HEALTH AND WELLBEING BOARD – FEBRUARY 27 2013

Title of paper: NHS Nottingham City CCG’s Strategic Priorities 2013-2015

Director(s)/ Corporate Director(s):

Hugh Porter, Clinical Chair Dawn Smith, Chief Officer NHS Nottingham City Clinical Commissioning Group

Wards affected: All

Report author(s) and contact details:

Dawn Smith, Chief Officer and Hugh Porter, Clinical Chair NHS Nottingham City Clinical Commissioning Group Tel 0115 8839510

Other colleagues who have provided input:

Relevant Council Plan Strategic Priority: World Class Nottingham Work in Nottingham Safer Nottingham Neighbourhood Nottingham Family Nottingham Healthy Nottingham ���� Leading Nottingham Summary of issues (including benefits to citizens/se rvice users): Following an engagement programme carried out in 2012, NHS Nottingham City Clinical Commissioning Group (CCG) developed six strategic priority areas that are directly based on the needs of local people, as informed by the Joint Strategic Needs Assessment and on the things that people said mattered to them:

• Improving the health and wellbeing of the frail and elderly • Improving mental health outcomes • Cancer • Long-term conditions • Children and young adults • Urgent Care

The CCG has now set out a range of key commissioning actions and ‘stretch’ targets for each of these six strategic priority areas and is seeking the views of partners on these proposals prior to finalising its three year strategy. It is important to emphasise that having strategic priorities does not mean that the CCG will only concentrate on these things. The strategic priorities are those areas where the CCG will seek to go above and beyond the ‘standard’ things it is expected to do as an NHS commissioner. The CCG’s response to the requirements placed on all NHS bodies in 2013/14 by the NHS Commissioning Board is set out in a separate paper to the Board. (Response to Everyone Counts: Planning for Patients 2013/14) Recommendation(s): 1 Note the proposed commissioning actions and measures set out by the CCG in its three

year strategy and consider feedback in relation to the questions set out on pages 24 and 25 of the attached engagement document

1. BACKGROUND 1.1 The Health and Wellbeing Board noted the six strategic priority areas

proposed by the CCG at its meeting in August 2012. 2. REASONS FOR RECOMMENDATIONS (INCLUDING OUTCOMES OF CONSULTATION) 2.1 See attached document for a rationale as to why each strategic priority area was

selected. 3. OTHER OPTIONS CONSIDERED IN MAKING RECOMMENDATIO NS 3.1 N/A 4. FINANCIAL IMPLICATIONS (INCLUDING VALUE FOR MONEY) 4.1 The financial impact of implementing the strategy has been accounted for as part of

the CCG’s annual planning cycle 5. RISK MANAGEMENT ISSUES (INCLUDING LEGAL IMPLICATION S, CRIME AND DISORDER ACT IMPLICATIONS AND EQUALITY AND DIV ERSITY IMPLICATIONS) 5.1 The CCG has its own framework for the management of risk which includes the

delivery of its strategy. 6. EQUALITY IMPACT ASSESSMENTS (EIAs) 6.1 The CCG will carry out an EIA on key commissioning actions although actions are

all based on identified need which includes addressing disadvantaged groups 7. LIST OF BACKGROUND PAPERS OTHER THAN PUBLISHED W ORKS OR THOSE DISCLOSING CONFIDENTIAL OR EXEMPT INFORMATIO N 7.1 CCG Chief Officer’s update to the Health and Wellbeing Board in August 2012 8. PUBLISHED DOCUMENTS REFERRED TO IN COMPILING THIS R EPORT N/A

February 2013

Dear Colleague

Seeking your views on our strategic priorities

Over the past year, NHS Nottingham City CCG has held many discussions with local people, patients, clinicians, staff and partners about the future direction of local healthcare services.

As a result of our extensive engagement programme, we have co-created and agreed a vision, values and six strategic priorities. These are directly based on the needs of local people, as informed by both the Nottingham City JSNA, and the things that people tell us matter most to them. We have also been careful to make sure that our priorities align with those of our partners, most notably the Nottingham City Health and Wellbeing Board, neighbouring CCGs across Nottinghamshire, and healthcare providers.

Since agreeing our priorities, we have identified clinical and managerial leaders for each of the six programmes, supported by various clinicians and professionals from across health and social care. These teams have shaped the vision for each of the priority areas, proposed key commissioning actions, and suggested a number of stretch targets for each. These targets are over and above the national NHS measures against which we are assessed, and reflect the transformation that we intend to realise within these particular areas.

