3.2. Ethnic Profile Deprivation / Inequalities Current Population Health Status and Projected Health Needs Figure 5...

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2 1. Contents 1. Contents Executive Summary Our Populations Need Population Profile...7 Figure Ethnic Profile...8 Figure Table Deprivation / Inequalities Current Population Health Status and Projected Health Needs...10 Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure 13 B Figure Table Figure Lifestyle Factors Population need summary Health and Wellbeing In Bury Commissioning In Partnership North East Sector Partnership Approach Greater Manchester Transformational Change Joint Commissioning Arrangement with the Local Authority Provider Landscape...32 Figure Secondary Care Independent Sector Provision

3 Figure Mental Health Primary Care Community Services Third Sector Future Commissioning Aarrangements The Populations Use of Health Services in Bury Secondary (hospital) Care...38 Table Table Figure Independent Sector...40 Figure Mental Health & Community Services Performance against Quality, Existing Targets and Local and National Health Priorities...41 Table Performance & Quality Finance and QIPP...44 Table Vision for Bury What is our vision for future Vision for Financial Stability Vision for Performance & Quality Vision for Provider landscape Vision to establish a culture which fosters innovation Vision to improve the Health and wellbeing of the population and Focus on Prevention Plans on a Page Conclusion

4 2. Executive Summary This Strategic Plan covers the period 2012 until 2016 and should be read in conjunction with the 2012/13 Operating Plan, which contains NHS Bury Clinical Commissioning Group s (CCG s) detailed objectives for the current financial year. Strategic Plan sets out the aspirations that Bury CCG, its partners and stakeholders aspire to achieve within available resources. As such, the Plan tells the story (which is depicted in Figure 1 below) of: The current context in which we are commissioning (commissioning describes the process of purchasing health services for the local population) Our vision for the future The delivery programmes we plan to implement The outcomes we aim to achieve Specifically, it describes how we are continuing to develop the competencies required to commission services that are fit for the future, responsive to the needs and aspirations of local people within the changing environment of the NHS. This plan is underpinned by the Joint Strategic Community Needs Assessment (JSCNA), the Health and Wellbeing Board s Pledges and the Local Area Agreement. These building blocks provide the basis for the effective partnership working between the CCG and Bury Metropolitan Borough Council, together with the Team Bury Local Strategic Partnership. This Plan is about clinical innovation and clinically led service redesign with sustained financial stability and about services which meet the needs of patients and are not just fit for purpose, but the best for purpose and fit for the future. 4

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6 3. Our Populations Need The following section outlines the health needs for Bury in the following areas: Population Profile Ethnic Profile Deprivation and Inequalities Life expectancy Mortality and prevalence Health needs of Bury population in each priority area The health needs data within this document has been drawn from a number of sources, including the Bury Joint Strategic Community Needs Assessment (JSCNA) which can be accessed via this link: The JSCNA is a holistic analysis of the needs of the community, and its purpose is to form the basis of intelligence led strategic decision making and commissioning within Bury. This analysis allows the better identification of areas that need more detailed examination by the sponsoring stakeholders, to inform the type of service reconfiguration, decommissioning and commissioning of services in the most effective manner. NHS Bury Clinical Commissioning Group in partnership with Bury Metropolitan Borough Council, NHS service providers, Bury 3rd Sector Development Agency and other partners is currently refreshing the JSCNA. The aim is to ensure that it includes a focus on action to: Reduce inequalities by developing healthy places for people to live Develop integrated public service delivery Develop services that deliver shared outcomes, with service users as equal partners Target and personalise all services more effectively Deliver a proactive model of needs assessment that is more integrated and intelligence based and supports a predict and prevent approach, moving away from the more traditional detect and manage model The refreshed JSCNA will: Provide a wider understanding of the needs and underlying health and social care issues affecting local communities Better address the wider determinants of health, inequality and equality and diversity needs of the local population by using intelligence on: o Socioeconomic status, deprivation and the Equality Target Groups o Relevant topics, relevant targets and outcomes o The health needs of different population sub-groups o Inequalities in service provision for all equality target groups o Cost effectiveness of interventions and services o Forecasting for future health needs o Aspirations of local populations as well as their needs As we move forward, the continuing work on the JSCNA will enable stronger partnership working and will become central to our efforts in transforming the commissioning process. Key to this will be the full engagement of all commissioning stakeholders. 6

