formula 66Medium term financial plan 66Efficiency 68

7 Enabling Delivery of the Strategy 72Working in Partnership to Achieve Excellence 72Involvement & Engagement 73Contestability & Marketing 77Practice Based Commissioning 79Quality, Commissioning Outcomes and Patient Experience 81Workforce development 83Our approach to equality and diversity 85Other supporting strategies 85

8 Implementation and Monitoring 879 Declaration of Board Approval 90Appendices1 Strategic context 912 Prioritisation Tool 983 Public Transport Access Times for Gloucestershire to GP and Acute Services 1004 Key Statistics for Gloucestershire 1015 Summarised Income and Expenditure comparison 103

Registered name: Gloucestershire Primary Care Trust.

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1. Executive Summary1.1 This is the second Strategic Plan of Gloucestershire Primary Care Trust (NHS Gloucestershire).

Since our first plan was produced in 2008 we have continued to refine our strategy, engage with local people to understand their needs, work hard with our partners to organise care around our patients and the public and deliver against national and regional NHS performance requirements. NHS Gloucestershire (the PCT) is in good financial health and we have also been able to meet our local commitments to improving health and access to services in line with our plans.

1.2 However, as we enter this second year of our strategic planning, public services, including the NHS, are facing one of the most financially challenging periods since the Second World War. The economic downturn will see almost ten years of unprecedented growth in health spending reduced, most likely, to a standstill in funding over a number of years from now on.

1.3 Despite this position, the expectation is that the NHS and therefore NHS Gloucestershire will continue to improve the experience of care for patients, meet the demand for services and above all, improve the quality of the care we provide to deliver the improved health outcomes we are seeking. So, we continue to pursue our vision of Achieving Excellence in Health for the People of Gloucestershire. We have also developed six strategic principles which underpin this vision and our values and these are:

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ceto improve health and wellbeing and work to create equality in life 1 expectancyto improve access to care and treatment and provide safer services2 to provide care closer to home3 to provide clinically effective, person-centred care which our patients and the 4 public judge to be of a high standardto ensure that all of our care providers will be active partners and 5 contributors to the broad network of health and social care across Gloucestershireto responsibly develop our business to meet our vision for the future.6

1.4 The people of Gloucestershire are amongst those who enjoy the best health of any community in Europe. The level of funding increase we have enjoyed over the last decade has enabled us to develop, improve and extend services across the board, to reach and maintain this position. The good news about the future, is that research shows that the quality and outcomes of care are not always dependent on high levels of funding. Some of the lower funded health care communities in the developed world exhibit some of the best health outcomes. Others have already made the order of change in funding and improvement that we must achieve.

1.5 In order to continue to improve health moving forward the PCT will need to learn from such health systems and refocus its efforts around a new set of enabling priorities which also support our vision, values and strategic principles by:

making services as productive and efficient as possible, especially those which •support frontline clinical services

rigorously ensuring we adopt national or international best practice and strong •evidence in designing services to make them as clinically effective as possible

relentlessly pursuing service quality in terms of safety, patient experience and •good access

providing services in the most appropriate, but least costly settings – and these •will often be more convenient for patients

putting more effort into working with communities and developing services to •prevent or delay ill health and avoidable conditions.

1.6 NHS Gloucestershire spends around £860 million per year on providing healthcare for its residents. Over the next five years our plans will reflect national and local policies for improving health and services, especially as set out in “High Quality Care for All” – The NHS Next Stage Review which promotes greater emphasis on promoting good health, reducing inequalities and preventing ill health. This vision is further developed in NHS South West’s Strategic Framework and these key policy documents are reflected in our strategic objectives. We will also use the Department of Health’s World Class Commissioning Framework to help us in developing our organisation to become truly world class in its approach to commissioning.

1.7 Our priorities for improving health over the next five years are:dealing with the consequences of an ageing population, and better supporting •people with long term conditionsaddressing the differences in health and life expectancy between the most and •the least deprived communitiestackling growing levels of obesity•tackling smoking•reducing levels of suicide and self harm, especially amongst men.•

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1.8 We will address these priorities through the development and delivery of high level plans called Strategic Commissioning Frameworks which will also address the joint health priority areas we have agreed with our local partners through the Gloucestershire Health & Community Wellbeing Strategy. These plans set out the specific initiatives we will deliver over the next 3-5 years to implement our priority improvements in health and service outcomes. They also indicate how these programmes will contribute to our medium term financial plan.

1.9 These Strategic Commissioning Frameworks cover nine broad service areas and we will develop more during 2010. The nine are:

Staying Healthy•Maternity & Newborn•Children & Young People•Long Term Conditions•Acute Care•Planned Care•Mental Health•Learning Disabilities•End of Life Care.•

1.10 We have also developed a new model of care provision which will support delivery of the nine frameworks. This model of care provision will address the service quality and efficiency gains we need to make to ensure we can continue to improve health, whilst living with a much tighter financial position. Key features of the PCT’s future model of care provision reflect our vision, enabling priorities and strategic principles and ensure:

Focus on Quality, innovation (best practice), Productivity and Prevention (QIPP)•Greater choice of service type and provider•More personalised and integrated care delivery •Clearly defined, high quality, specialist acute care•Facilities that are modern and fit for purpose.•

1.11 Finally, our plans for improving health can only be delivered if supporting, enabling strategies are robustly delivered. Some of the key enabling strategies are summarised in this document.

1.12 Although this plan covers a five year period, it is a live document and will be updated annually to reflect the changes happening both within NHS Gloucestershire and the environment around us.

1.13 This version of the plan is primarily intended for our main partners and providers. A summarised, more “reader friendly” version is being prepared for a much broader audience and will be available in February 2009.

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ce2. NHS Gloucestershire Strategy2.1 The people of Gloucestershire deserve a Primary Care Trust that is ambitious in the

pursuit of excellence in health – making sure that services are sensitive to the needs of the individual, accessible and focused on encouraging and maintaining independence and quality of life. Our strategy is focused on achieving this.

Our Vision Achieving excellence in health for the people of Gloucestershire

Our Values

We will:

Work with our patients to promote and support healthy living and self care•

Promote innovation in patient care and celebrate success•

Provide sustainable services as close to the patient’s home as possible where this is •consistent with safe, quality and cost effective care

Pay proper attention to partnerships and involve service users, carers, staff, •contractors, partners, and the public in developing services

Listen to our local communities and learn from feedback•

Communicate clearly and be honest about what can be achieved and the •challenges ahead

Treat our service users, carers and staff fairly with respect and politeness•

Trust and support our staff.•

How our vision and values were developed2.3 We have worked with our local partner organisations and talked to our community to

help to develop a vision, values that reflect those expected of the NHS as a whole and, as set out in “High Quality Care For All” – the NHS Next Stage Review.Our vision and values were adopted by the Board in January 2007 and they continue to be the touchstone against which we test ideas and innovations for improving our services. Vision and Values statements were developed using feedback from the organisation’s “grass roots” (staff at all levels), the PCT Professional Executive Committee and the Board.

Our Strategic Principles

2.4 We again worked with staff and local stakeholders to develop six strategic principles. We want to respond to the way people would like to experience health services, which will also help to promote our vision and values.

2.5 The six principles are:

1 To improve health and wellbeing and work to create equality in life expectancy

2 To improve access to care and treatment and provide safer services

3 To provide care closer to home

4 To provide clinically effective, person-centred care which our patients and the public judge to be of a high standard

5 To ensure all of our care providers will be active partners and contributors to the broad network of health and social care across Gloucestershire

6 To responsibly develop our service to meet our vision for the future.

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2.6 The six strategic principles along with the vision and values, provide a framework which NHS Gloucestershire uses to develop and review its Commissioning plans in individual service areas. The principles also enable us to appropriately reflect national and regional policy and are consistent with improving health outcomes in our priority areas. A summary of the national and regional policy framework in which our plan has been developed is shown at Appendix 1.

2.7 As individual strategies and implementation plans are developed, they are tested against these core elements of our strategy.

What the Principles mean in practiceImprove health and wellbeing and work to create equality in life expectancy

2.8 We will continue to support people to live active and independent lives. We will maintain our priority of addressing inequalities and increase our focus on promoting good health and preventing ill health. However, NHS Gloucestershire cannot achieve this alone and we will continue to work with our partners in the Gloucestershire Conference to achieve the health improvements we seek.

Improve access to care and treatment and provide safer services2.9 We will continue our focus on patient safety, ensuring that all of our service providers put patient

safety at the heart of their organisation. We will actively seek improvements in access to care across all services, in terms of waiting times and appropriate local availability. In particular we will insist on the inclusion in contracts of clear access standards.

Provide care closer to home 2.10 We will retain a strong preference in our commissioning for local, community and home based services.

Where appropriate, we will actively seek to commission services from alternative providers who are able to provide clinically appropriate, very local services, preventing the need for people to travel outside of their local communities.

Provide clinically effective, person-centred care which our patients and users judge to be of a high standard

2.11 We will continuously seek to improve the quality of the care and services we commission whilst ensuring that we improve service productivity and efficiency and secure better value for money. We wish to extend choice for local people across the full pathway of care, from prevention to specialist intervention, using the most up-to-date technologies and approaches to extend the range of choices available. We will ensure that patients and/or their carers are actively involved in decisions about their care. We will continue to seek the views of the local population on the services that we commission, using a range of methods and recognise the importance of reaching seldom heard individuals and communities.

All of our care providers will be active partners and contributors to the broad network of health and social care across Gloucestershire.

2.12 In commissioning services from existing and new providers, we will insist on principles of integration and joint working, with a focus on the patient experience of care. We will support providers in working together and encourage effective sharing of information between agencies where this will improve care outcomes.

Responsibly develop our business to meet our vision for the future 2.13 We will consistently recognise the local environment and economy of Gloucestershire within which

we are a partner: as a provider of care; an employer; a consumer and a leader. We will continue to focus our strategic direction on the health and wellbeing challenges that face our community and encourage working with our partners and providers to do the same. Our business development also needs to be sustainable, taking account of the challenging economic conditions. This will include engagement in both commissioning new improved services as well as de-commissioning services as necessary. We face some difficult choices ahead in terms of investment decisions and we will need to be determined in our commitment to the health improvement priorities we have identified. We also need to consider the environmental impact of service delivery and we will

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cework to reduce waste, improve service quality and productivity and improve our energy efficiency to reduce our carbon footprint.

2.14 The adoption of these principles is further demonstrated in our medium term strategic commissioning frameworks summarised in section 5.

Our Health Need priorities

2.15 The Joint Strategic Needs Assessment (JSNA) is the means by which we analyse the health and social care needs of our population. They reflect both the analysed health status of our population and increasingly include the results of engagement with patients and the public. The plans we are developing and delivering to meet these health needs are designed to ensure we reflect all of the key elements of our strategy

2.16 The key issues resulting from the JSNA process are as follows:

Health Need Priorities for Gloucestershire Source JSNA

Consequences of an ageing population z

Closing the life expectancy gap between the most and least deprived areas z

Closing the health inequalities gap between the most and least deprived areas z

Tackling obesity in children and adults z

Tackling smoking in adults z

Reducing mortality rates from suicide and undetermined injury z

Health Outcomes

2.17 To help provide a focus for improvement around these and other key health priorities arising from the JSNA, NHS Gloucestershire has engaged with clinical staff and other stakeholders to identify a set of specific measurable health outcomes. The nationally agreed metrics associated with these outcomes will be used as sample measures of the health improvement progress for Gloucestershire as a whole, over a five year period, as part of the World Class Commissioning Assurance process.

2.18 The health outcomes we selected are shown in Table 1.

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Table 1: The health outcomes:

Outcome Metric Reason for selection1 Health inequalities Slope Index of inequality for life

expectancy at birth at LSOAMandatory. Will improve the health of our most deprived communities

2 Life expectancy Life expectancy at time of birth, Years

Mandatory. Will demonstrate the overall impact of health improvements

3 Smoking quitters Rate per 100,000 population aged 16 and over

Single biggest influence on the health of the most deprived in our population

4 Under 18 conception rate

Teenage conception rate per 1000 females, aged 15-17

High levels disproportionately impact the health & social care system

5 Percentage of patients receiving their first definitive treatment for cancer within two months of urgent referral for suspected cancer

Number of patients receiving their first definitive treatment within two months (62 days) of a GP or dentist urgent referral for suspected cancer

Need to improve timely access to services

6 Self reported experience of patients & users

Patient/user experience defined by five key dimensions:Access and waitingSafe, high quality co-ordinated servicesBuilding closer relationshipsClean, friendly, comfortable place to beBetter information, more choice

We need to get better at understanding and responding to the needs and wishes of patients and the public to maximise the clinical benefits we can achieve in delivering services

7 Coronary Vascular Disease (CVD) mortality

Directly standardised rates per 100,000 standard European population for all CVD mortality, (ICD10 I00-I99). Premature mortality (under 75 years)

A helpful overall measure of the impact of extensive service improvements being made for people with heart disease and at risk of stroke

8 4-hour A&E waiting time target

Percentage of patients who spent less than 4 hours in A&E

A key performance target which is not currently being met and will improve urgent and emergency access to services

9 Proportion of all deaths that occur at home

Proportion of all deaths that occur at home

A good measure of the impact we need to make in better care planning and offering choice to those at the end of life

10 For Improving Access to Psychological Therapies (IAPT) services the number of people assessed as moving to recovery as a proportion of those who have completed a course of psychological treatment

For IAPT services the number of people assessed as moving to recovery as a proportion of those who have completed a course of psychological treatment

Need to increase access to effective psychological therapies as a precursor to reducing the likelihood of suicide and self harm

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ce2.19 The health priorities and health outcomes upon which we have chosen to focus are

also consistent with the key priorities agreed through our local partnership strategy for health and wellbeing, The Gloucestershire Health and Community Wellbeing Strategy (see from paragraph 2.26).

Our Strategic Objectives

2.20 These objectives are measurable statements of action to meet the health needs and outcomes and future service delivery requirements for Gloucestershire. They also provide a focus for particular areas of service delivery where NHS Gloucestershire wishes to make significant improvements over the next five years as well as delivery of key national policy initiatives.

2.21 These objectives and stretch trajectories are the key drivers for nine strategic commissioning frameworks. These are high level delivery plans which detail the key initiatives planned to ensure our strategic objectives and outcomes are met.

NHS Gloucestershire Strategic ObjectivesSTAYING HEALTHY1.1 Reduce health inequalities between the most deprived and most affluent of our

communities, measured by a 30% reduction in the life expectancy gap1.2 Reduce mortality rates from heart disease and stroke and related diseases in

people aged under 75 to 65 per 100,000 European standardised population by 2013

1.3 Reduce mortality rates from suicide and undetermined injury to 7 per 100,000 ESP by 2013

1.4 Reduce smoking levels in the South West to equal the best in Europe by 20131.5 Have jointly agreed plans in place by 30 June 2009 in each local authority area to

reduce adult obesity (completed)1.6 Halt the rise in hospital admissions for alcohol related harm and achieve

downward trend by 2013

MATERNITY AND NEWBORN CARE2.1 Reduce the gap in infant mortality between the routine and manual group and

the population as a whole by at least 10% by 31 March 2010 (this applies to children under one and the baseline is 1997-1999)

2.2 Increase the percentage of women breastfeeding their children at 6-8 weeks to 60% by 31 March 2011

2.3 Continue to reduce maternal deaths and stillbirths each year2.4 Full delivery in each health community of Maternity Matters: Choice, access

and continuity of care in a safe service ahead of the national timescale of 31 December 2009. Target achieved. Additional work being undertaken to improve services. (Achievement of this ambition is predicated on parallel increases in the number of home births, increased midwifery led care and an increase in the number of normal deliveries).

2.5 Choice of type of antenatal care, including midwifery care or team care by 31 March 2009 – target achieved.

2.6 Choice of postnatal care, including how and where to access postnatal care by 31 March 2009 – target achieved.

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CHILDREN AND YOUNG PEOPLE3.1 By 2012 achieve a minimum of 90% immunisation against measles, mumps and rubella

(MMR)3.2 Ensure that same-day urgent assessments for acute care are available to all children who

need them, so as to halt the rise in emergency admissions for children by 31 March 20103.3 Ensure that by 31 March 2010 every child and young person needing long term support has

an identified care co-ordinator who manages their care needs and transition to adult services3.4 Make available the full range of specialist community-based child and adolescent mental

health services (Tiers 2 and 3) to residents by 31 March 20113.5 Reduce admissions to inpatient (Tier 4) child and adolescent mental health services by 20%

by 31 March 2011 from the 2006/07 baseline3.6 Reverse the trend in childhood obesity to achieve a clear downward trend in the level of

childhood obesity by 20133.7 Fully implement the National Service Framework for Children and Young People and

Maternity Services ahead of the national timescales of 2014

LONG TERM CONDITIONS4.1 Fully implement the quality requirements of the National Service Framework for Long Term

Conditions ahead of the national timescale of 20154.2 Fully implement the standards set out in the National Service Frameworks for older people,

Coronary Heart Disease, Diabetes and Renal services ahead of national timescales for their delivery

4.3 Reduce emergency bed days for people with long term conditions by 30% from the 2006/7 baseline by 31 March 2012

4.4 To reduce emergency admissions as a result of a fall by 30% from the 2006/7 baseline by 31 March 2012 through effective falls prevention and bone health programmes

ACUTE CARE5.1 95% of fractures requiring surgery will be operated on within 24 hours of admission or

becoming fit for surgery by 31 March 20105.2 95% of acute medical patients will have an assessment by an acute physician consultant

within four hours of admission by 31 March 20115.3 50% of patients who attend emergency departments (minors only), minor injury units, walk-

in centres, general practices and community settings for urgent care will have treatment initiated within two hours of arrival by 31 March 2011

5.4 Patients with a fractured neck of femur will have a length of stay in the best quartile for England by 31 March 2010

5.5 Accident and emergency attendances at acute hospitals will reduce over five years as people receive care in more appropriate local settings

5.6 No ambulance handover times at emergency departments will be greater than 15 minutes by 31 March 2010

5.7 The length of stay for acute medical care will be in the best quartile for England by 31 March 2011

5.8 NHS Gloucestershire will achieve emergency ambulance response times in the upper quartile nationally by 31 March 2010

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cePLANNED CARE6.1 90% of diagnostic tests are carried out and the results available to the referrer

within two weeks by 31 March 2011.6.2 75% of the 160 procedures identified by the British Association of Day

Surgery will be carried out as a day case or in line with the best practice recommendations of the Association by 31 March 2011

6.3 Outpatient follow-ups will be reduced to achieve best quartile performance by 31 March 2011

6.4 By 31 March 2011, 90% of new patients referred by a general practitioner will be able to book appointments, diagnostic tests and treatments at times and dates convenient to them

6.5 90% of admitted patients and 95% of non-admitted patients to be treated within eight weeks by 31 March 2011. This includes therapy services and the provision of wheelchairs.

6.6 Everyone wishing to access an NHS dentist will be able to do so by 31March 2011, with year-on-year improvement in the number of people accessing NHS dental services.

6.7 All patients to have an option available to them of extended opening hours in general practice by 31 March 2010

6.8 The National Cancer Reform Strategy (December 2007) will be implemented by 31 March 2011 in the South West, two years ahead of the national timetable.

MENTAL HEALTH7.1 Full implementation of the standards set out in the National Service Framework

for Mental Health by 31 December 2009 ahead of the national timescale of 31 March 2010

7.2 Improved access to specialist mental health services: routine multidisciplinary assessments started within eight weeks by 31 March 2010 and within four weeks by 31 March 2011. This includes responding to the particular needs of mothers, children, adolescents, adults of working age and older people

7.3 Improved access for carers: assessments and initial care plans for the identified main carer started within four weeks of a service user assessment by 31 March 2010

7.4 Adults with mild to moderate depression and anxiety to have access to psychological therapies by 31 March 2011, three years ahead of the national requirement

7.5 Specialist community-based eating disorder services, as defined in National Institute for Health and Clinical Excellence guidelines, to be available to residents by 31 March 2011

7.6 People who have experience of serious mental illness, and are discharged to primary care, to have a named worker in primary care to ensure rapid response and access to information and support by 31 March 2010

7.7 Use at least three best practice pathways, based on published guidelines from the National Institute for Health and Clinical Excellence, and incorporate service user-led outcomes in our commissioning requirements by 31 March 2011

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LEARNING DISABILITIES8.1 95% of general practices will be able to identify the people with a learning disability in the

practice population by 31 March 2009 – Achieved8.2 Each person with a learning disability will have full access to the physical and mental

health care they need. The health care is to be based on a comprehensive annual health check, included in a personal health plan and checked by a primary care professional by 31 March 2010

8.3 All people in NHS campus accommodation are to be housed in accommodation of their choice, with the appropriate level of care and support by 31 March 2010 –

8.4 People with a learning disability will have the same access to screening services as everyone else. Screening rates for breast and cervical cancer will be increased year-on-year, towards the same uptake rate as the general population of 80% by 2013

8.5 Full implementation of Valuing People: a new strategy for learning disability for the 21st century

END OF LIFE CARE9.1 Full implementation of all actions and recommendations of the national End of Life strategy 9.2 People can access at all times the ‘basic building blocks’ for effective care (community

nursing, equipment, palliative care drugs, specialist advice, the patient plan and rapid discharge from hospital) by 31 March 2011

2.22 These strategic objectives are the key drivers for nine Strategic Commissioning Frameworks, which describe the 3-5 year high level delivery plans for each of the headings. These frameworks show the strategic read through from our health priorities, delivered in the context of national and regional policy, using the specific measurable goals and outcomes shown above. They also demonstrate the application of our strategic principles which will ensure that key expectations of patients and the public are addressed.

How we developed our Strategy

2.23 Our strategy provides our high level approach to addressing the required role of PCTs, set out in national policy guidance.

2.24 The strategic direction of NHS Gloucestershire is determined by a number of key factors:The health needs of our population as set out in the Joint Strategic Needs Assessment (JSNA) •and their prioritisation. We have been developing the JSNA as a web based tool over the past 18 months and this now provides a rich and clear source of health needs information which is driving prioritisation and decision-making throughout the organisation down to individual GP practice level. Its development is ongoing and increasingly includes the results of public engagement.The needs and wants identified by patients and the public. We continue to enter dialogue on •a regular basis with patients and the public to ensure that their views are taken into account in the shaping of our priorities and changes to service delivery.National and regional health policy in the form of guidance and targets has a significant role in •determining our priorities and the nature of service developments.Resources available reflect how health needs and service developments are prioritised in order •to ensure that we deliver a comprehensive range of value for money services. This is set out in our resource strategy.The agreed roles and responsibilities of key partners and the extent to which we work •effectively together. We have developed effective working relationships with our key local statutory organisation partners primarily through a number of key forums and these are described in more detail in section 7.1.

2.25 In September 2008, in response to the health issues highlighted by the JSNA, the Gloucestershire Community Health & Wellbeing Partnership published the Gloucestershire Health & Community Wellbeing Strategy.

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ce2.26 The overall aim of the strategy is:

“To improve the overall health and wellbeing of people living in Gloucestershire and to narrow the gap in health outcomes between communities and groups living in our disadvantaged and more affluent areas”.

2.27 The strategy sets out how we will work together to make improvements in health in partnership with local councils, the police, voluntary and community groups and other service providers. The document covers work we will be doing over the next ten years across 10 shared priority areas:

Promoting active and healthy ageing1 Reducing Obesity (especially in childhood)2 Reducing alcohol harm3 Reducing smoking4 Improving sexual health5 Improving access to services for all6 Making workplaces healthier7 Improving emotional health and well-being8 Putting people first through the transformation of social care9 Providing accessible, healthy and safe housing.10

2.28 NHS Gloucestershire is committed to working in partnership in these areas which contribute significantly to health-specific priorities of NHS Gloucestershire. There is deliberate and significant overlap between the Gloucestershire Health & Community Wellbeing Strategy and the NHS Gloucestershire’s core strategy to ensure that areas of common priority across the Gloucestershire community and those for which the health community needs to lead, are given appropriate focus.

2.29 Figure 1 shows how the key elements of our strategy interrelate.

Figure 1.

Gloucestershire Healthand Community

Wellbeing StrategyPriority Areas

PCT Strategic Principlesand Priorities

Joint Strategic Plans PCT StrategicCommissioning Frameworks

PCT Enabling Strategiese.g. O.D., Estates, Choice

PCT and JointService Delivery Plans

PCT Operating Plan

2.30 We have undertaken public NHS Offer Conversations over the past two years to help us get a better understanding of how the local community’s views about the challenges that face the NHS and their preferences on how best to meet them.

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2.31 Under the themes of our strategic principles, NHS Gloucestershire asked the public, partners and our staff to influence future priorities at an early stage by sharing their thoughts and preferences. The findings helped us to develop this more comprehensive strategic plan.

2.32 The feedback from our ‘NHS Conversation events’ over Summer 2008 enabled us to build on the local commitments we made in 2007 and develop some new proposals around areas that people told us are important. These commitments form part of our annual operating plan and are consistent with our strategic direction.