We would now like to seek your views on the proposals we have developed for each of our strategic priority areas. We would also like to know whether you agree that they are complementary to your own priorities, and we would welcome your ideas and suggestions on how we might work together to deliver plans more effectively.

For ease of reference, our ‘strategy on a page’ can be found on page 1, and the diagram on page 2 shows how our own priorities map with those of our partners. Pages 3 to 23 detail our proposals, and suggested questions for consideration by partners are on pages 24 to 25.

Please send your comments, no later than the 22nd February 2013 , to: • Email: citizen.panel@nottinghamcity.nhs.uk

• Post: Strategic Priorities, NHSNottinghamCity, FREEPOST (RRAX-CCSC-

SSUS), Standard Court, Park Row, Nottingham NG1 6GN

We very much look forward to your feedback and thank you for your time in

helping us to develop local healthcare services.

Dawn Smith Chief Officer

Dr Hugh Porter Clinical Chair

NHS Nottingham City CCG’s strategy on a page

NHS Nottingham CCG’s Priorities and how they align with those of partners

DELIVERING NHS NOTTINGHAM CITY CCG’S STRATEGIC

PRIORITIES

The following section describes in more detail our strategic

priorities and how we will deliver them. For each priority we

have both developed a vision for that area, and identified

measurable outcomes to enable effective performance

management and accountability.

Our Strategic Priorities

Our strategic priorities are the six most important elements of healthcare that we will focus on improving over the next three years and beyond. These have been developed directly as a result of talking to local people, as well as other organisations we work with such as Nottingham City Council. They are also based on facts and figures about the current state of people’s health in Nottingham. In this section, we describe why each priority is so important, our vision for future services, and what we will do over the next three years to help make this vision happen. Lastly, we have set some targets for our CCG. We will use these to make sure our actions are making the right difference to people’s health and outcomes. We will also share these measures openly with people so that we can be held to account for delivering the things we have promised. These targets are in addition to the NHS targets we are measured against nationally. Having strategic priorities does not mean that we will only concentrate on these things. It does mean that we will push ourselves in these areas to go above and beyond the standard things we are expected to do as an NHS commissioner.

Priority 1:

Improving the health and wellbeing of the frail and elderly This priority focuses on Nottingham’s older population, particularly those who are living with one or more long-term conditions, including dementia. Why this is a priority for us

Around 38,000 people registered with a Nottingham City GP practice are aged 65 and older. Of these, an estimated 5,600 are aged 85 and over. Many of these people (as well as some younger people) have a degree of frailty. In other words they need help with aspects of daily living such as washing, dressing or eating. Health conditions can lead to frailty, and in turn, frailty itself can cause health problems. Many are at far higher risk of a fall. Nearly half of our older people have at least one long-term condition, such as dementia, diabetes or respiratory disease. The need for better access to care, particularly during crisis, and for better prevention and self-care in the community setting result in far too many avoidable emergency admissions. Such admissions can lead to the loss of independence in the long-term for frail elderly patients. Nearly 1,800 of our older people live in a care home, and a third of these people have dementia. In total, 2,600 local people are thought to have dementia in Nottingham, but only two-thirds of them have been diagnosed. By 2030 the number of people with dementia in NottinghamCity is predicted to rise by 38%. Older people who have fallen account for ten percent of all 999 calls across the East Midlands. More than 10,000 older people in NottinghamCity are considered to be at risk of a fall. An estimated 24,000 informal carers provide care and support to some of the most vulnerable people within our local population. Of these carers, 84% are believed to be aged between 60 and 90, many of whom are at greater risk of social isolation and poorer health, and are more likely to be admitted to hospital themselves. Over the course of a single year, one in four carers reported sustaining an injury as a result of their caring activities.

From what local people tell us, we know that we need to improve co-ordination of services, and communication with patients and their carers. We also know that services can sometimes be limited or hard to access, and that the quality of these services can vary. Care also needs to be better co-ordinated between health and social care, and there needs to be better sharing of information.

People also say there needs to be more support for people who are at the end of their lives, particularly during evening and night-time hours.

