NHS SCARBOROUGH AND RYEDALE CLINICAL COMMISSIONING …€¦ · current draft the CCG intends to...

of 45 SRCCGIntegratedPlanSeptember2012_V11.docx

NHS SCARBOROUGH AND RYEDALE CLINICAL COMMISSIONING GROUP

INTEGRATED COMMISSIONING STRATEGY

2012 – 2016

INCLUDING:

• INTEGRATED COMMISSIONING PLAN 2012-13;

• DRAFT COMMISSIONING INTENTIONS 2013-14;

• 2012 – 2016 FINANCIAL PLAN.


Table of Contents Section Content Page

Foreword 3 1. Introduction 4 2. NHS Scarborough and Ryedale Clinical Commissioning Group 5 3. Strategic Context 5 4. Strategic Commissioning Aims 6 5. Delivery Domain One – Sustainability 7 6. Delivery Domain Two – A Strong Community System 13 7. Delivery Domain Three – Health improvement and reducing health

inequalities focussed on priority areas 17

8. Delivery and Performance Management 22 9. Quality and Performance management 24 10. Organisational Structure and development 29 11. Joint Commissioning 30 12. Securing Commissioning and Business Support 31 13. Governance and Assurance 34 14. Stakeholder engagement and Patient Choice 35 15. Financial Plan 36 16. Equality 44 17. Summary 45

Appendices 1. Scarborough and Ryedale CCG Joint Strategic Needs Assessment 46 2. GP Practice Populations 54 3. Activity Forecasts 55 4. Draft Commissioning Intentions 2013-14 58 5. Organisational Structure 61 6. The Public Health Offer 62 7. CSU letter of intent to complete Service Level Agreement 67 8. CSU Memorandum of Understanding (02/2012) 68 9. 4 Year QIPP Delivery Plan 73 10. QIPP – Going Further and Faster 74


Foreword Welcome to NHS Scarborough and Ryedale’s strategy document. This document contains our plans for the coming three years and sets out the evidence on which they are based. The Health and Social Care Act that created Clinical Commissioning Groups have at its heart a desire to increase the involvement of both clinicians and the public in the design of the healthcare system. NHS Scarborough and Ryedale has been keen, from the outset, to engage in a meaningful way with the public and patients. Our Patient Representative Group is up and running and patients are beginning the journey of true involvement and consultation such as with the COPD and Me Booklet consultation. We should however be under no illusion that things will be easy and the historic financial challenges faced by our predecessor will continue to be ever present. In order to operate effectively in this climate it is inevitable that we will need to make some difficult decisions, some of which may not sit comfortably with some people. However, we are committed to making sure that you, in whatever relationship you have with our CCG, have the opportunity to have your say over any changes we may propose. Whilst the NHS Scarborough and Ryedale Governing Body will have overall responsibility and accountability for the commissioning of services for our communities, the challenges we face can only be achieved by this local team working in partnership with providers and stakeholders to ensure we deliver quality services for our local communities. Although it is a time of unprecedented change for the NHS, I truly believe that bringing the responsibility for the commissioning of health services to a more local level and empowering clinicians to make decisions about what services are best for their patients can only be a positive move for patient care. The strategy laid out in this document explains how we intend to progress for our communities.


1. Introduction

This document provides the integrated strategy and commissioning plan for NHS Scarborough and Ryedale Clinical Commissioning Group (SRCCG), from its first year as a commissioning body under the auspices of NHS North Yorkshire and York (NHS NYY), its first full year as a statutory body and towards the end of the financial year 2015-16. The document lays the foundation for SRCCG’s strategic development, providing a straightforward and deliverable plan for the CCG’s authorising body. Furthermore, it provides a statement of intent for the CCG to engage with its patients, public, and stakeholders: a statement on the direction, vision and major aims and objectives of the CCG. However, SRCCG recognises its success is critically dependent on the support, engagement and commitment of its stakeholders and the CCG vision has to be aligned with these stakeholders. The plan integrates the major strategic principles of the CCG; its major commissioning targets; the organisational structures and development to implement the plan; and a financial framework providing the CCG with a sustainable resource envelope from which to deliver high-quality patient care and improved patient outcomes. The current integrated plan is the result of dialogue between the CCG, its member practices and a wide range of stakeholders. This has included focus groups with stakeholders such as the Local Involvement Networks (LiNKs), voluntary sector organisations, and the relevant Local Authorities. Following the production of this current draft the CCG intends to conduct even more widespread engagement and consultation, so that decisions that affect you, as patients and partners, are made with you. Values After debate within the CCG and with its stakeholders the CCG confirms its core values, summarising how it wants to conduct its activities:

• To commission high quality services

• To engage patients, carers and other organisations in our planning and decision process

• To ensure value for money

• To be open and honest in our transactions, and accountable to our communities

• To respect our staff and promote a learning environment

• To improve health outcomes


Vision The overarching vision for the CCG is:

2. NHS Scarborough and Ryedale Clinical Commissioning Group

SRCCG is comprised of 17 practices across the areas of Scarborough and Ryedale, with a registered population of 118,086. The CCG has a relatively elderly population with 21.9% of its population aged over 65 (see Appendix 1 for Joint Strategic Needs Assessment summary). Over 50% of the CCG population live in the most deprived population quintile of North Yorkshire. The demographic profile of the CCG provides it with the combined challenge of an elderly population with high health resource usage; and significant areas of deprivation with associated poor health outcomes. As such this is a challenge unlike any other in North Yorkshire or York. The 17 practices have a range of patient list sizes (see Appendix 2) and support approximately 100 GPs working in the CCG area. The commissioning budget of the CCG as delegated from the PCT Board is over £144 million. It is anticipated the allocation of the CCG in 2013-14 will be of comparative scale.

3. Strategic context

The election of the Coalition government in 2010 was followed by the announcement of radical changes to the NHS, summarised in the 2010 Health White Paper (Department of Health 2010). The NHS changes will emerge in the context of an ‘age of austerity’. Commissioning will need to respond to the ‘Nicholson Challenge’: the NHS Chief Executive’s requirement for the NHS to deliver annual efficiency gains of 4%, totalling £20 billion over a five year period (House of Commons 2011). After a period of increased


investment and significant growth, the short to medium term period is likely to see financial growth only close to that of inflation. In addition to the dynamic national context and the historic issues the CCG will face significant financial challenges from inception. The current financial problems of NHS North Yorkshire and York may result in the CCG inheriting a financial position that restricts the CCG’s ability to achieve its aims. Furthermore, the CCG’s main acute provider Scarborough and North East Yorkshire Healthcare NHS Trust (SNEY) has received significant levels of additional funding over its recent past. Although the acquisition of SNEY by York Teaching Hospitals Foundation Trust (YFT) provides a potential longer term solution to this issue, YFT will be working to provide increasing levels of cost improvement in the Scarborough health economy. Consequently, the health economy faces a double challenge of limited funding from commissioning and excessive cost base within providers. Historically the CCG’s parent organisation, NHS NYY, has struggled to achieve financial balance, but has done so with a largely healthy population, with low levels of deprivation, and long life expectancy. The exceptions to this picture of general good health have been significant pockets of deprivation: many concentrated within the current SRCCG boundaries. Thus, the CCG faces a complex series of challenges, including not only responding to the economic environment, but at the same time actively promoting health improvement to bring the health and wellbeing of its communities closer to those of the majority of North Yorkshire. In 2011 the former Yorkshire and Humber Strategic Health Authority commissioned a review of health provision in North Yorkshire and York: the North Yorkshire and York Review (NYYR). This provided an assessment of the future financial challenge and a range of possible actions that may support NHS NYY moving towards recurrent financial balance. The CCG has been involved in both the review’s initial production and its on-going implementation. In addition to significant areas of deprivation, the CCG locality also includes a relatively elderly population. This provides significant challenges to the provision of health and social care. In addition to the need to plan for services to support those are able to live in their own homes, the locality has a significant population living in care homes, with at times inadequate care support. Furthermore, the locality is considered to have relatively low levels of alternative provision to care homes, such as extra-care housing, and this accentuates the challenges faced by a CCG wanting to support older people’s independent living.

4. Strategic Commissioning Aims

The CCG establishes three strategic commissioning aims:

• Commissioning sustainable, high-quality services within the available resources (people, money, buildings).


• Delivered by a stronger community system, integrating care across the whole care economy.

• Securing improvement in priority areas of health need and reducing health inequalities.

5. Delivery Domain One – Sustainability Sustainability will provide assurance and security to the CCG’s population that its services are safe, consistent, and not vulnerable to threat. The health economy has experienced threats from an inability to secure the appropriate clinical staff; from constant financial pressure; and from varying levels of physical capacity.


This principle is that the strategy and the CCG’s commissioning should seek to establish consistently high-quality, safe services, within a financially and clinically sustainable framework. QIPP The 2012-13 QIPP plan develops the three year plan developed and implemented in 2011-12. The current three year plan provides tangible actions for 2012-13 that will be taken forward, consolidated, and enhanced in years two and three. The detailed phasing of the plan has been developed, reflected in the contract plan for 2012-13 and will inform future contract negotiations with service providers. SRCCG has a challenging QIPP target to manage to a position of in-year financial balance and to manage any legacy debt arising from the current NYYPCT. The QIPP plan is a further development from that established in 2011-12. It focuses on four areas: planned care; unscheduled care; prescribing; and other initiatives. Planned Care The plan continues with the positive actions taken in 2011-12. Referral variation will be managed through the CCG and its constituent practices. Outpatient follow-ups will reduce further, as part of an agreed plan to move towards upper quartile performance. The clinical thresholds developed in 2011-12 will continue, with the expectation of a full-year effect gain in 2012-13 and beyond. Service redesign has been successfully implemented in Ophthalmology, and is being developed for musculoskeletal services. Unscheduled care This area provides the greatest opportunities but the most significant challenges. The plan includes a focus on urgent care: reducing the cost of GP out of hours through contract negotiation; and reducing A&E demand by practices targeting high A&E users, in collaboration with the A&E service. The inpatient plans are broadly grouped into Long-term Conditions (LTC) and redesigning community services. The CCG is actively engaged in the national programme (see below) and has used the opportunities afforded from the QOF QP indicators (QP11) to engage local practices in the active management of LTC patients. The CCG, through partnership and engagement, is working to redesign the community system to support more patients in their own homes, facilitate earlier discharge, and reduce the reliance on hospital care, thereby reducing the volume of excess bed days. Prescribing The CCG in partnership with the Commissioning Support Unit (CSU) medicines management team has developed target areas for practices to focus on to reduce prescribing costs. The CCG is continuing to work with secondary care to manage the costs of Payment by Results (PbR) excluded drugs. The aspired savings relating to the move away from ranibizumab and towards bevacizumab are a small but significant part of the overall plan. Others There are a number of specific initiatives developed by the CCG, some of which relate to contractual changes. Where any opportunistic efficiency gains appear, the CCG will seek to exploit them, even if they are outside of the main strategic priorities.


The summary of QIPP initiatives and forecast financial efficiencies for 2012-13 is shown below.

Scheme (2012-13) Target (£000)

Reducing variation in GP referrals £200,000 Reduce number of Ophthalmology referrals using LES based Optometrist scheme £85,000

Reducing outpatient follow ups £785,000 MSK redevelopment £100,000 POLCV / Thresholds £60,000 Hip/Knee replacement thresholds £100,000 Reducing LTC related emergency admissions £150,000 Short stay elderly care pathway £150,000 Levels of Care & strengthened community systems £200,000 A&E - reducing repeat attendances £104,000 GP OOH £120,000 Medicines management £150,000 Non PbR Drugs reduction £100,000 Clinical thresholds for expensive anti-psychotics £50,000 Reclassifying Day hospital activity to tariff £198,000 Move from Ranibizumab to Bevacizumab for ARMD £300,000 Decommission theatres at Malton £239,749 Sub-total £3,091,749 In-year Contingencies CCG Management Costs Allowance - Saving £1 per head £100,000 Reablement Slippage £200,000 Further Initiatives on GP Prescribing £92,251 Reduced MIU Activity/Out of Hours integration £100,000 GP Urgent Transport Pathway Change £100,000 TOTAL £3,684,000

The QIPP plan lays the basis for the achievement of recurrent in-year financial balance (so-called ‘run-rate balance’) and provides a platform for the CCG to work with the other North Yorkshire and York CCGs and the NHS Commissioning Board (NHSCB) Local Area Team to address any legacy deficit issues that may remain from 2011-12. The Financial Plan includes the summary of the 4 year QIPP plan, provided in detail as Appendix 9. The significant financial challenge faced by NHS NYY and emerging cost pressures threatened achievement of the CCG targets in 2012-13. In support of financial recovery the CCG has instigated two corrective actions: a series of additional actions in 2012-13 as detailed in the schedule above; and a ‘Going Faster Further’ programme to accelerate QIPP delivery. This is consistent with the initial QIPP plan but involves local clinicians working intensively to improve efficiency and secure resources for essential services. The narrative summary of the plan is included as Appendix 10.


The CCG believes the QIPP plan provides a credible plan to provide financial sustainability for Scarborough and Ryedale. Early Successes - QIPP SRCCG delivered over £2 million of recurrent savings in 2011-12 and is forecast to deliver over £3 million in 2012-13. An example of clinical engagement supporting financial efficiency is demonstrated from outpatient follow-ups. The CCG facilitated 10 speciality table-top discussions of GPs meeting with hospital consultants to review patient case-notes of follow-up attendances. The reviews confirmed a number of patient types could be safely discharged back to primary care.

Whole system Pathway Reconfiguration Alongside the elements of system redesign covered in other elements of the integrated plan (such as QIPP and Service Improvement) the CCG has prioritised its major work of whole system redesign for the medium-term. Highest among the priorities are stroke care and paediatric services. The CCG has identified the need to reconfigure stroke care services to provide services that are clinically effective, deliverable, financially affordable, and consistent with the exacting standards of stroke accreditation, within a configuration that is sustainable for the longer-term. The CCG is leading the process of service reconfiguration involving all major partners and stakeholders and will have an initial assessment of the options for sustainable excellent services by the end of the 2012 calendar year. The areas identified as requiring action within the reconfiguration include:

• Establishing effective comprehensive access to stroke thrombolysis

• Strengthening access to stroke therapy in and out of hospital

• Providing effective early supported discharge for patients who would benefit

• Improving education and support post-stroke Early Successes – Stroke Care The CCG has engaged closely with its main provider to address weak stroke care performance. Over the past year this has seen the percentage of patients spending 90% of their time on a stroke unit increase from 20% to over 80%, and the establishment of greater access to Transient Ischaemic Attack (TIA) clinics in Scarborough. GP direct booking into TIA clinics will reduce non-attendance and improve early diagnosis and management.