2.33 Most recently, specific stakeholder events have been held during 2009 to test out the strategic principles underpinning this strategy and to seek further views on what our priorities should be. Alongside the stakeholder events, a questionnaire has been circulated widely to a range of patient and carer representatives and this has also been made available on-line.

2.34 We will continue to hold similar engagement events to support the ongoing process of strategy development.

2.35 NHS Gloucestershire remains strongly committed to public and patient involvement and we will continue to develop new approaches to ensuring that we are listening to our local population and in particular making every effort to reach “seldom heard” groups within our local communities.

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ce3. Health Need in Gloucestershire3.1 Our strategy is significantly informed by understanding the health needs of our

population. NHS Gloucestershire has a well developed Joint Strategic Needs Assessment tool (JSNA) which provides powerful analysis of the health issues we need to address in conjunction with our key partner organisations.The JSNA, when used alongside cost information, enables NHS Gloucestershire, Local Authorities and Local Strategic Partnerships (LSPs) to understand where they are spending their resources and identify the potential for shifting resources between activities to produce better outcomes and improved clinical effectiveness. This information is available locally at GP practice level.

Gloucestershire Demography

3.2 Gloucestershire is a diverse county with a population of approximately 597,500 residents. It is mainly rural, with the two major urban centres of Gloucester and Cheltenham at its heart. Nearly 40% of the county’s population live in Gloucester and Cheltenham.

Expected population changes

3.3 Estimates suggest that the county’s resident population will increase by 8.8% between 2007 and 2026 to 647,2001.The age structure of the population varies within the county, with some districts having a ‘younger’ profile than others. Figure 2 shows the projected population change for each district in Gloucestershire between 2007 and 2026.

Figure 2: Projected population in districts (thousands) 2007-2026

1 Gloucestershire Story, 2008. Research Team Chief Executive Support Unit, Gloucestershire County Council

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Cheltenham 114.5 115.1 114.9 114.6 114.4 114.1 114.3 114.5 114.5 114.6 114.7 114.9 115.0 115.1 115.4 115.6 115.7 115.8 116.1 116.4

Cotswold 84.8 85.2 85.4 85.5 85.7 85.8 85.9 86.0 86.1 86.3 86.5 86.6 86.8 86.9 87.2 87.4 87.6 87.9 88.1 88.5

Forest of Dean 84.1 84.2 85.6 86.8 88.0 89.2 88.9 88.6 88.2 88.1 87.9 87.7 87.4 87.2 87.1 87.1 87.0 86.9 86.9 86.9

Gloucester 116.5 117.5 117.4 117.2 117.1 117.0 117.6 118.1 118.7 119.2 119.8 120.4 121.0 121.7 122.4 123.1 123.9 124.6 125.3 126.1

Stroud 113.9 114.2 115.8 117.4 119.1 120.6 120.8 120.8 120.9 121.1 121.3 121.5 121.6 121.8 122.0 122.4 122.7 122.9 123.2 123.5

Tewkesbury 80.9 81.3 83.4 85.4 87.5 89.6 90.7 91.8 92.9 94.1 95.2 96.4 97.6 98.7 99.9 101.1 102.3 103.5 104.6 105.8

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

Source: Gloucestershire Story 2008. Research Team, Gloucestershire County Council

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3.4 Overall, the population of Gloucestershire is expected to follow national trends with an increase in the numbers of older people and single person households, creating an increased demand on housing, health and social services. Our older population (65+) is expected to grow by almost half between 2008 and 2025, from 106,800 to 158,200 – an increase of 52,400 people. Figure 3 shows the distribution of the population across age groups for males and females in 2008 (represented by bars) compared with 2025 (represented by the lines).

Within 3 years, people aged over 65 will outnumber people aged under 19 years in our county for the first time

Figure 3: Gloucestershire population pyramid: Showing change in age profile between 2008 and 2025

Source: eJSNA data

3.5 The county’s 0-19 population (138,800) is expected to remain almost static between 2008 and 2025, with a predicted increase of only 400 young people. The number of working age people (20 to 64 years old) is projected to increase by only 1.1% (3,700 people)2. This proportionate diminution in the working age population may further add to the burden of institutional care required over time, as the capacity for caring within families and communities may also become less.

3.6 The growth in Gloucestershire’s ageing population is predicted to result in a steep rise in the need for adult social care. This is illustrated in figure 4 which shows the percentage change in projected population and percentage change in Gloucestershire’s Community and Adult Care Directorate (CACD) service users between 2007 and 2026. The number of CACD service users is predicted to increase markedly by 49% in this time, from 20,848 CACD service users in 2007 to 31,068 in 2026.

Source: Gloucestershire Story 2008. Research Team, Gloucestershire County Council

2 Gloucestershire JSNA 2008

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ceFigure 4: Percentage change in projected population and percentage change in CACD service users between 2007 and 2026

Ethnicity

3.7 The latest data we have on the ethnic population of Gloucestershire comes from the Census 2001. This shows the county is also home to black and minority ethnic [BME] communities which tend to be located in the urban areas. For example, 7.5% of the residents of Gloucester city are from BME communities compared with only 2.8% in the county as a whole. In fact Gloucester city has the second highest proportion of BME residents in the South-west, exceeded only by Bristol (8.2%).

Migration

3.8 Since the Census 2001, there has been an increase in migrant workers, including those from Eastern Europe and this will not be reflected in the Census 2001 figures. A report produced by Gloucestershire County Council in November 2006 indicated that Gloucestershire is second only to Bristol as a destination for migrant workers into the South West region. Since 2003, 11,373 migrant workers have registered for work in Gloucestershire. All districts have seen an influx of migrant workers, with the Forest of Dean district recording the largest number of registrations (although they may be living outside the county)3 and Tewkesbury the smallest. Most (60.4%) of migrant workers who registered in Gloucestershire were from Eastern Europe, a further 15.8% were citizens of former soviet states. Polish workers accounted for 39.5% (4,488) of all the registered migrant workers. The numbers of migrant workers registering annually from the Indian subcontinent, Africa and South East Asia have decreased considerably since 2003-04. There are proportionately more males than females registering as migrant workers4.

3 There is some question over the interpretation of the data for Forest district, which is covered in greater detail in the report.

4 Migrant Workers In Gloucestershire, Fiona Williams, The Research Team Chief Executive’s Support Unit, Gloucestershire County Council.

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Gypsies and Travellers

3.9 It is not known exactly how many Gypsies and Travellers there are in the county as there is no mechanism for registering and counting this ethnic minority group. However, a local needs assessment of Gypsies and Travellers estimated there are 2,000 Gypsies and Travellers in the county. This includes ‘Show people’ and a proportion of Gypsies and Travellers in bricks and mortar accommodation5.The Census, whilst providing significant statistical data every ten years, has to date not included a category of Gypsies and Travellers. The Office for National Statistics is currently considering the inclusion of Gypsies and Travellers as an ethnic category for the 2011 census.

NHS Gloucestershire has taken specific steps to engage with this population, holding a workshop with representatives to help us to understand the issues they face when accessing health services. This has helped to shape our approach to delivering services to this, often hard to reach, community.

Homelessness

3.10 We do not know definitively the number of homeless in the county. The definition of homeless itself can be very broad and can include rough street sleepers, sex workers who have ”survival sex” and those who are “sofa surfers”. The homeless can have complex health needs and may need to engage with a wide variety of different services including mental health services and drug and alcohol services. They are also more likely to experience difficulties in accessing services.A homeless health needs assessment has been completed in 2009 which will enable NHS Gloucestershire to understand the health needs amongst both urban and rural homeless, across the county, so that effective services can be put in place to meet the needs of the population.

Deprivation

3.11 Deprivation throughout England can be measured using the Indices of Multiple Deprivation (IMD)6. These include 38 indicators of deprivation contained in seven domains relating to:

income deprivation•

employment deprivation•

health deprivation and disability•

education, skills and training deprivation•

barriers to housing and services•

living environment deprivation•

crime.•

3.12 The IMD measures the levels of deprivation that people experience within different areas of the country. This information is then used to identify areas where resources may need to be targeted.Table 2 shows the proportion of each locality’s patients who are registered with a Gloucestershire family doctor (GP) practice and who are living in neighbourhoods belonging to each of the five deprivation bands. These bands or ‘quintiles’ were derived by arranging all the local neighbourhoods (Lower Level Super Output Areas) in England in rank order according to their deprivation scores on the Index of Multiple Deprivation, and dividing them into five equal groups. It shows that there are 46,660 registered patients in Gloucestershire living in the most deprived fifth (20%) of areas nationally. Most of our areas of deprivation are in Cheltenham and Gloucester. Cotswold, Forest of Dean and Stroud do not contain any local neighbourhoods in the category of most deprived when compared nationally.

5 Hall, C, 2004, Health Inequalities in Gypsies and Travellers in Gloucestershire.

6 See www.communities.gov.uk.

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ceTable 2: Registered patients by district and quintile of deprivation (IMD 2007)

Local Authority

Quintile 1 – Most deprived Quintile 2 Quintile 3 Quintile 4

Quintile 5 – Least deprived Total

Cheltenham 14,099 18,643 14,599 24,459 45377 117,177Cotswold 1,219 11,584 37,508 30585 80,896Forest of Dean 9,579 41,141 22,505 1568 74,793Gloucester 31,167 23,390 19,163 20,968 26431 121,119Stroud 8,276 16,113 53,381 37227 114,997Tewkesbury 1,394 7,100 18,840 15,787 35839 78,960Gloucestershire 46,660 68,207 121,440 174,608 177027 587,942

Source: eJSNA

3.13 The IMD 2007 is an updated version of the IMD 2004 and uses the same methodology. This allows us to compare levels of deprivation in 2007 with those seen in 2004. IMD scores are ranked at a national level and it is therefore a ‘relative’ score. The results of this comparison are shown in Table 3. According to the IMD 2007, deprivation in Gloucestershire increased overall between 2004 and 2007 mainly relating to barriers to housing and services, crime and the living environment.

Cheltenham appears to have an increased level of deprivation compared to 2004; •Gloucester city also shows increased levels of deprivation compared with 2004; •Stroud district shows slight increase in deprivation compared to 2004;•Tewkesbury district has moved out of the least deprived fifth of areas (quintile) of •local authorities nationally;In Cotswold, there is also a slight move towards increased deprivation but it is still, as •a district, in the least deprived quintile nationally;Forest of Dean has improved its ranking showing a slight decrease in deprivation •compared to 2004.

Table 3: Comparison of Gloucestershire’s IMD rank scores between 2004 and 2007 (A move towards a rank of 1 indicates increasing deprivation)

District IMD 2004 rank IMD 2007 rankCheltenham 224 202Gloucester City 139 118Stroud 289 280Tewkesbury 296 279Cotswold 314 298Forest of Dean 195 201

Source: JSNA

3.14 Research shows a strong association between ill health and deprivation. Levels of smoking, obesity, alcohol-related hospital admissions and mental health problems, resulting in poorer health outcomes, are all higher in poorer neighbourhoods. Initial findings from the JSNA indicate that families and children in Gloucester are more likely to be living in areas of deprivation than the rest of the population.

Summary of health and life expectancy variation

3.15 Gloucestershire’s health compares favourably with national figures according to the 2001 census. Overall, 70.9% of the Gloucestershire population consider themselves in good health. Only 7.3% feel their health is ‘not good’, compared to a national figure of 9.2%.

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Between 1995-07, all age all cause mortality, early deaths from cancer and early deaths from heart disease and stroke has been steadily declining in the county and is lower than the average for England. Early death rates from circulatory diseases have been declining in all districts and are below the England and Wales average with the exception of Gloucester which has the highest rates of early deaths from circulatory diseases in the county, with rates in line with the England and Wales average.

Life expectancy3.16 The relatively good health experienced by Gloucestershire residents is reflected in life expectancy

measures, which measures average expected life span. The national Public Service Agreement (PSA) target on Life Expectancy at Birth (LEB) is shown below. In 2005-07 the average LEB in the county was high, being 82.7 years for females and 78.7 years for males, compared with 81.8 and 77.7 for England.

The national PSA target on life expectancy at birth

By 2010, increase average life expectancy at birth in England to 82.5 years for women and 78.6 years for men

LEB is a key indicator used to measure health inequalities. LEB rates differ significantly across the county. The most recent data we have shows that male LEB in the most deprived quintile of Gloucestershire is 8.3 years less than in the most affluent quintile (Figure 6).Source: ONS (PHMF & PHBF), Exeter database, DCLG 2007

Similarly, a female at birth in one of the most deprived areas of Gloucestershire can expect to have her lifespan shortened by 7.3 years compared to a female born into the most affluent areas (Figure 6).Source: ONS (PHMF & PHBF), Exeter database, DCLG 2007

Trends in Life Expectancy at Birth in Gloucestershire3.17 Figures 5 and 6 compare trends in males and female LEB between the most and least deprived

quintiles in Gloucestershire. Figure 5 shows that between 1999-2007 the trend in male LEB increased in both the most and least deprived quintiles in Gloucestershire, however the gap between our most and least deprived areas has not decreased. Figure 6 shows that between 1999-2007 the trend in female LEB increased in the least deprived quintile and decreased (worsened) in the most deprived quintile. Therefore the gap in female life expectancy in Gloucestershire has actually widened.

Figure 5: Showing trends in Male Life Expectancy at Birth in Gloucestershire’s most and least deprived quintiles

Notes: Life expectancy (years) at birth 1999-2001 to 2003-2005 (3 yr pooled values) from abridged life table technique – resident basis NB: Change from IMD 2004 to IMD 2007 for calculation of 2005-07 figures Source: PHIU

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ceFigure 6: Showing trends in female Life Expectancy at Birth in Gloucestershire’ most and least deprived quintiles

3.18 The Association of Public Health Observatories (APHO) has developed a tool to help primary care trusts and local authorities to understand inequalities within their area7. We have used the Health Inequalities Intervention Tool to analyse the diseases that contribute to the life expectancy gap within each district in Gloucestershire and to suggest preventive interventions that will impact on the life expectancy gap within each district and save years of life for the county’s residents.The key diseases making up the life expectancy gap in Gloucestershire’s districts vary by district and for males and females. This is shown in tables 4 and 5.

Table 4: Top 5 Key diseases making up the gap in life expectancy within each district of Gloucestershire (males)

Cheltenham FOD Gloucester Stroud Tewkesbury Cotswold1 Coronary heart

diseaseCoronary heart disease

Coronary heart disease

Chronic obstructive airways disease



2 Chronic obstructive airways disease

Lung cancer Chronic obstructive airways disease


StrokeOther cardiovascular diseases

3 Suicide and undetermined Injury

Suicide and undetermined injury

Chronic cirrhosis of the liver

Other cancers Lung cancer Stroke

4Lung Cancer

Deaths under 28 days

Suicide and undetermined Injury

Suicide and undetermined injuries


Road traffic accidents

5Pneumonia

Mental and behavioural disorders

Mental and behavioural disorders

Other accidentsOther digestive diseases

Other accidents

Source: adapted from Health Inequalities Intervention Tool, London Health Observatory (LHO), June 2008

7 www.lho.org.uk/HEALTH_INEQUALITIES/Health_Inequalities_Tool.aspx.

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Table 5: Top 5 Key diseases making up the gap in life expectancy within each district in Gloucestershire (females)

Cheltenham FOD Gloucester Stroud Tewkesbury Cotswold1 Chronic

obstructive airways disease

Coronary Heart Disease





2Other cancers Lung cancer


Other digestive diseases

Breast cancer Stroke

3 Coronary heart disease

Other cancers Other cancers StrokeChronic obstructive airways Disease

Other cancers

4Pneumonia Pneumonia Lung cancer

Suicide and undetermined injuries

Lung cancer / other cancers

Other digestive diseases

5

Lung cancer


Deaths under 28 days


Chronic cirrhosis of the liver

Ill defined conditions

Source: Source: adapted from Health Inequalities Intervention Tool, London Health Observatory (LHO), June 2008

3.19 It is estimated that more than half of the gap in health inequalities is attributable to smoking. The more deprived people are, the more likely they are to smoke, to inhale more nicotine (even when they smoke the same number of cigarettes as more affluent smokers), and the less likely they are to succeed in quitting8. Reducing smoking among the most deprived groups in Gloucestershire is crucial to narrowing the gap in life expectancy between our most and least deprived areas.

Infant Mortality

3.20 Infant death rates are one of the most sensitive indicators of health inequalities, with long-standing differences between social classes. Reducing this difference is a key national target and will help to break the inter-generational cycle of inequalities. Preventing infant deaths offers an effective approach to increasing life expectancy within a population. In Gloucestershire between 1997 and 2007, there has been a persistent gap in the infant death rate between our most and least deprived fifth of areas (quintiles) with higher rates in our more deprived areas. This is shown in Figure 7.

Figure 7: Infant mortality in Gloucestershire 1997-2007 by deprivation quintiles (five year pooled rates)

Source: eJSNA

8 Beyond Smoking Kills: Protecting Children, Reducing Inequalities, ASH, October 2008

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ceOverall, Gloucestershire’s infant mortality rate of 4.5 deaths per 1,000 live births, over the period 2004-06, is lower than the England average of 5.0. While there was variation within the districts over this same period, there was no statistically significant difference between them.

During the period 1996-05, babies born in the most deprived areas of Gloucestershire were twice as likely to die in their first year of life compared to those in the most affluent. While the local mortality rate is below the national rate, we still had 84 babies who died before their first birthday between 2004 and 2006.

Health needs and inequalities priorities

3.21 Data from the JSNA was used to inform The Healthy Gloucestershire Strategy. Part of the JSNA which relates to Gloucestershire as a whole is shown in Appendix 4. This has enabled us to identify some priority issues for Gloucestershire. Table 6 shows a summary of key issues emerging from the JSNA for each district in Gloucestershire.

Conclusion

3.22 The JSNA has been used to identify both the joint and health specific priorities stated in this plan. The key strategic health needs for Gloucestershire are stated in section 2.16.

Table 6: Key health issues for Gloucestershire districts identified in JSNACheltenham FOD Gloucester Stroud Tewkesbury CotswoldLevels of deprivation

The number of lone-pensioner households

The number of overcrowded households

The rate of hospital admissions related to alcohol

The rate of premature deaths from cancer

Levels of mental illness

Male life expectancy is lower than the county average

The rate of early deaths from all causes

The rate of premature deaths from circulatory diseases

The rate of premature death from cancer

The number of deaths from smoking

The levels of obesity in adults

The number of road injuries and deaths

The levels of teenage pregnancy

The number of people providing unpaid care


The number of older people admitted to hospital after a fall

The number of people with long-term limiting conditions

The most deprived district in Gloucestershire

The number of lone parent households

The number of overcrowded households

Life expectancy in males and females is lower than county average

The rate of premature deaths from circulatory diseases

The rate of premature deaths from cancer

Levels of healthy eating in adults

Levels of physical activity in adults

The rate of hospital admissions related to alcohol

The levels of physical activity in children

The levels of teenage pregnancy

The number of adults who smoke

The number of deaths from smoking


The increasing older population

The number of unpaid carers

The number of older people admitted to hospital after a fall





The increasing older population

The number of lone pensioner households


The levels of obesity in children


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4. A future model for service delivery Summary:4.1 NHS Gloucestershire has developed a clear vision for delivering our strategy which reflects our

key health needs, strategic principles and strategic objectives. In order to meet the health need and economic challenges we face, NHS Gloucestershire will aim to provide fully integrated effective care as close to the patient’s home as possible. We will be rigorous in ensuring that services are efficient and clinically effective and with an increasing focus on preventing ill health. This model will best support the needs of our ageing population, avoiding the need for hospital admissions and attendances. Hospital care will be clearly defined, specialist and high quality, such that unscheduled stays in hospital become shorter and less frequent for those with long term conditions and planned care is organised around the most effective pre-determined patient pathways. We also expect that patients will be more involved in the planning and delivery of their care and as far as possible, through a single point of contact.

4.2 We expect that this will mean measures to carefully contain the costs of health care in hospitals whilst expanding the range of clinically appropriate services available in community and primary care settings such as diagnostics and clinically assess and treat services (CATS). This will also include expansion of services which can prevent ill health such as weight management programmes and falls prevention.

4.3 Whilst expanding services in the primary and community care sectors, we also anticipate that significant efficiency and productivity gains can to be made here through service redesign and rationalisation via the Transforming Community Services agenda – a national policy initiative to improve community service design and delivery. This will include thorough analysis of our provider market and the use of collaboration with existing providers to achieve required improvement and market testing where this is likely to achieve a step change in service quality and performance.

Current Provider Landscape4.4 NHS Gloucestershire commissions services from local NHS Trusts including Gloucestershire Hospitals

NHS Foundation Trust, Gloucestershire Care Services (the PCT’s own provider arm), 2Gether NHS Foundation Trust, North Bristol NHS Trust, Great Western Hospitals NHS Foundation Trust, and University Hospitals Bristol NHS Foundation Trust.The Primary Care Trust also coordinates the planning and funding of all local NHS independent contractors including: 105 community pharmacies 85 GP practices 76 dental practices75 optometric practices

4.5 In addition to its commissioning responsibilities, the provider arm of the Primary Care Trust (Gloucestershire Care Services) is also a significant provider organisation in its own right, responsible for the provision of services in 10 community hospitals, community nursing, public health nursing, health visiting and school nursing, therapy services and a range of specialist community services to the Gloucestershire population.

KeyfeaturesofthePCT’sfutureservicemodelwillreflectourstrategicprinciples and in addition ensure:

Focus on Quality, innovation (best practice), Productivity and Prevention (QIPP)•

Greater choice of service type and provider•

More personalised and integrated care delivery •

Clearly defined, high quality, specialist acute care•

Services that are modern and fit for purpose•

4.6

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ce Delivery Model Structure

4.7 The PCT will develop services based upon four delivery levels. In addition to the proposed shift in health care provision settings to less acute environments, we are also committed to ensuring service effectiveness, productivity and value for money across all areas of service provision. The major opportunity for shifting care in this way is through the Transformation of Community Services which is now a major work programme in its own right within the PCT, in response to a national policy initiative. The delivery levels are set out below and are described in Figure 8.

Figure 8

Tier 4Acute

Tier 3Community BasedSpecialist Services

Tier 2Primary Medical andCommunity Services

Tier 1Self Help and Prevention

Tier 1 – Self-help and Preventive Services

4.8 Services in this tier will be characterised by:supporting individuals to take responsibility for their own health and some of their •health care needs

innovative provision of information and ill health prevention activities and support •using a variety of methods

providing informed choices about healthy lifestyles and services to improve health •and maintain independence

service provision and support from a diverse range of providers recognising that the •skills required for this work may be better developed in sectors other than health

services will focus in particular around tackling smoking, obesity, the needs of older •people, sexual health and mental health

success in this area should reduce and/or delay mortality in key disease areas •over time.

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Tier 2 – Primary Care General Medical and Community Services, including Mental Health Services

4.9 Services in this tier will be characterised by:services more traditionally delivered in primary care and in the community (such as GPs and •district nurses)

an increasingly wide range of activities including minor surgery, diagnostics such as blood tests, •electrocardiographs (ECGs) and follow up of patients after surgery (e.g. removal of sutures)

extended role for specialist opinion and treatment•

services targeted at the management of long term conditions, ill health prevention and best •practice management of planned care

an increased range of screening services to identify individuals most at risk of developing a •number of potentially serious conditions. For example, early detection and monitoring of high blood pressure with early treatment of high cholesterol and early identification and intervention for people with mild to moderate depression and anxiety

a reduced requirement for onward referral of these patient groups to secondary care specialists•

development of new facilities to accommodate a significant number of new and existing •services in a single primary care setting. This might include dentists, pharmacist, district nurses, social care staff and voluntary organisations.

Tier 2a – Children’s Centres and the Extended Schools Network

4.10 Services in this tier are characterised by:the continued presence of children’s centres across the county, closely linked into the network of •primary care

integrated working around a locality rather than a specific GP list across a broader range of •services including health visiting, psychology and speech & language therapy

developing integrated Family Support Services with a focus on the 0-4 age group•

for older children, focus will shift to the extended schools network where the Children’s Centres •will facilitate access to services at primary school level and occasionally secondary schools

access to some advice or open access services for healthy lifestyles (e.g. sexual health, drug and •alcohol use) will be available from a wider range of outlets where young people attend.