“You are looking after one person – you don’t want it split into different aspects”

“You shouldn’t have to decide which bit is social care and which bit is health care – it should all be one”

Our vision for future services for frail and elderl y services We will make special efforts to identify older people at risk of needing urgent or emergency care before they get poorly, to help identify what is wrong with them earlier. We can then start them on treatment or arrange support to help prevent them from needing to go to hospital in an emergency. We will support carers and help patients to manage their conditions with the help of GPs, community nurses and others, making sure they know how to get the right care when they need it. We will work together with social care to help our frail elderly patients to maintain their independence for as long as possible, and we will support them in a compassionate way when they are no longer able to do so. We will make sure that the various services used by older and frail elderly people are more co-ordinated. Where appropriate, we will integrate health services with those of social care, delivering some services together as a single, united team. Any patients with long-term conditions will have effective and thorough care plans in place right from the outset. All patients will be engaged and involved in all aspects of their care from the moment they first access our services. More people at the end of their lives will be able to die in the place of their choosing, and better support will be given around the clock both to these patients, and to those who care for them. Key commissioning actions for frail and elderly ser vices

Our focus will be on achieving a better quality of life for older people living with long-term conditions, and for their carers. We will: • Develop and implement risk-stratification tools to identify people with conditions -

such as diabetes or respiratory problems - earlier. This includes people who are registered with a GP, people in care homes, or those in hospital. We will then make sure these people get the treatment and support they need

• Work in partnership with Nottingham City Council to change the way community services work, so we are delivering services together. We will have better information systems meaning that we can use and share information more easily; and we will work together to look at a patient’s needs as a whole

• Invest in community nursing services to support a more consistent, proactive case management approach to care

• Commission in-reach services where community health staff go into hospital to identify patients whose needs might be better met within the community

• Find better ways of identifying people who have dementia but have not yet been diagnosed. This will mean that they get better care and treatment earlier, and so will have a better quality of life

• Increase access to specialist respite services for people with dementia and those

at the end of their life to help provide more support to carers

• Implement the ‘independence pathway model’ of assessment and reablement (helping to get people back to how they were before their illness) through

transforming our existing crisis response, intermediate care, reablement and self-care services

• Develop a dedicated care homes nursing team, which will include Care Home Matrons and comprehensive geriatric assessment for all residents

• Launch an Integrated Falls Response (ambulance) service, to provide an immediate response and clinical assessment following a fall

• Work in partnership with Nottingham City Council and other providers to ensure that carers are identified at the earliest opportunity and have their needs assessed in full (a ‘holistic carers assessment’)

• Help carers to have the right skills and equipment to perform their caring duties in a way that is safe for both the carer and the person they are caring for

• Develop an Electronic Palliative Care Co-ordination System in conjunction with other health commissioners across Nottinghamshire. This will improve co-ordination and communication between organisations, helping us to meet the individual wishes, preferences and treatment care plans of patients at the end of their lives

• Provide appropriate support to residential and nursing homes through GP support and through developing community services to have a focus on people living in care homes

Our CCG targets for frail and elderly services

By March 2015:

• A 3% reduction in admission to acute or long-term care for people aged 85 years and over

• A 3% reduction in attendance at the Emergency Department for people aged 85 years and over

• At least 64% of the number of people living in Nottingham whom we estimate to have dementia will be diagnosed (with dementia)

• 45% of people at the end of their lives will be supported to die at home

Priority 2: Improving mental health outcomes This priority focuses on our mental health service users, particularly where there are opportunities to provide care in a more appropriate place and to deliver more services in the community. Why this is a priority for us

In Nottingham, there are an estimated 46,000 people with common mental health problems, such as depression, anxiety or obsessive compulsive disorders. Adults with mental health problems are more likely to engage in unhealthy lifestyles, such as smoking, alcohol and drug misuse. Having poor mental health also increases the risk of having poor physical health, and vice versa. For example, people with depression are four times more likely to develop heart disease, and people with long-term physical health conditions, such as diabetes, are three to four times more likely to experience mental illness than the rest of the population. Good mental health is central to an individual’s quality of life and economic success. Unemployment and debt are known to contribute to people having anxiety and becoming clinically depressed. This means the current economic downturn will impact negatively on the health and wellbeing of many people in Nottingham. Nottingham’s ethnic make-up also means it has more people from communities most likely to develop poor mental health. For example, women from some South Asian communities are more likely to experience common mental health problems, and schizophrenia is more frequently diagnosed in African-Caribbean men. The national guidance, Everyone Counts: Planning for Patients 2013/14, identifies the need for a particular focus on improving access to psychological therapies as part of the commitment to full rollout by 2014/15. This includes increased access for black and minority ethnic groups and older people, and for people with severe mental illness and long-term health problems. It also identifies the need to improve the physical health of patients with mental illness.

People say they want more mental health services based within the community and shorter waiting times. Services should be more responsive to the different needs of individual users, and should respond quickly at times of crisis. People want to see services which are better co-ordinated, easier to navigate, and supported by helpful information and knowledgeable staff who are available when

needed.

“We need better access to more community-based mental health services.”

“Waiting times should be shorter.”