The CCG recognises the outcomes from the recent Strategic Health Authority (SHA) stroke accreditation assessment (a local SHA assessment against the objectives of the national stroke strategy). This suggests there will need to be continued work to develop and redesign stroke services for the population. Such redesign appears entirely consistent with the CCG’s current work, and thus SRCCG will be a lead agency in this


development. The precise elements of service provision will become clearer by the end of 2012-13. The development on the York Teaching Hospitals Foundation Trust (YFT) acquisition of SNEY provides significant opportunities to modernise paediatric services. The acquisition is accompanied by access to capital funding, allowing redevelopment of the current Scarborough Hospital estate, and facilitating a new paediatric unit. However, although this opportunity is present, it requires effective engagement, and a strategic approach to service planning to maximise this opportunity and provide a modern, fit for purpose service. The CCG’s GP-Consultant engagement forum is leading the initial scoping to assess options to most effectively configure the future of paediatric services in the locality. Clinical Service Redesign SRCCG is working to redesign and rationalise services in priority clinical specialities:

• Neurology

• Rheumatology

• Musculoskeletal Medicine

• Chronic Pain Management Neurology and Rheumatology are considered vulnerable services in the locality as being both led by lone consultants and incurring significant demand pressures. The CCG plans to establish sustainable local access in both clinical specialities, including local access to sub-specialist expertise. Rheumatology Outcome Integration of Scarborough and York Rheumatology service with developed shared care protocols across primary and secondary care Performance Indicator Increased access for primary care referrers Establishment of shared care protocols Performance Measure Waiting times for first outpatient attendance Reduced outpatient follow-up attendances Evidence of shared care protocols and their implementation in patient management Action Integration of currently separate services Development of shared care protocols Milestones Joint service provision – April 2013 Development of shared care protocols – April 2013 Review of protocol implementation - October 2013


Neurology Outcome Integration of Scarborough and York Neurology service with establishment of non-face-to-face triage Performance Indicator Increased access to Neurology expertise including sub-specialist opinion Improved management of patients with epilepsy Performance Measure Waiting times for first outpatient attendance Provision of sub-speciality clinics in the locality Establishment and activity data on triage service Emergency admissions and re-admissions related to epilepsy Action Integration of currently separate services Establish rota of sub-speciality clinics in the locality Establish triage service Appoint specialist nurse for epilepsy Milestones Epilepsy Neurology Specialist Nurse appointment - November 2012 Establish triage service January 2013 Joint service provision – April 2013 Establish sub-speciality rota – April 2013

The locality has an established musculoskeletal medicine (MSK) service: however, this was established as a stand-alone service and is not fully integrated with the Orthopaedic service. Strong evidence suggests there is significant duplication between the two services and that for many patients the MSK service provides a potentially unnecessary step in their pathway. The CCG plans to move to fully integrating the two services and to reduce unnecessary duplication. Musculoskeletal medicine Outcome Fully integrated community facing MSK service providing wherever possible a one-stop service for patient referrals Performance Indicator Reduced duplication of multiple attendances, onward referrals and inappropriate investigation Performance Measure Reduced Orthopaedic first outpatient attendances Reduced Orthopaedic follow-up outpatients Reduced overall volume of MSK related diagnostic tests Action Co-locate current separate services in Scarborough and Malton Implement single referral pathway for GPs Milestones Co-location – January 2013 Single pathway implementation – January 2013


The locality has historically had a chronic pain service based on secondary care medical management. The CCG plans to implement a multi-disciplinary community oriented model, consistent with NICE. The integration of the Scarborough and York pain services will support this development. Chronic Pain Management Outcome NICE compliant multi-disciplinary chronic pain service in the locality Performance Indicator Availability of MDT service including appropriate levels of capacity in all disciplines Rapid access for referral from GPs Performance Measure Activity delivered through an MDT based service Reduced activity through conventional pain clinics Action Develop local version of MDT model Link pain service to developing MSK service Establish capacity gaps across different MDT disciplines Implement MDT based service with staged roll-out Milestones Model developed – October 2012 Capacity Gap assessment - October 2012 Aligned pathway with integrated MSK – January 2013 Implement MDT service – October 2013

6. Delivery Domain Two – A Strong Community System


If there is one area where the commissioning strategy intends the health system to look different it is in the development of a much stronger, integrated community system. Thus, the redesigned system will provide:

• Capacity – through a transfer of resource into primary and community services, closer to patients.

• Efficiency – through streamlined pathways and less use of hospital resources by supporting patients in their own residences

• Effectiveness – through integrating services within healthcare (across primary, community, and secondary care boundaries) and through integrating across health and social care

• Responsiveness – through partnership working with a range of agencies, in particular the local voluntary sector.

• Workforce – a flexible streamlined workforce, reducing service duplication, with a transfer of resource from hospital based to community based services.

The work-streams in 2012-13 and 2013-14 are:

• Long-term conditions programme – As part of the national programme with an established local implementation group.

• Developing Neighbourhood Care Teams (NCTs) – bringing together community nurses, therapists, and social care staff, clustered around General Practice.

• Elderly Care assessment (‘Frailty Service’) – Developing a rapid geriatric assessment service as part of a ‘frailty service’ to support the vulnerable elderly.

• Improving End of Life Care - through improved support to Care Homes, including developing Care Home link nurses.

Delivering the programmes in 2012-13 will be through a range of coordinated specific actions. Long-term conditions The CCG is actively involved in the national programme to improve the management of LTCs. Local implementation includes focussed action in a number of areas. Risk stratification and patient optimization Outcome Proactive management of vulnerable patients to identify those in need and then optimise their management Performance Indicator Identification of patients not previously targeted by General Practice Improved appropriate prescribing Improved referral rates to appropriate rehabilitation services Improved referral rates to case management Performance Measure Number of patients identified not actively managed before risk stratification


Proportion of practice populations with optimal prescribing for their disease pathway Proportion of patients referred to pulmonary rehabilitation Number of patients on an active case management caseload Action Implement Adjusted Clinical Groups (ACG) tool in pilot practices Roll out ACG to remaining SRCCG practices Target identified patients for optimised prescribing Through the reablement programme increase capacity for pulmonary rehabilitation Agree local model for community case management Implement case management model. Milestones ACGs in pilot practices – June 2012 Audit of Heart Failure (HF) patient prescribing – June 2012 Action plan for HF prescribing – July 2012 Increase in pulmonary rehabilitation capacity – November 2012 Re-audit HF prescribing – Spring 2013

Model pathway implementation for respiratory diseases Outcome All patients managed according to the model pathways for COPD and all patients on oxygen therapy in the community to be fully assessed Performance Indicator COPD related emergency admissions Appropriate oxygen prescribing in the community Performance Measure Non-elective admissions with COPD as a primary diagnosis code Levels of prescribing in the community for different oxygen types Overall cost of community oxygen Action (Pulmonary rehabilitation see risk stratification above) Implement community oxygen assessment service Audit compliance of patient management with model pathway Initiate a programme for GP practice nurse education in managing COPD Milestones Audit compliance with pathway from GP practice audit – June 2012 Implement community oxygen assessment - October 2012 (Implement increased capacity for pulmonary rehabilitation)

Neighbourhood care teams One of the evidenced actions seen to be effective in managing LTCs is effective integrated community teams. The CCG is commissioning a Neighbourhood Care Team (NCT) model, designed to work close to General Practice, supporting patients in their usual residence. Outcome Establish integrated teams involving previously separated social care, community care, and voluntary sector teams clustered around General


Practice. Performance Indicator Teams identified and established Single Point of Coordination (SPOC) provided for community services Provision of case management for vulnerable people with complex needs Performance Measure Referrals into SPOC Patients referred to integrated case management Action Develop outline commissioning specifications Implement SPOC Hold engagement events across health and social care Milestones Engagement events - May to July 2012 Agree service specification – October 2012 Assess implementation through Contract Management Board – December 2012, March 2013

The Frailty Service The CCG has identified the management of the frail elderly as a strategic priority. The demographic data supports the view that the CCG has a high proportion of elderly people, many of them with significant health needs. The CCG plans to improve the management of a significant cohort of elderly patients: the frail elderly, who need specialist assessment, diagnostics, and treatment planning, but who may not be optimally managed through conventional hospital admission on lengthy inpatient stay. The Frailty Service model provides rapid access to specialist Physicians supported by prompt access to diagnostic services, with patient returning home within 12 hours supported by NCTs and General Practice. Successful models of this type have been observed in Sheffield and the CCG believes this action will support improved patient outcomes and reduce the need for a large hospital bed base. Outcome Provision of Frailty Service for complex elderly patients, providing rapid assessment, care planning, and support to remain at home. Performance Indicator Reduced emergency admissions for complex elderly patients Reduced length of stay for complex elderly patients Performance Measure Emergency admissions in Elderly Medicine Non-elective Excess Bed Days in elderly Medicine Delayed Transfers of Care from Hospital Action Establish rapid assessment service utilising Elderly Medicine outpatient clinics Develop integrated Frailty Team as part of the Community Services, linked to SPOC Milestones Availability of rapid assessment clinics – October 2012


Care Homes project Linked to its elderly population, the CCG has a significant population living within care homes, both residential and nursing. In 2011-12 the CCG had 486 emergency admissions to hospital from care homes, of which 95 patients died during their stay in hospital, 30% within 48 hours of admission. Whilst the CCG recognises patients in care homes have every right to the appropriate hospital care, it is working with partners to improve the quality of care in care homes and to work towards ensuring patients are able to choose to remain in the care home for their final period of care (end of life care) where it is safe and appropriate to do so. Where acute admissions are unavoidable the service will work with the care home to enable a discharge home as soon as is possible and avoid unnecessary delays. This will be delivered by improved care planning, education and support for care home staff, and access to specialist support for complex patients. The plan is to establish a locality wide care home forum to facilitate education and development. The appointment of care home link nurses will provide the expertise to support patients more effectively without admission. Outcome Improved management of patients in care homes, reducing unnecessary admissions to hospital from patients in care homes Performance Indicator Reduced overall emergency admissions to hospital from care homes Reduced emergency admissions to hospital dying within 48 hours of admission Provision of advanced care planning Performance Measure Emergency admissions to hospital from care homes Emergency admissions dying within 48 hours of admission Numbers of patients in care homes with advanced care plans Action Identify baseline activity information – May 2012 Establish care home link nurses posts to coordinate action Establish local care home forum Review performance against established baseline Milestones Link nurse posts recruited – June 2012 Care Home forum established - July 2012 Activity review – December 2012, March 2013.

7. Delivery Domain Three – Health improvement and reducing health inequalities focussed on priority areas

SRCCG will continue to work closely with North Yorkshire County Council to improve health and reduce health inequalities as identified in the JSNA and draft Health and Wellbeing Strategy. The relevant sections of the JSNA include those for North Yorkshire as a whole as well as specific issues identified for SRCCG and can be found at Appendix 1. Public health improvement programmes commissioned by North Yorkshire County Council will be supported and implemented locally, including smoking


cessation, drug and alcohol treatment services as well as immunisation and screening programmes that will be commissioned by NHSCB. The stronger community system will support improved outcomes through clinically and cost-effective models of delivering sustainable, safe, patient focussed services. The aim of the services will be to improve the health outcomes of our communities, with particular focus on areas considered high priorities.

From analysis of the Joint Strategic Needs Assessment (JSNA) the CCG has identified four priority areas for improvement in health outcomes.

• Cancer • Cardiovascular care • Elderly Care • Mental Health

Cancer Cancer is the single largest cause of premature mortality in SRCCG. Although the quality of cancer treatment for the CCG population is considered good, there remain opportunities to improve outcomes through earlier diagnosis. The CCG with its practices is reviewing the use of the ‘two-week wait’ system and has agreed for practices to perform case reviews of all patients diagnosed with cancer to identify whether their point of referral or management may have been improved. The CCG has actively involved the Humber and Yorkshire Coast Cancer Network to support the process. Cardiovascular care Cardiovascular outcomes are significantly worse for the CCG population than for the rest of North Yorkshire and contribute significantly to the health inequalities evident in the most deprived areas of the CCG. The most significant contribution to tackling the gap in life expectancy is therefore likely to come from the risk factors common to all these diseases, particularly smoking cessation, as well as


the detection and improved management of hypertension, raised cholesterol, coronary heart disease and diabetes. The graph below demonstrates the impact of cardiovascular disease on mortality.

The CCG in 2012-13 is targeting improvements in stroke care, in line with current NICE guidance with the aim of: improving the time stroke patients spend in a dedicated stroke unit; improving access to TIA clinics; and instituting early supported discharge for appropriate stroke patients. The focus on improving outcomes from stroke will support the service redesign as part of the local stroke accreditation process. The CCG and partners will continue the implementation of the developed model pathway for Congestive Heart Failure (CHF). Further developing work will focus on managing hypertension and angina in primary care. Elderly care Alongside the work developing for LTCs the CCG is committed to improving the services for the frail elderly. The CCG intends to commission a rapid assessment service for elderly patients with complex needs. The CCG will use service improvement methodologies in support of this redevelopment. The aim is to provide rapid assessment and treatment planning for elderly patients (whether in or outside the hospital) seeking to avoid unnecessary hospital admission. Linkages to social care and the voluntary sector will support an approach of seeking to ‘maintain normality’ by promoting reabling solutions. Mental Health SRCCG aims to improve the quality of primary care based mental health services, through redesigning access to counselling and related services. It has been agreed with the main mental health provider to review the usage of anti-psychotic drugs. There is multi-agency agreement to develop a more comprehensive local CAMHS service and to explore how the CCG can more effectively commission mental health liaison services with its main acute providers.