Tier 3 – Community Based Specialist ServicesThese services will generally be provided in the County’s 10 Community Hospitals or Care •Homes or in larger Primary Care Practice developments/health centres. (see figure 9)

These centres and services will sit between the services provided by the Tier 2 centres described •previously, and acute hospital services

These facilities may incorporate primary care and community services and will be commissioned •largely by the locality practice-based commissioners. Emphasis will be on services that can be based in the community but serve a population larger than tier 2 centres serve because of their more specialist nature and the economies of scale

Services will exploit new technology to reduce the need for inpatient stays in hospital.•

4.11

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ce4.12 NHS Gloucestershire undertook a significant engagement exercise in July 2008 to help

us develop the service principles which will influence how community hospital provision will develop over the next five years. The results were as follows:

1 All residents of Gloucestershire should have access to community hospital services within twenty minutes drive time.

2 A significant proportion of outpatient appointments (say, 50%) should be arranged in local centres.

3 Most local hospitals should offer ‘admission avoidance’ beds – the opportunity for a very short stay locally instead of transfer to one of the acute sites. Typically, for observation, assessment, or to allow a patient to stabilise.

4 Most local hospitals should offer ‘step down’ beds. So that if a patient from a locality with a community hospital is in an acute hospital, they may be transferred back to their local hospital as soon as possible.

5 There should be a county-wide ‘dynamic rehabilitation’ service that uses the network of community hospitals. ‘Dynamic’ means effective and active work to return patients to independent living where this is a possibility – it is different from ‘looking after.’

6 Most diagnostic images or procedures (e.g. endoscopy) should be arranged in local centres.

7 Most routine antenatal appointments should be arranged locally, including ultrasound examinations.

8 All Gloucestershire residents should have access to a minor injuries unit within 20 minutes.

9 Community hospitals will have proper income and expenditure accounts which will relate income to clinical activity and will be expected to be financially viable.

11 All local services will operate within clear clinical governance frameworks, will report on their clinical outcomes and will be expected to conform to national standards.

12 Local services will be provided in modern, fit for purpose healthcare facilities.

13 Non NHS investment and activity will be encouraged where appropriate.

14 Community hospitals must be fully integrated in the network of NHS and social services. This means that they must be active partners with primary care, social services, acute hospitals and all other providers.

15 There should be an increased focus on providing ‘Wellness’ services (sports, exercise, social activity) and other activities that draw in local residents and strengthen the ‘civic’ importance of the hospital.

Gloucestershire’s Community Hospitals

4.13 Gloucestershire has ten community hospitals which have a long history in the communities that they serve. They are run by the PCT’s provider arm, Gloucestershire Care Services and are mainly situated in rural market towns – see figure 9, and designed to serve wider rural populations in a large county with often poor transport links to the main acute hospitals in Gloucester and Cheltenham. Appendix 3 shows GP and acute service public transport access times, demonstrating the key role community hospitals have to play in maintaining and improving equity of access to services across the County.

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Figure 9.

KeyID Community Hospitals

C1 Berkeley Hospital

C2 Stroud General Hospital

C3 Cirencester Hospital

C4 Fairford Hospital

C5 Moore Cottage Hospital

C6 Moreton District Hospital

C7 Winchcombe Hospital

C8 Tewkesbury Hospital

C9 Dilke Memorial Hospital

C10 Lydney and District Hospital

4.14 In order to ensure the existing hospitals meet, or could be supported to meet, the proposed service model, the service principles listed above and essential environmental standards, they are being reviewed. This has included assessing the drive times from all areas of Gloucestershire to the nearest community hospital to determine whether there is equity in provision and access to inpatient and minor injury services. Other areas of work have included assessing the ability of community hospitals to support the delivery of an ambitious shift of outpatient services from the current 17% to at least 50% and to provide more diagnostic endoscopy in an appropriate number of sites.

4.15 As a result of the review, the following changes, in line with our service model, are either proposed or have already taken place:

The potential development of community hospital inpatient type beds in 1. Gloucester to serve patients from the Gloucester Practice-based Commissioning Cluster. In particular, this will support the practice based commissioning cluster’s (PbC) urgent care strategy to reduce the level and length of stay of inpatient episodes in Gloucestershire Royal Hospital. The project will be delivered during 2010. The potential development of community hospital inpatient beds in 2. Cheltenham to serve patients from the three PbC clusters who are currently accessing community beds much further away in Tewkesbury. The cluster will also use the facility to reduce the level and length of stay of inpatient episodes in Cheltenham General Hospital.An outline business case has been approved to replace the existing 3. Berkeley Vale Community Hospital with a new hospital in Dursley which now has the greater population. It will also replace a local health clinic which is not fit for purpose. Funding has been agreed from the Community Hospitals Development Fund subject to SHA approval. The new hospital is being developed with local PbC clusters using the described service model.An outline business case has been approved to replace the existing community hospitals 4. in Moreton-in-Marsh and Bourton-on-the-Water. Funding has been agreed from the Community Hospital Development Fund subject to SHA approval. The new hospital at Moreton-in-Marsh is also being developed with the local PbC cluster in line the strategic service model described here.C5. irencester Hospital is now host to the Independent sector provision of surgical services which include a range of day case procedures. As one of the larger community hospitals in the County, the PCT will further need to review the range of services currently provided to ensure a good efficient ongoing service fit with the needs of the local community.

Cirencester

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ceFairford Hospital inpatient services and minor injuries unit were closed in 2006 6. reflecting the fact that the size of the population the hospital served was no longer sufficient for the services to be cost effective and viable. However the well-loved hospital now provides a range of outpatient services provided both by secondary care consultants, primary/community care and diagnostics.A satellite renal dialysis unit in 7. Cinderford in the Forest of Dean is planned to open in 2011.An extension to the outpatient department at 8. Lydney Hospital is due to be completed by the end of 2009 through a partnership with the Friends of the Hospital. This will provide necessary new space for the provision of an intermediate Musculo-Skeletal Assessment and Treatment Service due to start in December 2009, as well as allowing an increased number of local outpatient services.Refurbishment of part of the 9. Dilke Memorial Hospital in Cinderford has increased the numbers of single rooms and a mobile chemotherapy service is located at the hospital one day a week.In 10. Tewkesbury a Strategic Outline Case has been approved for the development of a new community hospital to be co-located with the three GP practices. The current hospital site was exposed as problematic during the floods of 2007. The Outline Business Case is due to be submitted to the Board in late 2009 and sources of funding other than NHS capital are being explored.Stroud and Cirencester theatres and the Endoscopy Unit at Stroud have recently 11. been upgraded. A review of near patient testing is planned to include pathology and the potential to deliver more local diagnostics including mobile MRI.The community hospital 12. in Winchcombe was closed in 2008. The hospital was not fit for purpose and the local population was no longer large enough to warrant the development of a new hospital. The community now has six beds commissioned from a local care home which are supported by NHS nurses, therapist and GPs and have proved to be very popular with patients and the community. Outpatients services are being provided and increased from a site in the centre of the town until purpose-built premises are developed.

Tier 4 – Acute Sector Services

4.16 The Gloucestershire Hospitals NHS Foundation Trust with its range of secondary and tertiary services will continue to be the main hospital for Gloucestershire residents. However, as patients become more aware of the possibilities under patient’s choice they may take the opportunity to use other hospitals in the local area together with the NHS Diagnostic and Treatment Centres at Cirencester and Emersons Green for their planned care. We also expect to increase patient attendances at other neighbouring hospitals in Bristol, Worcestershire, Swindon and Oxford.

4.17 Services in this tier will be characterised by:a more planned and deliberate approach to new investment and service •developments in secondary care with more rigorous testing of clinical and service effectiveness including more regular benchmarking and service line reviews

more comprehensive and detailed service specification•

services which are high quality, appropriately specialised, readily accessible and •responsive to patient’s needs

increasing levels of efficiency and productivity with shorter lengths of stay, clearer •admission criteria and consistent adherence to clinical care pathways leading to fewer beds

Fairford

Stroud and Cirencester

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consistent compliance with national standards for waiting times in A&E brought about by the •above and the effective delivery of the new service model for community and primary care described above, which will reduce demand for acute hospital beds

increasing levels of follow up treatment after admission to hospital which will, in future, be •delivered in the community

increasing levels of primary care direct access to diagnostic tests via clinical protocol, and •providing a greater range of more sophisticated diagnostics outside of the acute hospital

the approach to acute mental health services will similarly continue to focus on ensuring that, as •far as possible, patients are effectively managed without the need for hospital admission

continuing to review the extent to which patients have to travel to receive very specialist care, •aiming to commission services more locally where this is practical and affordable; currently Gloucestershire patients look mainly towards Bristol, Oxford and Birmingham for tertiary services, although a small number of patients travel even further afield for treatment.

continuing to participate in our local specialist commissioning consortium with other PCTs •and ensuring that we maximise the clinical and financial benefits of the arrangements for Gloucestershire residents.

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ce5 Delivering Excellence in Health – Commissioning a Comprehensive Range of Services Introduction NHS Gloucestershire has developed nine Strategic Commissioning Frameworks

which describe the three to five year implementation plans for delivering our strategy. They include the relevant strategic objectives shown in section 2.7 above and describe the key initiatives planned to deliver our selected objectives and outcomes.

Strategic Links: In developing these frameworks, commissioning leaders in the PCT have focused plans on delivering initiatives which meet our identified health priorities within the context of relevant national and regional policy. Plans also reflect our strategic principles, the partnership and engagement agenda and in particular, the priority areas identified in the Gloucestershire Health and Community Wellbeing Strategy. Commissioning leads have developed strategic objectives for their area to reflect the Strategic Framework Developed by the Strategic Health Authority which is the regional response to the NHS Next Stage Review undertaken by Lord Darzi, setting the strategic direction for the NHS as a whole.

QIPP: Given the current economic climate, plans and initiatives are being developed and reviewed to test their affordability and cost effectiveness in the context of the Quality, Innovation, Productivity and Prevention (QIPP). Initiatives within these frameworks are also being tested against the PCT’s high level financial and activity assumptions, to ensure that they deliver the most effective service changes and health outcomes.

Stretch Trajectories: Commissioning leads for these frameworks are developing relevant “stretch trajectories” for each of our selected health outcomes shown in section 2.6. NHS Gloucestershire has adopted a prioritisation tool which was used to identify the outcomes we selected. In addition, commissioners are being encouraged to use the tool (shown at Appendix 2) to prioritise the most effective of their initiatives.

World Class Commissioning Competencies: The World Class Commissioning assurance process identified 11 key competencies which define excellent commissioning capability. Each of the commissioning frameworks has been developed with these competencies in mind. Feedback from commissioners on their experience of developing these and other commissioning plans, is being used to produce an organisation development plan which will ensure that our commissioning capability improves over time and so improves the health outcomes for our population.

Equality & Diversity: NHS Gloucestershire believes there is a strong case for building relevant equality considerations into our commissioning process in order to work to towards ensuring all sections of our communities access and experience health care according to their needs.

This section provides a short summary of each of the nine frameworks:

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5.1 Staying Healthy5.1.1 The ‘Staying Healthy’ commissioning framework covers all Gloucestershire residents and is

intended to bring together, under one umbrella, a number of frameworks that commission for healthy outcomes across health, local government and non-statutory organisations, working together to reduce health inequalities. Our high level vision for ‘staying healthy’, as detailed in Healthy Gloucestershire (Health and Community Wellbeing Strategy 2008-2018) is:

“To improve the overall health and wellbeing of people living in Gloucestershire and to narrow the gap in health outcomes between communities and groups living in our disadvantaged and more affluent areas.”

5.1.2 NHS Gloucestershire has a well developed Joint Strategic Needs Assessment tool (JSNA) which provides powerful analysis of the health issues we need to address in conjunction with our key partner organisations. Specific public health issues identified in the JSNA where rates are higher than in England include:

obesity and/or overweight in children •

obesity in adults•

smoking in adults•

smoking during pregnancy•

mortality rates from suicide and undetermined injury in males.•

5.1.3 NHSG will commission services targeted in areas and groups with poor health outcomes to achieve a level of health and wellbeing that is closer to those in more affluent areas and in more advantaged groups, thus benefiting all local residents. In addition, we will commission programmes, work-streams and services to meet the differential health and social care needs of different groups and communities, so that everyone in Gloucestershire has the opportunity to maximise their health outcomes.Health and Community Wellbeing Partnership strategy forms the basis of NHSG’s ‘Staying Healthy’ Commissioning framework. The strategy focuses on ten priority areas for action. Reducing health inequalities is a cross cutting theme that underpins all:

active and healthy ageing•

reduced obesity•

reduced alcohol harm•

reduced smoking prevalence•

improved sexual health•

better access to services for all•

healthier workplaces•

improved emotional health and wellbeing•

putting people first – transforming social care•

accessible, healthy and safe housing.•

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ce5.1.4 Care pathways, commissioning frameworks and service specifications are being drawn

up for some priority areas e.g. weight management and falls prevention, under the overall umbrella of this strategic commissioning framework. NHSG will commission:

Population interventions across the broader public health canvas•

Public health programmes and pathways focused at the level of the individual•

Health improvement as an integral element of all healthcare services•

A reorientation towards promoting health and wellbeing, and proactive prevention •of ill health:

to make healthier choices the easier choices•

to support and enable people to improve their health and wellbeing•

to empower and mobilise local communities for health and wellbeing•

to create a healthy, health promoting workforce and environment.•

Services and programmes will be delivered through a range of in-patient and community-based services which includes health, social care and voluntary organisations to deliver the health improvement ‘big wins’ identified in Choosing Health.

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5.2 Maternity and Newborn Care5.2.1 Service Vision

We aim to provide women, fathers, babies and families in Gloucestershire with:

high quality, evidence-based services which support them before, during and after birth, •which are consistent with accepted good practice, and which respond to their psychological and physical needs at all levels of complexitybirths that are as normal as possible, based on assessment of individual need, with 1:1 care in •labour and with interventions taking place only where necessary services which are viable and sustainable within the financial constraints of Gloucestershire, •and take into account the impact of service provision in neighbouring ‘counties’ante-natal and post-natal services provided away from general hospital sites, in community •locations and environments e.g. children’s centres which are accessible and suitable for the purposechoices regarding where they can have their baby, which will include home birth and •midwife-led birthing units amongst the options available, based on an appropriate assessment of their need and riskcontinuity of care provided by a well-trained and suitably qualified maternity workforce; •adopting a team approach incorporating clerical and care assistants; using caseload approaches to care; and care pathways

The configuration of services will develop in response to the above vision, and be consistent with providing high quality services which are safe, accessible and affordable, and which offer choice to women.

Health inequalities will be tackled via a multi-agency and multi-disciplinary approach to service delivery which will facilitate access to service provision.

High Level Needs Assessment

Overall Birth information5.2.2 Total Bookings. Approximately 7,500 bookings are carried out by the Gloucestershire Hospitals

NHS Foundation Trust (GHT) and Gloucestershire Care Services midwifery staff each year.Total Births are approximately 6500 per year – 6100 attended by GHT staff and 400 attended by Gloucestershire Care Services staff. Based on previous years activity we anticipate that in any one year the distribution across the county would be:

GRH: 3200 per year (2700 on delivery suite & 500 on Birth Unit)•CGH: 2800 per year•SMH: 280 per year•Home: 215 (45 GRH; 70 CGH; 50 SMH; 50 Forest of Dean) •

GRH = Gloucestershire Royal Hospital; CGH = Cheltenham General Hospital; SMH = Stroud Maternity Hospital

The remainder give birth outside of Gloucestershire, in Bristol, Swindon and other neighbouring areas.

Birth rate projections from the Office for National Statistics indicate that the birth rate for the county is expected to be as shown below for the years 2009-2014

2009: 6417; 2010: 6447; 2011: 6451; 2012: 6430; 2013; 6393; 2014: 6363

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ce5.2.3 A more detailed Needs Assessment (see full Commissioning Framework for Maternity)

has been carried out which identifies a range of needs for women and babies and which need tackling if the inequalities in health and outcomes are to be addressed. These areas include:

infant mortality•

low birth weight•

smoking during pregnancy•

initiation and maintenance of breast feeding•

teenage pregnancy•

The overarching priorities and high level health outcomes for NHS Gloucestershire outlined in the Strategic Plan include the need to reduce smoking during pregnancy and the under-18 conception rate. The latter is the subject of a specific target as outlined below:

Teenagers

5.2.4 The National Teenage Pregnancy Strategy launched in 2000/01 set specific priorities and targets which have been prioritised locally through the Gloucestershire Teenage Pregnancy Strategy. These were focused on reducing the teenage conception rate (by 50% by 2010/11 against the 1998/99 baseline) and by providing better support for teenage parents.The priority on these areas is based on the generally poorer outcomes that can follow from teenage pregnancy, as summarised below.

Good progress has been made locally against the trajectory to reduce the rate of under-18 conceptions by 50%, though this will not be achieved in the 10 year deadline by 2010/11.

Nationally:at age 30, teenage mothers are 22% more likely to be living in poverty than others •giving birth aged 24 or over, and are much less likely to be employed or living with a partner

teenage mothers are 20% more likely to have no qualifications at age 30 than •mothers giving birth aged 24 or over

children of teenage mothers have a 63% increased risk of being born into poverty •compared to babies born to mothers in their twenties and are more likely to have accidents and behavioural problems

teenage mothers have three times the rate of post-natal depression of older mothers •and a higher risk of poor mental health for three years after the birth

looked after Children and Care Leavers are a particularly vulnerable group of teenagers•

In Gloucestershire:

5.2.6 The under-18 conception rates in the county are generally lower than the national rate. Although having fallen in recent years, it appears to be on the rise again. There are certain geographical locations (Hot Spots) across Gloucestershire where further intervention is required, typically in the most deprived areas – of the approx 300 births to women under 20yrs old, two thirds come from the 30% most deprived areas in Gloucestershire. We know that:

teenage mothers are 3 times more likely to smoke throughout their pregnancy than •older mothers

5.2.5

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teenagers are more likely to have low birth weight babies than older women•

teenagers are more likely to bottle feed than older women, rather than breast feed•

All of the above are amongst the biggest contributors to the health outcomes of babies and children.In addition, the infant mortality rate in Gloucestershire for babies born to teenage mothers is 60% higher than for babies born to older mothers.It remains a priority and ambition for NHS Gloucestershire working with its partners to achieve the target to reduce teenage conceptions, and the trajectories below identify the trend that needs to be followed in order to achieve this by 2014.Progress against this specific outcome requires a multi-agency and multi-disciplinary approach on a number of fronts including:

Continued improvement of sexual health education, promotion and prevention messages•Improved and targeted access to contraception and sexual health services for young people•Improved and targeted access to midwifery and maternity services for pregnant teenagers.•

5.2.7 All of the above requires a tailored and targeted approach to the needs of young people which addresses the other lifestyle pressures that may lead to unintended pregnancy.Table 7 Actual under 18 conception rates Trend based on actual U18

conception rates1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Gloucestershire U18 conceptions

per 1,000 females aged 15-17

41.6 35.3 35.2 38.0 35.4 31.5 34.1 26.8 29.3 31.2 27.4 26.2 25.0 23.9 22.7 21.5 20.4

% change in rate from 1998

baseline- 15.1% 15.5% 8.8% 15.1% 24.4% 18.2% 35.6% 29.5% 25.1% 34.2% 37.1% 39.9% 42.6% 45.5% 48.4% 51.0%

Figure 10: Under 18 conception rates – Gloucestershire

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Calendar year

U18

con

cept

ions

per

1,

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fem

ales

age

d 15

-17

Actual U18 conception rates 50% reduction target (20.8) Linear trend based on actual U18 conception rates

Policy Context

5.2.8 Public Service Agreements:PSA 12 Improve health and well being of children and young people, NHS South West Ambitions, CYPP Priority 1.6a, LAA HCOP 1 & NI53 – Increase breastfeeding rates at 6-8 weeks among vulnerable women.

PSA 18 & LAA HCOP 1 Promote better health and well being for all – Reduce inequalities in infant mortality rate by 10%, reduce the number of expectant mothers who smoke and reduce the number of low birth weight babies <2500g and <1500g.

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cePSA 19 Ensure better care for all, NHS South West Ambitions – Increase the number of women who book before 12 weeks gestation.

PSA 14 Increase the number of children and young people on the path to success – linked to National Indicator (NI) 112 and CYPP Priorities 1.7 & 5.1 – to reduce the under 18 conception rate; and increase the % of teenage parents in education, employment or training.

Key DocumentsGloucestershire Children and Young People’s Plan (CYPP) 2009-2012•

Maternity Matters: choice, access & continuity of care in a safe service (DH 2007) •

National Service Framework for Children, Young People and Maternity Services •(2004)

RCOG Maternity Standards (2008)•

The Child Health Promotion Programme – Pregnancy and the first five years of life •(2008)

NICE guidance on antenatal care, intrapartum care, postnatal care, maternal and •child nutrition, breastfeeding and mental healthTowards Better Births (HCC 2008)•

Tackling Health Inequalities: A Programme for Action (DH 2007) •

Standards and guidance for Supervisors of Midwives in the South of England April •(2005)

Teenage Parents: Who Cares? (2008)•

Teenage Parents Next Steps (2008)•

Our Health, Our care, Our Say (2006)•

Making it Better For Mother and Baby (2006)•

Every Child Matters (2004)•

Hidden Harm (2003)•

Saving Mother’s Lives (2003-2005)•

Clinical Negligence Scheme for Trusts (CNST) Maternity Standards•

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Strategic Aims & Objectives

5.2.9 Our Strategic Aim is to deliver our vision for Maternity Services and achieve the key ambitions outlined in Maternity Matters and this Commissioning Framework. This includes improved choice for women and families in terms of access to services; type of antenatal and postnatal care; and place of birth.

NHS Gloucestershire and NHS South West Ambitions5.2.10 Table 8 – Ambitions reflecting the NHS Gloucestershire Strategic Objectives

Ambition NHSG strategic objective

Reduce the gap in infant mortality between the routine and manual groups and the population as a whole by at least 10% by 31 March 2010

2.1

Increase breastfeeding at 6-8 weeks to 60% by 31 March 2011 2.1/2.2Continue to reduce maternal deaths and stillbirths each year 2.3Full delivery of Maternity Matters: choice, access and continuity of care in a safe service.

2.4

% Home births increased to 10% Ambitions target by March 2011 2.4% Births Midwife-led units increased to 30% Ambitions target by March 2011 2.4Normal birth rate to increase by 1% per year. Reduce caesarean section rates by March 2011

2.4

Achieve Baby Friendly Initiative by March 2010 2.1/2.2See also The Commissioning Framework – 5.2.15 - 5.2.17.

Current Service(s) and Recent ProgressGloucestershire Hospitals NHS Foundation Trust (GHT) provides consultant and midwifery-led •maternity services at Gloucestershire Royal Hospital and Cheltenham General Hospital. GHT also provides community midwifery for Gloucester, Cheltenham and the Cotswolds/east of the county.

Gloucestershire Care Services (GCS) provides midwifery-led maternity services at Stroud •Maternity Unit and also provides community midwifery services in Stroud/Berkeley Vale areas and the Forest of Dean.

Neonatal Services are provided as part of a South West Network for very vulnerable babies. •There is some provision within Gloucestershire and peaks and troughs in demand are managed through a sub-regional network approach.

Current issues include:Future configuration of birthing/delivery units:

GHT is building a new women’s centre on the GRH site, due to open spring 2011 providing for •consultant and midwife led deliveries

CGH will provide midwife led only deliveries from 2011 in line with the above development•

SMH will continue to provide midwife led deliveries.•

Successful implementation of this change will result in:

Increased access to midwifery led services•

Increased activity for community midwifery, including greater numbers of home births•

Increases in normal births and shorter lengths of stay following consultant led births and a •reduction in caesarean section and other interventions.

Normal Births/Caesarean Section rate5.2.13 Our strategic intention is to sustain a reduction in caesarean sections and other interventions,

increasing the number of normal births.

5.2.11

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ceVulnerable women/Infant Mortality

5.2.14 Achievement of our strategic objectives and targets requires improving access for vulnerable/hard to reach groups of women who we know have the poorest access to, and outcomes from, maternity services, and whose babies are most at risk of poorer health outcomes as a result.Proposals for a new model of midwifery services which targets these women will help achieve our wider aims and objectives as well as impacting positively on infant mortality rates.

The Commissioning Framework

5.2.15 In support of our vision as described on page 35 our overall commissioning intentions are that all families in Gloucestershire will have easy access to supportive, high quality maternity services, designed around their individual needs and those of their babies. Specifically it is our intention to:

improve health outcomes and to reduce health inequalities by:•

improving breastfeeding initiation rates•increasing smoking in pregnancy cessation rates•decreasing low birth weight rates•increasing numbers of women booked by 12 completed weeks of pregnancy•increasing normal birth rates•increasing home birth rates•

provide choice in place of antenatal, intrapartum and postnatal care.•

empower women and their families in order that they will be able to parent •confidently and competently

increase integration and collaborative working with children’s services across •Gloucestershire including in Children’s Centres.

5.2.16 In order to have an impact on the widening gap in infant mortality rates and on improving outcomes for vulnerable women and children, maternity services need to be developed so that there is equity of outcome for women and babies rather than providing equity of resource regardless of need as is done currently. It is our intention to develop an enhanced midwifery service with assertive early interventions during pregnancy and in the early weeks after birth provided for women from vulnerable and disadvantaged groups.