Our vision for future mental health services

People with poor mental health will have access to consistent, high quality care services, which are based in the community where appropriate. The voluntary sector will be a key provider of mental health support services. GPs will have access to the information and advice they need to direct patients effectively to the best services to suit their needs. There will be better identification of people with poor mental health, and more effective case management. Mental health services will be more co-ordinated, and effective collaboration across health and social care services will help individuals to move seamlessly between the various services or ‘pathways’. More people will have access to improved psychological therapy services, and health promotion will be targeted at Black and Minority Ethnic (BME) groups and other specific groups, ensuring better awareness and uptake of services. Key commissioning actions for mental health service s

Our focus is on improving access to community-based services and reducing the reliance on hospital-based care; training and developing clinicians and professionals within primary care; and developing better services which are well co-ordinated between different providers of care, and which are delivered together as a single team where appropriate. We will: • Analyse referral patterns to make sure that services and treatment packages

meet the needs of our population

• Support health promotion campaigns to improve mental wellbeing

• Improve skills, knowledge and access to more services in primary care, by making sure that GPs and others get the training, education and development they need

• Work in conjunction with all providers to develop efficient and effective pathways of care

• Audit the way services are currently provided against the recommendations of the National Mental Health Strategy and make sure improvements are made where needed

• Ensure the Early Intervention in Psychosis, Assertive Outreach and Crisis Response and Home TreatmentServices are effective and delivered in line with national policy

• Commission an effective Primary Care Psychological Therapies service which is easy to access

• Promote mental health issues and services to the BME population and monitor uptake

• Implement the ‘Physform’ – a physical health checklist – within our main provider, Nottinghamshire Healthcare NHS Trust

• Work with health and social care partners to make the journey for patients going into or coming out of an acute hospital smoother and better, whether they are going back to the place where they live, or onto another care service

Our CCG targets for mental health services

• Improve the physical health of patients with mental illness by implementing the ‘physform’, targeting 15% of patients with serious mental illness in the first year

• Increase the proportion of patients who are managed in the community by the Crisis Response and Home Treatment Team by 5% each year. This will result in avoided hospital admissions

• Increase the proportion of people from BME communities who access psychological therapies, demonstrating a year-on-year increase

Priority 3: Cancer This priority focuses on improving cancer prevention and early detection. We will make improvements to the cancer pathway to result in better survival rates and to deliver more cost-effective care. Why this is a priority for us

We know from benchmarking with other similar areas, that we can do more to enhance the quality of our cancer prevention and treatment services, and to improve upon existing prevalence, mortality and survival rates across Nottingham City. Cancer accounts for around one in four deaths in Nottingham, and half of all such deaths are from lung, bowel, breast and prostate cancers. Cancer is the joint largest contributor to our life expectancy gap for women, and the second largest for men. Cancer is more common in areas with higher levels of deprivation, and is the second highest cause of death in BME groups. Overall, cancer mortality rates in Nottingham are higher than regional and national rates, and the number of new cancers for men is higher than the rest of the East Midlands. Nottingham City has significantly poorer survival rates for cancer, with one-year survival rates for breast, bowel and prostate cancer in the bottom 20% for England. This is thought to be largely as a result of patients leaving it longer before seeing a health professional, meaning that their cancer is more advanced when diagnosed.

There is a significant opportunity to make a positive impact on health outcomes by addressing the risk factors for cancer, many of which are prevalent among Nottingham City’s population – Nottingham has the third highest smoking prevalence rate in the country. Other positive lifestyle changes can also reduce the number of individuals who are affected by cancer, such as taking more exercise and eating healthily. In addition, effective screening, leading to early diagnosis, can significantly increase the likelihood of a positive outcome and reduce the intensity of treatment required. In tandem with

increasing the take-up of screening tests, raising awareness to encourage people to self-check and to see a health professional earlier will also help to improve outcomes. In our focus groups, some patients reported that not enough was done to listen to them when they first approached their GP with symptoms, and cited a number of examples where these issues appeared to delay diagnosis. Patients ask for communications with patients and carers to be improved, with information presented in plain English, and without the use of medical terminology and jargon. Patients felt the need for more advice and information about diet and nutrition.

“Information should be in plain English, without jargon or lots of unnecessary medical terminology.”

“Not enough was done to listen to me when I first saw my GP with symptoms. It meant it took longer to diagnose my cancer.”

“I needed more advice about diet and nutrition.”