7 3.1. Population Profile Bury has a younger population profile than the UK and also the North West as a whole, (reference, JSCNA). Currently 51% of the population of Bury is female and 49% male. The early estimate from the 2011 Census for the crude population of Bury is 185,100. Using the ONS (Office of National Statistics) mid-year 2010 figures, the population of Bury is predicted to increase to 187,300 by 2012 (representing a 1.2% increase) and 193,300 by 2022 (representing a 4.4% increase). Figure 2 below compares the predicted population increase (represented by the bar) against actual (represented by the line). Figure 2 By 2022: The number of children and young adults is predicted to reduce by 1.8%. The number of people under 25 years old is expected to reduce by 4%. The population in every 5-year age band over 50 years old is expected to increase by at least 20% with: o The over 65 year olds population expected to increase by 29%. o The over 85 year olds population expected to increase by 54%. The 2001 Census outlined there were over 34,000 people with a Limiting Long Term Illness (LLTI). This equated to 18.9% of the population. The population is ageing, if there is no change in the age specific rates there will be an increase in the number of people with LLTI by approximately 7500 people (1.9%) from 2001 to 2021, (65% of this is due to population growth and 35% due to changes in the age structure). This predicts there will be 36,000 people suffering with a LLTI by 2021 if the rate of change stays the same. If the rate of increase becomes the same as the worst in Greater Manchester, there would be an expected increase of approximately 14,000 people with an LLTI The change in the population demonstrates a significant rise in the over-65 population by This and the increase in LLTI will place significant demands on local services particularly in the management of chronic diseases and long term conditions. 7

8 3.2. Ethnic Profile The 2001 census reported that Bury has a predominantly white population, with 93.9% of the population falling within this category. The School Census data from 2006 to 2008, Figure 3 below, shows a decrease in the white population and an increase in the Pakistani population. Figure3 Source: Bury School Census Although this data is seen as a more recent, accurate picture of the ethnic profile of the population of Bury, it has to be considered that the Pakistani community is predominantly young (with 65% of the population aged under 30), and that many of the migrant worker population that has been received within Bury may not be represented within these figures. A detailed breakdown of ethnic groups is outlined in Table 1 below from the 2001 census. 8

9 Table 1 Ethnic Group Bury England White - British 163,898 (90.75%) 42,747,136 (87.0%) White Other 5,652 (3.12%) 1,932,225 (3.9%) Mixed 1,977 (1.10%) 643,373 (1.3%) Asian or Asian British 7,311 (4.04%) 2,248,289 (4.6%) Indian (0.67%) (2.1%) Pakistani (3.04%) (1.4%) Bangladeshi (0.09%) (0.6%) Other Asian (0.24%) (0.5%) Black or Black British 856 (0.47%) 1,132,508 (2.3%) Caribbean (0.28%) (1.1%) African (0.15%) (1.0%) Other Black (0.04%) (0.2%) Chinese or Other Ethnic Group 914 (0.51%) 435,500 (0.9%) Total Population 180,608 49,138,831 The proportion of ethnic groups varies between Wards from 1% to 20% of the population. The 2001 Census stated that Bury had 5% Jewish population, which is the highest in the North West. The growing population of Black and Minority Ethnic Groups bring specific health needs for example increased risk of coronary heart disease, diabetes, kidney disease and hypertension (high blood pressure). People of Asian or Afro Caribbean background are also up to six times more likely to develop type 2 diabetes and are also more likely to develop it ten years earlier Deprivation / Inequalities In the Index of Multiple Deprivation (IMD) for 2010 NHS Bury was nationally ranked the 84 th most deprived district out of 151 in England. Inequalities within Bury are widening. Eleven Super Output Areas within Bury are in the bottom 10% of Super Output Areas nationally. These figures show that Bury has some challenging areas of deprivation that have significantly poorer health than the rest of the borough; this is outlined further later in this document. Health Intelligence has been strengthened and initiatives such as the JSCNA have been utilised to good effect in driving service changes within health services and across the Team Bury Partnership. Each pathway redesign has taken into account the needs of specific population groups and drawn upon the relevant local needs assessment as well as paying attention to the available evidence on effective interventions for tackling health inequalities (e.g. 10 high impact changes for tobacco control). 9