5.2.17 The Business and Service case for delivering this approach in Gloucestershire was approved by NHS Gloucestershire PEC in November 2009. Sustainable funding for this initiative will be released by reductions in interventions and this will allow development of the model during 2010 with review of outcomes by 2013.In addition to this, a separate work programme is being led by NHS Gloucestershire to redevelop women’s services on the Cheltenham and Gloucester sites by Spring 2011. NHS Gloucestershire is actively working with providers to ensure excellent services are delivered through this development.

Finance and Activity Plans

5.2.18 Current Spend (figures 07/08 provided by finance & information teams at NHSG)Payment by Results (PbR) is where the provider gets paid a set tariff for in-patient activity. The amount paid for in-patient maternity services in the county in 07/08 came to approximately £12.2 million.

Block Contract is the contract for community midwifery services in the county including the running of SMH. This is paid as a lump payment and is equivalent to the cost of the service infrastructure (salaries etc) rather than being related to activity.

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Total Spend in 07/08 was approximately £16 million. The breakdown is as follows:

GHT:

Total Spend was £14.1 million and was a combination of PbR and Block.

PbR: £11.8 million (£7.3million births; £2.7million non-birth admissions; £1.8million outpatients)

(N06&N07) Normal Births – £3.06million

(N08 & N09) Assisted Delivery – £1.2 million

(N010 & N011) Caesarean Section – £3.04million

(N12) Antenatal Admissions (non-birth episode) – £2.7million

(560 & 501) Outpatient Appointment – £1.8million

Block: £2.3 million (Community Midwifery)

Gloucestershire Care Services: 5.2.19 Total Spend was reported by Care Services to be £1.7million and this is part of Care Services’ total

Block contract.It is anticipated that there will be no recurrent additional funding in this service area during the period of this strategic framework.

Implementation and Monitoring

RisksStrategy and Vision

5.2.20 There is a need to confirm a common shared vision, direction of travel and strategy for maternity services across all key stakeholders as the basis for implementing service improvements.

Activity5.2.21 Changes within one part of the maternity service system inevitably impact upon the other parts in

terms of activity and costs/spend.The new GHT provision due to open in 2011 means that community services need to be improved and be delivering to a new model agreed as part of the contract/s from 2010/11 onwards, if targets and business case assumptions (such as increases in home- and midwife-led births) are to be achieved.

Funding5.2.22 There is a need for a shared understanding across commissioners and providers of the financial

and funding flow issues and potential solutions for flexibly moving resources across services if our targets and ambitions are to be achieved from within existing resources.

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ce5.3 Children and Young People5.3.1 Service Vision

We aim to commission and/or develop services that:

promote and improve the emotional and physical health and wellbeing of children •and young people

deliver local services which are joined up across agencies•

identify an individual’s needs promptly, and in the context of their family and social •network, and their history

allow for early assessment and intervention to help prevent these needs becoming •more serious, with a clear pathway to early multi agency support

meet children and young people’s needs in universal settings wherever possible and •always at the lowest level of service appropriate to need

support access to more specialist support as necessary, on a “step up/step down” •approach; i.e. children and young people being managed up into more specialist services in a timely way and then managed back down into non-specialist services, rather than being “discharged”

provide very specialist help as close to home as possible, supporting children and •young people in their local network of family, friends, community and schools wherever possible

are based on evidence of “what works” and on recognised “best practice” and risk •management

ensure children and young people have a ‘voice’ and, particularly, are involved in •developing, monitoring and evaluating services

meet the needs of vulnerable and ‘hard to reach’ priority groups in flexible and •appropriate ways

are available consistently and equitably across the county (delivering “equity of •outcome”)

use existing resources effectively and efficiently•

High Level Needs Assessment

5.3.2 Gloucestershire is a good place to grow up and live for most children and young people. In 2007 there were 140,094 children and young people aged between 0-19 living in Gloucestershire. It is estimated that 66% of Children and Young People live in urban (city and town) areas and 34% in rural (countryside) areas. Most of our children and young people have good health, achieve well at school and feel good about themselves. Our children and young people are confident about their future with 77% of all pupils reporting that they were likely to go on to further education or training.

5.3.3 However, there are some children and young people who do not enjoy the same positive experience as the majority. Some children and young people live in pockets of deprivation throughout the county. The main deprived areas are found in Gloucester and Cheltenham. Some of them are in the most deprived 20% of areas in England. Gloucester has 25.3% of its residents living in the lowest band of deprivation. These areas have above the regional percentage of children living in poverty. Children and young people told us “living in poverty has a real impact on people, everyone needs to have their basic needs met.”

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5.3.4 In addition, we need to ensure that all children and young people have a healthy active childhood in order to prevent a dramatic increase in rates of diabetes, heart disease and other obesity-related illnesses later in life. Over the next three years, from the areas that impact on children and young people, the Gloucestershire Local Area Agreement has prioritised smoking, obesity, breastfeeding, and alcohol misuse.

5.3.5 Further detail is available from the Children & Young People Needs Analysis which supports the development of the Gloucestershire Children & Young People’s Plan. This is refreshed on an annual basis. During 2009-2010 this will be merged increasingly with the development of the Joint Strategic Needs Assessment where the bulk of needs assessment information for the population at large is also held.

5.3.6 Overall, the Needs Assessment suggests that whilst universal provision needs to ensure that the majority of children and young people continue to experience good health outcomes, there is a need for better targeting of resources for those children and young people whose outcomes are likely to be less good.

Policy Context

5.3.7 The “Every Child Matters Programme” is the key national policy for children’s services, and was developed to support implementation of the Children Act 2004. The National Service Framework for children, young people and maternity (2004) and subsequent reports including the ‘Healthy lives: brighter futures’ national strategy for children and young people’s health, all form important parts of the policy context. The policy context defines five overarching outcomes for all children and young people to achieve. These are that children and young people should:

be healthy•

stay safe•

enjoy and achieve•

make a positive contribution•

achieve economic well being.•

5.3.8 These outcomes overlap significantly with each other, and agencies working in Gloucestershire understand that their achievement requires them to work in partnership. This framework concentrates on the “be healthy” outcome. However, it is important to recognise that NHS Gloucestershire contributes to other outcomes, and that other partners contribute to the “be healthy” outcome. In particular all partners have a significant role to play in the “stay safe” outcome. The “be healthy” outcome is defined as:“Enjoy good physical, mental, emotional and sexual health and live a healthy lifestyle by, for example, maintaining a healthy weight and choosing not to take illegal drugs”

Every Child Matters5.3.9 The Gloucestershire ‘children’s trust arrangement’ is the Children and Young People’s Strategic

Partnership (CYPSP). NHS Gloucestershire and the other NHS Trusts are all members of the CYPSP and contribute to the development of its multi-agency strategic plan (the Children and Young people’s Plan CYPP). A new 3 year CYPP was developed during 2008/09 for the period 2009-2012, which has been adopted by NHS Gloucestershire Board and all other partners (including the NHS organisations).Key documents: (this list is not exhaustive)

Gloucestershire Children and Young People’s Plan (CYPP) 2009-2012•

National Service Framework for Children, Young People and Maternity Services (2004)•

Every Child Matters (2004)•

Healthy lives, brighter futures (2009)•

Tackling Health Inequalities: A Programme for Action (DH 2007) •

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Better Care Better Lives (2008)•

Strategic Aims & Objectives5.3.10 The Children and Young People’s Plan has the following overall objectives:

Table 9

Priorities 2009 – 2012 Prevention ‘Universal’

ECM Outcomes

Outcome focus (‘results’, conditions of wellbeing for children and young people and their parents/carers)

1 Healthy Lifestyle Choices Be Healthy Better healthy lifestyle choices and better outcomes for parents, children and young people

2 Personal Safety Stay Safe More children and young people feel safe at school and in their community

3 Ready for employment and adult life

Achieve Economic Wellbeing

More support, information and guidance for young people in choosing academic subjects, finding jobs, further and higher education and benefits; this includes children and Young People with learning Difficulties and/or disabilities

4 Child Poverty Achieve Economic Wellbeing

The impact of poverty on children and young people is reduced

Priorities 2009 – 2012 Early and Sustained Intervention ‘Targeted’

Outcome focus (“results”, conditions of wellbeing for children and young people and their parents/carers)

5 Improved Emotional Health and Wellbeing

Be Healthy Children and Young People with emotional wellbeing difficulties, and their families, have been helped and supported

6 Educational achievement for vulnerable children and young people is improved

Enjoy and Achieve

Good outcomes for most children and young people sustained and improved. The gap in attainment of vulnerable pupils compare to their peers is reduced

7 Increased Safeguarding of Children and Young People

Stay Safe Children and young people are kept safe through quality of practice and consistent thresholdsChildren are safer from risks or the effects of witnessing domestic abuseChildren in care have improved stability of placements

8 Positive outcomes for Children and Young People with Learning Difficulties and/or Disabilities

Positive Contribution

Improved outcomes for children and Young People with Learning Difficulties and/or Disabilities across all five Every Child Matters OutcomesMore choice and support for families

In support of these strategic aims and objectives, there are also NHS specific targets which form part of the NHS Gloucestershire Operating Plan, including in the areas of Child & Adolescent Mental Health Services and Children with Disabilities and/or Complex Health Needs.

NHS Gloucestershire has also developed strategic objectives for children and young people which complement those in the children and young people’s plan.

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Current Service(s) and Recent ProgressGloucestershire Hospitals NHS Foundation Trust (GHNHSFT) provides hospital, maternity and •community paediatric services

Gloucestershire Care Services (GCS) provides universal services – community nursing services •(including Health Visiting and School Nursing), Maternity, Allied Health Professionals

2gether Foundation Trust provides specialist community child and adolescent mental health •services and learning disability services

significant out of county providers include Great Western Hospitals Trust, North Bristol Trust and •United Bristol Hospital Trust

In addition to this, Gloucestershire County Council is a significant provider of services to children.

Approach5.3.12 The Children and Young People’s Strategic Plan (CYPSP) provides the strategic steer for all multi-

agency work related to services for children and young people in Gloucestershire. It was set up in 2002 when the county recognised that it needed to work more closely when planning and providing services for children and young people across Gloucestershire. Gloucestershire County Council is responsible for leading the Change for Children programme locally, and bringing together key organisations and partners involved in providing services for children. It is making this happen through the CYPSP, which has agreed a local Change for Children programme to help the management and co-ordination of activity within the county. The CYPSP includes representatives from Gloucestershire County Council, district councils, health, Connexions, the Learning and Skills Council, police, probation service, voluntary and community sector, schools and colleges. The CYPSP also has a sub group dedicated to Children and Young Peoples participation.

5.3.13 The Children and Young Peoples plan for 2009 – 2012 is underpinned by a comprehensive needs analysis covering health and social care needs. In addition to this, the views of children have been sought through the Online Pupil Survey for Gloucestershire. This is an annual survey which captures children’s views on their needs and priorities for service provision.

The Commissioning Framework5.3.14 Over the lifetime of this Framework, we will be concentrating our efforts on improving outcomes

and services in the following areas:

Emotional Health and Wellbeing5.3.15 Our aim in Gloucestershire is to have in place an innovative, responsive, needs-led emotional

wellbeing service that is safe and effective; demonstrating improved outcomes for children and young people and representing value for money.NHS Gloucestershire, with the support of the CYPSP and Gloucestershire County Council, is currently leading the redesign of our Child and Adolescent Mental Health Services (CAMHS), in order to deliver these improvements through a new service model and pathway with a view these being in place from April 2011.

5.3.11

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ceChildren with disabilities and/or complex health and palliative care needs

5.3.16 Our aim is for children with disabilities and / or complex health needs and their families to have improved access to, and improved outcomes as a result of, health service support and intervention.This means that we want the health needs of disabled children and young people to have been met through a timely response from universal, targeted and specialist services as and when appropriate, as locally as possible to their home and with smoother transitions to adult services.This includes support in the community wherever possible, rather than in hospital environments.Areas of specific work include:

supporting the transformation of short breaks provision for children and families •being led by the County Council

improving and sustaining access to therapy services •

developing options for individualised budgets and support•

developing a strategy to meet the needs of children with life limiting and palliative •care needs.

Health and Wellbeing5.3.17 National and local research identifies the clear link between lifestyle and lifestyle

choices and the subsequent health and wellbeing of children and subsequently their health and wellbeing as adults. Priority 1 of the CYPP is focused on addressing these issues including in the areas of:

healthy eating and childhood obesity•

physical activity and play•

emotional health and wellbeing•

personal safety•

sexual health and teenage pregnancy•

substance misuse.•

NHS Gloucestershire jointly commission and provide with the County Council the countywide Health and Wellbeing Team which coordinate the delivery of health promotion and prevention messages in this area of work.

Obesity5.3.18 A Gloucestershire Strategy for Tackling Overweight and Obesity has been developed

which includes action to be taken in relation to children and young people. Priorities include:

local care pathways for the prevention and treatment of overweight and obesity •

continued implementation of the National Childhood Measurement Programme for •all eligible reception age and year 6 school children

continued use of the Healthy Schools and Healthy Schools Plus Programmes to •implement obesity prevention measures within local schools

continued building on the range of health improvement programmes that are •currently delivered across the county.

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Acute and emergency care 5.3.19 Our vision for services for children and young people supports, amongst other things, a focus on

earlier assessment, identification of need and intervention and meeting needs at the lowest level of service as possible and as close to home as possible. In relation to acute and emergency care, we wish to ensure that:

there is improved coordination between primary care, urgent care, out of hours services, •emergency departments and paediatric departments

only those children who actually require care in an acute hospital bed are admitted and their •length of stay is commensurate with their acute care needs

pathways are developed based on clinical evidence•

needs are met wherever possible in the community, and in ways that improve access.•

Public health nursing5.3.20 Specific service commissioning frameworks exist for public health nursing 0 – 5 and 5 – 19

(traditionally known as Health Visiting and School Nursing). Gloucestershire Care Services are undertaking an internal review to address workforce issues in response to these frameworks and NHS Gloucestershire is collaborating with them over their implementation.The focus is on addressing health inequalities, aligning services to the multi agency network including through locality hubs and children’s centres and responding to the expectations of the National Child Health Strategy, Healthy Lives – Brighter Futures, including the National Child Health Promotion Programme, all in the context of the Transforming Community Services Programme.

Speech, language and communication needs5.3.21 The Bercow Report Better communication: Improving services for children and young people with

speech, language and communication needs (2008) identified the significant impact that speech language and communication difficulties have on all aspects of a child’s life and their subsequent outcomes. NHS Gloucestershire is reviewing how speech, language and communication needs (SLCN) are currently met by mapping current service provision against our understanding of need. Our intention is to commission improvement in earlier identification, assessment and intervention.

Teenage Conceptions 5.3.22 The NHS Gloucestershire Strategic Plan for 2009-2014 identifies a number of high level health

outcomes to be achieved for the population. These include reducing the under 18 conception rate.This is explored in detail in the Maternity & Newborn Care Strategic Commissioning Framework but overlaps with this Framework for children and young people due to the impact this issue has on outcomes for teenage mothers, young fathers and babies/young children.

Finance and Activity Plans

5.3.23 NHS Gloucestershire operates to a resource strategy that acknowledges the changes in demography that are due to take place over the next 15 years, which are expected to result in a drop in the child/young people population, and an increase in the proportion of older people across the county. Resources for children and young people are therefore expected to remain at their current levels and/or be reduced in line with these changes and also be consistent with any targets for savings and cost efficiency.As a result, any service developments / improvements are expected to be funded from existing resources, by engineering / decommissioning.

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5.3.24 The Children and Young People’s Strategic Partnership will monitor progress against the Children and Young People’s Plan every three months. Comparison with other Local Authorities will routinely be used to help check our performance. Progress against the Plan will also be monitored by a Scrutiny Committee made up of County Councillors. The elements that are part of the Local Area Agreement will be monitored by Gloucestershire’s Community Strategy Executive Board.Priority Action Cards have been designed to support this that set out:

Outcomes – ‘headline’ results that we want to achieve, in terms of conditions of •wellbeing for children, young people and their families

Performance Indicators – ways of measuring progress against set targets•

Milestones – significant events or tasks that support improved performance.•

The Children and Young People’s Strategic Partnership risk register summarises key risks that might stop the plan from happening, and what has been put in place to reduce these risks. This is monitored quarterly.

5.3.25 In addition to this, the commissioning framework will inform the NHSG Operating Plan over the next 3 – 5 years and fit with NHS Gloucestershire performance monitoring process for regular monitoring.

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5.4 Long Term Conditions5.4.1 NHS Gloucestershire has developed a commissioning framework to ensure that long term

conditions are managed through a consistent and integrated approach which will empower and inform patients and lead to better outcomes. Services will be delivered through a range of flexible, community-based services, based on a whole system approach which includes health, social care and voluntary organisations and is based around a single point of access. The framework focuses on the following themes, in accordance with the condition and the individual’s needs, and will be delivered using case management approaches, supported by telecare:

Prevention: managing risk factors in the general population•Primary care: treating early indicators of disease•Acute episodes of care: treating conditions as a medical emergency where necessary•Rehabilitation: rehabilitation and dealing with disability•Long term care: chronic disease management and palliation•End of life care: specialist condition related.•

Priorities for 2009/10 include:

Dementia5.4.2 A multi-agency Project Management Board has been established to oversee the local

implementation of the strategy. A number of work streams are being set up, and a GP Clinical Lead for Dementia Services has been appointed to lead on primary care developments, which are a key focus of both the national strategy and the local action plan. A Commissioning Development Manager has been appointed to drive service improvements and lead on the development of a three-year action plan.

Neurological review5.4.3 A joint commissioning strategy for physical disabilities is in place. This will be updated following a

system-wide review of neurological services for patients with MS, MND and physical disabilities. The review is being supported by the Commissioning Support Services, which is an organisation developed by the PD Society, MND Association and the MS Society. The review, which should take 9-12 months to complete, is being led by users and carers, and will involve reviewing the range of health, social care and voluntary sector services available for these conditions.

Stroke5.4.4 A three year action plan has been developed, and a Commissioning Development Manager

appointed to lead on its implementation. Focus has been placed on improving thrombolysis services, and on developing community-based rehabilitation across the county. Initiatives around befriending and a conversation partner scheme for people with aphasia are underway.

Community Hubs5.4.5 Community hubs were initially developed within the local Partnership for Older People’s Project,

and support our drive towards developing a health-campus community model, with local people as an important resource. Hubs support interaction between communities and care homes, encourage care homes to be part of wider, local provision by providing outreach services to older people within the local community and encourage volunteer and fair share groups to work with older people in care homes as well as within the local community. Hubs can be flexible and creative, developing services within local communities that maintain mental and physical wellbeing. Work can be at the level of primary prevention/promoting well-being or at secondary prevention, to slow down deterioration or identify risk.

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5.4.6 Diabetes developments continue to be overseen and steered by the countywide Diabetes Managed Network. Sub-groups have been established to direct and develop further work in specific areas such as the review of diabetes education services, pre-conceptual counselling and the further development of the diabetic retinopathy screening service. Moreover, a significant programme of work evaluating and informing the future organisation of (intermediate) care is due to start in the Autumn.

COPD5.4.7 The newly constituted countywide Respiratory Care Steering Group, chaired by the

incoming PCT PEC Chair, has recently re-ordered its work programme in order to prioritise those service developments that align most closely with the PCT’s aims and ambitions. Most notably, the development of proposals for the countywide provision of pulmonary rehabilitation and oxygen assessment together with the work around an integrated care pathway for COPD and asthma are providing the predominant focus.

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5.5 Acute Care 5.5.1 The vision for unscheduled care in Gloucestershire is for a robust system that directs

care for patients into planned responses from unplanned and that integrates pathways across organisations.

Principles

5.5.2 Services should besimple to access from the point of view of patients, carers and the public•

designed around the specific needs of the patient and delivered by the professional best able to •meet those needs

cost effective and in line with the overall NHS Gloucestershire strategic principles•

commissioned, delivered and monitored to clear specifications•

delivered to a standard of quality that is consistent whether delivered by telephone, in the home •or at a fixed location e.g. A&E or a medical centre

commissioned and delivered specified outcomes and measurement for continuous improvement.•

Needs

5.5.3 There has not been a recent strategic needs assessment specific to the development of unscheduled care. However, the work done within the overall JSNA, points to the key issues that will impact on the unscheduled care system for the future, including the significant increase in the population over 65 and the differential issues around access for both urban and rural populations.

Definition

5.5.4 For the purposes of the strategy, unscheduled care includes:“The range of responses that health and care services provide to people who require – or perceive the need for – urgent advice, care, treatment or diagnosis. People using services or carers should expect 24/7 consistent and rigorous assessment of the urgency of their care need and prompt response to that need.”(Page 12: Direction of Travel for Urgent Care 2006)

Policy framework

5.5.5 The strategy has been compiled having reviewed the policies, toolkits and evidence described in the “Emergency Services Review Good Practice Guide in Delivering Emergency Care: A Guide for Local Health Communities. July 2009”.

Targets and Performance

5.5.6 The relevant SHA ambitions, therefore, adopted by NHSG for this area include:75: – A&E attendances at acute hospitals will reduce by 10% over 5 years as people receive care •in more appropriate settings

76: – 70% of patients who attend emergency departments, minor injury units, walk in centres, •general practices and community settings for urgent care will have treatments within 2 hours of arrival by 31st March 2010. moving to 95% by March 2011.

78: – No ambulance handover times at emergency departments in Gloucestershire will be •greater than 15 minutes by 31st March 2010.

5.5.7 Currently unscheduled care in Gloucestershire is not delivering to key targets. An unscheduled care network group has been established. Current action includes the implementation of a peer review action plan and the implementation by Gloucestershire Hospitals Foundation Trust of UTOPIA, a project to improve delivery of unscheduled care.

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5.5.8 Unscheduled care is a key area for development. Demand for acute services continues to rise and pressure on the service is too frequently resulting in failure to maintain national standards. The transformation in the model of primary and community care is intended to reduce reliance on acute hospitals’ services through a more rapid and comprehensive response to unscheduled care needs. Key components of this model are outlined in Figure 11. Work is underway to develop the key components of this system working with partners in the Unscheduled Care Network. In addition, work will be done to make links to the preventative agenda in health and social care, to divert unplanned into planned responses. Future developments include better integration of urgent care including MIUs, primary care and work towards the patient and public Single point of access (SPA).

Figure 11

GP or other health and social care referral

Non 999 ambulance calls

Nursing home

SINGLE POINT OF CLINICAL ACCESSCapacity and demand managementEscalationDirectory of services (availability of alternatives)

Integrated health and social care locality team urgent response:

Community hospital bedIntermediate care bedStep up and step down

Acute service:Assessment•Specialty bed•Urgent outpatient •appointment

Finance and activity shifts

5.5.9 Further modelling is underway to understand the key shifts in activity achievable with such a model. This will require the UTOPIA model to bed down to understand better the impact on other aspects of the system.

Implementation

5.5.10 Current proposed implementation dates are as follows:

Initiative Date for implementation

Outline Plan available

Primary Care Discharge TeamCore teamCluster coordinators working with PBC clusters

November 2009April 2010

September 2009

Single point of clinical access April 2010 November 2009Health and social care integrated locality teams April 2010 November 2009

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5.6 Planned Care5.6.1 Planned or elective care covers a range of services which are usually planned or booked in advance of

the service being required. It includes all elective surgery, planned diagnostic tests; routine outpatient services; planned dentistry, community pharmacy services and cancer services. Planned care is increasingly being delivered in a variety of settings including community hospitals, Independent Sector Treatment Centres and mobile units. In some cases, services previously provided in hospitals can be provided in primary care or high street settings (for example, hearing tests). Patients increasingly have an expectation of a choice of provider, place and time of delivery and are seeking information about the standards and outcomes achieved by the providers they choose.

5.6.2 Currently, the PCT believes that too many patients are referred or admitted to an acute hospital for diagnosis and assessment of need when this process, and often appropriate treatment, can be delivered either with a very short admission or through additional support in primary and community settings. In addition, many patients continue to have “unplanned” admissions to hospital when targeted management of their condition could allow a planned intervention. There are a large number of patients who remain in an acute hospital bed when their needs no longer require this level of specialist care.

5.6.3 The reform of planned care services is a crucial goal for Gloucestershire PCT and includes recognition that a wider range of providers will, in the future, be able to offer services that will further the delivery of our strategic objectives.