Our vision for future cancer services Local healthcare and other services will target health promotion and education to areas and communities which have the poorest outcomes linked to cancer, including BME groups and people living in the most deprived areas. More people will make healthy lifestyle choices, including giving up smoking, losing weight, eating more healthily and reducing alcohol intake. Many will access the advice and support services provided by healthcare and other organisations, where they will receive the encouragement and information they need. Local people will have good awareness of the symptoms of cancer and what to do if they are worried. More people will take up the offer of cancer screening and these factors, together with improvements in primary care, will lead to an improvement in both the early diagnosis of cancer, and survival rates. Unplanned admissions for cancer patients will be reduced through improved care planning and better patient management. Key commissioning actions for cancer services

Our focus will be on improving early detection of cancers, delivering better cancer survival rates, and ensuring an enhanced patient experience. We will focus on those areas and communities which have the poorest outcomes relating to cancer. We will: • Make it easier for GPs and others in primary care to get access to diagnostic

testing so that more people with cancer can be detected earlier

• Work with communities and primary care to increase the number of patients who take up the offer of cancer screening

• Support Nottingham City Council, the voluntary sector and others in delivering health promotion initiatives to raise awareness of cancer and its symptoms

• Support public health in the commissioning of on-going stopping smoking services

• Commission improved care pathways for cancer that both support a patient’s recovery from cancer, and enable greater access to end of life services where they are needed

• Implement the Cancer Reform Strategy

• Deliver the Nottingham City Joint Carer Strategy in partnership with Nottingham City Council

Our CCG targets for cancer services

• 95% of people will survive breast cancer within 1 year of diagnosis – an increase of 2.5% by April 2015

• 33% of people will survive lung cancer within 1 year of diagnosis – an increase of 2% by April 2015

• 75% of people will survive bowel cancer within 1 year of diagnosis – an increase of 3% by April 2015

• By April 2015, 60% of all people offered a bowel screening test will take the test

• By April 2015, 85% of all women offered a cervical cancer screening test will take the test

Priority 4: Long-term conditions This priority focuses particularly on patients with diabetes and respiratory conditions, including asthma and Chronic Obstructive Pulmonary Disease (COPD). We will take a targeted approach to groups with higher prevalence and poorer outcomes, particularly those from within Black and Minority Ethnic (BME) communities. Why this is a priority for us

Nottingham City has high numbers of people with long-term conditions, and the numbers are expected to rise owing to an ageing population and the impact of certain lifestyle choices, such as smoking or being overweight. Diabetes and respiratory conditions are particularly problematic. Currently patients may be on several disease care pathways, yet their needs are not being met fully. Although co-ordinated care is important for patients with a single long-term condition, it is essential for the substantial proportion of people who experience the presence of two or more conditions simultaneously. Enhancing the quality of life for people with long-term conditions is also one of the top five priorities identified within the NHS Outcomes Framework (please see figure 6 on page 25) Respiratory

People living within the most deprived areas of Nottingham City are six times as likely to have a respiratory condition as those living within the most affluent. This is directly linked to lifestyle factors such as smoking, for which, in 2010, Nottingham had the third highest rate in the country. Two-thirds of people with COPD are thought to be currently undiagnosed, and many people re-admitted to hospital with COPD are still unknown to the community support service. Access to certain respiratory services is very different from one GP practice to another, and there is limited provision in the community to support patients being discharged from hospital. 120 people die from COPD each year in Nottingham, and two in five of them are aged under 75. This is twice the rate of those living in the county, reflecting the high number of smokers locally. Benchmarking suggests that investment in Nottingham City in respiratory care is comparatively low, and there are gaps in provision, particularly in relation to asthma and bronchiectasis (an obstructive lung disease). Diabetes

More than 13,000 local people have diabetes, and the number of people developing diabetes is rising continually, linked to both an ageing population and to rising levels of obesity. Diabetes is particularly common amongst people with South Asian and Black Afro-Caribbean backgrounds, with an earlier age of onset in the former group. The quality of diabetes services and related health outcomes differs greatly from one GP practice to another, as does the number of people recorded with diabetes, for example, the prevalence of patients with diabetes, as recorded by GPs, ranges from 0.4% to 10% across practices.

Diabetes reduces life expectancy, and outcomes for people with diabetes are a major health inequality issue within Nottingham City. This group of patients are twice as likely to be admitted to hospital, and at any point in time at least one person in ten in hospital has diabetes.

People say they want better access to GP services and care based closer to home, and which are delivered by qualified specialists such as specialist nurses. Patients want better support in the community when their condition worsens, to avoid needing emergency treatment. They would like to see more healthcare professionals attending their community self-help groups.