The specific objectives for 2012-13 are: Cancer GP practices to complete retrospective review of cancer patient referral pathways. Outcome Increased cancer early detection through the two-week wait (2WW) system Performance Indicator Number of referrals to 2WW clinics Number of positive cancer diagnoses identified from 2WW referrals Performance Measure 2WW referrals 2WW cancer diagnoses Reduced number of emergency admissions with a cancer primary diagnosis Action GPs to review all cancer patient pathways GP audit of practice referrals into 2WW system Milestones GP review of cancer cases – June 2012 Baseline assessment of 2WW data – April 2012 Review of 2WW data – March 2013

Cardiovascular care Implement agreed action plan with the main acute and community healthcare provider as first step towards service reconfiguration of stroke care. Outcome Reduced mortality from stroke Performance Indicator Over 80% of stroke patients spending over 90% of their hospital stay in a stroke unit. Reduced hospital length of stay through early discharge to supported community care. Performance Measure % of patient spending % of time in a designated stroke unit Number of patients accessing a TIA clinic within 48 hours Number of patients discharged and referred into a designated Early Supported Discharge (ESD) service Action Increase access to TIA clinics through clinic reconfiguration Implement GP on day referral clinic booking to TIA clinics Implement ESD service through reablement plan Milestones Increased clinic slot access – April 2012 GP direct booking – September 2012 Establish jointly provided ESD service with NYCC – October to December 2012


Implement whole system heart failure pathway. Outcome Reduced hospital admissions and readmissions from Heart Failure Performance Indicator Reduced hospital admissions and readmissions from Heart Failure Performance Measure Non-elective hospital admissions and readmissions with a primary diagnosis of heart failure Action Audit of primary care heart failure management Development and implementation of primary care prescribing action plan Milestones Primary care management audit – June 2012 Development of prescribing action plan – July 2012 Review implementation through re-audit – January 2013

Elderly Care Major priorities in improving elderly care are the frailty service and the project to improve management of patients in care homes (for both see above). In addition to these two short-term actions the CCG recognises the significance of dementia as a disease process posing significant challenges to the health economy. Mental Health Mental health priorities target improved supportive care to General Practice management and targeting significant service gaps in the locality. The establishment of a comprehensive Children and Adolescent Mental Health (CAMHS) service has been an aspiration for some time, but now the CCG has affected clinical dialogue to deliver real improvement in year. CAMHS Outcome Establish comprehensive access to CAMHS support Performance Indicator Emergency patients supported by CAMHS out of hours an in hours Performance Measure Patients admitted to the acute hospital requiring CAMHS support receiving active support and specialist management within 4 hours of admission Action Agree local out of hours CAMHS pathway Implement revised consultant staffing rota to provide out of hours support Milestones Agree local pathway – April 2012 Implement revised rotas and establish 24/7 CAMHS support – October 2012


Primary Care Counselling Outcome Establish primary care based mental health counselling for all required patients with access within 6 weeks Performance Indicator Patients requiring counselling referred into a designated service Performance Measure Patients referred into a designated service Waiting times to access counselling Patients unable to access counselling within 6 weeks of needing referral Action Develop local PC counselling pathway Agree process for developing local provider map Milestones Local pathway developed – July 2012 Develop procurement plan – September 2012 Implement procurement process for counselling providers – Sept to January 2013

8. Delivery and Performance Management Describing the vision, values and direction for the health community does not inevitably mean the associated objectives are achieved. Effective means to execute the strategy and deliver its benefits are the main work of the CCG and its partner agencies. As such all delivery mechanisms, and corporate elements should reflect planning and implementation of the strategy. Assurance frameworks, including risk management, should take the strategy as their foundation: assurance of strategic delivery as their main concern.

Delivery will be supported by:

• Strong practice engagement. As a membership organisation this will be critical to the CCG. This active membership will not merely support the CCG Governing Body: it will be its main method of delivering the strategy. This will include


performance management of practice performance and facilitating innovation through tools such as practice grouped CCG learning sets.

• Joint Commissioning. The CCG will actively seek out arrangements with other commissioners to support effective, planning, procurement, and contracting. Current examples include the established joint commissioning committee with North Yorkshire County Council. Joint commissioning will support ‘delivery at scale’: those areas where commissioning or redesign at a larger geographical level may provide benefit. As such the CCG will continue to support certain elements of the work emerging from the North Yorkshire and York Review.

• Joint health promotion initiatives. Working with upper-tier and lower-tier Local Authorities and the current PCT Public Health team, the CCG is engaged in actions relating to reducing the incidence of smoking (particularly in pregnancy) and in alcohol and substance abuse (statistically the CCG has the most significant challenges in the county).

• Programme management. The CCG’s officer team will manage the competing priorities and workload through a systematic use of project management methodology, linking with that used in other agencies to provide effective programme coordination. The overall strategy will be treated as a 4 year transformation programme. The integrated plan will be underpinned by a detailed project delivery plan, detailing specific actions, timescales, and project deliverables.

• Service improvement. The CCG does not believe that in every area it seeks improvement it can clearly describe a blueprint for success: rather it may need to use proven service improvement methodologies to facilitate bottom-up service redesign that is meaningful to a local context and has been designed by patients, public, and local clinicians.

• Communication. Integration in particular will be delivered more effectively by staff being empowered to communicate with each other and to redesign communication channels when they are seen to be ineffective. Appropriate points of communication and coordination will support better multi-agency working and smooth the patient journey.

• Leadership. The critical test for SRCCG is that it can provide clinical leadership to implement its strategy and improve its healthcare system. The emerging CCG leaders will be the champions of the strategy and its vision for the future.

• Patients and the public. If the leadership needs to promote a sense of collective ownership to shared problems, it presupposes that the collective will support problem solving. The most important element of delivery is that of engaging patients and the wider public in decision-making, resource allocation, and service planning.

• Organisational development. Underpinning the delivery mechanisms of the CCG will be an organisational development plan that focuses on supporting strategic delivery and developing CCG corporate capacity.


To support programme delivery and to provide assurance as to the quality of existing commissioned services the CCG has established a strong performance management framework. It has reviewed the risks of performance delivery of existing services and developed a performance management plan to address high-risk areas and support effective delivery.

9. Quality and Performance management

In exercising its functions the CCG will have a general duty to act with a view to securing continuous improvements in the quality of services for patients and in outcomes, with particular regard to clinical effectiveness, safety and patient experience. This means that the CCG has to put in place effective systems and processes to proactively identify early warning of failing services, monitoring and acting on patient feedback, identify quality including safety issues and secure continuous improvements in the quality of services provided. SRCCG’s Quality and Performance Committee is responsible for providing assurance to the Board that commissioned services are being delivered to a high quality and in a safe manner. A range of data from many different sources will ensure that the CCG captures relevant information on the three domains of quality: effectiveness, safety and patient experience. Our sources of intelligence will include but will not be restricted to the following which are grouped for ease of reading but which cut across all three domains: Quality • Staff satisfaction and wellbeing evidenced through improved Staff Opinion

Survey results • External assurances via audit reports, peer reviews and inspection reports • On-going compliance with CQC Essential Quality and Safety Standards • Contract Performance Schedules/CQUINs/Quality Accounts • Quality of care in care homes • Quality of primary care provision • Quality impact assessment of service redesigns • Quality impact assessment of Provider Cost Improvement Programmes • Priorities set out in the Operating Framework relevant to quality Safety • Safeguarding children and young people • Safeguarding adults • Safeguarding Looked After Children • Serious Incidents, never events and homicide reports/unlawful killing • CAS alerts closure rates and outstanding issues • NRLS trends analysis • Infection prevention and control


• providing assurance on the clinical governance arrangements in commissioned services

• Compliance with NICE guidance (implementation and adherence) • Analysis of mortality rates (HSMR, SHMI and crude rates) Patient experience • Patient experience reports including complaints reports • National Patient Survey results and associated improvement plans • Compliance with Eliminating Mixed Sex Accommodation guidance • Patient engagement and communication activities including patient and carer

forums SRCCG will be relying on the services and expertise within the Commissioning Support Unit to convert the mass of data and information into intelligence that can be easily analysed and monitored pro-actively, across care pathways and all care settings, to assess risk and promote continuous quality improvement. A Quality Dashboard is being developed to facilitate this process. Quality Assurance Framework Our quality assurance framework will include but will not be limited to: • SRCCG Governing Body • SRCCG Quality and Performance Committee • SRCCG Patient Engagement and Communication Committee • Practice Patient forums • Local Safeguarding Children’s Board • Local Adult Safeguarding Board • Health and Well Being Board • Joint Strategic Commissioning meetings • Safeguarding Children’s Framework • Safeguarding Adults Framework • Serious Incident Review Group • Care Home Forum • Data Group • GP Member Consortia meeting • Contract Management Boards • Contract Management Quality and Performance Sub Groups Contract Management Quality schedules and CQUINs which form part of the contract between the CCG and providers contain a range of key performance indicators and stretch targets relating to patient experience, patient safety and clinical outcomes. The provider reports against the Quality Schedules and CQUINs on a monthly basis. Contract Management Board meetings provide a forum for detailed oversight and scrutiny of provider performance against service quality, performance schedules and CQUINs frameworks. With smaller contracts, where a Quality and Performance sub


group has not been established, a CCG Officer (or a CSU officer delegated to act on behalf of the CCG or a Host Commissioner) leads this dialogue through the main contract meeting. Where performance issues arise, plans are put in place to achieve compliance as detailed in the Quality and Performance/CQUIN schedule, and unresolved issues are escalated to the overarching contract sub group. The Quality and Performance Committee is developing mechanisms to receive monthly reports on the performance of providers against their respective quality and performance schedules and CQUINs and monitors any plans put in place to resolve compliance issues as set out in the schedules or by agreement. The SRCCG Board receives a monthly exception report that currently covers underperformance and on-going risks. Reporting of Patient Safety Incidents Patient safety incident reporting is ultimately the responsibility of healthcare professionals in the first instance to flag up and report incidents when they happen. SRCCG will work with the providers to promote a culture of openness and transparency to ensure that expected levels of reporting continue. Incident reporting is a vital mechanism for identifying downward trends in the quality of care and facilitating learning. All Serious Incidents (SIs) are reported through the Department of Health’s central Strategic Executive Information System (StEIS). On behalf of the CCG the CSU will manage the process of receiving and reviewing completed investigation reports from the provider to ensure that comprehensive investigations have been undertaken which identify organisational learning and confirm assurance with regards to patient safety. CCGs will remain accountable for the sign off and closure of SIs and as such needs to establish internal mechanisms for carrying out this duty including sharing any learning and picking up on trends to support improved quality and patient safety. It is proposed that in order to promote shared learning and to make best use of the CSU resource, that the CCG collaborates with other CCGs, in partnership across North Yorkshire, in either case through a restructured and augmented SI review group (facilitated by the CSU). The Quality and Performance Committee will receive a monthly report summarising the Serious Incidents (SI) and incidents that have occurred and identifying the number of incidents, emerging themes and actions taken to address concerns. Feedback from the public, patients and staff The CCG is utilising a variety of approaches and relevant sources of information on patient and public feedback to identify quality issues before they become serious failures including; complaints and Patient Advice and Liaison Service (PALS) data, national survey data. The CCG will take steps to look at better ways of obtaining real time data and more innovative ways to collect patient experience data.


During the transition the PCT Cluster retains responsibility for dealing with primary care complaints, and the reporting of serious incidents in primary care. It is important the CCG develops a system to ensure CCG is able to obtain intelligence from these and triangulate where possible. The CCG will take appropriate steps to engage with any new process or systems that the emerging NHSCB Local Area Teams establish in relation to incident reporting and complaints management in Primary Care. The CCG will be working with the CSU to ensure a comprehensive Complaints process is developed and will agree the relevant route within the CCG governance framework in order to review themes and trends and identify patterns for recommending change in practice. The CCG will receive at least quarterly summaries including the complaints and PALS activities, to identify emerging themes and trends and details of actions/recommendations made to improve services through the experience of and learning from complaints, and other contact with our patients and the public. Quality Accounts Publication of an annual Quality Account is a Department of Health requirement to encourage provider and commissioning organisations to assess quality across the entire range of their healthcare services, with a focus on continuous quality improvement. Quality Accounts are a key mechanism to demonstrate that a focus on improving service quality is being maintained. The CCG will need to contribute in the planning and development stage of the providers quality account and will be responsible for providing scrutiny and a supporting statement which will be included within the account, which are publicly available documents. The CCG is committed to putting quality at the heart of everything we do. Using a continuous quality improvement (CQI) methodology, it will strive to commission high quality services for its patients.

Core Concepts of CQI

• Quality is defined as meeting and/or exceeding the expectations of our customers.

• Success is achieved through meeting the needs of those served. • Most problems are found in processes, not in people. CQI does not seek

to blame, but rather to improve processes. • Unintended variation in processes can lead to unwanted variation in

outcomes, and therefore CQI seeks to reduce or eliminate unwanted variation.

• It is possible to achieve continual improvement through small, incremental changes.

• Continuous improvement is most effective when it becomes a natural part of the way every day work is done.

CQI is an approach to quality management that builds upon traditional quality assurance methods by emphasizing the organisation and systems: it focuses on "process" rather than the individual; it recognizes both internal and external "customers"; it promotes the need for objective data to analyse and improve processes.


CQI is a management philosophy which contends that most things can be improved. The CCG will endeavour to develop a culture where CQI is applied to everyday work to meet the needs of the population served and the services commissioned.

The CQI framework:

Continual quality improvement & achievement of our priorities

Through the achievement of national and local goals in line with the NHS Outcomes Framework and CCG Strategy

Success measured against Key Performance Indicators

Assurance – by monitoring progress against KPIs within an appropriate timescale

Performance reviews – will be undertaken monthly, quarterly, mid-year and end of year

Responsibility – will be delegated to project leads

Accountability – will be delegated to the Performance and Quality Committee on behalf of the Board

NHS Operating Framework 2012-13 The national direction of the NHS is set out in the NHS Operating Framework 2012-13. This policy document is the framework that will be used by Secretary of State for Health to hold the NHS Commissioning Board (NHSCB) and CCGs to account for improving quality and delivering better health outcomes for people using NHS services. The strategy and priority projects for 2012-13 have been designed around the key themes in the Operating Framework as a foundation for providing a mandate for delivering quality: • Preventing people from dying prematurely

• Enhancing the quality of life for people with long term conditions

• Helping people to recover from episodes of ill health or following injury

• Ensuring that people have a positive experience of care


• Treating and caring for people in a safe environment and protecting them from avoidable harm

The framework will ensure that progress is monitored against key performance indicators and that named individuals in the CCG take responsibility for delivering projects.