Key Issues to Address

5.6.4 Demand for planned services is influenced by a number of factors, including:the demographic make-up of the local population•

the prevalence rates of certain conditions•

supply side factors, including Independent Sector provision•

clinical behaviour•

national and local access targets•

patient choice.•

5.6.5 The PCT has developed a three year (2008-2011) capacity plan which takes these factors into account. This plan details the PCT’s commissioning intentions for planned care by speciality and provider. Our aims in developing this plan further will be:

to commission a range of clinically effective services which ensure that patients receive the •right treatment, in the right place at the right time and in particular, provided closer to home in a primary care or community setting e.g. outpatient services. This will be achieved through robust commissioning of best practice pathways of care which incorporate a deliberate shift of appropriate interventions out of the acute hospital setting

to offer genuine and informed choice through a plurality of providers and relevant service •alternatives, particularly through greater use of the independent sector

to maximize the benefits of Practice Based Commissioning and primary care led innovation, •particularly through the increased provision of enhanced services

to ensure that patients and clinicians have access to a more speedy and extended range of •diagnostic services outside of a hospital where appropriate, so that diagnosis can be confirmed at the earliest stage

to prevent unnecessary admissions to hospital. An admission should not be necessary simply •because it is the only route for a consultant or GP to obtain a diagnostic procedure for his or her patient.

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ce Strategic objectives for this framework

5.6.6 The priorities for this framework are as follows: 90% of diagnostic tests are carried out and the results are available to the referrer •within two weeks by 31 March 201175% of the 160 procedures identified by the British Association of Day Surgery will •be carried out as a day case or in line with the best practice recommendations of the Association by 31 March 2011outpatient follow-ups will be reduced to achieve best quartile performance by 31 •March 2011cancer patients will receive earlier diagnosis. By 31 March 2010 90% of all diagnostic •tests for suspected cancer patients will be carried out and the results available to the referrer within seven daysby 31 March 2011, 90% of new patients referred by a general practitioner will be •able to book appointments, diagnostic tests and treatments at times and dates convenient to them90% of admitted patients and 95% of non-admitted patients to be treated within •eight weeks by 31 March 2011, with a two week maximum wait for access to therapy services and the provision of wheelchairseveryone wishing to access an NHS dentist will be able to do so by 31March 2011, •with year-on-year improvement in the number of people accessing NHS dental servicesall patients to have an option available to them of extended opening hours in •general practice by 31 March 2010the National Cancer Reform Strategy (December 2007) will be implemented by 31 •March 2011 in the South West, two years ahead of the national timetable.

Initiatives

5.6.7 NHS Gloucestershire is developing a number of initiatives in partnership with Practice Based Commissioners to be implemented across the county which support delivery of the key objectives outlined above

Reviewing clinical effectiveness5.6.8 Benchmarking and review has revealed that NHS Gloucestershire is providing many

more of some types of planned care than other primary care trusts with a similar demographic profile. Also, as new technologies and procedures are introduced the need for some interventions is decreasing. NHS Gloucestershire is developing a programme of work to undertake more regular and extensive benchmarking and clinical pathway review to reduce the number of procedures which are known to have limited clinical benefit for patients and to understand why some of our intervention rates are higher than expected. Initial work is targeting orthopaedic and general surgery. Other specialties will follow.

Supporting Clinical decision Making5.6.9 Where patients require onward referral by their GP or other clinician to another service,

NHS Gloucestershire will develop tools and protocols to support clinicians to make the most effective decision for their patients. We would like to develop a local intranet-based “map of medicine” to help clinicians navigate the complex array of services available to them and provide all of the information required by those receiving referrals to enable them to assess what action is appropriate. This work will be integrated into specialty specific care pathway design and will need to be updated on an ongoing basis to reflect most up to date clinical best practice.

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Community based Musculoskeletal Service

5.6.10 Development of a locally commissioned, but county wide intermediate clinical assessment and treatment service (CATS) for people with a range of musculoskeletal conditions which will provide robust “work up” of patients requiring onward referral to secondary care, or alternative community based care, where appropriate. A full market testing exercise is being undertaken in two PbC areas which will maximise the impact of the service. This initiative will provide learning and a potential model for development of similar CATS services in other specialties.

Audiology

5.6.11 Improving access times and extending the range of providers to enable local access to care.

Dentistry

5.6.12 NHS Gloucestershire commissions a range of dental services from a variety of providers including:Health Promotion•

Dental Helpline•

Primary Care Dental Services from high street Dentists through a General Dental Service •Contract (GDS /PDS)

Community Dental Access Centre and Special Care needs through the PCT Care Services from a •PCT Dental Service Agreement (PCTDS)

Complex dentistry and oral surgery from Gloucester Royal and Cheltenham General Hospitals •through a Foundation Trust Contract

More complex dentistry, oral surgery and maxillo-facial services from United Hospitals Bristol •Trust.

A new oral health strategy was developed in September 2009.

NHS Independent Sector Treatment Centre

5.6.13 Offering people a choice through plurality of providersFrom November 2009, UKSH will be providing a range of inpatient and day case services at their purpose built facilities in Emerson’s Green, South Gloucestershire and at Cirencester Hospital in Gloucestershire. The facility at Cirencester will be part of the existing community hospital there and will follow the refurbishment of part of the hospital to offer an excellent environment for outpatient and day case services. People in Gloucestershire will be able to access both facilities and will be offered this as a choice alongside existing providers.

Waiting times for community therapy services

5.6.14 Improving access to care in local settingsNHSG has worked hard with its provider arm to reduce the waiting times for adult and children’s therapy services, which are often overlooked in the national focus on acute care waiting times. The PCT has commissioned a maximum 2 week waiting time for all therapy services provided in Gloucestershire and will continue to work with community providers to ensure that this improvement is sustained and extended to other areas of care.

Delivering more outpatient services in community settings

5.6.15 Improving access to care in local settingsNHS Gloucestershire is working closely with Practice Based Commissioners to review the needs of local populations and to increase the % of outpatient and diagnostic appointments that are delivered in community settings. This work is using the opportunities offered by the redevelopment of the community hospital and clinic estate in Gloucestershire to ensure that the built environment not only promotes excellent care for our patients and excellent working environments for our staff, but also delivers our strategic objectives by increasing the range and volume of services offered in local community settings.

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ce Developing Community Diagnostic Services5.6.16 In order to deliver more ambulatory care services in community and primary care

settings, a wider range of diagnostic services will need to be available. This is being addressed primarily through the specific community hospital developments outlined in sections 4.5 - 4.7. However, a more comprehensive review is required to ensure that enough locations are equipped to support the desired transfer of activity from acute hospital to local settings.

Renal satellite units5.6.17 Improving access to care for people with long term conditions. NHSG has carried out

an extensive engagement process with people who currently receive renal dialysis units as part of developing plans for commissioning the required increases in dialysis capacity. As a consequence of talking to service users and carers, two satellite units are being commissioned in the Forest of Dean and Stroud areas, which will improve access for people living in the more rural communities within Gloucestershire. This is seen by the PCT as the initial stage in changing the way that these services are delivered, with an ambition to be able to support more people in receiving home dialysis and/or dialysis in smaller, locally based units.

Cancer services5.6.18 NHS Gloucestershire is part of the 3 Counties Cancer Network (3CCN) which serves a

catchment population of approximately 1 million people, who live within two Strategic Health Authority (SHA) boundaries: South West and West Midlands. The core Network is Gloucestershire, Herefordshire and South Worcestershire. This Network is served by the non-surgical oncology service in the Gloucestershire Oncology Centre, Cheltenham. Patients also access supra-specialised services in different locations, including Bristol, Birmingham and Oxford.

5.6.19 Overall cancer incidence in Gloucestershire is slightly higher than national, but lower than regional rates and this is also the general pattern for the four cancers that account for over half of all new cases of cancer (breast, lung, bowel and prostate cancers). In terms of trends, Gloucestershire’s experience is similar to those of the Southwest, its Office of National Statistics (ONS) Cluster (referred to in 5.6.24)and nationally in terms of an increase in the incidence of cancer over the years. This should be expected as people live longer and survival rates increase.

5.6.20 In 2007, the Department of Health published the Cancer Reform Strategy (CRS) building on from the NHS Cancer Plan in 2000, which sets out a clear direction for the next five years and actions to be put in place to improve cancer outcomes. Within the South West ambitions, there is an aim to implement the CRS by March 2011.

5.6.21 Whereas previous cancer plans centred more on the organisation of cancer services and access to treatments, the CRS focuses on new challenges and opportunities, in particular prevention, early detection and in-patient care. This is because the incidence of cancer is increasing as people are living longer and more people are surviving cancer. The CRS sets out a programme of action across ten areas; six areas are designed to improve cancer outcomes and four areas are to ensure the effective delivery of cancer services.

5.6.22 These areas are:Reduce the risk of developing cancer in the population.1. Improve early detection.2. Provide access to high quality treatment at every stage and strive to improve quality 3. of cancer services available.Ensure those living with and beyond cancer have the support they need.4. Ensure access for all to the best possible cancer experience and outcomes.5. Enable care to be delivered in the most clinically appropriate and 6.

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convenient setting.Enable patients to obtain information about cancer services, enabling them to make 7. informed choices.To ensure strong commissioning of cancer services in line with the standards needed to 8. achieve world class commissioning.To make use of programme budgeting intelligence to ensure appropriate funding for NHS 9. cancer services.To build the workforce and facilities for the future.10.

5.6.23 In 2002, the Department of Health initiated the National Programme Budget Project. The aim of the project was to develop a source of information, which can be used by all bodies, to give a greater understanding of where the money is going and what we are getting for the money we invest in the NHS. Spend on ‘cancers and tumours’ has been included as one of the 23 categories in the Programme Budgeting Analysis. Looking at the expenditure for 2007/8, which is the latest year that comparative data is available, it can be seen that NHS Gloucestershire has expenditure 13% higher than the cluster average and 18% higher than the national average. The expenditure in Gloucestershire per weighted head of population is ranked the 20th highest in England.

5.6.24 During 2008/9, benchmarking was undertaken to compare NHS Gloucestershire to a peer group of 14 PCTs that were most similar to NHS Gloucestershire as judged by the source data that the Office of National Statistics use to create standard national clusters. This peer group should be a more comparable baseline than a simple national average. The analysis covered a number of areas; however some of the key messages within that analysis relate to significantly higher access rates (activity per 1,000 population) than our peer group and the cost implications for our admitted care cancer services (elective and non-elective combined).

5.6.25 Progress towards delivery of the Cancer Reform Strategy raises some specific challenges for both Gloucestershire and the Network. The key issues are;

Prevention5.6.26 Progressing with strategies and initiatives which reduce the risk of developing cancer.

Early detection5.6.27 Continuing to deliver high quality screening services and extending the target population in line

with national developments reducing the variance of screening uptake between practices and promoting awareness and early diagnosis.

Improving the quality of Cancer Services5.6.28 Meeting and sustaining national wait times targets, being fully compliant across all Improving

Outcomes Guidances (IOGs), developing services in the most clinically appropriate and convenient setting.

Supporting End of Life Care and Survivorship5.6.29 Responding to the increase in incidence and survival rates to ensure appropriate range and levels of

services are in place, especially to deliver patients’ and their carers’ wishes at end of life.

Using programme budgeting intelligence to ensure appropriate funding for NHS Cancer Services

5.6.30 Progressing a programme of work to move Gloucestershire’s spend closer to the average whilst maintaining quality of care.

Pharmacy5.6.31 National policy and local intent is determining that NHS Gloucestershire is working more

closely with community pharmacy services to extend the range of services they provide, for the convenience of patients. Their roles are already expanding to include health promotion and ill health prevention activities and marketing campaigns are encouraging people to use pharmacists as a frontline service for minor urgent care needs. Medicines reviews are well established but need to be more integrated with other primary care level intelligence. We will also consider the introduction of some screening services into pharmacies in future.

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Health services are managed through a consistent and integrated approach which will empower and inform patients leading to better outcomes. Services will be delivered through a range of inpatient and community-based services which includes health, social care and voluntary organisations. We must ensure that services are in place and are being delivered that appropriately meet the needs of all people living in Gloucestershire. We believe that the people of Gloucestershire should have access to a range of mental health services that promote mental well-being, inclusion and recovery through:

ensuring the most effective use of resources• which means making services affordable and best value for money

supporting independence• to enable people to lead as full and independent a life as possible

challenging discrimination and promoting social inclusion• by making maximum use of mainstream services

providing effective, equitable and single access points• , which means:

Having easily identifiable points of access which can ensure the speediest or most i. appropriate response.

Enabling timely responses – (24 hours a day, 365 days a year) for those who need ii. this level of urgency.

Providing treatment as near to a person’s home as possible.iii.

Taking account of the person and their circumstances as well as their needs when iv. considering access to services.

Focusing on the service user experience which means:•

ensuring smooth transition between services as well as across primary, secondary v. and tertiary care regardless of age, gender, culture, religion or disability

respecting and promoting the individual’s right to privacy and dignityvi.

engaging service users and, if appropriate, carers using a person centred vii. approach regarding decisions and choices about their care, whilst working within agreed care pathways with referral protocols.

Strategic Framework for Mental Health includes:

5.7.2 1. Development of Mental Health Promotion Strategy – A multi-agency mental health promotion and wellbeing strategy is now at the consultation stage of development and will be in place with action plan for implementation from April 2010.2. Suicide Prevention Strategy – is currently under review with Public health and key partner agencies within the county Suicide Action Group. The revised strategy will be in place for implementation for 2010.

3. Mental Health & Social Inclusion Strategy – a multi-agency strategy supported by an Executive group and Action Planning forum that aims remove mental health inequalities and improve opportunities by engaging individuals, organisations and communities in influencing decisions that will improve the quality of life of those with mental illness, their carers and families.

4. Dementia – A multi-agency Project Management Board has been established to oversee the local implementation of the strategy. A number of work streams are being set up, and a GP Clinical Lead for Dementia Services has been appointed to lead on primary care developments, which are a key focus of both the national strategy and

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the local action plan. A Commissioning Development Manager has been appointed to drive service improvements and lead on the development of a three-year action plan.

5. Joint Commissioning priorities for Mental Health include;i) To commission a county specialist Personality Disorder Service in line with recent national guidance and service standards.

ii) To commission a county community Multi-disciplinary case management team for people with Asperger’s.

iii) To increase the level of voluntary sector provision to deliver key services within the Day and Vocational service plan and to build on existing partnership arrangements with Barnwood House Trust in developing Bridge Builder services.

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(2008) and Six Lives, and, in order to provide public services to people with learning disabilities (2009), NHS Gloucestershire is developing a broad range of health care improvements in order to reduce the health inequalities experienced by people with learning disabilities and their families.

5.8.2 This requires an improved understanding of the needs of the population that will better inform the planning and commissioning of services appropriate and effective at meeting these needs. All GP practices in Gloucestershire now have registers of the people with learning disabilities known to them.

5.8.3 The focus is on developing mainstream services to more effectively understand the particular needs of this population, their responsibilities in meeting these needs and the support to achieve this. It is not simply equal access to health services but the achievement of equal health benefit from health services.

5.8.4 Working with partners through the Health Action Sub Group of the Learning Disability Partnership Board, the Primary Care Trust will ensure the effective commissioning and monitoring of services. Working at a local level, agencies will ensure that the views of people who use services are heard, that they are supported to live independently and that they are at the centre of individual and collective planning.

5.8.5 NHS Gloucestershire have been working with partners through the Learning Disability Partnership Board over the last year to build on existing good practice in health care for people with learning disabilities. The centre point of this wide consultation activity was a conference “The Big Health Check” at which existing health services in Gloucestershire were evaluated and priorities set for achievements over the next 2 years by people with learning disabilities, family carers and paid staff. This formed part of NHS Gloucestershire’s commitment to the South West region’s ‘Whole System Approach’ to improving the health of people with learning disabilities in the area.

5.8.6 The findings of the consultations were presented to the Health Action Sub Group who decided on 6 priority areas to be achieved over the next 2 years. These were then added to priorities set by recommendations from the reports mentioned above to form our 12 priority areas.These priority areas will be monitored by the Health Action Sub Group and evaluated again at a “Big Health Check” conference in early 2010.

5.8.7 These are:People with learning disabilities to be offered a comprehensive health check every •year.

The two main acute hospitals will have two liaison nurses for people with •learning disabilities.

More information about health that is easy to understand should be provided.•

All staff who work in the NHS should have training about how to make services •better for people with learning disabilities

All people with learning disabilities should be offered a Health Action Plan•

Information sharing between services to improve•

GPs know which of their patients have a learning disability•

Those with learning disabilities to be offered more health screening•

Those with learning disabilities to be given a choice about where they live.•

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Those with learning disabilities and their carers to be given a voice about services, to bring •about change.

We need to get better at dealing with challenging behaviours.•

Those disadvantaged by leaning disabilities deserve fairer treatment to reduce higher health •problems and mortality rates.

Many initiatives to tackle these priorities are already underway.

5.8.8 NHS Gloucestershire has established a project management team to co-ordinate the various work streams and provide recommendations that ensure services are modernised to be inclusive of and ensure equal health gain for people with learning disabilities in Gloucestershire.

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ce5.9 End of Life Care Service Vision

National End of Life Care Strategy 2008•

National Dementia Strategy 2009•

NHS Next Stage Review 2008•

Carers Strategy 2008•

NICE Guidelines for Supportive and Palliative Care 2004•

Improving Outcomes Guidance for Caner and Palliative Car•

Service Framework

5.9.2 NHS Gloucestershire has developed a commissioning framework which will empower and inform patients and lead to better outcomes. Services will be delivered through a range of flexible, community-based services, based on a whole system approach, which includes health, social care and voluntary organisations.Key themes for the framework are:

Identification of end of life phase•

Communication and coordination of services•

Rapid access to care•

Delivery of high quality care•

Care after death•

Needs Assessment

5.9.3 Death rates by age and gender for 2006 were 2576 male and 2980 female (total 5556) 4764 of which were 65 and over. Of the causes of death, 1477 were from cancer whilst 1976 were attributed to circulatory disease. This illustrates the need to commission comprehensive end of life services across all life limiting conditions, not only cancer. Commissioning comprehensive and equitable services will include person centred care not only to meet needs across a range of conditions but also taking into account cultural issues, people living in disadvantaged areas and special needs such as having a learning disability.The National Council for Palliative Care (NCPC), based on a random telephone survey, suggests that over 50% of people would choose to die at home. A similar question, recently asked of Gloucestershire’s residents, indicates about 40% would prefer to die at home. It is estimated that about 20% of deaths in Gloucestershire occur in the home; therefore there is a need to focus on improving end of life care provided in the home and other community settings to increase real choice.

Strategic Aims & Objectives

Our service model aims to provide:a well educated and trained workforce, both in health and social care, to deliver •generalist and supportive care

access to a range of specialist services based on need•

a wide range of supportive services to support care at home•

a resource to facilitate the established palliative care tool, to include Gold i. Standards framework, Liverpool Care pathway, Preferred priorities for Carea comprehensive education and training programmeii.

The delivery of high quality services to patients, within a tight financial framework requires effective management systems.

5.9.1

5.9.4

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5.9.5 Our strategic objectives are as follows:all health communities to be able by 31 March 2011 to identify the number of people with a •plan for their death and to report the percentage of cases where the preference about place of death has been delivered

public to have access at all times to the ‘basic building blocks’ for effective care (community •nursing, equipment, palliative care drugs

availability of specialist advice, the patient’s personal end of life plan and rapid discharge from •hospital) by 31 March 2011

through responding to individual preferences, reduce by 10% adult deaths in acute hospitals for •each of the next three years

through providing support at home, reduce unplanned admissions to hospital from nursing •homes in the last 12 months of life by 10% per annum (from the 2007 baseline)

to implement the actions and recommendations of the National End of Life care Strategy as •prioritised by the Gloucestershire EOLC Steering group:

identification of end of life phasei. communication and coordination of servicesii. rapid access to careiii. delivery of high quality careiv. care after deathv.

Summary of Progress

5.9.6 Progress to date includes:County-wide implementation of tools for End of Life Care.1.

Gold Standards Framework in 81/83 practices since 2005. Review of GSF is required to ensure 2. compliance and effective outcomes.

Liverpool Care Pathway implementation: The LCP will be used within Primary Care, 3. Community Hospitals and Acute Hospitals by December 2009. The LCP is being piloted in a cohort of Care Homes. Sustainability planning is in progress.

Advanced Care Planning is being piloted in Care Homes as part of a Practice-Based 4. Commissioning initiative.

Education and Training Strategy Group to address local training needs and provision to 5. generalists groups.

Public awareness, local involvement and service user/ carer involvement: Plans include closer 6. working with local carers groups and involving the public through local engagement events. Partnership working also includes Gloucestershire County Council through involvement with the National Carers Strategy. A local newsletter is published quarterly and a conference planned for February 2010.

Partnership working with Mental Health and Learning Disability services (2gether NHS Trust) to 7. develop an action plan for improving End of Life Care in line with national and local priorities.

Collaborative working with Children’s Palliative Care commissioners to ensure consideration is 8. given to the needs of individuals and families in the transition to adult care services.

District Nursing Service extended to 24 hour/7 day a week service to avoid issues arising out 9. of hours leading to inappropriate hospital admission.

Hospice at Home services available across the county.10.

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ce Priority initiatives for future implementation

5.9.7 Priorities for delivering this framework are;Establishing a Single point of access for specialist palliative care to provide more 1. coordinated provision of and access to specialist care. This priority has developed into a locality based strategy for provision of specialist care in the county by June 2011.

Providing 24 hour, 7 days a week access to specialist palliative care advice to achieve 2. compliance with NICE Guidance. Achieved January 2009.

Improving services available in the community through developing the range and 3. location of therapeutic day services. 2008/10.

Supporting the development of assessment and advanced planning to reduce the 4. need for urgent Out of Hours care by creating a post to develop the tools needed. 2008/09.

Further developing Hospice at Home to provide improved interface services between 5. generalist and specialist care and provide care closer to home. 2008/10.

Providing resources at Practice Based Commissioning level for each to assess local 6. need for investment in order to deliver this strategy. 2008/09.

Investing in respite services to improve support to carers and to continue the 7. outcomes of the PoPPs project. 2008/10.

Extend the Expert Patient Programme to support patients in managing their 8. condition and decision making. 2009/10.

Improving access to bereavement services to support families after death.9.

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6 Resourcing the Strategy Background

6.1 A resource strategy was adopted by the Board in November 2006 which agreed a strategic financial framework for the organisation.The main strands were as follows:

1. Creation of a 2% contingency reserve (c. £15m) to be held at PCT level to facilitate long term stability and enable service redesign

2. Recurrent pump priming budget established (£2m)

3. All budgets set correctly and adequately

4. Choosing Health monies to be set at an indicative level

5. 3% cash releasing efficiency savings applied on all expenditure (increasing to 3.5% for 2010/11 and 4.5% thereafter)

6. Investments to be prioritised as follows;

mandatory cost pressures

unavoidable legally contracted expenditure

achievement of unavoidable key targets

7. Target level of expenditure on management costs, both in commissioning/corporate functions and in the provider functions

Current overviewNHS Gloucestershire has seen significant growth over the last 5 years but is expecting to be •heading towards a more financially challenged period.

Understanding and re-prioritising existing spend commitments will be key to the continued •development of services for the people of Gloucestershire.

Detailed benchmarking will aid the organisation in understanding where to target its efforts in •service re-design.

Using the wider economic conditions and the market place to drive out efficiency will be •important.

The use of competition may drive out some efficiency but equally important will be cooperation •with our main partners and providers to deliver more efficient care pathways and the reduction of duplication in the system.

Table 9: Opening 2009/10 Application of Funds

Application of Funds – Revenue Budgets £’m %Headquarters and central programmes 24 5Public Health and Health inequalities 5 1Provider Services 79 9Primary Care Commissioning 190 22Secondary Care Commissioning 487 57Non healthcare & non NHS Commissioning 71 8TOTAL 856 100

Economic Climate

6.2 The UK economy has moved into economic recession which changes the context for the NHS. The NHS financial settlements over the last 5 years have been significant taking NHS Gloucestershire’s budget from £684m in 2006/07 to £899m in 2010/11, an increase of 31%.

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ceThe next 5 years from 2011/12 onwards are expected to be very different and it is likely that the NHS will receive no further financial growth over the next few years. This is a significant change but we have some warning of this and can start to plan accordingly.

Allocation Formula

6.3 In December 2008 a new allocation formula was published. This introduced a new dimension to the distribution of the NHS resource across the country which was to weight the resource available to reducing health inequalities.NHS Gloucestershire will be 1.3% over its target allocation at the end of 2010/11. This will mean that if financial growth is applied to the NHS we can expect to receive average allocation uplifts in future years.