Services should be more integrated between primary, secondary and community teams, and patients support better education and training of GPs in respiratory conditions. People ask for services to meet the needs of the working population, where accessing healthcare does not interfere adversely with their work commitments. Patients also ask for better, more accessible information and support to enable them to manage their own conditions effectively. Our vision for future long-term condition services

Clinicians and healthcare professionals within primary, secondary and community care will have increased skills, capacity and capability in diagnosing and supporting people with long-term conditions. More patients will be diagnosed earlier, meaning better treatment and management of their illness. Services will be centred on the patient, meeting the needs of modern working lifestyles. Patients and carers will feel informed, supported and confident in managing their conditions effectively, knowing that they have easy access to support within the community should they need it. Improved information and education will lead to better awareness of conditions and their symptoms across the population, and there will be targeted approaches to those groups most at risk of developing a long-term condition, e.g. those from BME communities. Services will be more integrated, and treatment will utilise the latest technology.

“It is important for patients to have a management plan in place in the event of exacerbation of the condition.”

“There need to be better services at GP practices and in the community, especially at times when my condition gets worse.”

“Education is crucial, and information needs to be easier to find.”

Key commissioning actions for long-term condition s ervices

We will: • Commission services which target local communities, in particular BME groups,

with high numbers of people with long-term conditions and poorer outcomes. We will continue to focus on smoking, weight management and healthy living, and better glucose control

• Commission services that help patients to manage their own care effectively, and which allow patients to continue to work at the same time as managing their condition

• Implement an integrated approach to care with Nottingham City Council, focusing strongly on Telehealth(the delivery of health-related services and information via telecommunications technologies)

• Increase the availability of structured education programmes, and increase the number of patients diagnosed with diabetes who attend them

• Develop localised training and education events to increase the skill and knowledge of GPs and other primary care staff

• Fund additional specialist community-based respiratory nurse prescribers and specialist diabetes nurses

• Develop a rapid assessment clinic to support the assessment and discharge of respiratory patients within a 4-hour window to reduce avoidable admissions to hospital

• Increase the capacity of providers to improve diabetes awareness and prevention Our CCG targets for long-term condition services

• 5% reduction in avoidable emergency admissions over a three-year period

• 3% reduction in follow-up of diabetic patients by secondary care over a three-year period

• 2% increase in the number of people with diabetes having all nine quality standards1 assessed

• 2% reduction in Type 1 re-admissions to hospital within 30 days

• 200 patients each year to take up pulmonary rehabilitation and complete the eight week programme

• 300 more patients each year are offered a care plan

1These standards are linked to prevention, identification, empowerment, clinical care of

adults and children, management of emergencies, care during admission to hospital,

diabetes and pregnancy, and detection and management of long-term complications

Priority 5: Children and young adults Achieving this priority will enable us to improve care pathways for children and young adults from birth to 24 years, and for their families. They will be better supported through their transition from adolescence to adulthood. We will also focus on delivering more flexible services for young people and students, which take better account of their needs and preferences in terms of accessing care and support when they need it. Why this is a priority for us

There are 71,300 children and young people aged from birth to 19 years living in Nottingham, of whom 19,200 are under five years. These numbers continue to increase more than for other ages because of increasing birth rates, two large universities, and growing numbers of asylum seekers and refugees. Because the time that these groups live in Nottingham is sometimes brief, commissioning healthcare services for them is increasingly challenging. The number of local children born with complex health needs and surviving into adolescence is increasing, and the number of children with disability is rising. There are around 4,000 children and young people in Nottingham with a disability, of whom 900 are considered severe. Around 8,500 children and young people in Nottingham have a diagnosable mental health issue, such as self-harming, autism and Attention Deficit Hyperactivity Disorder (ADHD). Some 450 young people enter the criminal justice system each year, many of whom have poorer health outcomes linked to deprivation and lower usage of health services - many are not registered with a GP. In this group in particular, some will have unaddressed health needs, such as those relating to learning disabilities, sexual health screening and vaccinations, as well as the need for support with diet and nutrition, and stopping smoking. Nearly 11,000 children and young people (aged 0-17) attended the local Emergency Department because of accidental injury in 2011. Most injuries to children aged under five occurred in the home and were related to falls and burns. Nottingham has significant safeguarding needs and there are high numbers of referrals to children’s social care services. The highest numbers of child protection plans in the city relate to neglect, and over 500 children are currently within the care of Nottingham City Council. Families ask for more support for children and young adults approaching the end of their lives, making it easier for individuals to die in their place of choice.