10. Organisational Structure and development

SRCCG does not underestimate the challenge of building a new organisation. In order for the CCG to be fit for purpose a structured organisational development plan has been developed to help shape the interventions required to help the new organisation evolve into a responsive, collaborative and effective team that is known to “make a difference through clinical leadership. SRCCG is committed to supporting developing individuals as well as the team in which they work and we recognise the importance of working in partnership with the Commissioning Support Unit (CSU) and other CCGs to deliver efficient and cost effective commissioning for the local healthcare economy. The Organisational Development plan sets out the interventions that are needed to demonstrate to member practices, the NHS CB and patients and public that SRCCG is fit for purpose and recognises the areas that need to be strengthened. Organisational development is “the practice of planned intervention to bring about significant improvements in organisational effectiveness” and the plan sets out how SRCCG intends to continue to develop. The CCG and has developed an organisational structure that reflects the need to promote clinical leadership and effectively utilises staffing resources. The principles behind the structure are:

• Clear leadership roles for clinical leaders within the CCG • A core team of highly skilled officers and support staff to facilitate clinical

commissioning • Strong joint commissioning relationships with other local CCGs and Local

Authorities • Strong support from the Commissioning Support Unit (CSU) across a broad

range of areas

The full CCG organisational structure is presented in Appendix 5. Until the formal establishment of the CCG as a separate statutory body in April 2013, the statutory functions of the Audit Committee and Remuneration Committee will be provided through the NHS NYY Cluster. The operational Committee Structure of Scarborough and Ryedale CCG is described in the chart below


11. Joint Commissioning Strategic Alliances with CCGs SRCCG is engaged in collaborative commissioning arrangements with 4 other North Yorkshire and York CCGs1 in addition to engaging in strategic commissioning initiatives with the East Riding of Yorkshire CCG. The arrangements between the 5 former North Yorkshire and York CCGs are covered within the terms of the Strategic Collaborative Commissioning Board (SCCB). The SCCB Terms of Reference are provided as a supplementary document. Joint Commissioning with Local Authorities The CCG has established a Joint Commissioning Committee with representation from:

o the lead Clinical Commissioning Group (CCG) (Scarborough and Ryedale CCG to act as host liaising with other CCGs as associate commissioners)

o North Yorkshire County Council (NYCC) Adult and Community Services Directorate

o The North Yorkshire Public Health Directorate (currently under the auspices of the PCT, but later under the auspices of NYCC.

The Board will function as joint forum of the SRCCG Board and of NYCC Adult and Community services, with delegated responsibility from both bodies. The JCB will initially take responsibility for the management of:

o The current intermediate care pooled budget (circa £200k) o The resources used to commission care related voluntary sector

provision (currently jointly commissioned but not through a pool)

1 NHS Harrogate and Rural District CCG, NHS Hambleton and Richmondshire CCG, NHS Airedale, Wharfedale and Craven CCG, NHS Vale of York CCG


o The locality reablement resource, feeding into the county wide joint board.

Health and Wellbeing Board The CCG has been a lead partner in the shadow North Yorkshire Health and Wellbeing Board (HWB) from its inception. It is a contributor to the developing HWB strategy, of which the current CCG strategy aligns very closely. The CCG will be an active player in the further development of this strategy and its on-going implementation. Local Strategic Partnerships (LSP) The CCG has been actively involved in the LSPs of Scarborough and Ryedale lower-tier authorities. This has included work targeting support to the vulnerable elderly and on childhood obesity. Support for improving the wider determinants of health is being delivered through the CCG’s engagement in support of the wider economic regeneration initiates in the locality.

12. Securing Commissioning and Business Support

Over the last year the CCG has been working closely with the emerging North Yorkshire and Humber Commissioning Support Unit (NY&H CSU) to support delivering a range support services. The aim is to access a suite of services to support delivery of all aspects of the commissioning cycle. The NY&H CSU is in a state of on-going development. The organisation was formed in early 2012. An interim leadership team, including an interim Managing Director, was in place by Easter 2012 and an interim organisational structure was established by April 2012. Simultaneously, the CSU has been working with SRCCG and 7 other Clinical Commissioning Groups across North Yorkshire and Humber to establish a clear service provision agreement. Service provision covers two key areas: • Services to support direct commissioning functions, and; • Services to support business enabling functions. Current Status The NY&H CSU introduced the role of Relationship Managers in April 2012 focusing on a more customer focused organisation, one of whom has been working closely with SRCCG over the last few months to progress intentions into a commercial agreement


with the CSU. Going forward the role of Relationship Manager will be to work alongside the CCG to ensure the CSU meets the organisation’s needs. They will provide a main point of contact and contract and performance management of the services purchased. The CSU commercial terms have been developed to inform the production of a Service Level Agreement (SLA) and a letter of intent is attached (Appendix 7). This is over and above the Memorandum of Understanding signed in February 2012 (Appendix 8). The emphasis of these commercial arrangements remains continued collaboration between the CSU and the CCGs to ensure services are fit for purpose and resourced appropriately for both parties. Summary of Services to be provided by the NY&H CSU There have been a number of joint workshops with the CSU and full engagement from the Governing Body to determine what services to buy from the CSU, to support and complement CCG structures. This has included engagement through a Stakeholder Board, which incorporates all CCG clinical leads and shadow accountable officers. The chart below provides a summary of the services offered by the CSU. Discussions continue to be held with the CSU to finalise the scope of the services required within our financial envelope. These conversations are expected to be concluded by the end of September 2012.

Service Range Purchased by S&R CCG

Corporate √ Communications and Engagement √ Workforce √ Finance X Procurement √ IM&T √ Service Delivery and Assurance (including Continuing Health Care and Individual Funding Requests)

√

Provider Performance (Contract Management) MH/LD, CHC and Children’s only

Provider Performance (Business Intelligence) √ Quality and Outcomes √ Medicines Management √

For all of the services identified to be purchased from the CSU, detailed work has been undertaken to agree service specifications, supported by clear business process maps. These had the support of all parties in providing a clear understanding about the relationship and the “hand-offs” clarifying the roles and responsibilities of both organisations. The full suite of business process maps produced by the CCG and CSU provide examples of service specifications for service delivery and assurance and procurement. More detail about what products each of the above Service headings includes is detailed below:


It can be seen from the above that in some cases the CSU will act as a gateway (or a conduit) to services on a bigger scale if appropriate. The joint approach is to design and deliver services at scale if this can support effective delivery and drive efficiencies. Transition dates and staffing model There is a considerable degree of organisational change taking place across North Yorkshire and the Humber, with PCTs planning their close down strategies for March 2013 and the creation of CCGs, CSUs and the Local Area Team. There has been an extensive on-going HR process to support the degree of change and the CSU has recently appointed to approximately 90% of its structure. The CCG is in a position to commence the new working arrangements with the CSU from the 1 October 2012. The staffing models agreed with the CSU have been designed to ensure, where appropriate, staff employed by the CSU will be embedded within the CCG. The design principles for the delivery model of the CSU are outlined below. Hub and Spoke Model The CSU will, in the short term, have two fixed bases (hubs) at York and Willerby with a local presence within the CCG (spokes), to meet the specific needs and particular ways of working in the CCG. Embedded Resources The CSU is providing the CCG with embedded resources to support on-going CCG activity and management. Under this model, pay, rations and professional support come from the central CSU. Embedded staff (for example in commissioning intelligence analysts, some communications and engagement staff, medicines management staff) are being line managed by the CSU but ‘managed’ day to day by individual CCGs. There is protected time for the CSU embedded staff to share best practice as a CSU team from which the CCG will benefit.


The model includes other staff (such as IT Support) that are named individuals who may be located with the CCG for several days/ week but managed day to day by the CSU. The Central CSU team (Hub) which performs services once on behalf of multiple customers (such as procurement), or provides the same service to all customers using an identical process. The process maps referred to provide further clarity about how these arrangements will work operationally, providing detail of clarity about roles and responsibilities. Public Health Support The CCG is actively engaged with the current PCT Public Health team, including co-opting a Consultant in Public Health Medicine on the CCG Governing Body. As demonstrated within the actions and objectives identified above, and described within the accompanying case studies, the CCG is enthusiastically engaged with public health partners to improve health outcomes and to bring the health of the CCG population closer to that of the overall North Yorkshire average, thereby reducing the evident health inequalities demonstrated in the JSNA (see Appendix 1). To formally secure on-going support and engagement the CCG and the NHS north Yorkshire and York Public Health team have developed an agreed ‘Public Health Offer’ detailing the services provided to the CCG. This is included as Appendix 6. Procurement The CCG will commission a Procurement Service for specialist support and advice on the procurement process for clinical or a business support functions. This initially will be provided by the CSU. Dependent on the function to be procured the CCG has specific posts identified to administer a full procurement exercise. The Board will nominate a board member to be the procurement sponsor and the Programme Co-ordinator in conjunction with subject matter experts from Service Improvement, Finance and Contracting will carry out the procurement. Other input such as Legal and Communications initially will be provided by the Commissioning Support unit. However, if this causes a potential conflict of interests in the procurement the CCG will source expertise from outside agencies.

13. Governance and Assurance SRCCG has developed a strong assurance framework, supported and delivered by its organisational structures and corporate leadership. The Seven Principles of Public Life (often referred to as the ‘Nolan Principles’) underpin the objectives and behaviour of the CCG. They are:

• Selflessness Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends.


• Integrity Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties.

• Objectivity In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit.

• Accountability Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.

• Openness Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands it.

• Honesty Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.

• Leadership Holders of public office should promote and support these principles by leadership and example.

The CCG has established appropriate policies to support its good governance including producing and publishing a conflicts of interest register as part of a corporate conflicts of interest policy. The Board Assurance Framework has been developed to provide assurance to the Governing Body that the CCG strategic objectives are being delivered and corporate risks managed. The outline assurance framework is provided as a supporting document, along with the latest version of the corporate risk register.

14. Stakeholder engagement and Patient Choice The CCG has developed a strong process for engagement of all major stakeholders. This has been led by the Governing Body’s Communication and Engagement Committee (CEC), which has produced an ambitious Communications and Engagement Strategy (provided as a supporting document). This strategy sets out plans for enhancing the way the CCG communicates and engages with patients, the public and wider stakeholders, describing the methods that will be used and the evaluation of its relative success. The CCG is actively supporting patient choice. This includes engagement with GP practices to maximise the effective use of the Choose and Book system. As part of its approach to procurement the CCG is working with NHS NYY to develop Any Qualified Provider (AQP) services in: Non-Obstetric Ultrasound; Wheelchair services; and Podiatry. AQP will be seen as a useful tool to support effective service commissioning and promote patient choice.


15. Financial Plan Financial Framework Scarborough & Ryedale Clinical Commissioning Group (CCG) are seeking authorisation to become an NHS body and become operational from 1 April 2013. The CCG is currently operating in shadow form and whilst the financial strategy specifically relates to the CCG some elements are derived from a disaggregation of the NHS North Yorkshire and York (NHSNYY) financial plan. Most importantly NHS NYY operates within a very challenging financial environment and for 2012/13 has submitted a deficit plan of £19m. The CCG strategy assumes a proportionate amount of that deficit will transfer over to the CCG in 13/14. Due to the challenging financial position of NHSNYY not only does the CCG face the prospect of commencing operations with a requirement to repay a proportion of inherited deficit it also needs to ensure there is sufficient focus on the underlying recurrent position (run rate position). The transformation the CCG aims to achieve will require a shift of resources across the health system; the challenge will be to do this at scale, without significant resources to pump prime initiatives. The overarching vision of the CCG is to take a whole system approach with significant partnership working with all Local authorities within its boundaries and a collaborative approach with its main acute and community provider York Teaching Hospitals NHS Foundation Trust. Details of CCG level allocations are not expected until autumn 2012 so planning assumptions are currently based on a disaggregation of NHS NYY allocations. Financial analysis is derived from the national data collection baseline exercise, which considered NHSNYY financial accounts outturn for 2011/12 and financial plan for 2012/13. As at the date of publication NHSNYY has not delegated running costs budgets and so assumptions are based on the national running cost maximum expenditure allowance. There will be amendments to the financial data collection in relation to specialist commissioning although the planning assumption is any budgetary or allocation change would be matched with an expenditure change. As such this financial strategy should be seen as an evolving document and will require periodic updates as clarity on the operation, funding and responsibilities within the new NHS architecture is confirmed. It is anticipated a formal review will be conducted once CCG allocations are notified and once the NCB publishes its Charter for 2013/14. Medium term financial plan 2012/13 – 2015/16 SR CCG has developed its outline strategic plan, based on a range of scenarios, it is important to emphasise that the significant financial risk in the local health system means any variance from plan in 12/13 has a material impact on the whole strategic programme. There are three scenarios presented here. • The base case is a CCG level plan derived from the PCT 12/13 plan of a £19m deficit, this plan assumes full delivery of all QIPP schemes and no contract budget overspends. The planning assumption for the SRCG is that a proportion of this deficit will become chargeable against the 2013/14 allocation (£2.196m)


• A revised scenario details the impact of a £752k budgetary overspend (this is over and above the CCG’s share of the planned £19m deficit), this is based on month 4 SR dashboard information and assumes the required actions to bring spend back in line are undelivered.

• A revised scenario based on a £3m budgetary overspend, this is based on provider predictions of activity and expenditure growth throughout the remained of 2012/13

The three scenarios are summarised in the table 1 to 3 below and more detailed is provided in Appendix 9. The initial planning assumption (base case) shows a return to balance in 2014/15.