Medium Term Financial Plan

6.4 NHS Gloucestershire adopted a medium term financial plan (MTFP) in November 2008. Since then it has become clear that economic situation faced by the wider economy has worsened and that this will inevitably impact on the resources available for the delivery of public services.We have now revised the growth assumptions presented in the adopted MTFP and have created plans based on 3 different scenarios:

Scenario A: No inflation pressures are funded and CRES of 4.5% is required linked to a moderate case capacity plan

Scenario B: No inflation pressures are funded and CRES of 4% is required linked to a worst case capacity plan

Scenario C: The PCT receives a small uplift to its baseline allocation and CRES of 3.5% is required linked to a best case capacity plan

Table 10: Anticipated allocation uplifts

Allocation uplift2010/11 2011/12 onwards

Scenario A 5.2% 0.0%Scenario B 5.2% 0.0%Scenario C 5.2% 2.5%

Table 11: Anticipated inflationary uplifts for all scenarios

Gross uplift2010/11 2011/12 2012/13 2013/14 2014/15

Tariff (NHS providers) 3.5% 2.5% 2.5% 2.5% 2.5%Non NHS providers 3.5% 2.5% 2.5% 2.5% 2.5%Prescribing 8.5% 8.5% 8.5% 8.5% 8.5%Pay (net) 2.3% 1.0% 1.0% 1.0% 1.0%CQUIN (non rec) 1.5% 1.5% 1.5% 1.5% 1.5%

Table 12: Anticipated SIF contributions

SIF contribution as % of baseline2010/11 2011/12 2012/13 2013/14 2014/15

Surplus 1% 0.69% 0.45% 0.15% 0.15%Contingency 0.38% 0.41% 0.45% 0.45% 0.45%Topslice 0.38% 0.41% 0.45% 0.45% 0.45%Uncommitted headroom 0.75% 1.24% 1.65% 1.95% 1.95%TOTAL 2.50% 2.75% 3.00% 3.00% 3.00%This will effectively mean that we will need to release resource every year to fund inflation, innovation developments, population changes, new drugs and service

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changes.

In addition to modelling different resource scenarios different expenditure scenarios have been modelled through our capacity plan:

Scenario A: GP referral growth at 2% with non elective activity growth of 2.3%

Scenario B: GP referral growth at 4% with non elective activity growth of 3.3%

Scenario C: GP referral growth at 0% with non elective activity growth of 1.3%

The outputs of these scenarios can be seen within the summarised income and expenditure positions in Appendix 5.

In summary in all scenarios we will need to release resource every year to fund inflation, innovation developments, population changes, new drugs and service changes.

The Strategic Fit

6.5 The key principles of our strategy need to be reflected in our financial strategy.NHS Gloucestershire’s strategic plan ‘Achieving Excellence’ has several key themes. These themes are supported within the financial strategy and finance plans as follows:

Developing Our Workforce and aiming to be an employer of choice zNHS Gloucestershire has established a training budget which represents 2 percent of pay budgets to ensure continuous professional development of our workforce and enable the delivery of innovative and responsive services.

Care Closer to Home zThe medium term capital programme is heavily weighted towards schemes that underpin this strategic objective with major re-developments of community facilities planned in North Cotswolds, Berkeley Vale, Gloucester, Tewkesbury and Cheltenham. These schemes will support improved service provision for local patients and help deliver more efficient and effective services through redesigned care pathways and better utilisation of the capital estate and improved access for all patients (DDA compliance).

The increased revenue costs will be funded from activity transferred from secondary care and we are working closely with Gloucestershire Hospitals NHS FT to ensure that strategic and financial plans for both organisations are aligned.

Our medium term financial plan is built on an activity capacity model that includes a reduction in non-elective and A&E admissions and GP referrals. These plans are consistent with substantial work being undertaken to manage unscheduled care outside of the acute sector and a review of elective pathways, for example we have agreed to commission a new community based musculoskeletal service for two Practice based Commissioning confederations.

Reducing Health Inequalities zTackling health inequalities will need us to evaluate the impact that resource decisions have on health outcomes and ensuring that services are targeted to specific populations.

The NHS Gloucestershire medium term financial plan includes continued, increasing investment into Choosing Health schemes, from a recurrent budget of £5.4m in 2009/10 to £7.5m in 2010/11. This funding is being used to support various schemes that will address health inequalities in the county including targeted stop smoking services, social marketing campaigns, cancer screening programmes that are aimed at widespread coverage and specific targeting of hard to reach groups.

Improve Access to Services zWe have invested in reducing waiting times and this is continued in the planning period to sustain 15 weeks referral to treatment performance throughout the period. We have also invested in reducing community service waiting times which are now at 2 weeks for the first assessment with an 8 weeks referral to treatment time. NHS Gloucestershire has invested in

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cemental health services (including crisis response, psychological therapies, carers assessment, community based eating disorder service, personality disorder services) to ensure fast access to services at an early stage.

Prioritisation Framework

6.6 Delivery over the medium term will require careful prioritisation of both investment and disinvestment decisions. The development of a transparent prioritisation framework will be an important tool in ensuring engagement and understanding of how these difficult decisions have been made.NHS Gloucestershire has used a set of commissioning principles to guide investment and prioritisation decisions for large scale schemes, as follows

Any proposal under consideration should:

be financially cost neutral and deliver value for money, or should be an investment to •save in the futuremaximize potential for disease prevention and promotion of independence and well •beingmeet national standards of quality and clinical safety•Aim to ensure a viable market from which to commission•Deliver a service as near to home as can be viable or effective for the patient•provide flexible services that are able to respond to changing demographics and •technology etc.reflect the needs for a particular community of interests within the Gloucestershire •health priority contextfacilitate an integrated person-centred model of care•

Prioritisation Criteria We are currently testing and proposing to adopt the Dudley PCT prioritisation tool to assist in assessing the effectiveness of more routine commissioning or provider led service development proposals. This tool contains a broader range of criteria, which can be weighted to provide a robust and consistent assessment of schemes. A copy of the tool is attached at Appendix 2.

Benchmarking

6.7 NHS Gloucestershire is expecting to receive baseline funding of £868m revenue funds per annum from 2010/11. This is a very significant budget and it is important that we spend time ensuring that we understand how we are using it and where we can make the money go further. We are doing this through using a number of various metrics and ensuring that financial information is considered in the wider context of population and outcome data.There are various strands to the work we are undertaking;

Allocative efficiency•Operational efficiency•Spend efficiency•Capital efficiency•

AllocativeEfficiencyWe can benchmark the way we allocate our resources compared to the national assumptions as published in the Exposition Book.

This shows that there is a split of the overall allocation into 3 elements;

Hospital & Community Health Services (HCHS)•

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Prescribing•Primary Care•

Within the HCHS element of the formula we can review how this is spent on our population by age group compared to the anticipated resource utilisation by each age range.

Age Bands Target Target Actual Actual Difference % £m % £m £m

0-19 11.7% 67.2 13.6% 77.6 10.4

20-64 46.5% 266.6 48.5% 277.8 11.2

65+ 41.7% 238.9 37.9% 217.3 -21.6

Total 100.0% 572.7 100.0% 572.7 0.0

This analysis suggests that there is an apparent over investment in both the 0-19 population and •the 20-64 population.There is an apparent significant under investment in services for older people which will become •more acute as this sector of the population grows.Contributing factors to the levels of expenditure in the 20 to 64 age group are cancer services •where spend is 52% for working age adults and within mental health services the significant area of spend (72%) is in the adults of working age group.Demographic projections show very low growth for the working age adult population and no •growth for the young people age range (0 -19 years) over the next 15 year period. The number of older age adults (65 + years) will grow proportionately and absolutely and put pressure on health and social care services. This means proportionately more investment in older people’s services is required in future years with a relative reduction in young peoples and working age adult services.

Operational Efficiency6.8 Operational efficiency is about reviewing how we run our services and delivering more within the

same or a reduced resource envelope.Some key strands of analysis that we have already got in progress are as follows;

Benchmarking of acute services access rates and lengths of stay. This is a detailed piece of •work that compares NHS Gloucestershire to a selected peer group of PCTs with very similar population profiles to our own.

This has shown that NHS Gloucestershire has very high access rates to Clinical Oncology Services and higher than expected access rates to Trauma and Orthopaedic services and Thoracic medicine. More detailed work is now being taken forward in these areas, with a view to, where appropriate, bringing spend levels to a comparable position within our peer group.

It also showed that our population experience higher than expected length of stay in hospital in •a number of specialities. Work to reduce this is being taken forward through the unscheduled care network and will partly be addressed by the Gloucestershire Hospitals NHS Foundation Trust’s project Utopia.The second programme of work we are engaged in is a project to look more closely at •programme budgets.

We are developing a project to review how Programme Budgeting and Marginal Analysis (PBMA) could be used in Gloucestershire to improve efficiency and health outcomes.

PBMA is an economic technique to assist priority setting in healthcare. There are two elements to this;

Programme Budgeting• assesses how resources are currently spent across programme areas and within programme areas and links this to current data on outcomes.Marginal analysis• assesses how we could improve health outcomes or equity by changing the way resources are used.

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ceThis technique is included in the Department of Health World Class Commissioning Competencies under investment prioritisation, and benchmarking data is available on the Department of Health website to support this process.

A project plan was developed for discussion at the Professional Executive Committee on 14th July 2009. The draft project plan will identify potential priority areas for applying PBMA in Gloucestershire, following a review of existing information, and identify the key processes and support required for the implementation of PBMA in the priority areas.

Spend Efficiency6.9 Looking at how we can derive more efficient use from our resources through using our

buying power and the innovation of the market.We now have an Assistant Director of Procurement in post and we are developing the team capability to appropriately use competition to drive out greater efficiency and improved services for the people of Gloucestershire.

Gloucestershire has very little history of using multiple providers and so it is early days in terms of there being some competition to deliver improvements. The introduction of a private provider to provide some elective care at Cirencester Hospital is seen as a significant step towards patients having more access to choice of provider.

A key element of the resource framework for NHS Gloucestershire will be to ensure that a robust approach to delivering efficiencies, including cash releasing efficiencies, across the organisation is adopted. Delivery will use benchmarking to systematically identify priority areas for targeted intervention to deliver performance improvement. This will be expected to deliver cash releasing efficiency savings of a minimum of £150m over the next two comprehensive spending review periods.

Capital Efficiency6.10 How we use our buildings and the type of buildings that we use in the provision of

services can greatly affect both the cost of the services but also the patient experience.One of the key strands of our strategic direction is to provide more care closer to home. This is key in the wider sense of sustainability in that fewer people should travel to main hospital sites for services. However we need to ensure that the buildings are fit for purpose and to understand the impact that they have on the wider environment.

We review key performance indicators for all our sites which give information on backlog maintenance, heating costs, water usage, energy consumption and other indicators. However part of the wider strategy is also about reviewing how much activity takes place in each of our sites and ensuring that we are making efficient use of our space. The PCT has responded enthusiastically to the national policy direction on Transforming Community Services including strong engagement in the Commissioners Investment and Asset Management System (CIAMS). We intend to embed robust and effective estate management into the commissioning process building on the current assessment undertaken using the CIAMS toolkit and related information eg., Estates (ERIC) data.

The capital programme, adopted in March 2009, assumes that developments to the estate will be funded via:

Community Hospital Development Funds -

SHA operational capital funds -

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Capital receipts from the sale of existing assets -

Other funding mechanisms. -

Table 13: Capital programme

£’m2009/10 2010/11 2011/12 2012/13 2013/14 2014/15

North Cotswold & Berkeley Vale Community Hospital Developments 2.1 12.5 5.9 0.0 0.0 0.0Purchase of EJC 8.2Holly House fit out 2.3Cheltenham community hospital 0.2 2.5 3.5 7.5 2.5Tewkesbury community hospital 2.5 3.5 7.5 2.5Capital grants to non NHS organisations 1.2 0.5 0.5 0.5 0.5 0.5Operational capital schemes 8.2 1.8 1.8 1.8 1.8 0.5

19.7 19.8 14.2 13.3 12.3 3.5

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ce7 Enabling Delivery of the Strategy Working in Partnership to Achieve Excellence

7.1 NHS Gloucestershire believes that working with its partners is integral to commissioning and delivering high quality health and social care services to the local population. For the future, our partnership working arrangements will need to:

maximise the benefit of social care and health partnerships to improve outcomes for •people and patients and to increase cost effectiveness plan services on the basis of a whole system approach across health and social care•seek to influence sector-wide commissioning arrangements across the whole care •pathway and use resources effectively at a primary, secondary and tertiary level.

Joint Planning and Commissioning Arrangements7.2 Gloucestershire Primary Care Trust is committed to developing a strong and collaborative

working relationship with the local authority, with the aim of delivering seamless, integrated health and social care services to the population of Gloucestershire, with an increasing focus on responding to individuals’ needs. These arrangements must be effective in addressing our health priorities and the consequences of our changing demography, especially relating to the increase in older people.

7.3 Joint commissioning arrangements are in place or are being developed with Gloucestershire County Council for:

Mental Health services People with Learning DisabilitiesChildren & Young Peoples’ servicesOlder Peoples’ servicesSubstance Misuse

These joint commissioning arrangements will be strengthened and extended over time to include more pooling of budgets and greater collaboration between the two organisations so that patients’ and clients’ experiences and outcomes are measurably improved. We also anticipate that integration will eventually extend to other areas of commissioning and provision, such as education and housing, where considerable improvements in integrated provision might also be achieved in adopting a single approach to addressing common issues.

7.4 As commissioners, we expect that, in order to deliver more integrated and personalised services around individual patients’ needs, providers will also need to work in a more integrated way. There are currently a number of joint appointments with county social services within Gloucestershire Care Services and this enables some joint micro commissioning around community based care packages. In future however, we will expect much more joint working around health and social care teams, where health, social, and 3rd sector services are fully integrated around a GP registered population.

For instance, in providing more services directly into people’s homes, we should see more single assessment and single source micro-commissioning to meet patients’ needs, commissioned through comprehensive case management. This approach will also support personalisation as greater levels of direct funding go to patients. We should expect to see a much more multi disciplinary team approach to care delivery which is designed to reduce hand-offs, reduce clinical risk, increase productivity and improve effective communication.

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Strategic Partnerships7.5 Our participation in the Gloucestershire Conference forms the main vehicle for our strategic

partnership work with other key local stakeholders, and especially the County Council, District Councils, Local Strategic Partnerships, the voluntary sector, police and the Regional Development Agency.Together, these partners plan for the future of the County. The Conference has set out its goals in its Local Area Agreement called “Our Place: Our Future – a Sustainable Community Strategy for Gloucestershire.”

This strategy:

Sets out the current and future challenges affecting Gloucestershire and is being reviewed in •light of the changing economic climate.Recognises the new expectations that are being placed on services and service delivery, and •agrees the five aims that set our framework for joint action over 10 years, for Gloucestershire to be a place:

where the future matters•where communities matter•where everyone matters•where people want to live•that thrives.•

7.6 Our Place: Our Future is supplemented by the delivery plans of its five thematic partnerships. The Gloucestershire Health and Community Wellbeing Partnership is one of those thematic partnerships and, of the five, is that in which NHSG plays the most significant part, although we have a significant presence in all of the partnerships, in particular, Children and Young People. The five thematic partnerships are:

Health and Community Wellbeing •Children and Young People•Safer and Stronger Communities•Economic Development and Enterprise•Natural and Built Environment.•

There is also a network of six Local Strategic Partnerships (LSPs), one for each district council area, taking a more local perspective on issues as well as contributing to the countywide agenda. These include NHS Gloucestershire representation with an Executive Director sitting on the Board of each, and in two cases, chairing the LSP.

Involvement & Engagement

7.7 ‘Listening to our local communities and learning from feedback’ and ‘paying proper attention to partnerships and involving people, carers, staff, contractors, partners, and the public in developing services’ are amongst NHS Gloucestershire’s stated values.To support these values the NHS Gloucestershire Involvement and Engagement Strategy was approved by the Board in 2008. The Strategy is designed to provide a strategic direction for NHS Gloucestershire and its partners, to promote health and wellbeing and commission and provide ‘world class’ services, which are high quality and value for money and aspire to continuous improvement, thereby meeting the health needs of local people.

7.8 The Strategy’s core aim is:To put in place the essential conditions for NHS Gloucestershire to make effective involvement and engagement a reality.

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ceIt will achieve this through describing a strategic direction for NHS Gloucestershire, which facilitates an informed, ongoing dialogue with our local population, partners and decision takers (i.e. the Board) supporting NHS Gloucestershire’s ongoing strategic development through promoting:

the benefits of an open organisation, which is flexible in its approach to •cultural change with a willingness to share power i.e. be open to influences on decision making

the development of mutual trust and respect between NHS Gloucestershire and its •population

an increase in the ‘health literacy’ of Gloucestershire’s population•

opportunities for all services users and communities to be involved if they choose to •be

a coordinated implementation of relevant policy initiatives and legislative •requirements.

The Engagement Cycle7.9 Published by the Department of Health in April 2009, The Engagement Cycle mirrors

NHS Gloucestershire’s emphasis upon ongoing engagement, but illustrates in finer detail, a way of approaching patient engagement at each stage of the commissioning cycle:

Strategic Planning Specifying outcomes and procuring services Managing demand and performance

It can be used to facilitate improvements in world class commissioning, particularly concerning Competency Three – engaging with patients and the public. A representational model, it highlights who needs to do what to engage patients and the public at each stage of the commissioning cycle. It provides checklists for action and will be developed to include links to policy documents, case studies, toolkits and other materials.

The Engagement Cycle

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Involvement and engagement to support the development of the NHS Gloucestershire’s Strategic Plan

7.10 The floods in Gloucestershire in 2007 reinforced the value of public bodies and local communities working together towards a common goal to deliver the very best for local people both in terms of personal wellbeing and access to timely and responsive services. NHS Gloucestershire is publicly accountable to its population and therefore its strategic planning and decision making processes are influenced by its local people’s needs, expectations and experiences of the service it provides.. Over the past three years NHS Gloucestershire has sought the views of local people, staff and stakeholders through a range of involvement activities including, face-to-face meetings, public deliberative events, on line questionnaires and targeted events for ‘seldom heard groups’. The outputs from all involvement activity were collated and reported to the NHS Gloucestershire Board. Recent key events which have influenced the development of this strategy have been covered in sections 2.3.

NHS Gloucestershire also recognises its role as a “mindful” employer and business. Our engagement extends to ensuring that we participate in local initiatives which have aims beyond improving health. For instance, we have financially supported the recruitment of Village Agents, where informal local representatives’ roles have been acknowledged and formalised to provide much stronger links between statutory organisations with some of our rural communities on all sorts of local issues. We have also sponsored twinning of schools across rural and urban areas to establish a better understanding of the differences and similarities between communities. Feedback suggests that this kind of relationship building has potential to increase the impact of health inequalities reduction work.

NHS Constitution7.11 The publication of the Constitution means that patients and the public will know what they are

legally entitled to and how they can exercise their rights, as well as understand their responsibilities regarding their own health and well-being. It outlines the roles we all have to play in protecting and developing the NHS and will help the public to understand their rights, our pledges, values and responsibilities.

Our work with local partners to develop plans and priorities for improving our health and well-being

7.12 We continue to work with key partner organisations such as the County and District Councils, Gloucestershire Hospitals NHS Foundation Trust, 2gether NHS Foundation Trust, General Practitioners, voluntary organisations and patient and public representative groups such as LiNK, to help us develop our future strategy. We have an effective relationship with our local Health Overview & Scrutiny Committee and we have also recruited a number of lay representatives who participate in an increasing number of PCT work streams. Some of the work we have done together includes:

The Joint Strategic Needs Assessment (JSNA) which identifies the specific health needs and •health inequalities within the Gloucestershire populationThe Healthy Gloucestershire Strategy (HGS) – Produced by the Gloucestershire Health & •Community Wellbeing Partnership. This sets out the joint work we will do with our partners to tackle the issues coming from the JSNA over a 10 year periodLocal Area Agreement (LAA) – This is a shorter term plan of action to tackle health, social and •economic issues across health and local council areas.

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ceOur Commitment to working with the Voluntary and Community Sector in Gloucestershire

7.13 Building upon the strong partnership which already exists between the NHS and the voluntary and community sector (VCS) in Gloucestershire is vital for our success. Gloucestershire’s Compact is recognised as being one of the strongest nationally and has provided a solid base upon which to work better together for our residents. The VCS in Gloucestershire is significant and through the Voluntary Sector Assembly, the sector has a strategic voice that influences and informs the commissioning of health and social care services. NHSG acknowledges and values the diversity of the VCS in Gloucestershire through our commitment to the local Compact and investment in infrastructure services. NHSG has developed a strategy to consult and involve the VCS in all stages of the commissioning cycle to ensure that:

VCS organisations can influence the design of services as part of the commissioning •cycle

VCS organisations can offer innovative solutions to meet local needs•

Better partnership working occurs through proactive use and implementation of the •local Compact by all partners engaged in the commissioning cycle

Working closely with the VCS can secure better health outcomes for local people•

All NHS commissioners are aware of the diverse range of VCS organisations able to •deliver outcomes

We embrace the potential within the VCS to support increased choice and address •health inequalities.

Planned Activity 2009-20107.14 We have invested in the development of a VCS Commissioning strategy for

Gloucestershire. This work is led by the VCS, but involves all statutory sector commissioners. The strategy will be completed in June 2010. We acknowledge the health benefits of volunteering for staff and service users and support this by investing in volunteer support services, infrastructure support and strategic engagement with the VCS. NHSG will be developing existing policies to embrace employer supported volunteering. Volunteers make a vital contribution to our organisation in our Community Hospitals, through delivery of programmes such as the Expert Patient Programme and in their support for service users.Further information on the VCS in Gloucestershire can be found at:

http://www.gloshub.org.uk/

Information on the Gloucestershire Conference, the family of partnerships can be found at http://www.gloucestershire.gov.uk/index.cfm?articleid=3987

Social marketing – Our Approach7.15 We are committed to taking a social marketing approach to our public health

programmes. This is in line with our commitment to evidence based commissioning; and public and patient involvement. Social marketing will support effective targeting and promotion; and help ensure that we design services and communications which meet the needs of end-users, and have a positive impact on behaviour. Social Marketing is about more than advertising campaigns. It is grounded in audience research, and interventions may involve improved training for service providers, or redesigning existing services, in addition to the traditional tools of health promotion.

7.16 We are working with the South West regional branch of the National Social Marketing Centre (NSMC) to benefit from national best practice in this area, and share knowledge with other PCTs. Training in the application of social marketing is underway with Public Health Managers to build capacity within the team. Where relevant, the NSMC

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‘benchmarking criteria’ will also be incorporated into commissioning frameworks to guide the work of our provider organisations.A particular focus will be to use social marketing techniques to increase our understanding of the needs and wants of vulnerable and seldom heard groups, and those living in areas of greater health inequality.

7.17 As part of this, we are developing our segmentation tools. The data contained in the eJSNA will be supplemented with psychographic data, and the findings of audience research, to build a more rounded profile of the local population. In common with other PCTs, it is planned to commission a commercial market segmentation tool (such as MOSAIC) to assist with this.

7.18 Monitoring and evaluation are integral parts of the process; all social marketing campaigns will be evaluated to ensure that interventions remain responsive to local needs, and deliver measurable benefits.

Campaigns7.19 We have shortlisted a number of areas to focus our social marketing activities on in 2009/10-

2010/11, these include:engaging young people on sexual health issues, specifically linked to uptake of Chlamydia -screening

optimising the uptake of cancer screening among minority ethnic communities -

understanding the factors behind alcohol misuse, and designing appropriate interventions. -

Contestability & Marketing

7.20 NHS Gloucestershire recognises that becoming a stronger commissioner means taking a more active part in managing the range and function of providers and potential providers in key areas in our local market. The local health economy is currently dominated by its NHS monopoly providers and Gloucestershire needs to encourage wider uptake of choice of provider. As a commissioner we believe that there are opportunities to provide better services for the population through better management of this local market. The priority outcomes for work on market development will be five-fold:

To drive transformational service improvement and innovation•

To improve the patient experience•

To secure best value for money and a step change in service productivity•

To increase patient choice•

To introduce competition amongst providers where this is deemed beneficial.•

7.21 As part of its service redesign strategy NHS Gloucestershire has established a dedicated procurement resource to drive forward service change via commercial market interventions. Alongside this NHS Gloucestershire has strengthened its contract management team through the recruitment of suitably qualified personnel.With the development of more plurality of provision and a greater degree of competition for service provision, NHS Gloucestershire recognises that it has a responsibility to ensure, in making complex commissioning (procurement) decisions, it must be transparent and non-discriminatory.

7.22 NHS Gloucestershire agreed a contestability framework in March 2008. This framework and supporting policies (Any Willing Provider and Dispute Resolution) are currently under review to ensure clarity of process and engagement within the wider organisation. NHS Gloucestershire’s procurement strategy was endorsed at its January 2009 meeting. To signal areas of market development and to promote openness with the market, these policies will be published on NHS Gloucestershire’s website with a list of service reviews which may lead to future market opportunities.

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7.23 Contract managementAn important element of market management is strong contract management. NHS Gloucestershire is in the process of developing service specifications for all existing services to support the implementation of the new national NHS contracts. These new contracts and specifications will increasingly have an outcomes focus and will be used to ensure better management of existing providers and improving quality of care and value for money of existing services.

All major contracts have formal contract boards in place to review contract performance on a monthly basis. Our approach is also intended to enable more formal contractual arrangements with a greater number of smaller providers who have previously provided their services on the basis of a grant from the PCT. In relevant markets this should enable us to encourage more of these smaller providers to bid for service provision.