Students Nearly one in five of Nottingham’s population is classed as a student, compared with 1 in 25 nationally. This group has particular health needs in terms of mental health, sexual health, teenage pregnancy, smoking, use of alcohol and drugs, and lack of physical activity. There is a higher proportion of BME students compared with the rest of Nottingham, and around 8% of all students are registered with a disability. Providing treatment and effective access to services can be problematic, as many students do not stay in Nottingham outside of term-time. Local people tell us that services need to be more accessible, responsive and flexible to meet the needs of individuals and their families. Care should be delivered closer to home where possible, and there should be better choice about the care and support that can be accessed.

People say that communication needs to be improved, and that there is often duplication of activity across different care providers, including multiple assessments and having to repeat information. Services provided by health and social care need to be more integrated, particularly for those with complex health needs. Parents want more support for children and young people

withlearning difficulties, particularly in the transition from children’s to adult services. Students want more information about accessing services. This is particularly important for international students, many of whom say they do not understand how the NHS system works. People say they would like maternity services to be more flexible and to offer women more choice about their care. Families ask for more support for children and young people approaching the end of their lives, making it easier for individuals to die in their place of choice. Our vision for future children and young adults’ se rvices

Services will be easily accessible, high quality, family-focused and integrated. They will be tailored to the needs of children, young people and their families, and will deliver improved health outcomes. There will be a significant focus on prevention and early intervention, and seamless care pathways will enable a smooth transition from children’s to adult services. Services for young people, including our British and overseas students, will be more responsive to the challenging needs of this group in terms of accessing services, as well as supporting them better as they move from adolescence to adulthood. Young people will feel better informed and supported by local health and other services in making healthier lifestyle choices which will ultimately improve their long-term health outcomes.

“One international student reported they thought they had to pay to ring an emergency number”

“Young people with learning difficulties sometimes fall through the net when they hit the age of 25”

Key commissioning actions for children and young ad ults’ services We will:

Children and Young Adults

• Work with partners to develop accessible, family-focused and responsive services, including early intervention, which are tailored to the needs of the child and their family

• Review safeguarding services to ensure they incorporate the latest evidence-based practice and are supported by strong multi-agency working

• Continue to develop effective Child and Adolescent Mental Health services in the community

• Integrate services for children and young adults with acute and additional health needs, including disability and complex needs, to ensure a single point of access and co-ordinated assessment, treatment and review

• Implement personal health budgets for children and young adults with complex and continuing care needs

• Strengthen the maternity pathway and offer women a choice of services based on their needs

• Develop and improve services for target groups, such as youth offenders, children in care, and those with autism and ADHD

Students

• Develop health promotion material which is geared towards the interests of young people and will therefore drive the desired behavioural changes

• Work in partnership with Nottingham City Council and public health to ensure that sexual health screening and contraceptive services are refined and developed to meet the needs of young people and students

• Expand on existing work between the universities and the Early Intervention in Psychosis teams to improve mental health services for students

• Commission flexible services that are able to cater for the student population, e.g. they are able to provide appointments on days when students can attend, such as in term time

• Improve the quality of care pathways to ensure that the transition from children’s to adult services is seamless and supportive

• Develop and learn from the Eating Disorder in Student Services project to remove stigma and improve access for young adults with eating disorders

Our CCG targets for children and young adults’ serv ices

• 5% reduction in avoidable emergency admissions for children and young people by 2015/16

• 95% of all young people within the Youth Offender Service will have a comprehensive health screen completed within four weeks of entry into the service

• 95% of children and young people referred for a continuing care assessment will have a decision for eligibility made within 23 working days of referral

Priority 6: Urgent Care This priority focuses on improving the resilience and effectiveness of the urgent care system across the City. It is a very important programme of work that requires health and social care partners to work together effectively. This priority is particularly critical, as it underpins the successful delivery of our five other strategic priorities. Why this is a priority for us

Every year, more people attend the Emergency Department than the year before, although more recently the rate of growth has slowed as a result of various initiatives. We see some of the highest number of readmissions to hospital within the East Midlands. The most frequent users of urgent and emergency care services are older people, many of whom have had a fall; people with long-term conditions; parents with young children; and patients whose condition is related to the consumption of alcohol.

Based on benchmarking and research, we know that there are significant opportunities to improve the quality and cost-effectiveness of urgent care within Nottingham, including improving access and waiting times, and working with partners to improve the quality of discharge and transfers of care. People tell us that arrangements to access urgent care need to be clearer, particularly outside of

normal GP working hours. Some say they would prefer to be looked after in the community than be admitted to hospital. There are often difficulties in the sharing of information between providers as patients are transferred along the emergency pathway, and this is leading to poor patient experience. Some patients report undue delays when they have expressed an urgent need for care. Having a well-managed urgent care system is essential because it leads to better patient care and outcomes, as well as more flexible health and social care resources.