Table 1 Base Case, achievement of 2012/13 plan including share of £19m PCT deficit

Table 2 Assumed £752k in year overspend (in addition to share of £19m deficit)

Table 1Rec NR Total Rec NR Total Rec NR Total Rec NR Total

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Anticipated Resources Available 139,630 2,770 142,400 143,540 2,770 146,310 144,975 2,770 147,745 146,425 2,770 149,195

Anticipated Expenditure -153,169 456 -152,714 -151,682 167 -151,515 -150,904 833 -150,071 -150,914 0 -150,914

Surplus/(deficit) -13,539 3,226 -10,313 -8,142 2,937 -5,205 -5,929 3,603 -2,326 -4,489 2,770 -1,719

Planned efficiencies 8,117 0 8,117 7,692 0 7,692 6,952 0 6,952 6,969 0 6,969

-5,422 3,226 -2,196 -450 2,937 2,487 1,023 3,603 4,626 2,480 2,770 5,251

Contingeny 0 -500 -500 0 -1,440 -1,440 0 -1,440 -1,440Defict repayment 0 -2,196 -2,196 0 -209 -209 0 2,977 2,977

-5,422 3,226 -2,196 -450 241 -209 1,023 1,955 2,977 2,480 4,308 6,789

2015/16

Surplus/(deficit)

Surplus/(deficit)

2012/13 2013/14 2014/15


£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000



Surplus/(deficit) -14,291 3,226 -11,065 -8,934 2,937 -5,997 -6,733 3,603 -3,130 -5,202 2,770 -2,432


-6,174 3,226 -2,948 -1,212 2,937 1,726 265 3,603 3,868 1,751 2,770 4,521

Contingeny 0 -500 -500 0 -1,448 -1,448 0 -1,447 -1,447Defict repayment 0 -2,948 -2,948 0 -1,723 -1,723 0 698 698

-6,174 3,226 -2,948 -1,212 -511 -1,723 265 433 698 1,751 2,021 3,772

2015/16

Surplus/(deficit)

Surplus/(deficit)

2012/13 2013/14 2014/15


Table 3 Assumed £3m in year overspend (in addition to share of £19m deficit)

Financial Planning Assumptions The financial parameters included within this document build on the principles set out in the 12/13 Operating Framework, and supporting documents such as Payment by Results guidance. The following assumptions have been made • Allocation uplift at PCT level for 2012/13 was 2.8% this is assumed to continue until

2013/14, the forward projection from 2014/15 has been assumed at 1%

• The CCG control total for 2012/13 will be a deficit of £2.196m, this is a % apportionment of the NHSNYY deficit plan of £19m

• The plan is structured to fulfil the requirement to create recurrent headroom of 2% which can only be utilised on a non-recurrent basis.

• Inflation on tariff and non-tariff is 2.5% and continues at this level for the duration of the plan

• Efficiency on tariff and non-tariff is -4.3% in 2012/13, and assumed to be -4.0% in each future year. The net impact on the tariff and non-tariff from 2013/14 onwards is therefore -1.5%

• The assumptions on tariff inflation and efficiency will be reset annually upon publication of the national tariff guidance.

• Payments for non-elective activity will continue at 30% marginal tariff rate for the duration of the plan, similarly any QIPP reductions related to non-elective activity would also be at 30% marginal rate unless activity returns to a level below the 2008/09 threshold

• The financial impact of non-payment for readmissions has been built into the plan although the clinical audit to review the baseline is underway


£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000



Surplus/(deficit) -16,539 3,226 -13,313 -11,301 2,937 -8,364 -9,135 3,603 -5,532 -7,595 2,770 -4,824


-8,422 3,226 -5,196 -3,489 2,937 -552 -2,001 3,603 1,603 -504 2,770 2,266

Contingeny 0 -500 -500 0 -1,470 -1,470 0 -1,470 -1,470Defict repayment 0 -5,196 -5,196 0 -6,248 -6,248 0 -6,116 -6,116

-8,422 3,226 -5,196 -3,489 -2,759 -6,248 -2,001 -4,115 -6,116 -504 -4,815 -5,320

2015/16

Surplus/(deficit)

Surplus/(deficit)

2012/13 2013/14 2014/15


• The locally negotiated financial envelope for CQUINS payments of 1.5% is only assumed for 2012/13, the plan reverts to an assumption of 2.5% from 2013/14 onwards

• Additional health and social care funding for re-ablement is excluded from this financial plan as resources have transferred to the Local Authority, they will however be referenced in the overall strategy as a key enabler to the redesign of the local health and social care system.

• The assumption for prescribing is that inflationary increases are offset by efficiencies and therefore no uplift in prescribing expenditure is planned for until 2014/15 at which point a 1% increase is assumed.

• At this stage in the planning process there is no assumed investment in strategic developments, and service redesign or QIPP schemes are based on in year pay back and the QIPP plan should be net of any required investment. A strategic review is underway across the wider health economy and decisions on investment will be made in line with the published strategy.

• Demographic growth is assumed to be 2.8% in 2013/14 then increases to 3% from 2014/15 onwards.

• The assumed level of QIPP is 2.54% in 12/13, 2.17% in 13/14 and 2% thereafter.

• Specialist commissioning figures submitted as part of the national baseline exercise are subject to change. As at the point of publication no notified changes have been made.

• As at the date of publication no corporate or running cost budgets have been delegated from the PCT cluster, the planning assumption is that budget delegation will match running cost assumptions as detailed in that section.

System Wide External Review Two of the three scenarios modelled above in the medium term financial plan show that the CCG would not achieve its statutory break even duty until 2014-15 or longer if further corrective action is not taken, This is not a new financial challenge that faces the local heath economy and the former PCT has received in the region of £100m of financial support up to the end of 2011/12. For 2012/13 the PCT will receive no external support and has submitted a deficit plan. The implications for the SR CCG is a brought forward deficit of £2.2m but with a higher underlying recurrent expenditure figure in the region of £5.4m In order to address the financial challenges the whole system faces an external review has been commissioned and is due to issue its findings at the end of October 2012. No assumptions have been made within this plan of those findings, other than further significant actions will be identified to deliver radical service reconfiguration options that deliver the system wide change required.


All key stakeholders with the health economy have committed to the review including the three acute and community providers within the North Yorkshire Patch, one of which; York Teaching Hospitals Foundation Trust, is the major service provider for Scarborough & Ryedale. Once the North Yorkshire wide review is published and key stakeholders commit to the implementation programme this plan will be revised to take into account those additional savings. Financial collaboration and risk sharing NHS North Yorkshire and York has existed in its current geographical structure since 2005/06, prior to that date there were 4 PCTs covering North Yorkshire, at that time there was a strong collaborative working model which has continued through a locality model, although not identical to the proposed CCG’s configurations there is a strong commitment across the health economy to maintain this collaboration, there are three key strands to this:

• Functions run at a North Yorkshire Level where there is an intention to continue through commissioning support services, for example continuing care, commissioning for vulnerable people, non-contract activity.

• The contract for the CCG’s main provider will be hosted by a neighbouring CCG, this is due to the merger of its main provider with York FT. As an associate it will retain a strong local focus via the shared Finance and Contracting team and the operation of a sub-committee of the formal CMB which covers all aspects of Finance, Quality, Performance and in particular service development changes/issues in light of the merger.

• There will be North Yorkshire “host” contract arrangements where one CCG will lead on negotiation, in year performance and contract management, for SR this will include Leeds Teaching Hospitals NHS Trust (LTHT), Hull and East Yorkshire Hospitals (HEY) and Tees and Esk Wear Valley Foundation Trust (TEWV).

• Financial risk sharing, this is proposed to cover three areas, continuing health care, funded nursing care, high cost patients. All four North Yorkshire CCGs will pool resources to share the risks and benefits of these areas, liaising with the associated CCG of NHS Airedale, Wharfedale and Craven.

Due to the challenging financial position across the whole of North Yorkshire a strategic review is currently underway, where it is beneficial both financially and strategically to collaborate, Scarborough & Ryedale CCG will do so. Run rate An important aspect of the financial plan for SR is the analysis of run rate expenditure. NHS North Yorkshire and York has had historical financial problems and in 12/13 submitted a deficit plan. It is important the CCG fully understand the recurrent


underlying rate of spend to ensure it is on a trajectory of improving the position and not heading further into deficit. It is essential that there is a forensic understanding of commissioning decisions, QIPP schemes and efficiency proposals and that these are all mapped to a monthly run rate analysis. This will be routinely monitored by the governing body 2012/13 onwards. Where does the money go? The table below: details where the CCG expends its resources. The majority of resource is expended with York Teaching Hospitals NHS Foundation Trust, following the acquisition of Scarborough and North East Yorkshire, accounting for 48% of expenditure. Table 4 where does the money go

Running costs The NHS Commissioning Board has set a running cost allowance for each CGG based on registered population adjusted to ONS clusters. For SR this is £2.914m which equates to £24.70 per head of population (unadjusted). This is in line with expectations and the initial management structure ensures the CCG will operate within its running cost total. Throughout the remainder of 2012/13 the CCG will work closely with the PCT cluster to develop its understanding of non-pay expenditure and conclude the business case for HQ location. A significant number of support functions will be provided by the North Yorkshire and Humber commissioning support unit.

12/13£000 %

Commissioned ServicesScarborough & North East Yorkshire NHS Trust 53,769,859.0 37.2%Tees Esk & Wear Valley MH 12,167,022.0 8.4%York Hospitals Foundation Trust (Acute services) 9,452,391.0 6.5%York Hospitals Foundation Trust (Community Services) 6,131,531.0 4.2%Harrogate District Foundation Trust (Community services 3,611,198.0 2.5%Hull & East Yorkshire NHS Trust 5,301,244.0 3.7%Yorkshire Ambulance Service 5,153,990.0 3.6%Leeds Teaching Hospital Trust 2,464,582.0 1.7%South Tees Foundation Trust 882,999.0 0.6%Ramsey Hospital - Clifton Park York 798,278.0 0.6%Total Major NHS Contracts above £1m 99,733,094.0

Other NHS Contracts below £1m. 1,124,406.0 0.8%NHS Non Contract Activity 1,960,140.0 1.4%Private Providers contracts below £1m 499,078.0 0.3%Other NHS Commissioning 2,127,935.0 1.5%

Total NHS contracts 105,444,653.0 72.9%

Partnerships 1,227,625.0 0.8%Hospice payments 744,304.0 0.5%Pooled Budgets 2,570,445.0 1.8%Continuing Care 13,355,101.0 9.2%Funded Nursing Care 2,367,775.0 1.6%

Total Non NHS Contracts 20,265,250.0 14.0%

Total Commissioned Services 125,709,903.0 86.9%

Primary CarePrescribing 18,886,811.0 13.1%

Total Primary Care 18,886,811.0 13.1%

Total Commissioned & Corporate Services 144,596,714.0 100.0%

deficit -2,196,343.0


The financial resource framework required to support CSU functions has been developed and provides the required functions within an affordable financial envelope. This will support the development of the CSU Service Level Agreement and a sustainable arrangement between the CCG and CSU. Table 5 Structure Costs (Pay and Non Pay) Running Costs £000’s Board of Governors £387 Clinical Engagement £238 Management Costs £538 Non pay (including CSU) £1,751 Total £2,914 Population 118,000 Running Cost per Head £24.70 National Running Cost Target £2,914 National Running Cost Per Head Target £24.70 (Note: the CSU costs above include staffing and non-pay costs incurred by the CSU but are treated as contracted services within the overall non-pay line) Practice Level information Up to 2010/11 the PCT utilised the DH fair shares toolkit to calculate practice level budgets as part of the practice based commissioning initiative. Once the CCG is established as a statutory NHS body it will be provided with an allocation, PCT level data collection exercises have been conducted in September 2011 and July 2012 to ensure the DH has sufficient information to map expenditure from the current NHS architecture to the new system which incorporates CCGs. In addition a revised allocation formula will be put in place. This will notify the CCG of its Actual allocation and an assessment will be made of its distance from a fair shares allocation. It is also anticipated that a policy on how CCGs may move to a fair shares allocation will be published. In a period of flat growth where uplifts to the overall NHS allocation are only intended to cover inflationary increases any movement towards fair shares will be small, as such the CCG should not anticipate any significant movement from the overall PCT allocation for 12/13, once it has been disaggregated. Once the overall CCG allocation is known the intention will be to refresh practice level budgets and ensure there is a consistent process for continuing the movement towards fair share practice level budgets. Cash CCGs will operate in a similar cash regime to PCTs. There will be an annual cash limit within which the CCG must remain. As part of the closedown of the PCT a greater understanding of the anticipated year end position will be sought, as with any business there is a time lag between service delivery and payment for those services, the CCG must ensure sufficient cash is available to meet those year-end obligations inherited from the PCT. Once the CCG is fully functioning in 2013/14 it will be responsible for the direct payment to providers for services. As the vast majority of CCG business is covered by


the standard NHS contract 74% of all cash expenditure will flow in equal 12ths. In addition almost 13% is to cover prescribing spend, this means that each month 87% of the CCG cash flow is known. In year adjustments would have to be made for contractual under/overtrades. Financial governance As part of its establishment the CCG is considering its requirement to establish robust financial and corporate governance arrangements, there are several key policy and procedure documents that the CCG will adopt prior to establishment, the key ones being:

• Constitution • Standing Orders and Standing Financial instructions • Prime financial procedure documents • Scheme of Delegation In addition the CCG will be using the SBS ledger system to ensure its obligations for accounting for public funding can be met, a scheme of delegation for authorisation of all expenditure will be embedded within the system. Committees of the board will be in place to seek assurance that the organisational governance is sound and assurance can be placed on the mechanisms in place, this will be done predominantly through the audit and governance committees.

QIPP The SR CCG QIPP scheme for 12/13 is £3.684m. A summary of the schemes are provided below, there will be a mix of new schemes and full year effect of schemes that commenced in 11/12. As 12/13 is the base year for the financial strategy it is essential all schemes are fully delivered. Table 6 Strategic QIPP plan

Summary Scheme

2012-13

2013-14

2014-15

2015-16

£000 £000 £000 £000 Outpatients £1,070 £1,410 £1,175 £100 Planned Care £260 £145 £50 £0 Unplanned Care £924 £990 £860 £350 Medicines Management £692 £600 £150 £100 Other £738 £0 £649 £2,329

Total £3,684 £3,145 £2,884 £2,879 In order to deliver the financial strategy detailed in table 1, QIPP schemes which are 2% of expenditure will be required from 13/14 onwards; these are in addition to any national provider efficiency requirements set in the operating framework and PBR tariff guidance. The medium term QIPP schemes are tabled above. The detailed schemes


are a continuation of schemes already commenced. There is still some required but unidentified QIPP at this point. Capital Once established it is not anticipated the CCG will have any significant assets, buildings within the locality are in the process of transferring to Foundation Trusts or NHS Property Company, The majority of IM&T infrastructure relates to those buildings or is to support primary care so is assumed not to be on the CCG balance sheet. Future capital may be required as part of the system redesign aspirations, however it is assumed that the CCG will work with the NHS and other partners to secure any necessary capital. At this stage the CCG does not anticipate that it will have a baseline capital allocation.