10 A range of partnership projects are already in existence which target health inequalities at the community level, a number of which are funded through partnerships using resources made available to Bury as a Spearhead borough. Outcomes from the NST Health Inequalities support visit will be translated into action plans and strategies across the Team Bury partnership as appropriate Current Population Health Status and Projected Health Needs This section outlines the current and future health status and projected health needs considered by NHS Bury Clinical Commissioning Group to inform this Strategic Plan, including: Life Expectancy Mortality and Prevalence specifically: Stroke Coronary heart disease Respiratory disease Cancer The demographic analysis for the population of Bury shows a mixed society, diverse in culture with some significant pockets of deprivation. As a Spearhead CCG, it is no surprise that there are a significant number of issues which affect the population s health needs. Life Expectancy In Bury most people hope to live a long and healthy life, but for too many people, their hopes for the future are not realised. Too many people are dying early from illnesses such as circulatory disease (including heart disease and stroke), cancer, respiratory disease and respiratory disorders. The association between deprivation and ill health is all too clear; life expectancy in Bury reaches as low as 73 years for males in the most deprived areas of Bury, as opposed to 88.8 for females in the more affluent areas. The life expectancy for males in Bury was 77.5 years, compared with 78.6 years for England, and for females in Bury was 81.2 years compared to 82.6 for England, as outlined in Figure 4 below. 10

11 Figure 4 Life expectancy in Bury is rising for both males and females, however the gap between Bury and England as a whole is widening. Although there has been a significant improvement in life expectancy over the last ten years people living in Bury can still expect to die about a year earlier than the average for England. This reflects the higher level of illness and disability in Bury and led the Government to label Bury CCG a Spearhead CCG, (as its overall death rate is amongst the worst 20% of PCTs in the country). Bury CCG the Local Authority and other local partners are determined to improve this position. Figure 5 The focus of this Strategic Plan is improvement in main contributors to reduced life expectancy which are coronary heart disease, stroke and cancer. There have been continuing gradual improvements in health associated with a steady improvement in standards of living. Through the implementation of this plan, NHS Bury Clinical Commissioning Group together with the Health and Wellbeing Board will tackle important health problems where we know we can make a difference. 11

12 Mortality and Prevalence Infant mortality is an indicator of the general health of a population. Mortality during the first 28 days of life is considered to reflect the health care of both mother and baby. The Figures below demonstrate Bury has below average infant deaths for both infants under the age of one and under 28 days. This is also consistent with a below average rate of low birth weights. Figure 6 Figure 7 Bury has death rates that are higher than the England average (Figures below), with All Age All-Cause Mortality in being 660 for Bury and 595 for England. All Age All- Cause Mortality is falling across Bury, in line with the England average. If current trends continue in both Bury and England, the gap between the All Age All-Cause Mortality of Bury and the England Average will remain the same for males and decrease for females. 12

13 Figure 8 Female Standardised Mortality trajectories - All Age 2008 to 2012 historic and estimated, cnsus adjusted NW region non-spearhead spearhead Manchester Bury all-age all-cause mortality feb09 apr09 jun09 aug09 oct' feb10 apr10 jun10 aug10 oct feb11 apr11 jun11 aug11 oct feb12 apr12 12 month moving average Figure 9 Male Standardised Mortality trajectories - All Age 2008 to 2012; historic and estimated census adjusted NW region non-spearhead spearhead Manchester Bury all-age all-cause mortality feb09 apr09 jun09 aug09 oct' feb10 apr10 jun10 aug10 oct month moving average feb11 apr11 jun11 aug11 oct The three disease areas which are most significant for Bury are: feb12 apr12 Chronic Heart Disease: with standardised mortality rate (per 100,000 population) for under 75s of 45.1, compared to 37.2 for England. Across Bury, the all age coronary heart disease mortality doubles from the least deprived to the most deprived wards. Stroke: Bury directly age-standardised rate (DSR) was 49.9 in , compared to 42.7 for England. Cancer: Bury directly age-standardised rate (DSR) was in , compared to for England. There are also approximately 7,500 registered diabetics with a predicted undiagnosed population of approximately 2,000 people. Stroke and Coronary Heart Disease NHS Bury Clinical Commissioning Group has a higher prevalence of coronary heart disease, than the national average, but has an average prevalence of hypertension based 13