In late 2012, the NHS Commissioning Board announced plans to review urgent and emergency care as part of plans for more seven-day services. This review will also aim to help CCGs find the right balance between providing excellent clinical care in serious complex emergencies, and maintaining or improving local access to services for less serious health needs.

“One patient with cancer was advised by her GP to go to A&E, but on arrival she was asked what she was doing there.”

“I would rather get care from community staff than have to go into hospital.”

“I get confused about where I should go to get help when I need it urgently, especially when my GP practice is shut.”

Our vision for future urgent care services The quality of urgent care services at night-time and weekends will match those provided during weekdays, and there will be better availability. Patients will be able to make informed, responsible and appropriate choices about how to access urgent care, regardless of the time of day. They will feel a sense of ownership over local health services and base their decisions on helpful and relevant information which is available to them when they need it. There will be better clarity of responsibilities between care providers, and more effective sharing of information between organisations and departments to enhance clinical decision making. This will enable patients to have a smoother journey through the urgent care pathway, leading to a better patient experience. Acute providers will consistently meet key standards relating to waiting times and emergency care. More GPs will be offered an appropriate alternative to hospital admission for patients requiring urgent care, and more 999 calls will result in managing patient needs effectively without needing to take them to hospital. Key commissioning actions for urgent care services

We will: • Implement the new ‘111’ telephone number for patients who need urgent advice

and treatment, but where it is not an emergency

• Ensure roll-out of the national summary care record programme and introduce electronic discharge summaries for GPs

• Where patients provide their consent, enable access to GP practice records by staff in the Emergency Department to enhance clinical decision making

• Increase the involvement of community services in the discharge process when transferring or discharging patients from hospital

• Invest in having GPs and/or other primary care staff at the Emergency Department to release emergency staff to treat patients with the most critical needs

• Make best use of capacity in the ambulance service to improve response times, both for people who have called 999, and for those needing admission to hospital

• Work with acute and other partners from the health and social care community to provide alternatives to hospital admission for certain conditions

Our CCG targets for urgent care services • By April 2014, 10% of all eligible patients will be streamed from the Emergency

Department to Primary Care, compared to 6.5% in 2012/13. We will increase this further to 12% by April 2015

• By March 2014 we will establish professional standards along the entire urgent care pathway, and by the same time we will agree baselines and improvement targets for delivery from April 2014

• We will deliver an improvement in the number of ambulances arriving on time, when they have requested by a GP to take a patient to hospital urgently. By April 2014, 10% more GP-requested ambulances will arrive within the time specified

Key Questions for Consideration by Partners The following questions are prompts for partners to consider in their response to NHS Nottingham City CCG. QUESTION 1: Do you agree that these six strategic priority areas are the most important health issues we should address in Nottingham City? QUESTION 2: If you answered ‘No’ to Question 1, please tell us why. Also please tell us if there is anything else that you think we should consider when we next review our strategic priorities, or when we set our plan for 2013 -2014. QUESTION 3: Do you agree that our six strategic priority areas align with those of our partners, for example, the Health and Wellbeing Board, healthcare providers, or neighbouring CCGs. QUESTION 4: If you answered ‘No’ to Question 3, please tell us why. QUESTION 5: Do you agree with our vision for future services for:

• frail and elderly people

• mental health

• cancer

• long-term conditions

• children and young adults

• urgent care QUESTION 6: If you answered ‘No’ to any of the areas listed in Question 5, please tell us why. QUESTION 7: Do you think that our key commissioning actions to improve services are the right things for us to do for: • frail and elderly people

• mental health

• cancer

• long-term conditions

• children and young adults

• urgent care QUESTION 8:

If you answered ‘No’ to Question 7, please tell us why. QUESTION 9:

Do you think that our proposed CCG targets for improving services are the right areas for us to measure for: • frail and elderly people

• mental health

• cancer

• long-term conditions

• children and young adults

• urgent care

QUESTION 10:

If you answered ‘No’ to any of the areas within Question 9, please tell us why. QUESTION 11:

Do you have any ideas and suggestions for how we might work together better or more collaboratively to deliver any of our strategic priorities? QUESTION 12:

Do you have any ideas and suggestions for how NHS Nottingham City CCG might support you better in delivering your own, or shared priorities? QUESTION 13:

Do you have any other feedback, suggestions or comments that you would like us to consider?

Please send your comments, no later than the 22nd February 2013 , to:

• Email: citizen.panel@nottinghamcity.nhs.uk

• Post: Strategic Priorities, NHS Nottingham City, FREEPOST (RRAX-

CCSC-SSUS), Standard Court, Park Row, Nottingham NG1 6GN