7.24 When making decisions on whether to work with or contest the market NHS Gloucestershire takes into account such considerations as those shown in the following table.

Contestability or Co-operation

Assessment ConsiderationWhat is the need?

Are new services required either in terms of new treatments or additional and discrete new provision?

Market Structure

Assess local, regional and national market in terms of where services are provided along current or desired patient pathways (vertical market structure)Assess the number of local and regional provider organisations and understand current market structure (horizontal market structure)

Competition Assess behaviours that demonstrate competitive tension and responsiveness to patients and commissioner needs. Is there a case for introducing (more) competition to address choice, quality, efficiency or responsiveness?

Capacity Is there sufficient capacity (facilities, diagnostics and treatment equipment, workforce etc) to provide the required service?

Innovation Assess developments in the market in other regions and international benchmarks

Interest Assess market interest in opportunities, transparently and without discrimination, including whether a contract may be of interest to a provider from a member state.

Market Development7.25 In developing the market, the approach that NHS Gloucestershire has adopted can

broadly be defined as “strategic sourcing” and includes the following activities:segmenting services for market analysis•

understanding change levers, using collaboration and competition and engaging •clinicians

conducting market analysis•

creating sustainable and efficient markets•

building capacity.•

As a first step towards understanding existence and viability of markets, NHS Gloucestershire has performed market analysis on key projects such as musculoskeletal services and weight management services, both of which have gone forward as tender

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exercises. Current service reviews which are also part of a market analysis review are Child and Adolescent Mental Health Services (CAMHs); Patient Transport Services and Audiology.

NHS Gloucestershire is using the NHS ‘Supply to health web portal’ to advertise all tenders and will use selected journals as and when appropriate.

7.26 A further in depth programme of market analysis is also under way focusing on community based services as part of the Transforming Community Services national policy initiative. Commissioning leads have been asked to look at services under review and to test the way forward for improvement using the strategic sourcing approach. This provides a rigorous and transparent process for decision making about how a particular services or segment might be best improved, i.e. through competition or through more traditional co-operation. A potential recommendation for market testing is referred to the procurement team and a wider debate is held to determine the final outcome. Services/segment considered using this approach so far include; patient transport, orthopaedic intermediate care, respiratory care; stroke services and diagnostic services.

Procurement in NHS Gloucestershire7.27 The continued development of a good procurement (and market management) strategy will

support NHS Gloucestershire in increasing the rate of improving outcomes by creating more ‘commercial intelligence’ to support decision making and specification setting designed to drive improved outcomes.NHS Gloucestershire has recruited an Assistant Director Procurement to lead this work, who is supported by 2 newly recruited procurement specialists. A key focus of their work to support organisational development in 2009/10 will be the development of a procurement hand book, developing suitable training packages to improve the capability of the organisation, through the development of existing staff and to embed procurement for healthcare services into PCT functions.

Practice Based Commissioning

7.28 Practice Based Commissioning (PbC) was launched in the autumn of 2005 as a policy to strengthen clinical engagement in the commissioning of local services. This new role for primary care clinicians provides opportunities to shape services to be more responsive to the needs of patients, to see more services delivered locally and to see better use of NHS resources. It encourages frontline clinicians to play a greater role in the commissioning process; identifying the needs of patients, reviewing and developing services and monitoring progress.

7.29 Decisions made by general practitioners commit a substantial proportion of the local NHS budget, whether through prescriptions for medication or referral to community or secondary care services. Therefore, the views and input from our general practitioners, are seen as essential in developing our services and providing feedback on how services are received locally.

7.30 Research undertaken nationally concludes that in a mature system, PbC should not be seen as a separate policy area but, instead, is an integrated clinical commissioning function as a core part of PCT and practice business. NHS Gloucestershire will achieve this marker of maturity through further and continued development of PbC.

7.31 In March 2009, the Department of Health published its vision for the next stage of PbC in “Clinical commissioning; our vision for practice based commissioning”. This document reiterated the central role of primary care clinicians in having greater power and influence, working with PCTs, to shape how resources are invested so that they deliver better care and better value for both patients and tax payers. NHS Gloucestershire fully supports the vision described in this publication.

7.32 Practice Based Commissioning (PbC) is, therefore, a key area of clinical engagement and NHS Gloucestershire has processes in place to support the work of our PbC Clusters. The approach has been to encourage participation in PbC through self-selecting groups of practices (known as PbC Clusters) whilst allowing engagement at individual practice level where this is more appropriate. The approach for the future is to facilitate practices joining larger groups, recognising the increased resilience a larger unit provides. PbC configuration is still evolving. The accountability

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cearrangements, budgetary responsibilities and arrangements, management support and incentives have all been established in close liaison with our GPs, using learning from previous years to refine these processes.

7.33 In addition to direct funding, the PCT has structured a PbC management team covering 6 localities to mirror as far as possible Cluster arrangements. Lead by a Senior Manager, these teams also have medicines management pharmacist resources and service improvement support. PbC Clinical Leads from each cluster or individual practice meet with the PCT senior commissioning team on a regular basis which provides coordination and links between clusters’ individual working arrangements and the wider commissioning role of the PCT and its PEC. This has also allowed for sharing of learning from service development initiatives and supported the roll out of successful pilots countywide. An example of this approach is Pulmonary Rehabilitation, which has been developed in the county through this process.

7.34 In response to The Next Stage Review, NHS Gloucestershire intends to build on the positive relationships that have developed with PbC clusters. We will work with them to develop a clear strategy which will define how PbC clusters will engage more fully with the strategic commissioning processes of the PCT, including linking with the developing arrangements around joint commissioning. The PCT’s aim is to ensure that PbC clusters are more directly linked into the processes that support the development of county wide strategy and, thereby, have a stronger investment in developing locally sensitive implementation plans that reflect the overall priorities for the county as a whole. An example of this is the role that PbC clusters are playing in leading the development of local service models to support the planning of new and replacement community hospital facilities in North Cotswolds, Berkeley Vale, Gloucester and Tewkesbury. The clusters are working closely with the PCT and Social Services partners to ensure that the modelling assumptions and development plans are clinically appropriate, based on deliverable assumptions and financially viable for the longer term.

Key strategic developments for the future will be:The reinforcement of Practice Based Commissioning as the driving clinical force •behind commissioning for NHS GloucestershireThe configuration of NHS Gloucestershire’s commissioning arm to ensure a •stronger focus on PbC, in particular with greater influence from lead clinicians on decision takingThe gradual extension of the PbC devolved budgets and the development of the •accountability framework to reflect this stronger lead role.

PbC priorities for service change are;Leading the development of local service models to support planning of new 1. and replacement community hospital facilities in North Cotswold, Berkeley Vale, Gloucester, Tewkesbury and Cheltenham.

Identifying financial efficiencies through service redesign to support the development 2. of primary care facilities to improve patient experience and enable more care to be provided closer to home.

Addressing the needs of our growing elderly population through improved, locally-3. based orthopaedic services by extending the current provision to include a full Musculoskeletal triage, assessment and treatment service.

Improving urgent care services and shifting care closer to home by developing a 4. model of service based on a single point of clinical access, managed by experienced GPs, to maximise and coordinate alternative care pathways for patients. This to be supported by strengthened local community based teams comprising health and social care resources which are able to quickly respond to patients’ needs.

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Working with secondary care clinicians to review care pathways and referral guidelines for 5. referrals for elective care to ensure, when needed, patients can access timely care.

Utilising lead PbC Cluster arrangements to test out new ways of providing services ahead of 6. roll out across the county if of proven benefit. For example, community-based eye care for such conditions known as “red eye” where patients would have previously been referred into eye casualty.

Increasing the range of outpatient and other clinics available locally so that more patients can 7. access their care closer to home.

Quality, Commissioning Outcomes and Patient Experience

Key StatementThe commissioning of high quality care, ensuring it is safe and effective and that the patient •experience is understood is essential.

NHS Gloucestershire is committed to ensuring that high quality is inherent in the commissioning •and contracting of services and that we measure outcomes and monitor performance in relation to quality standards. We will also ensure that our providers obtain and act on feedback from their patients.

NHS Gloucestershire will seek to maintain and improve the quality of services delivered by all •providers.

7.38 National driversThe NHS Next Stage Review ‘High Quality Care for All’ places quality at the heart of everything the NHS does and outlines reforms which will have a significant impact on improving the quality and experience of NHS services.

‘High Quality Care for All’ recognises that to meet this challenge quality needs to be the ‘organising principle’ of the NHS and defines quality as having three core dimensions, namely:

Patient safety•

Effectiveness•

Patient experience •

7.39 The new national contracts provide a wide range of quality indicators that will help with ensuring that the services that we commission and contract for are safe and effective, and require providers to seek feedback from patients regarding their experience. Included in the contracts are the Commissioning for Quality and Innovation (CQUIN) incentives that will also help drive the delivery of the quality agenda.

7.40 There will be a national Quality Board, setting the direction and maintaining momentum on quality in the NHS and every region will establish Quality Observatories that will enable the better use of new and existing data streams to support clinicians and organisations.

7.41 Quality Accounts will need to be produced from April 2010 by all provider organisations. The core purpose of Quality Accounts is to enable Boards to focus on quality improvement, for the public to hold providers to account for the quality of services and to support patients with making better informed choices.

7.42 Local driversNational and regional quality metrics are being developed to support local initiatives. Current proposals include:

Infection rates•

Privacy and dignity•

Incidents, including medication errors•

Patient experience, including complaints and PALS•

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Falls•

Cancellation of procedures•

Pressure ulcers•

In addition, local quality metrics can be developed to address local service quality improvements or incentives, and some metrics that are specific to providers. The intention will be to extend the application of quality metrics and CQUINs to all providers (not just within NHS Gloucestershire).

7.43 A review of how we develop the commissioning for quality agenda has taken place and a refreshed structure proposed that includes a new Clinical Quality Commissioning Group that aims to ensure that clinical quality – including safety, effectiveness and patient experience – is properly considered in the commissioning of services.This Group will have a relationship with both the PEC and a pan-Gloucestershire Clinical Forum. The Clinical Forum will enable clinicians from all local health organisations to have an opportunity to come together to discuss and make recommendations around clinical and service developments and their prioritisation. The group will provide a useful forum in which to test significant commissioning change ideas which have a major clinical impact as well as helping to shape care pathways to improve clinical effectiveness and tailoring to meet local needs.

7.44 Increasingly PEC will be developed to support the PCT’s commissioning function so that clinical leadership is stronger and more able to contribute to development of our local health market and to service procurement through the development of robust service specifications with a focus on clinical quality.Further work will be undertaken in 2009 to develop service specifications for all of the services we commission and contract for. The specifications will include service and quality outcome measures.

Patient Safety7.45 The NHS Gloucestershire Board considers Quality and Patient Safety as fundamental

in commissioning all services. Quality indicators are included in contract specifications and monitored through contract review processes. Requirements relating to quality and patient safety include:

requirement on all providers to fully implement the National Patient Safety Strategy•

all providers to comply with MRSA screening in line with national guidelines•

Privacy and Dignity assurance – including same sex accommodation.•

7.46 All aspects of commissioning quality and patient safety assurance are managed through Commissioning for Quality Group and escalated as appropriate, through the Integrated Governance Committee, a formal sub-group of the Trust Board. A clinical forum will be established to provide a Gloucestershire-wide clinical Executive Group to oversee commissioning intentions, including quality. Quality accounts will be required to be published by June 2010, for both commissioner and providers.

7.47 Reducing healthcare associated infection rates is a key performance target for NHS Gloucestershire. National and regional trajectories have been agreed both for the providers and commissioner perspective. All providers are required through contracting to ensure a robust root cause analysis process is carried out for any SUI, including MRSA bacteraemia and C. Diff to address any key findings.

7.48 The final SUI reports from all providers, including Independent Contractors, are presented in the confidential section of the Board with the resulting action plans being monitored as part of the assurance process by the Integrated Governance Committee,

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to ensure learning outcomes are implemented.Triangulation of information will be used to monitor quality of services commissioned. This includes the following:

patient experience•complaints•patient outcomes •Hospital standardised mortality rates•Incidents.•

What does it mean in Gloucestershire?7.49 The SHA Strategic framework for Improving Health provides a regional vision created by clinicians,

staff, patients and local communities setting out stretching ambitions in an approach to delivering better quality of care. NHS Gloucestershire has responded in developing the Operating Plan and reflecting ambitions in provider contracts. NHS Gloucestershire has developed excellent working relationships with its provider trusts in the county and within the last year has developed its contracting role to ensure greater scrutiny of quality and performance issues alongside the traditional review of finance and activity. Contract Boards are in place for local providers with Clinical Quality Review Group subgroups in place.

Our plans/potential high level deliverables for commissioning quality services in Gloucestershire

The Clinical Quality Commissioning group was established in September 2009 •The NHS Gloucestershire Board will receive information about the quality of services that we •commissionNHS Gloucestershire will:•

develop and implement national, regional and local quality metrics•ensure that quality standards, outcome measures and performance indicators are •incorporated into commissioning frameworks and specificationshave Quality Accounts from April 2010•where services are commissioned by other lead commissioners NHS Gloucestershire will •engage with the regional Commissioning for Quality Group.

Workforce Development

Key statement/Aspirations:NHS Gloucestershire recognises that excellence can only be achieved through a positive ‘can 1. do’ culture and a motivated, engaged and a positively managed workforce. To achieve this, it continues its aspiration to be an ‘Employer of Choice’ in the local market place.

As a commissioner of services, we are committed to securing excellence in health for the local 2. Gloucestershire population NHS Gloucestershire serves. We recognise that to do this – provider organisations must effectively employ, engage, manage, develop and retain a high quality workforce.

As an organisation and a major local employer NHS Gloucestershire wants to be a part of the 3. local community, contributing mindfully, beyond the remit of our core business.

The financial challenge ahead requires significant service change with consequences for staff. 4. Working with our NHS partners across Gloucestershire to ensure that change is managed openly, effectively and sensitively, staff will be engaged in the process of change at an early stage. The impact on individuals will be minimised where appropriate through effective dialogue, meeting new training and development needs and through a fair and open process.

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aspirations.

National drivers

The Operating Framework Accountability Guidance for PCTs:7.51 Identified that unlocking the potential of its workforce is key to optimising service

delivery. The Trust has committed 2% of its’ pay bill to workforce learning and development activity.A workforce talent management programme was launched in 2007/08. Talent and leadership planning for NHS Gloucestershire will be focused on supporting its’ Organisation Development (OD) Plan.

World Class Commissioning (WCC) Competencies (One and Five)7.52 NHS Gloucestershire will carry out a full training needs analysis during 2009/10 to

identify its WCC knowledge and needs gaps. From which it will develop and implement a development programme to build strategic commissioning capability.

Transforming Community Services7.53 NHS Gloucestershire continues to implement ‘Transforming Community Services.’ Staff

are fully engaged via the ‘Listening into Action’ staff engagement process.New high quality HQ office accommodation has been procured for Gloucestershire Care Services, which will enable closer collaborative working between staff.

Staff will be engaged via a range of communication channels including our ‘Listening into Action’ process and good partnership working with local Trade Unions during the transformational process.

Consequences of the economic downturn7.54 The changes required for delivery of our strategy as a result of the future financial

challenge are very significant. The focus on improving quality and productivity will have a profound impact, particularly on staff delivering frontline services. As a commissioner, we expect the improvements to be achieved through staff working more effectively, in better designed systems rather than working harder and for longer hours. As our ability to specify services improves through our work on World Class Commissioning, so will our ability to understand the workforce capacity and redesign required to deliver. We will ensure that these factors are included in new contractual arrangements with providers.

Local drivers

NHS Gloucestershire Strategic Plan (2008 – 2013)7.55 The Workforce OD Plan will be annually refreshed to support the workforce issues

arising from the implementation of the Strategic Plan.

Gloucestershire Health and Wellbeing Strategy (2008 – 2018)7.56 As a pivotal part of its strategic plan, NHS Gloucestershire is proactively working with

its Gloucestershire Conference partners in implementing this 10 year plan. A number of workforce elements are being progressed as NHS Gloucestershire continues to position itself as an ‘Employer of Choice,’ e.g. leading the Gloucestershire Healthy Workplace Group.

Public Service Employment Partnership7.57 NHS Gloucestershire will continue to actively engage and work with local public sector

employers on workforce matters – sharing best employment practice and working collaboratively to maximise employment opportunities for the local population.

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What does it mean in Gloucestershire?

7.58 NHS Gloucestershire is dynamically engaged with its workforce as it builds, energises and positions itself to deliver the commitments set out in the Strategic Plan, World Class Commissioning intentions and Transforming Community Services. Furthermore it has extensively engaged with partner organisations in maximising employment opportunities for the local population.

Future workforce challenges

7.59 NHS Gloucestershire recognises the future challenges associated with anticipated ‘flat cash’ settlements for the NHS from 2011 onwards. It recognises the opportunities that transformational change can achieve in providing greater operational efficiency, value for money and high quality patient care. Consequently, new service models will be developed, commissioned and implemented in a planned and robustly managed way, with full consideration of the impact of new service models on existing providers, services and the workforces that operate them.

7.60 Workforce planning is fundamental to identifying the workforce implications and gaps in proposed new service models and is actively engaging existing providers to identify and plan for the challenges that face the local NHS in Gloucestershire.

7.61 NHS Gloucestershire recognises there are important workforce implications arising from the commissioning of new health care services and the decommissioning of existing ones. As a responsible commissioner it endeavours to ensure the resultant impact of new service models on provider workforces are identified early, and for these impacts to be sensitively and pro-actively managed following current employment law and best employment practice.

7.62 NHS Gloucestershire recognises that successful transformational change can only be successfully implemented if it effectively engages relevant stakeholders. Consequently, it is committed to working with both existing and new providers, their workforces and Trade Union representatives to ensure that the workforce implications from proposed transformational change are identified and addressed.

7.63 NHS Gloucestershire recognises that there is a wealth of skill and expertise in existing provider workforces and as a responsible commissioner it will always seek to retain this skill and expertise. It is therefore committed to working with providers to train and develop their existing workforces to effectively adopt and deliver new service models.

Our approach to Equality and Diversity

7.64 We believe we can only achieve excellence in health for the people of Gloucestershire by valuing diversity, striving for equality of opportunity and by respecting human rights.

7.65 We are committed to identifying and reducing health inequalities. Our comprehensive equality action plan will help ensure all our service users enjoy the same high quality of healthcare.

7.66 We aspire to be a welcoming and fair place to work. We believe we can best serve the needs of our diverse communities through a diverse workforce and that a diverse workforce can only meet its potential in an environment free from discrimination and victimisation.

7.67 We aim to be a listening and responsive organisation and to involve people in the decisions that affect them.

7.68 We will continue to strengthen this partnership with the people of Gloucestershire and involve them in developing a single equality scheme.

7.69 In this way we will ensure that equality and human rights sit at the heart of NHS Gloucestershire and everything we do.

Other Supporting Strategies

7.70 There are a number of other supporting strategies, not covered in detail in this strategic plan, which are also key to the overall delivery of our strategic plan:

Resource Strategy•

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ceStrategic service development Plan & Community Service Strategy •

Organisation Development Plan•

Primary Care Strategy•

Risk management plan•

Procurement strategy•

3- year capacity plan•

Annual operating plan•

Communication Strategy•

Knowledge management strategy.•

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8 Implementation and monitoring8.1 NHS Gloucestershire will focus efforts to deliver the strategy through the development of work

programmes which support our strategic objectives and the priority areas in the Gloucestershire Health & Community Wellbeing Strategy (GHCWS). The specific medium term plans which detail the work we will do are presented in the form of Action Cards for the GHCWS and three year strategic commissioning frameworks for the PCT specific work programmes. In turn these will be translated into our annual operating plan.

8.2 Developing Strategic Commissioning FrameworksNHS Gloucestershire is developing nine Strategic Commissioning Frameworks describing the 3 year high level programme of work reflecting stated strategic principles which will drive delivery of our identified health improvement priorities. They are intended to be living documents aiming to capture a summary of local needs, national policy and best practice and to set out key work programmes and initiatives for delivering our desired objectives. They will be regularly updated to reflect changes in national and regional policy and changes in local needs, wants and other circumstances. The frameworks will also provide NHS Gloucestershire with specific activities to support delivery of the GHCWS action cards.

Development of strategic commissioning frameworks is intended to provide plans to a consistent format, which are then more clearly identifiable within our planning hierarchy. All nine frameworks were completed and agreed in December 2009.

Risk Management

8.3 The responsibility for risk management has been delegated by the Board to the Integrated Governance Committee (sub committee of the Board). The PCT has in place a Risk Register and an Assurance Framework, which are reviewed on a regular basis through management structures, including monthly review by the Executive Team, and performance reporting to the Board. The risks associated with commissioning are managed in three ways:

risks associated with the Annual Operating Plan are monitored through the regular performance •management presented to the Boardrisks associated with the controls and assurances are monitored through the Assurance •Framework by the Integrated Governance Committeeall other risks associated with commissioning are managed through the directorate risk registers •with the finalised Corporate Risk Register being monitored by the Integrated Governance Committee.

8.4 The PCT has a web-based incident reporting system which covers the commissioning services within the organisation and is currently being implemented within Primary Care. Incident reporting is a regular agenda item at the Integrated Governance Committee.The most significant medium term risks relating to the PCT’s commissioning function are currently identified as:

Increase in GP referrals to secondary care impacting on finance and ability to meet referral to •treatment targetsIncrease in GP emergency admissions leading to pressure on the 4 hour A&E target•Failure to achieve ambulance response times•Failure to have in place a plan to respond to pandemic flu•

In addition, performance and risk reporting continues to focus strongly on infection control with detailed monthly reporting to the NHS Gloucestershire Board on achievement against MRSA and C.Diff thresholds.

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ce Performance management framework8.5 NHS Gloucestershire has implemented a robust, integrated performance framework

to monitor progress against its key indicators and objectives, across the breadth of its responsibilities. The performance management framework aims

to reflect the Primary Care Trust’s key priorities•to ensure that effective monitoring and reporting mechanisms are in place across the •whole of the organisationto ensure that directorates have ownership of, and are accountable for, the standards •for which they have the organisational leadto ensure that action is being undertaken, where necessary, to address any areas of •underperformanceto ensure that performance frameworks are included as an integral part of Primary •Care Trust business cases and project plans.

The performance management framework monitors NHS Gloucestershire’s progress against its principal areas of priority, including:

the requirements of all aspects of the Healthcare Commission’s Annual Health •Check, including:

the existing commitments and national priorities -the core and developmental standards for Better Health -

the Use of Resources framework •the Vital Signs, encompassing: •

Tier 1 (national requirements) -Tier 2 (national priorities for local delivery), and -Tier 3 (local priorities) -

the selected World Class Commissioning outcomes measures •the Local Area Agreement •the National Productivity Metrics •the key aims and objectives of the national policy documents and National Service •Frameworks other key national and local standards•

These principal areas of priority for NHS Gloucestershire are contained within the Operating Plan for 2009/10. This document includes all of the national and local targets the PCT is working to deliver in this year and identifies the metric which will show successful delivery of the target.

Monitoring tool

8.6 The Operating Plan and Vital Sign indicators are all loaded onto a web based performance system called Performance Accelerator. Each target has an identified owner and sponsor who, on a monthly basis, receives an email requesting an update on progress against plan. The owner is the manager responsible for the delivery of the target and the sponsor is the Executive Director with a strategic lead.

8.7 The main benefits of the Performance Accelerator system are clear ownership of targets and transparency of progress against targets with information available in real time. The system is also used to monitor progress against Standards for Better Health; Use of Resources and the Information Governance Toolkit.

Performance Reports

8.8 An established monthly report providing a summary of key performance issues and trends is presented to the Executive Director team and remedial actions are agreed if there is a risk to delivery of any of the targets. The Board and PEC also receive monthly

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performance reports highlighting any risks to delivery in the year, reporting on the 5 key national priorities monthly and all other targets on an exception basis. A quarterly report against the operating plan in its entirety is presented to the Board and PEC on a quarterly basis.

Annual Health Check 8.9 The Annual Health Check provides information in respect of NHS Gloucestershire’s performance

against key service objectives such as, the reduction of waiting times and, the improvement of patient access to primary and secondary care services. It also focuses on health outcome measures, such as mortality rates for cancer and coronary heart disease, which illustrate the progress which NHS Gloucestershire is making against its trajectories for the achievement of agreed standards.

8.10 As part of its performance management framework, NHS Gloucestershire maintains a self-assessment of its performance against the Annual Health Check indicators throughout the year. Areas of current or potential underperformance are identified and monitored, and indicator-specific action plans are developed in order to address any such areas. Performance against these action plans is reviewed on an ongoing basis, in order to ensure that progress is made towards the attainment of the required standards. This is measured through the Performance Accelerator System.