16. Equality The CCG has undertaken a baseline assessment against the national Equality Delivery System for the NHS. This has helped demonstrate initial progress on equality and diversity and will help us achieve compliance with the Public Sector Equality Duty/Equality Impact Analysis. In support of this the CCG has developed an Equality Assessment Toolkit and as part of its wider programme of engagement and consultation will perform a full equality impact assessment on the strategy and its major objectives and actions. Equality Impact Assessment will be undertaken to ensure proposals are considered and developed appropriately as part of the implementation process.


17. Summary

The integrated plan described above provides the basis for SRCCG’s development. It reflects the assessment of health needs contained within the JSNA, is consistent with the strategic aims of the Health and Wellbeing Strategy, and is driven by local clinical leadership. The planned aims are ambitious but are considered deliverable and an effective means to support effective, high-quality health commissioning for the CCG’s population. ‘Plan on a Page’


Appendix 1 Scarborough and Ryedale CCG Joint Strategic Needs Assessment

This geographical summary should be read in conjunction with the North Yorkshire summary as needs identified in the North Yorkshire section are applicable to all districts and CCGs.

Population

The map below shows the geographical boundaries (constrained to North Yorkshire County boundaries) for the Clinical Commissioning Groups.

Scarborough and Ryedale CCG comprises 17 General Practices with a combined registered population of 117,516, the vast majority of whom (74%) live in Scarborough district with a significant amount also living in Ryedale (25%).

Source: Exceter September 1

Deprevation Scarborough and Ryedale CCG has a large proportion (53.1%) of its registered population resident in the most deprived areas of North Yorkshire County.

Based on the overall IMD score, the map below shows the most and least deprived areas within Scarborough and Ryedale CCG (i.e. the most deprived fifth of the population within the CCG, through to the least deprived)

Outcomes Also see Scarborough and Ryedale District summaries for further detail on outcomes All age all cause mortality (AAACM) is a measure of the overall health of a population over a given period. Between 2004-06 and 2008-10 the AAACM rate fell from 592 per 100,000 to 514 per 100,000 in practices in Scarborough CCG, statistically significantly higher than the North Yorkshire average of 464123

Circulatory diseases are the leading cause of death amongst those registered with Scarborough CCG accounting for 40% of all deaths.

Between 2004-06 and 2008-10 the premature death rate (aged <75 years) fell from 296 per 100,000 to 243 per 100,000 in Scarborough and Ryedale CCG, statistically significantly higher than the North Yorkshire average of 210124

The leading cause of death for those dying prematurely (<75 years) in Scarborough and Ryedale CCG is Cancer, accounting for 38% of all deaths.

When comparing the life expectancy of the most deprived members of the community to the least deprived there is a clear inequality. Men who live in Scarborough CCG’s most deprived communities will die, on average 8.0 years earlier than their least deprived counterparts. Similarly, women in the most deprived communities in Scarborough CCG will die, on average 6.2 years earlier than those in the least deprived communities. Between 2001-05 and 2006-10, the Slope Index of Inequalities (SII) for males decreased from 9.7 years to 8.0 years. For females, the SII increased from 6.0 years to 6.2 years. However, these figures should be interpreted bearing in mind the wide confidence intervals around the SII. Community Health Profiles

The Department of Health commissioned the Network of Public Health Observatories to publish Community Health Profiles on an annual basis for each local authority in England. Although they are not published at CCG level, the district level health summaries that appeared in the 2011 profiles can be found in

the district summaries, outlining how the health of people in the districts compares with the rest of England. The 2012 profiles will be published in summer 2012 at http://www.apho.org.uk/default.aspx?RID=49802.

Scarborough and Ryedale CCG Big Issues

The issues received from people and organisations based in the Scarborough CCG area were overall similar to those received from other areas of the county. Issues from the Ryedale district part of the CCG area tended to have slightly more emphasis around transport, access to local services and other issues connected with rurality than from the less rural part laying within Scarborough district.

Issues that were mentioned during the JSNA events held in the Ryedale and Scarborough districts during December 2011 were fairly typical of other areas. All the issues raised during the Ryedale event covered topics also mentioned at one or more of the events held in other districts across the county. Although some of the issues that were mentioned during the JSNA Scarborough district event were typical of other areas, the total number of issues raised was higher than at most of the other events and several issues were uniquely raised that were not mentioned at any of the other events across the county.

Issues mentioned during discussion at the Ryedale and Scarborough district JSNA events Issues Event Access to services – transport, availability, location Ryedale Access to information, and in appropriate format Ryedale Care v reablement Ryedale Drugs & alcohol – culture change Ryedale Education about nutrition and other healthy lifestyle issues

Ryedale

Implications of an ageing population Ryedale Joined-up working Ryedale Social Isolation - cannot all be done by the community, Integrated solutions

Ryedale

What is already available locally? Ryedale Accommodation and housing – link to mental health.

Avoiding ghettos

Only mentioned at the Scarborough event

Advocacy Only mentioned at the Scarborough event Affordable childcare Only mentioned at the Scarborough event Alcohol – availability, changing attitudes and

behaviour

Scarborough district

Avoid duplication of services Only mentioned at the Scarborough event Education – information – lifetime investment Scarborough district Effective support for family carers Scarborough district Equal access to services (especially interpreters in

health services)

Only mentioned at the Scarborough event

Family support isn't always there Scarborough district Isolation (particularly older population) Scarborough district Mental wellbeing – responding earlier Scarborough district

http://www.apho.org.uk/default.aspx?RID=49802

Need doors opening to access community assets Only mentioned at the Scarborough event No short term funding – look to the future Only mentioned at the Scarborough event Obesogenic environment Only mentioned at the Scarborough event Simplification of assessment process (especially

social care)

Scarborough district

Stop Consultancy Only mentioned at the Scarborough event Supporting communities to be more supportive Scarborough district

Issues identified for Scarborough and Ryedale CCG

In addition to the needs identified across North Yorkshire, the following issues have been highlighted specifically in this locality. They have been described by Marmot Domain: A Give every child the best start in life Scarborough District has almost double the percentage of children in poverty as the rest of North Yorkshire (21%)

B Enable all children, young people and adults to maximise their

capabilities and have control over their lives • Lower educational attainment on most indicators compared to the rest of North

Yorkshire and England.

• Falsgrave Park, Ramshill, Castle, Central and North Bay wards had a significantly higher rate of teenage pregnancy than the national average.

C Create fair employment and good work for all • Higher unemployment rate in Scarborough compared to North Yorkshire and England.

D Ensure a healthy standard of living for all • Higher rate of households in fuel poverty in Scarborough (26.3%) and Ryedale (28.2%)

compared to England (18.4%). E Create and develop healthy and sustainable places and communities • Scarborough District has the highest and Ryedale District the lowest crime levels in

North Yorkshire.

• Ryedale has a house price to earnings ratio in the worst quartile for affordability compared to England.

• Scarborough had the highest incidence of overcrowded housing at 4.95% of

households, substantially higher than any other North Yorkshire district but lower than the national average of 7.13% for England.

F Strengthen the role of ill-health prevention • Recorded crime attributable to alcohol in Scarborough District is the highest (7.1 per

1000 population) in North Yorkshire.

• There is a need to develop a Falls Service in Scarborough/Whitby /Ryedale.

• For reception children, obesity prevalence was second highest in Scarborough

(8.0%).

• For year 6 children, obesity prevalence was highest in Scarborough (17.8%) and Ryedale (17.7%).

• Eastfield and Seamer fall into the bottom national quartile for expected levels of participation in at least 3 days x 30 minutes, moderate intensity adult physical activity.

• Children’s participation in sport and physical activity is significantly lower than the

England average in Ryedale District.

• Higher levels of Chlamydia screening in Scarborough District compared to North Yorkshire.

• Scarborough has the highest rates of smoking in North Yorkshire.

• Over the last five years, the percentage of mothers who were smokers giving

birth at Scarborough was consistently significantly higher than the national average. During 2010/11 at Scarborough, 19.5% (almost 2 in every 10 mothers) were recorded as being a smoker at the time of delivery.

• During 2009/10, all districts within North Yorkshire had smoking attributable

hospital admission rates per 100,000 population that were significantly lower than the national average, with the exception of Scarborough, which was significantly higher.

G Maximise the effectiveness of condition or treatment pathways

(additional domain) • Scarborough and Ryedale Districts had Coronary Heart Disease

mortality rates significantly higher than the national average.

• The % of people with diabetes who have an HbA1c <7 was 2nd lowest in Scarborough and

Ryedale CCG across North Yorkshire.

• Scarborough is in the 2nd bottom quintile nationally for dying in place or usual residence

(i.e. below average).

• 24/7 community nursing service in Scarborough Area needs developing for end of life care.

• Blood pressure control for people with hypertension is lower in Scarborough and Ryedale CCG than other areas in North Yorkshire.

• Scarborough District had rates significantly higher mortality rates from stroke than the national average.

Population Groups

Carers

• Scarborough District has the highest rate of claimants for carer’s allowance in North

Yorkshire at 1.00% of the population, higher than the England average. Homeless

• The number of homelessness acceptances per 1000 households in North Yorkshire is

2nd highest in Scarborough (3.00 per 1000). Older People

• The number of people in Ryedale District aged 65 and over is set to increase from

12,300 to around 15,800 by 2021.

• The number of people in Scarborough District aged 65 and over is set to increase from

25,500 to around 31,300 by 2021.

Appendix 2 – GP Practice Populations

Practice Code

Practice Name CCG Code

CCG Name (NHS "name" CCG)

Practice Patient Population (1/7/2012)

1 B82001 Dr D A Oldroyd & Partners 03M Scarborough and Ryedale 10,5312 B82011 Dr D R Carrie & Partners 03M Scarborough and Ryedale 4,9063 B82024 Eastfield Medical Centre 03M Scarborough and Ryedale 7,6294 B82025 Derwent Practice 03M Scarborough and Ryedale 19,5785 B82037 Filey Surgery 03M Scarborough and Ryedale 8,7356 B82038 Prospect Road Surgery 03M Scarborough and Ryedale 7,8227 B82054 Scarborough Medical Group 03M Scarborough and Ryedale 12,1808 B82056 Claremont Surgery 03M Scarborough and Ryedale 5,7769 B82058 Norwood House Surgery 03M Scarborough and Ryedale 6,701

10 B82063 Dr P J Robinson & Partners 03M Scarborough and Ryedale 7,84411 B82088 Trafalgar Medical Practice 03M Scarborough and Ryedale 5,08112 B82092 Belgrave Surgery 03M Scarborough and Ryedale 4,18413 B82106 Hackness Road Surgery 03M Scarborough and Ryedale 3,28914 B82609 Ampleforth Surgery 03M Scarborough and Ryedale 3,90615 B82611 Peasholm Surgery 03M Scarborough and Ryedale 4,02116 YO2669 Castle Health Centre 03M Scarborough and Ryedale 1,84617 B82628 Dr M D Meeson & Partners 03M Scarborough and Ryedale 4,057

TOTAL 118,086

Practice Codes - NHS Yorks and the Humber - July 2012

Appendix 3 Activity Forecasts The basis of the activity forecast is the Office Of National Statistics (ONS) population forecasts for the CCG areas (Subnational Population Projections, 2010-based projections)

Scarborough Borough

Ryedale District

DataAGE GROUP 2011 2012 % 2012 2013 % 2013 2014 % 2014 2015 % 2015 0-4 5.5 0.0% 5.5 0.0% 5.5 0.0% 5.5 3.6% 5.75-9 5.2 1.9% 5.3 0.0% 5.3 1.9% 5.4 1.9% 5.510-14 5.5 -1.8% 5.4 -3.7% 5.2 1.9% 5.3 0.0% 5.315-19 6.4 -3.1% 6.2 -1.6% 6.1 -4.9% 5.8 0.0% 5.820-24 6.6 0.0% 6.6 -1.5% 6.5 -1.5% 6.4 -3.1% 6.225-29 5.2 3.8% 5.4 3.7% 5.6 1.8% 5.7 0.0% 5.730-34 4.4 2.3% 4.5 0.0% 4.5 4.4% 4.7 4.3% 4.935-39 5.4 -7.4% 5.0 -6.0% 4.7 0.0% 4.7 -2.1% 4.640-44 6.7 -1.5% 6.6 -4.5% 6.3 -3.2% 6.1 -3.3% 5.945-49 7.9 -1.3% 7.8 -2.6% 7.6 -2.6% 7.4 -4.1% 7.150-54 7.7 2.6% 7.9 1.3% 8.0 0.0% 8.0 0.0% 8.055-59 7.3 -1.4% 7.2 2.8% 7.4 2.7% 7.6 2.6% 7.860-64 8.7 -6.9% 8.1 -3.7% 7.8 -2.6% 7.6 -2.6% 7.465-69 7.4 9.5% 8.1 3.7% 8.4 2.4% 8.6 0.0% 8.670-74 6.0 0.0% 6.0 1.7% 6.1 3.3% 6.3 3.2% 6.575-79 4.8 0.0% 4.8 4.2% 5.0 4.0% 5.2 0.0% 5.280-84 3.7 -2.7% 3.6 0.0% 3.6 0.0% 3.6 2.8% 3.785-89 2.3 0.0% 2.3 4.3% 2.4 0.0% 2.4 0.0% 2.490+ 1.4 0.0% 1.4 0.0% 1.4 7.1% 1.5 6.7% 1.6Grand Total 108.1 -0.4% 107.7 -0.3% 107.4 0.4% 107.8 0.1% 107.9

DataAGE GROUP 2011 2012 % 2012 2013 % 2013 2014 % 2014 2015 % 2015 0-4 2.4 0.0% 2.4 4.2% 2.5 0.0% 2.5 0.0% 2.55-9 2.5 4.0% 2.6 0.0% 2.6 0.0% 2.6 0.0% 2.610-14 3.0 -3.3% 2.9 0.0% 2.9 -6.9% 2.7 3.7% 2.815-19 3.7 -2.7% 3.6 -5.6% 3.4 -2.9% 3.3 -6.1% 3.120-24 2.2 0.0% 2.2 0.0% 2.2 0.0% 2.2 0.0% 2.225-29 2.0 0.0% 2.0 10.0% 2.2 0.0% 2.2 9.1% 2.430-34 2.2 0.0% 2.2 -4.5% 2.1 4.8% 2.2 0.0% 2.235-39 2.8 -7.1% 2.6 -3.8% 2.5 -4.0% 2.4 0.0% 2.440-44 3.7 -2.7% 3.6 -2.8% 3.5 -2.9% 3.4 -5.9% 3.245-49 4.1 2.4% 4.2 -2.4% 4.1 -2.4% 4.0 -2.5% 3.950-54 3.9 2.6% 4.0 5.0% 4.2 0.0% 4.2 2.4% 4.355-59 3.9 0.0% 3.9 0.0% 3.9 0.0% 3.9 2.6% 4.060-64 4.4 -4.5% 4.2 -4.8% 4.0 0.0% 4.0 0.0% 4.065-69 3.8 5.3% 4.0 5.0% 4.2 2.4% 4.3 0.0% 4.370-74 2.9 0.0% 2.9 6.9% 3.1 3.2% 3.2 3.1% 3.375-79 2.2 9.1% 2.4 0.0% 2.4 0.0% 2.4 0.0% 2.480-84 1.8 0.0% 1.8 0.0% 1.8 0.0% 1.8 0.0% 1.885-89 1.0 0.0% 1.0 0.0% 1.0 10.0% 1.1 9.1% 1.290+ 0.6 0.0% 0.6 16.7% 0.7 0.0% 0.7 0.0% 0.7Grand Total 53.1 0.0% 53.1 0.4% 53.3 -0.4% 53.1 0.4% 53.3