Benchmarking and Productivity Improvement

8.11 In order to contextualise its own performance and identify areas for improvement, NHS Gloucestershire reviews its performance against the performance of its peer organisations locally and nationally. Regular comparison is undertaken, of performance against key indicators with other Primary Care Trusts in the South West, which facilitates the sharing of examples of good practice which have led to performance improvements.

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ce9 Declaration of Board Approval

The Trust Board of NHS Gloucestershire has been extensively involved in the development of this strategic plan.

Plans of a strategic nature are routinely discussed and approved by the board at its formal meetings. In addition, the board has regular development sessions at which the board has provided specific input to the development of this strategy.

This Strategic Plan is a comprehensive account of the work undertaken by NHS Gloucestershire to develop its strategy and is supported by the Trust Board.

Ruth FitzJohn Jan Stubbings

Chair Chief Executive

November 2009

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Appendix 1

Strategic Context1.1 Gloucestershire Primary Care Trust (NHS Gloucestershire) was established on 1 October 2006,

replacing the three former Primary Care Trusts, West Gloucestershire, Cheltenham & Tewkesbury and Cotswold & Vale. The main function of NHS Gloucestershire is to commission high quality health services to meet the needs of the population of Gloucestershire, working with partner organisations in the NHS, local authorities and the voluntary sector.

1.2 The Primary Care Trust (PCT) has an annual commissioning budget of £835 million and serves a registered population of 604,000. It employs over 4000 staff, mainly in our substantial provider arm: Gloucestershire Care Services

Provider Landscape1.3 Gloucestershire Primary Care Trust commissions services from local NHS Trusts including

Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire Care Services (the PCT’s own provider arm), 2Gether NHS Foundation Trust, North Bristol NHS Trust, Swindon & Marlborough NHS Foundation Trust, and University Hospitals Bristol NHS Foundation Trust.

1.4 The Primary Care Trust also coordinates the planning and funding of all local NHS independent contractors including: 100 community pharmacies 84 GP practices 75 dental practices 63 optometric practices

1.5 In addition to its commissioning responsibilities, the provider arm of the Primary Care Trust (Gloucestershire Care Services) is also a significant provider organisation in its own right, responsible for the provision of 10 community hospitals, community nursing, public health nursing, health visiting and school nursing, therapy services and a range of specialist community services to the Gloucestershire population.

National and Regional Policy Context1.6 The NHS Gloucestershire Strategy “Achieving Excellence” 2009 – 2014 has been developed in the

context of current government policy, taking into account the reform agenda including the White Paper “Our health, Our care, Our say”, the NHS Next Stage Review, World Class Commissioning and the draft Strategic Framework for Improving Health in the South West 2008/09 – 2010/11.

Commissioning a Patient-led NHS 1.7 “Commissioning a Patient-led NHS” was published by the Department of Health in July 2005 and

set out a new framework for organising and delivering services in order to meet the aspirations of the NHS Improvement Plan, placing the interests of the patient at the heart of the service and focusing as much on quality as capacity.

1.8 Key themes and priorities for the continued reform of the NHS include improved information for patients, stronger standards and safeguards, developing a choice of providers, health promotion and prevention, clinical leadership, organisational development through Foundation Trusts and strengthened Primary Care Trusts.

1.9 For the first time a clear distinction was drawn between the functions of commissioning and provision of NHS services with a new, stronger commissioning function for Primary Care Trusts. A major reorganisation of Primary Care Trusts and Strategic Health Authorities was initiated, with reconfigured Strategic Health Authorities being established in April 2006, and Primary Care Trusts in October 2006. This led to the establishment of Gloucestershire Primary Care Trust on 1 October 2006 and the separation of the Provider and Commissioner governance arrangements from April 2008.

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ceHealth Reform in England: Update and Commissioning Framework

1.10 “Health Reform in England: update and commissioning framework” was published by the Department of Health in July 2006 and defines commissioning as the means by which we secure the best value for patients and taxpayers. Best value is identified as:

The best possible health outcomes, including reduced health inequalities.•

The best possible healthcare within the resources made available by the taxpayer.•

1.11 The changed role and function of Primary Care Trusts is seen as critical to delivering the vision for a patient centred service. The need for PCTs to work more closely with clinicians, providers and other partners (local authorities in particular) is also given major emphasis in this achievement.

Practice Based Commissioning 1.12 Practice Based Commissioning guidance was first published by the Department of

Health in 2004 and introduced the devolvement of commissioning responsibilities from Primary Care Trusts to primary care practices, with the introduction of indicative practice budgets, to provide better and more local care for patients.

1.13 Practice Based Commissioning is about engaging practices and other primary care professionals in the commissioning of services. Through Practice Based Commissioning, front line clinicians are being provided with the resources and support to take the lead in commissioning decisions and to tailor services to the needs of the local community.

Our Health, Our Care, Our Say – a New Direction for Community Care 1.14 The White Paper “Our health, our care, our say” was published in January 2006 and

expands the reform agenda set out in the NHS Plan 2000 with a much wider vision for the future organisation of the NHS and the way services should be delivered.

1.15 In particular the White Paper reflects the aspirations of the public for health services which enable individuals to remain independent by being able to choose services which are not only effective in clinical terms but are accessible close to where they live. The White Paper highlights the effect of poverty and discrimination on people’s health and the variations in access to treatment depending on where in England people happen to live.

1.16 The White Paper has four main goals: better prevention services with earlier intervention•more choice and a louder voice for patients •tackling inequalities and improving access to community services •more support for people with long term needs •

1.17 Most importantly, the White Paper shifts from the narrow focus of treating illness to promotion of the broader concept of well being. It requires local areas to promote outcomes that address health inequalities, inclusion and well being across the range of public services that affect people’s lives. A shift from hospital based to community based healthcare is indicated and integral to this is the requirement for better partnership working between health and social care professionals and community and voluntary organisations.

Commissioning Framework for Health and Wellbeing 1.18 The Commissioning Framework for Health and Wellbeing was published by the

Department of Health in 2006. The framework is about action, with a particular focus on partnership. It is also very strongly focused on the reorganised NHS with its clear separation of the commissioner function from that of the provider. It has three aims:

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to shift towards services that are personal, sensitive to individual need and that maintain •independence and dignity.to strategically promote and invest in health and well being, investing now to reduce future •costs of ill health

to focus more strongly on the role of commissioning the services and interventions that will •achieve better outcomes across the NHS and local government, working together to promote inclusion and tackle health inequalities

The NHS Next Stage Review ‘Our NHS, Our Future’ 1.19 In July 2007 the Secretary of State for Health announced a wide ranging review of the NHS to be

led by Professor Lord Ara Darzi aimed at ensuring a properly resourced NHS that is clinically led, patient centred and locally accountable. This review, which directly engaged patients, NHS staff, and the public, concentrated on four critical challenges:

working with NHS staff to ensure that clinical decision making is at the heart of the future of •the NHS and the pattern of service delivery

improving patient care, including high quality, joined up services for those suffering long term •or life threatening conditions and ensuring patients are treated with dignity in safe, clean environments

delivering more accessible and more convenient integrated care, reflecting best value for money •and offering services in the most appropriate setting for patients

establishing a vision for the next decade of the health service which is based less on central •direction and more on patient control, choice and local accountability and which ensures services are responsive to patients and local communities

1.20 A key theme of the review was the importance of developing local self improving health systems, rather than systems predominantly driven by the requirement to meet national targets.

1.21 Eight clinical pathway groups were established across each of the ten strategic health authority areas in England, to propose the future direction and ambitions for the following topics:

maternity and newborn care•

children’ services•

staying healthy •

mental health •

acute care •

planned care •

long term conditions•

end of life care•

1.22 The clinical pathway groups, whose membership mainly comprised clinicians with additional members drawn from patient groups, NHS management, local authorities and the voluntary sector, met during October and November 2007. Their remit was to:

review an evidence base comprised of a summary of available research studies, international •case studies, and comparative data

identify what practice already exists which matches this •

identify what currently does not exist •

identify what prevents this happening: structural, organisational and other issues •

describe what needs to happen locally and nationally in order to deliver the optimal pathway.•

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ce1.23 Lord Darzi’s final review “High Quality Care for All”, published on 30 June 2008,

reflected the outcomes of the regional reviews and set out how the vision for the future can be delivered, working with staff, patients, and the public to ensure that it is developed and owned by all. The final review focuses on the need to bring about change at a local level, based on sound evidence and in partnership with patients and staff, with a ten year vision for an NHS which gives patients and the public more information and choice, works in partnership and has high quality of care at its heart.

1.24 High Quality Care for All highlights three key themes: High Quality Care for Patients and the Public with the development of personalised services which meet individual need and which focus on improving health as well as treating sickness; working in partnership with the many other agencies that also seek to promote health. The review outlines a range of measures to achieve this, including better support to help patients reduce their risk of ill health, more rights and control for patients and carers over their own health through increased choice, better information and the introduction of personalised care plans for people with long term conditions. This includes a focus on delivering care closer to home with a greater use of technology for planned care and outpatient care.

Quality at the Heart of the NHS providing high quality care as safely and effectively as possible with patients treated with compassion, dignity and respect, and with care that is personal to each individual. Measures to support the raising of standards include reduction in health care associated infections, systematic measuring and publishing of information about quality of care including patients own views, and ensuring continuous improvement in the quality of primary and community care.

Working in Partnership with Staff, the review seeks to empower frontline staff to lead change that improves quality of care for patients by placing a new emphasis on enabling NHS staff to lead and manage the organisations in which they work. There will be a clear focus on improving the quality of NHS education and training with a threefold increase in nurse and midwifery preceptorships, doubling of investment in apprenticeships for both clinical and non clinical staff and strengthening the arrangements to ensure staff have consistent and equitable opportunities to update and develop their skills

1.25 Underpinning the NHS Next Stage Review Final Report, a number of other documents were published in July 2008 including “The NHS Next Stage Review: Our vision for primary and community care” which sets out the vision for a continuously improving primary and community service where essential standards are guaranteed and excellence is rewarded. Patients should be able to expect to access services at times that are convenient to them, and have access to a growing range of health services in GP surgeries, in a range of other community settings and in their own homes. Primary and community care services should play a central role in helping people live healthy lives, and the public should have the support they need to take greater control over how they manage their care, particularly those with long term conditions.

World Class Commissioning

1.26 On 3 December 2007, the Department of Health launched the vision for World Class Commissioning, which clearly set out the goal for every Primary Care Trust to systematically develop and implement World Class Commissioning in a way that ensures the needs and priorities of the local population are met.

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1.27 The World Class Commissioning programme consists of three elements: 1. The vision and competencies required.

2. An assurance system.

3. Support and development for Primary Care Trusts.

Vision and Competencies 1.28 The World Class Commissioning programme aims to develop Primary Care Trust commissioning

competencies and describes a vision where commissioning is focused on ‘Adding life to years and years to life’ through:

better health and well being for all people live healthier and longer lives •

health inequalities are dramatically reduced •

better care for all services are evidence based and of the best quality •

people have choice and control over the services that they use so they become more •personalised

better value for all investment decisions are made in an informed and considered way, ensuring that improvements •are delivered within resources available

Primary Care Trusts work with others to optimise effective care •

1.29 The levers of system reform that NHS Gloucestershire is able to use to achieve the vision include: Patient Choice: individual service users driving improvement through exercising their right to •choose both the location and, increasingly, the nature of the service provided, with money following the patient via tariff based mechanisms such as Payment by Results. Practice Based Commissioning: resources and decision-making devolved close to the patient, •with practices and general practitioners able to redesign services and care pathways to secure care closer to home. Strategic Commissioning: in collaboration with Local Authority and social care commissioners, •using Joint Strategic Needs Assessments to inform decisions on investment/disinvestment across programme budget areas and geographies, to improve health and well being and reduce health inequalities. Market Management: encouraging and working with a wide range of service providers to •increase choice, improve value for money and quality of care.

1.30 The assurance system comprises three domains against which Primary Care Trust performance towards World Class Commissioning will be assessed. Health Outcomes and Quality: Primary Care Trusts choose eight measures from the “Vital Signs” published as part of the NHS Operating Framework, against which their progress will be assessed. These will cover the three elements of the World Class Commissioning vision: better health and wellbeing for all, better care for all and better value for all. Primary Care Trusts will set local stretch targets to move them towards the best in the NHS, and then towards world class.

Competencies: For each of the 11 competencies in the World Class Commissioning programme, the current capability of Primary Care Trusts is assessed. The results inform a development process to ensure that Primary Care Trusts progress to best practice. The World Class Commissioning competencies will be measured through a combination of self assessment, metrics and evidence gathering, 360 degree feedback and external panel review. The 11 competencies are loosely grouped into four categories:

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celeadership •

technical expertise •

change management, and procurement, and •

performance management •

Governance: This will examine the three elements of Board controls and processes, strategy and financial planning and will assess board capability, finance and the strategic planning process and content.

NHS South West Strategic Framework for Improving Health in the South West 2008/09 to 2010/11

1.31 The draft South West Strategic Health Authority Strategic Framework 2008/09 to 2010/11, published in May 2008, sets out the proposed future direction and priorities for action in NHS South West. The strategy was informed by the work in the South West on the NHS Next Stage Review: Our NHS, Our Future, and is designed to ensure that people in the South West experience the best that the NHS can offer; a world class service, leading to world class health outcomes.

1.32 The Strategic Framework for Improving Health in the South West 2008/09 to 2010/11 has drawn on the views of local people, especially service users, patients and carers, bringing together their experience, their local knowledge, their aspirations and ideas for improvement. It has also used the expertise and understanding of developments in care amongst local health and social care front-line staff, as well as partners in the wider public and independent sectors.

1.33 As well as describing the longer-term vision The Strategic Framework for Improving Health in the South West 2008/09 to 2010/11 sets out a clear set of actions and ambitions for delivery over the next three years to 31 March 2011. It sets out the local ambition in NHS South West over and above the commitments made by the NHS nationally. These are identified within a framework for improvement and underpinned by plans for developing workforce, technology and facilities. It also shows how investment in, and reform of the NHS will drive forward improvement.

1.34 The framework sets the direction and pace towards a vision of services characterised by consistently high quality and safety, where people in the South West live healthy lives and are free from:

avoidable death•

needless pain and suffering •

inequalities•

loss of dignity and respect •

unwanted waiting •

waste of resources, whether time or money.•

Whilst the Strategic Framework for Improving Health in the South West 2008/09 to 2010/11 sets the vision and principles that will be used to guide the future direction for health and healthcare in the South West and the parameters for action, it is the ambitions of local communities, led by the Primary Care Trust commissioners, which will deliver improvement for local people in local circumstances.

1.35 The case for change illustrates that if the NHS is to move from an illness based service towards a focus on health and independence, then a fundamental realignment of the health and social care delivery system is needed. The assessment of future challenges and the restatement of core principles for the NHS combine to create key priorities for improving health in the South West:

97

reducing health inequalities across populations and communities •

enhancing prevention to support individuals in keeping well, avoiding illness, improving the •speed and convenience of access to diagnosis and treatment, maximising independent living for people with long term ill health or disabling conditions

avoiding needless urgent and emergency admissions to hospital •

ensuring rapid response in an emergency or where urgent care is required •

removing needless delay from stays in hospital •

maximising the return to independence after a hospital stay•

ensuring dignity at the end of life.•

1.36 In every aspect of health care delivery there is a need to:improve the service delivered for vulnerable groups and those people who have specific diseases •and conditionsimprove clinical quality and safety to ensure that all care is of the highest possible clinical quality •and safety, removing avoidable error and harmimprove the quality of the user experience to ensure that, over and above receiving high quality, •safe care at the right time and in the right place, the experience of care is of dignity, respect and responsiveness for everyoneimprove value for money and productivity to ensure that in everything it does, the NHS obtains •value for money, releases resources from unproductive practices and allows front line teams to add more clinical value for service usersimprove the overall performance of all organisations in NHS South West.•

1.37 Nine specific priority areas have been identified locally where there are significant opportunities to bring about improvements. These reflect the Next Stage Review and the SHA’s Strategic Framework:staying healthy

maternity and newborn care

children and young people

long term conditions

acute care

learning disabilities

planned care

mental health

end of life care

1.38 Within the South West Strategic Health Authority Strategic Framework, each priority carries a set of specific ambitions against which the performance of Primary Care Trusts will be assessed and measured over a three year period. These ambitions are reflected in the NHS Gloucestershire Strategy through our strategic objectives.

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ceAppendix 2 Prioritisation Tool

Factor Scale ScoreVery Low 1

Low 2

Mid scale 3

High 4

Top 5

Scale Xranking

Strength of EvidenceHow strong is the evidence available for this service in terms of demonstrating a better clinical outcome.

No evidence of benefit

There is a limited amount of emerging evidence/small scale or observational study

There is some evidence that the intervention works from at least one controlled study

There is evidence of effectiveness from at least one randomised control trial

There is strong evidence of effectiveness from meta-analysis or randomised control trials

Magnitude of clinical benefit

What is the scale of the benefit in terms of Quality of Life improvements, cure, etc

Negligible improvement in health or life expectancy

A small improvement in health or life expectancy

Moderate improvements in health or life expectancy

Significant improvements in health or life expectancy

Large and proven improvements in health or life expectancy

Number of people benefitingHow many people is this likely to benefit / how many people are affected.

One person in the borough would benefit

2-99 people would benefit

100-999 people would benefit

1000 – 4999 people could benefit

Over 5000 people could benefit

Total cost of the development (If available to all those eligible)

The cost is more £1,000,000

The cost is between £1,000,000 & £500,000

The cost is between £500,000 – £250,000

The cost is between £250,000 – £50,000

The cost is less than £50,000

Patient acceptability There is demonstrable evidence that patients are likely to find it highly unacceptable

There is evidence that patients would find it somewhat unacceptable

There is evidence that patients would have no preference on acceptability

There is demonstrable evidence patients would find it acceptable

There is demonstrable evidence that patients would find it highly acceptable and desirable

National requirement or NHS target

as defined in the current years operating Framework and Healthcare Commission Indicators

Not a national requirement or NHS target

Addresses one target or national requirement

Addresses two targets or national requirements

Addresses three targets or national requirements

Addresses four or more targets or national requirements

Health InequalitiesAddressing health inequality or health inequity – i.e. where patients have not had service in the past or have had unequal access

Does not address an inequality or inequity

Partially addresses an inequality for a very small number of people

Partially addresses an inequality or inequity

Has the potential to make a significant impact on inequalities

Completely addresses an inequality or inequity for a specific group

Wider benefits to SocietyE.g. Provides local jobs for local people / contributes to raising the skill levels of local people

No wider benefits to society

Some benefit to society

Moderate benefit to society

Large benefit to society

Major benefit to society

Only treatment or alternative

There are many other treatment options with good outcomes

There are alternatives with better outcomes

There are other alternatives with equivalent outcomes

There are limited alternatives with poorer outcomes

There are no alternative treatment options

99

Local Priorities

Factor Scale Score

Very Low1

Low2

Mid scale3

High4

Top5

Scale Xranking

Promotes greater service integration / seamless care

This does not

improve service integration or provide more seamless care for patients

This makes a small contribution

This makes a moderate contribution

This makes a significant contribution.

This radically re-designs care pathways to make a substantial impact

Improves Communication Between services, professionals and with patients/public

This proposal makes no effort to improve communication

This proposal makes a small contribution

This proposal makes a moderate improvement

This proposal makes a significant contribution

This proposal makes a substantial and sustained improvement

Improves access for local people through reduced waiting times or care closer to home

This proposal demonstrates no improvement to access

Small improvement demonstrated

Moderate improvement potential demonstrated

Significant improvement demonstrated

Substantial improvement demonstrated

Provides patient centred and patient led care demonstrating patient involvement and demonstrable improvements in care focused around the patient.

No potential improvement on care being centred around the patient demonstrated

Some small potential improvements demonstrated

Moderate potential improvements demonstrated

Significant potential improvement demonstrated

Substantial potential improvements demonstrated with wider applications

Promotes wider health and well-being and enables people to remain independent and feel safe.

Appears to make no contribution to wider health and well being improvements

Has the potential to make some small improvements

Has the potential to make moderate improvements

Has the potential to make significant improvements

Has the potential to make substantial improvements

TOTAL SCORE A score (1-5) for each Factor is given based on the evidence submitted and multiplied by

the Weighted Ranking Value to give the Total Score.

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Public Transport Access Times for Gloucestershire to GP and Acute Services

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Appendix 4Key statistics for Gloucestershire

Gloucestershire England

Soci

al D

emog

raph

y

Resident population 2008 (ONS 2006 based sub-national projection) 586,100 51,487,500

Resident population, 2008 (local population projection 2008) 597,483Resident population in 2025 (ONS 2006 based sub-national projection)

657,800 58,310,700

Resident population 2025 (local population projection 2008) 644,230

Percentage of resident over 65 Population 2008 (%) (based on ONS projection)

18.2 16.1

Percentage of resident over 65 population 2025 (%)(based on ONS projection)

24.0 19.9

Percentage change in total population 2008 to 2025 (%)(based on ONS projection)

12.2 13.3

Percentage change in 65 and over population 2008 to 2025 (%)(based on ONS projection)

48.1 40

Hea

lth In

equa

litie

s

Infant mortality 2004-06 (per 1000 live births) 4.5 5.0Life expectancy at birth males (2004-06) 78.4 77.3Life expectancy at birth females (2004-06) 82.5 81.6Gap in life expectancy between the worst and best areas 2005-07 (years)- males- females

8.37.3

n/an/a

Life

styl

e

Estimate of obese adults, 2003-05 (%) 24.3 23.6Number of people predicted to have moderate or severe alcohol dependence

1,418 128,566

Number of people predicted to be dependent on illicit drugs 13,329 1,206,804Hospital admissions related to alcohol (Rate per 100,000 population) 2006-07

200.8 260.3

Binge drinking, 2003-05 (% aged 16 and over) 12.7 18.0Estimate adults who smoke, 2003-05 (%) 24.6 24.1Smoking in manual compared to non-manual groups manual n/a 0.3 non-manual n/a 0.2Smoking quitters aged 16 and over 2006-07 (per 100,000 population)

561.8

5 a day fruit and vegetable consumption persons – SW figures (%) 27.8 - males (%) 24.0 - females (%) 31.0Physically active, 2005-06 (weighted %, 16 and over) 12.7 11.6

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Chi

ldre

n an

d Yo

ung

Peop

le

Mothers smoking at delivery 2006-07 (%) 15.9 15.1Breast feeding initiation where status is known 2006-07 (%) 75.7 69.2MMR immunisation by 2nd birthday 2006-07 (%) 87.2 85.3MMR immunisation by 5th birthday 2006-07 (%) 88.3 85.9Immunisation for diphtheria, tetanus and pertussis booster at 5 years (%)

86.8

87.0Overweight children in reception, 2006-07 (%) 14.6 13.0Obese children in reception, 2006-07 (%) 9.6 9.9Overweight children in year 6, 2006-07 (%) 14.4 14.2Obese children in year 6, 2006-07 (%) 14.9 17.7Secondary school pupils who drink and reported that they get drunk frequently (%)

25.0

n/aSecondary school pupils who reported to have tried illegal drugs (%)

12.8

n/aSecondary school pupils who smoke and reported that they smoke >20 per week (%)

15.6 n/a

Old

er P

eopl

e

Uptake of pneumococcal vaccine, aged 65 and over (%) 0.1 n/a

Uptake of influenza vaccine (2006-07), aged 65 and over (%) 74.0 74.0

Estimates of people aged 65 and over with dementia (%) 0.1 0.1

Mor

bidi

ty a

nd M

orta

lity

Cancer prevalence (per 100 registered population) 1.0 0.9

Mortality rate from cancer in under 75 year olds (per 100,000) 105.5 117.1

Mortality rate from heart disease, stroke and related diseases in under 75 year olds (per 100,000)

67.9 84.2

Hypertension prevalence (per 100 registered population) 12.8 12.5

CHD patients with controlled blood pressure (%) 90.0 88.9

CHD patients with lipid level< 5.0 (%) 85.7 81.9

CHD prevalence (per 100 registered population) 2006-07 3.3 3.5

CHD emergency admissions per 100 on disease register 2006-07

7.8 8.3

CHD average length of stay 2006/07 8.6 6.7

Stroke/TIA prevalence (per 100 registered population) 2006-07

1.8 1.6

Stroke/TIA emergency admissions per 100 on disease register 2006-07

8.0 8.3

Stroke/TIA average length of stay 2006-07 23.0 19.0

Heart failure prevalence (per 100 registered population) 2006-07

0.8 0.8

Heart failure emergency admissions per 100 on disease register 2006-07

10.7 12.5

Heart failure average length of stay 2006-07 16.0 12.0

COPD prevalence (per 100 registered population) 2006-07 1.3 1.5

COPD emergency admissions per 100 on disease register 2006-07

10.5 13.1

COPD average length of stay 2006-07 10.9 7.9

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Transcript of excellence - Amazon S3s3.amazonaws.com/zanran_storage/ · excellence 2. NHS Gloucestershire...