From the ONS data the CCG has calculated based on recent historic activity the estimated activity by speciality and by major admission type. The tables show the top ten specialities for outpatient activity and the top fifteen for inpatient activity. Outpatient Activity

Inpatient Activity

Appendix 4 Draft Commissioning Intentions 2013-14 Derived from the strategic plan described in the main document the commissioning intentions for 2013-14 are a continuation of the strategy in to the next financial year and strategic objectives of the CCG. The intentions reflect the CCG’s plan to commission high-quality, sustainable services, addressing health priorities and targeting health needs, within the available financial resources. The commissioning intentions are driven by the assessment of health need and therefore, are consistent with the conclusions from the Joint Strategic Needs Assessment and are provided as the CCG’s mechanism for delivering the locality element of the North Yorkshire Health and Wellbeing Strategy. The success of the intentions will be measured against delivery of the targets contained within the domains of the NHS Outcomes Framework. The intentions can be grouped into:

• QIPP - Delivering financially sustainable services • Acute Care redesign - Improving service delivery and quality • Community care - Shifting care closer to home • Primary care - The healthcare hub of patient management • Emergency care - Redesigning care pathways • Health Priority Areas - Cancer; Mental Health;

Cardiovascular care; Elderly care.

QIPP Managing referral demand through reducing unnecessary variation Reducing unnecessary outpatient follow-up appointments to bring the overall first to follow-up ratio to 1:1.9 Implementing the Clinical Thresholds and Better Care Better Value indicators as described in the CCG clinical thresholds policy Implanting model pathways for the long-term conditions of diabetes, COPD, and Heart Failure (reducing, adjusted for demographic growth, the number of readmissions in the three conditions) Rapid Geriatric assessment complex elderly patients, increasing by 10% patients treated as less than 24 hour hospital stays (thereby reducing the volume of commissioned long-stay admissions and excess bed days) Commissioning a responsive non-ambulance urgent transport service for GP urgent patient transport

Acute Care Establish improved local access to an outpatient Neurology service, providing both a non-face-to-face triage service and sub-speciality opinion within rotating clinics in the locality. Develop and implement shared care protocols in Rheumatology Integrate the currently separate MSK and Orthopaedic outpatient services, with a triage of reducing by at least 30% the number of onward referrals into consultant outpatients following MSK assessment. Establish a guideline compliant chronic pain service linked to the integrated MSK service.

Community care Commission fully integrated Neighbourhood Care Teams (NCTs), integrating community health teams, with social care, clustered around General Practice. Establish a fully-functioning Single Point of Coordination for community services Extend health and social care support to beyond 6pm through an integrated out of hours initiative supported through reablement funding. In collaboration with upper-tier and lower-tier Local Authorities develop integrated pathway for the management of alcohol abuse Provision of case management for complex, vulnerable patients, linked to the NCTs and General Practice Improve access to rehabilitation in community hospital and domiciliary settings through reduced duplication of provision and improved prioritisation.

Primary care Increase access to practice based near-patient testing for coagulation monitoring using INR Star Increase uptake of Choose and Book to at least 75% of referred patients Continue with MDT review of vulnerable patients, supported by the use of risk stratification tools

Emergency care Commission the local implementation of the 111 service Align urgent care provision through the GP Out of Hours Service and the GP Walk-in centre to reflect the 111 front-end Commission a nurse-led primary care walk-in service aligned to extending access to primary care appointments.

Cancer Increase use of the two-week wait system to increase early detection (detailed work will be based on the assessment of the GP reviews of cancer pathways) Target smoking cessation at pregnant mothers to reduce by 5% the absolute numbers of mothers smoking at delivery (currently the CCG has the highest incidence across North Yorkshire and York).

Mental Health Commission a fully functioning 24/7 Children and Adolescent Mental Health (CEMHS) service for the locality, beyond its current working time provision (this will be established in 2012-13 with consolidation 2013-14). Commission alternative provider access to primary care counselling services, using an any qualified provider model. Commission increased local capacity to manage complex need cases within the locality and reduce the requirement for out of area placements.

Cardiovascular care Commission a guideline compliant stroke service for the CCG, including: greater access to hyper-acute stroke management (including thrombolysis); greater access to therapy; and the provision of early support discharge. Implement model pathway for heart failure, utilising risk stratification to identify patients; improved prescribing to optimise patient management; and the use of telehealth as an enabling supportive technology.

Elderly care The development of a Frailty Service in stages:

• Stage 1 – Rapid Geriatric Assessment • Stage 2 - Early access to discharge planning and supported return

home • Stage 3 – Multi-disciplinary Frailty Service providing rapid

assessment, diagnostics, treatment planning, and discharge for complex elderly patients.

Specialist link nurses to support care homes, increasing development of advanced care planning, supporting more developed management in care homes, and enabling more effective delivery of preferred place of death.

Appendix 5 - Organisational Structure

Appendix 6 – The Public Health Offer

Public Health Directorate support to Clinical Commissioning Groups and responsibilities for population health and healthcare

Memorandum of Understanding Author2 Dr Martin Hawkings, Consultant in Public Health on behalf of

Dr Phil Kirby, Interim Director of Public Health, North Yorkshire Rachel Johns, Associate Director of Public Health, York

Consultees representing NY&Y CCGs

Dr Alistair Ingram, Chair HARD CCG Dr Phil Garnet, Chair SR CCG Dr Graham Dickinson, Chair HRW CCG Dr Mark Hayes, Chair VOY CCG NHS NYY Locality Directors

Date December 2011

Introduction 1. The purpose of this Memorandum of Understanding (MOU) is to

establish a framework to maintain the working relationships between NHS North Yorkshire and York (NHS NYY) Cluster Public Health Directorate and its related Clinical Commissioning Groups (CCG).

2. The MOU will operate for the 2011/12 ‘shadow period’ of public

health transfer into local authorities and will be further developed for 2013 and beyond subject to further national guidance and support for the ‘Core Offer’ from public health to the NHS by both North Yorkshire County Council and City of York Council (CYC).

Context 3. With the implementation of the Health and Social Care Bill

2011, primary responsibility for health improvement and health protection will transfer at the national level from the NHS to Public Health England, and at local level from PCTs to Local Authorities. The responsibility for strategic planning and commissioning of NHS services will transfer to the NHS Commissioning Board and to Clinical Commissioning Groups.

4. Since 1974, within the NHS, specialist public health staff have

undertaken three core public health responsibilities on behalf of the NHS and local communities:

• Health improvement e.g. lifestyle factors and the wider

determinants of health.

2 With thanks to NHS public health directorates in Bradford and Airedale, Nottingham and Nottingham City, Worcestershire and Lincolnshire who developed previous versions of this document.

• Health protection e.g. preventing the spread of communicable diseases, the response to major incidents, and screening

• Health Services e.g. input to the commissioning of health services, health intelligence, evidence of effectiveness

5. Both North Yorkshire County Council (NYCC) and City of York

council (CYC) have expressed the strategic intent, following their own internal consultation process, to appoint their own Director of Public Health to lead and deliver the new role within each local authority. Each DPH will have their own team but in order to mitigate the risk associated with smaller teams, some public health functions may be best delivered at a larger population level and/ or as shared functions.

6. The developing system architecture for both NHS

commissioning and the new Public Health System can support specialist public health leadership into clinically led commissioning. This is critical in delivering both the NHS and Public Health Outcomes framework. During the transition period, the challenge will be to maintain existing public health support for NHS commissioning through CCGs while developing the new role of the local Authority for health improvement and health protection services. The role of public health in supporting the NHSCB and Commissioning Support Organisation at Cluster level will also need to be determined.

Public Health Directorate Commitment

7. The public health directorate will work with the Local Authority and CCGs as further guidance becomes available to define the public health leadership, functions and capacity to fulfil the future public health role in Local Authorities and the ‘core offer’ to the NHS mapped to each CCG and NHSCB to deliver the agreed outcomes. The model below identifies how this might be delivered for each CCG Appendix 1.

8. The underlying principle should be to make the best use of

specialist skills to benefit population health and in delivering the local authority role for health and wellbeing. Public Health functions in support of commissioning health services are shown at Appendix 2 and 3

Health improvement

9. The Health and Social Care Bill will give the Local Authority statutory duties to improve the health of the population from April 2013. CCGs and the NHSCB will be given duties to secure improvement in health and to reduce inequalities through the health services that they commission. This will require action throughout the life-course and along the entire care pathway

from prevention to tertiary care and in delivering both the Public Health and NHS Outcomes Frameworks.

10. During 2012/13 NHS NYY Public Health Directorate will:

• Lead work with both the local authority and CCGs and wider partners to develop future health and wellbeing strategies

• Lead health improvement partnership working and support development ofpublic health programmes around improving lifestyles and local efforts for health improvement and disease prevention.

• Support work to review strategies and commissioning plans to improve health and reduce health inequalities to ensure they are needs based and outcomes of preventive measures are monitored against key NHS and LA strategies.

11. During 2012/13 CCGs will work with Public health to:

• Contribute to strategies, commissioning plans and leadership of local public health programmes to improve health and reduce health inequalities and inequity of access to services

• Ensure primary and secondary prevention is incorporated within clinical practice and commissioning plans to improve health, reduce health inequalities and optimise management of long term conditions

Health protection

12. The Health and Social Bill will be followed by regulations that will determine the role of Local Authorities and the Director of Public Health in respect of local health protection arrangements in partnership with Public Health England and NHSCB. This may include monitoring and co-ordinating the response to outbreaks of communicable disease, environmental hazards and civil contingencies. The Bill gives CCGs a duty to ensure that they can respond to relevant emergencies.

13. The Public Health Directorate will ensure robust health

protection and emergency planning arrangements for 2012/13 and will:

• Lead and ensure that local strategic plans are in place for

responding to the full range of potential emergencies – e.g. pandemic flu, major incidents and provide assurance to PHE regarding the arrangements

• Ensure that these plans are adequately tested with partners, and that the capacity and skills are in place to co-ordinate the response to emergencies, through strategic command and control arrangements.

14. During 2012/13 CCGs will work with Public Health as the

future health protection and emergency planning architecture becomes clear and to:

• Understand their future role with respect to health protection

and emergency planning and response • Ensure that provider contracts and constituent practices

include appropriate business continuity and emergency response plans covering a range of contingencies arrangements.

• Participate in exercises when requested to do so. Health Services

15. The Health and Social Care Bill establishes CCGs as the main local commissioners of NHS services and that the NHSCB will commission primary care and certain specialist services. There is a duty to continuously improve the quality, effectiveness and safety of commissioned services.

16. The Health and Social Care Bill establishes the role of the

Health and Well-being Boards to lead partnership working in identifying the needs of the population through the JSNA and to ensure that these are addressed through jointly agreed strategies that these should be reflected in the commissioning plans and activities of CCGs.

17. Public health specialists currently provide leadership and support for a range of NHS commissioning functions (Appendix 2); the requirement for these skills will not diminish and guidance indicates that this should be obtained from a local public health specialist team.

18. During 2012/13 NHS NYY Public Health Directorate will:

• Lead and work with North Yorkshire CCGs, NHS NYY Cluster, NYCC and CYC to develop the future arrangements for public health specialist support to CCGs, and NHSCB as a public health ‘core offer’, including through the CSO (Appendix 1).

• Lead and develop with LAs and CCGs, on behalf of CCGs, the JSNA and strategies to maximise health gain and reduce inequalities

• Lead the co-ordination of appropriate health commissioning work between the NHS, PHE and LA at a local level.

• Support the CCGs in understanding the health and healthcare needs of the population at a local level and setting local commissioning priorities to deliver the NHS outcomes

frameworks • Support the CCGs in developing evidence based care

pathways, service specifications and quality indicators to improve patient outcomes and to reduce health inequalities

• Support CCGs in their role in delivering both the Public Health and NHS Outcomes Frameworks.

19. During 2012/13 CCGs will work with Public Health as the

future ‘core offer’ to the NHS’ becomes clear and to:

• Consider how to incorporate specialist public health leadership and advice into the CCG, and to exercise their functions with a view to securing continuous improvements in the quality of services including clinical effectiveness, safety and patient experience, and having due regard. to the need to reduce inequalities in healthcare

• Consider how to incorporate specialist public health leadership and advice into the CCG, including through partnership working with Local Authorities through Health & Wellbeing Boards and to reflect the JSNA and joint priorities in their commissioning plans

• To utilise specialist public health advice as part of its commissioning functions including working with the CSO as reflected in the draft model outlined in Appendix 1 and across public health functions to support commissioning as identified in Appendix 2.

Maintaining the public health function

20. Through the DPH, NHS NYY will work with partners to ensure that an appropriately skilled specialist public health workforce is maintained and supported through transition to ensure the future delivery of the public health for CCGs and in delivering both the Public Health and NHS Outcomes Frameworks.

Appendix 7 – CSU letter of intent to complete Service Level Agreement

[email protected] Direct Tel: 01653 605701 Reference

Scarborough and Ryedale CCG Scarborough Town Hall - York House

St Nicholas Street Scarborough

North Yorkshire YO11 2HG

Maddy Ruff Managing Director North Yorkshire and Humber CSU Health House Willerby HU10 6DT

Tel: 01653 605709 Fax: 01653 693794

Website: www.northyorkshireandyork.nhs.uk/

Dear Maddy

Re: Letter of Intent to sign Service Level Agreement with North Yorkshire & Humber Commissioning Support Unit

A Service Level Agreement (SLA) for the Commissioning Support Unit (CSU) has been developed with the intent to create a partnership with flexibility on both sides. These arrangements have been negotiated by the CSU Relationship Managers and the Commercial Director with the CCG Chair and Accountable Officer for each CCG. The key terms of these arrangements are:

• A three year commitment on both sides, with an annual negotiation of funding and service requirements, similar to acute contracts, to ensure both sides are clear on what is required, how it will be delivered and at what cost.

• 12 month notice period (which may be less for some services, subject to scale).

• Block contract for 2013/14 – the CSU has issued proposals to each CCG outlining their service requirements.

• Agreed service specifications and key performance indicators (KPIs). • Monthly reporting against the KPIs, but with a one page overview of

exceptions to aid ease of interpretation and save time. • Funding to be agreed on a standard package of services, based on the

financial envelopes already discussed with the CCG. • Introduce activity tariffs for certain services Service Delivery Assurance

(SDA), procurement and Public Health Observatory (PHO), for project related activity. Each project will be scoped and subject to a Project charter in advance.

• CSU paid in advance each month for block and in arrears for project activity. The Service Level Agreement is a more formal contract with the CCGs to ensure absolute clarity and provide a basis for performance management between the organisations. In accordance with the above, I can confirm that it is our intention to establish a formal Agreement subject to the approval of the CCG Board. Yours sincerely,

Simon Cox Chief Officer Designate

http://www.northyorkshireandyork.nhs.uk/

Appendix 8 – CSU Memorandum of Understanding (02/2012) Memorandum of Understanding for delivery of Commissioning Support Services from the North Yorkshire and Humber CSU 1. Commitment to the receipt of Commissioning Support Services from the North Yorkshire and Humber CSU – General Approach As part of the new Health and Social Care Bill, a number of new organisations are to be established to deliver the functions currently undertaken by Primary Care Trusts. Locally many of the commissioning functions will be undertaken by Clinical Commissioning Groups (CCGs) and the NHS Commissioning Board (NCB). These organisations are to be supported to efficiently work by Commissioning Support Services (CSU). This MOU provides commitment on behalf of the CCGs to receive commissioning support services from the NY&HCSU. To demonstrate their commitment to the receipt of CSU provision that is set out in this letter it is proposed that the Shadow Chair of the CCG countersigns this letter on behalf of the CCG. 2. Collaboration in development of CSU provision Further to the on-going engagement with the CCG by the CSU up to February 2012, on the potential implications for the CCG of the provision of Commissioning Support Services, the CCG is now asked to:

• commit to working with the CSU to develop the enhanced service specifications and other relevant documentation for the provision of commissioning services

• commit to engage in the clarification of service specifications and associated delivery aspects of service provision, confirming do/buy/share options, staffing structures, and costings;

• commit to engage with the CSU and other CCGs to develop a model for collaboration, where appropriate;

• commit to working with the CSU on understanding the need and content of a margin/surplus on CS services; and

• confirm that it understands that there could be implications for service delivery and staff arising from the development of the CSU and CCG.

3. Services to be provided The CSU’ current proposal for Commissioning Support Service is that there will be a service provided to the CCG based on your individual requirements and intended organisation structures. By 1st April 2012, the CCG will refine their specific requirement for CSU and expect provision of services in line with the detailed the initial service specifications, including:

– Inputs and Outputs – KPIs – Dependencies of other outputs – Responsibility and Accountability

CCG’s will be fully involved in decisions to define the full scope of the services during Outline Business Plan (OBP) (to be submitted at end March 2012) and Full Business Plan (FBP) development (to be submitted at end of August 2012). The initial service

specifications setting out the CCGs requirements will be completed before the OBP is submitted. The list below provides an overview of the services that may be provided to CCGs by the CSU: it is recognised that this may vary once the CCG requirement is determined. Commissioning Support Services Strategic Planning

• Using data to understand current, and model future, healthcare needs • Planning and prioritisation support service

Service redesign and change • Developing clinical specifications • Pathway redesign • Service reviews • Performance monitoring and demand management • Quality and improvement • Specialist commissioning such as continuing care, mental health and clinical

network services Procurement & Market Management

• Identifying best value providers to meet service needs • Formal contract management, • Tendering and negotiation • Legal compliance • Market management

Contract Management • Contract administration • Technical contract drafting • Contract negotiation • Contract monitoring and validation • Contract performance management • Contract advice and support • Contract improvement/ decommissioning • Performance management and improvement

Business Intelligence • Information collection and analysis • Data warehousing • Information to support decision making • Benchmarking services and identification of gaps in service

Communications & Engagement • Engaging key stakeholders and patients • Local consultations • Media handling • Social marketing

Business Support Services Finance

• Financial services and governance • Financial and management reporting • Financial accounting

• Business case support and investment appraisal • Financial planning

Corporate • Governance • Estates and Facilities management • Legal services • Information governance • Business continuity planning • Strategic risk management • Health and safety • Complaints • Equality and diversity • Project management and support • Administration support • Helpline and patient services (PALS)

Workforce • Leadership development • Learning and development • Workforce planning • Human resource management • Organisational development

Primary care support services • Primary care information systems • Medicines management • Primary care education and development • Primary care clinical governance • Maximising access to incentives

Information Management & Technology • IT support and service desk • Application and system support - access, training and configuration • IT infrastructure • IM&T programme and project management • Development services eg. Web portals • Information governance, IT security and compliance

Internal Audit • Assurance and opinions on the full range of business functions • Counter fraud services

Quality, patient safety and outcomes • Clinical risk management • Serious incident investigation and management • Quality assurance and improvement • Patient experience • Infection prevention and control • Safeguarding • Clinical audit and effectiveness • Research governance

4. Costs The CCG are asked to confirm recognition that a financial contribution to the delivery of CSU will be required. It is anticipated that for 2012/13 the CSU will be costed

through a block contract with the CCGs. It is currently expected that the CSU will be costed with a range of £9-13 per head. The CCG is asked to confirm recognition that the actual cost for the CCG will be dependent upon the requirement of the CCG, the scope of the running cost allocation (assumed to total £25 per head of population for each CCG) and gaining clarity of historic spend for the CCG. It is acknowledged that the price to a CCG of any service should not exceed that which was previously paid to their PCT for the same service.

5. Time Period The CSU will provide these services to the CCG from April 2012. These will be delivered via the CSU, which will operate in a shadow form from 1st April 2012, while the Cluster still remains accountable and in place until 1st April 2013. The CCG is asked to:

• commit to be provided with Commissioning Support from the NY & Humber CSU from 1st April 2012 to 31st March 2013.

• commit to a 12 month review period and a 12 month break clause for the CCG to exercise depending upon agreement on costs agreed in the previously agreed 12 month contract.

6. Escalation Route It is anticipated that any disputes will be resolved between the CSU and the CCG. The ultimate resolution within the CSU will be the Managing Director. In some circumstances, escalation may be necessary to the Cluster and then SHA for final mediation. The diagram below illustrates the escalation route.

7. Next Steps At the Stakeholder Board held on 17th February 2012, each CCG representative present agreed to the principles contained in this MOU. It was agree that the following steps will be undertaken by the CCG and the CSU to finalise this arrangement for 2012/13. Immediate steps (confirmed at the Stakeholder Board on 17th Feb 2012)

• Agreement in principle to receive commissioning support services from NY&H CSU from 1st April 2012 to 31st March 2013.

• Agreement that during this year the service will develop, and lines of managerial responsibility will change for staff.

Short term steps (by end of March) • Face to face meetings between the CCG and CSU to review the CCG

requirement and the CSU provision for 2012/13 - w/c 5th March 2012 • Confirmation of this MOU by each CCG Board • Finalise the 12/13 requirement and cost envelope for the CCG - by the end

of March 2012

Further steps (Beyond 1st April 2012) • Further refine individual service requirement, KPIs and detailed pricing

structures for the CCG • Implement national commercial arrangement between CCGs and CSU

As set out above I would be grateful if you would sign a copy of this Memorandum of Understanding on behalf of your Board to indicate your commitment to the approach outlined above for Commissioning Support Services and return it to me by Friday 9th March 2012. Please keep a copy for your own records. If you have any comments or queries, please do not hesitate to contact me. Yours sincerely Maddy Ruff NY&H CSU Managing Director (interim) Countersigned:

Clinical Lead of the CCG

Appendix 9 4 Year QIPP Delivery Plan

2012-13 2013-14 2014-15 2015-16 2012-13 2013-14 2014-15 2015-16

Reducing variation in GP referrals 200,000 100,000 100,000 100,000 1,812 906 906 906Reduce number of Ophthalmology referrals using LES based Optometrist scheme

85,000 50,000 25,000 0906 533 266 0

Reducing outpatient follow ups 785,000 1,259,950 1,049,532 0 7,436 11,935 9,942 0MSK redevelopment 100,000 75,000 50,000 0 991 743 496 0POLCV / Clinical Thresholds 60,000 20,000 0 0 100 33Hip/Knee replacement thresholds 100,000 50,000 0 0 24 12Reducing LTC related emergency admissions 150,000 100,000 50,000 50,000Short stay elderly care pathway 150,000 150,000 100,000 50,000Levels of Care & strengthened community systems 200,000 100,000 100,000 100,000 1,161 581 581 581A&E - reducing repeat attendances 104,000 100,000 100,000 50,000 1,000 1,000 1,000 1,000GP OOH 120,000 0 120,000 100,000Medicines management 150,000 150,000 150,000 100,000Non PbR Drugs reduction 100,000 50,000 0 0Ranibizumab tariff change 0 100,000 0 0Clinical thresholds for expensive anti-psychotics 50,000 0 0 0Reclassifying Day hospital activity to tariff 198,000 0 0 0 1,800Move from Ranibizumab to Bevacizumab for ARMD 300,000 300,000 0 0Decommission theatres at Malton 239,749 0 0 0CCG Management Costs Allowance 100,000 0 0 0Reablement Slippage 200,000 0 0 0Further Initiatives on GP Prescribing 92,251 0 0 0Reduced MIU Activity/Out of Hours integration 100,000 50,000 0 0 1,852 926 0Reconfigure Walk-in centre and Urgent Care Services 0 390,000 390,000 0GP Urgent Transport Pathway Change 100,000 100,000 0 0Unidentified QIPP 0 0 649,000 2,329,000

3,684,000 3,144,950 2,883,532 2,879,000 17,082 16,669 13,190 2,487

Target (Activity)

Target (Activity)

Target (Activity)

Target (Activity)Target (£)

Total

Scheme Target (£) Target (£) Target (£)

Appendix 10

NHS SCARBOROUGH AND RYEDALE CLINICAL COMMISSIONING GROUP

QUALITY, INNOVATION, PRODUCTIVITY, AND PREVENTION (QIPP) PROGRAMME

GOING FURTHER AND FASTER

1. Introduction

The NHS Scarborough and Ryedale Clinical Commissioning Group (SRCCG) recognise the financial challenge within its locality and the wider health economy of North Yorkshire and York. To support delivering statutory financial duties the CCG has developed actions to accelerate QIPP delivery as both corrective actions for the financial challenge in 2012-13 and as one of the foundations for the CCG’s 4-year financial plan.

2. Referral Management and Clinical Thresholds The King’s Fund research into referral management (King’s Fund 2010) suggests the most cost effective and clinically effective referral management strategies are those:

• built around peer review and audit • supported by consultant feedback • with clear referral criteria and evidence-based guidelines.

The analysis suggests that the greater the degree of intervention, the greater the likelihood that the referral management approach will not represent value for money. Thus, if this analysis is to be accepted, the use of large-scale stand-alone referral management services may not provide an effective solution. The approach developed by the CCG involves the following actions:

• Implement a referral template on primary care information systems to be used for all referrals, providing the required core information for providers

• Use the existing CCG learning sets to perform peer review of sampled practice referrals

• CCG board leads to engage with high-volume speciality hospital consultants to agree referral thresholds

• All referral thresholds to be re-circulated • The Audit of compliance with hip and knee thresholds to be completed and

shared with practices • Referring, where appropriate, smoking patients to the smoking cessation

service before referring for non-urgent treatment. The learning sets will conduct retrospective and prospective referral review, with the aim of sharing good practice and reducing overall referral variation.

3. Outpatient Follow-up Appointments

As this is considered to represent a high-cost service area much of which could be managed in primary care, this is a target area for the CCG to move to performance levels at the highest benchmarked standards. For the last quarter of 2012-13, to support in –year financial recovery, the CCG will commission activity at a level of 1:1 first to follow-up overall. Such a dramatic shift in such a short-time may not be sustainable into 213-14. Thus, the CCG intends to commission at 1:1.5 for the whole of 2013-14, before moving to 1:1 as an on-going ratio from 2014-15. To support this shift the CCG will:

• Provide GP clinical support to all high-volume outpatient specialities to assist in safely and appropriately discharging patients back to primary care.

• Develop ‘expert consulting’ services for the major specialities providing GPs with non-face-to-face support to assist in patient management without follow-up.

• Agree specific procedures and patient types where routine follow-up will not be required and where patients can be discharged back to management in primary care.

4. Primary care prescribing In 2010 primary care delivered significant efficiency gains through prescribing initiative labelled the ‘30-day Plan’. To support financial recovery in 2012-13 a similar scheme is developed, targeting prescribing changes that will release significant resource. The estimated full-year effect of the current plan is an additional full-year saving of £300,000. Practices will each be given their own prescribing data and targets for specific drug switches, identifying the forecast efficiency gains. The plan will take effect from early November 2012 and will form an on-going element of the 4-year QIPP programme.

5. Urgent Care Access The CCG is engaged in a detailed review of attendances at Accident and Emergency (A&E) departments, as part of the delivery of the Quality and Productivity indicators with the Quality and Outcomes Framework (QOF). To further increase urgent care efficiency, the CCG is actively engaged in redesigning the urgent care pathways into the localities Minor Injury Unit, and GP Walk-in centre, in addition to further integrating the current GP Out of Hours service with other access routes into urgent care. The direct financial gains are likely to be small in 2012-13, but will form part of the longer-term efficiency programme. Simon Cox Dr Phil Garnett Chief Officer Designate NHS Scarborough and Ryedale clinical Commissioning Group

Clinical Chair NHS Scarborough and Ryedale clinical Commissioning Group

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