14 on Quality and Outcomes Framework (QOF) data. The death rate from coronary heart disease, is declining fast in Bury which is in line with national figures. The number of people registered as having a stroke related illness within Bury is 3,607 based on Quality and Outcomes Framework (QOF) 2010/11. Comparison of expected and observed (QOF) prevalence of coronary heart disease and hypertension is demonstrated in Figure 10 below. This model suggests NHS Bury Clinical Commissioning Group prevalence figures collected through the QOF accurately reflect the expected prevalence in most areas. Figure 10 The prevalence of all the above conditions is expected to rise and have a further effect on the population of Bury as outlined in Figure 11 below. Figure 11 14

15 Figure 12 The Hypertension Model of the Association of Public Health Observatories (February 2007), suggests that the prevalence of hypertension within Bury will be 31.71% once recording improves. Current prevalence based on the 2010/11 QOF registers for this is only 13.2%. This indicates there may be a significant rise in patients who are diagnosed with hypertension and may therefore require treatment with anti-hypertensive and statins across Bury. Statins can reduce cardiovascular disease by at least 20% in compliant users. Respiratory Disease Secondary care (hospital) activity data for the period 2011/12 specific to respiratory disease shows a total of 635 admissions into secondary care. The QOF registers indicate a stark difference in prevalence across Bury, and this is reflected in the admissions to hospital for patients with these conditions. There is a marked difference between wards for admissions to hospital from chronic obstructive pulmonary disease (COPD). In Sedgley ward there are 1.6 admissions per 1,000 admissions for COPD. In East ward there are 6.2 admissions per 1,000 admissions for COPD. There has been significant focus on prevention of COPD and enabling people with the disease to remain at home and manage their exacerbations with community based support through redesign of the COPD pathway. 15

16 Figure 13 Below shows the marked difference in admissions between wards within Bury. Bury had the 8th highest rate of hospital admissions for childhood asthma in England in In 2011/12 91% of childhood hospital admissions for asthma had a length of stay of two nights or less. It is therefore likely that the vast majority of these episodes could be safely managed in a Paediatric Observation and Assessment Unit with appropriate support from the Community Paediatric Nursing Team. A launch of the redesigned Paediatric Asthma Pathway in primary care took place in 2010 with educational support for both Doctors and parents underpinning this pathway. Cancer The incidence of cancer is increasing and since 2009 overall mortality has begun to increase. Between 1993 and 2007 the age standardised mortality rate fell by 15% in men and 20% in women, however between 2009 and 2010 there has been an increase in cancer mortality in both males and females. Mortality from cancer in Bury has remained higher than the England and Wales average. Figure 16 below shows the cancer incidence for Bury against England during the period 2007/09. Figure 14 16

17 It is believed that over 50% of cancers are preventable. Various risk factors for cancer are more common in the North West including smoking, alcohol misuse and sexually transmitted infections. In 2007 the percentage of current smokers was 21% and as of 2010 this was recorded to be at 18.6% showing a reduction of 2.4% over the last three years. 49.8% of Bury s population is overweight or obese. Whilst NHS Bury Clinical Commissioning Group has invested in a range of lifestyle support programmes (Health Trainer Service, Expert Patient Programme, Stop Smoking Service and Bury Exercise And Therapy Service also known as BEATS) efforts need to be focussed in developing cross cutting prevention strategies which seek to change risk taking behaviour using a range of techniques including social marketing and community engagement models. Table 2 shows the uptake of the breast screening programme in Bury for women aged years As at 31st March England North West SHA Bury PCT As with breast screening, the uptake of cervical cytology is good in Bury as shown in Figure 15 shows cervical screening coverage for 2002/03 to 2010/11. Figure 15 The Bowel Cancer Screening Programme was launched in March As part of the programme, a new Bowel Cancer Screening Service has been set up at Bury s Fairfield General Hospital, which is run by Pennine Acute Hospitals NHS Trust. Bowel cancer screening could reduce deaths from bowel cancer by 16 percent in those invited for screening. There are a number of planned extensions over the next five years to the 17

18 national screening programmes which will impact on finance, and service and treatment provision. As screening provision increases so must the efforts to ensure that local communities are aware and are engaging in these, if we are to bridge the health inequality gap. Incidence of cancer is not equally distributed across the population. Research has shown that the following communities and groups experience inequalities in cancer: Those from lower socioeconomic groups Black and Minority Ethnic (BME) communities Those with mental illness Those with learning disabilities Those with physical disabilities Rural communities Lesbian, gay, bisexual and transgender communities Older or younger people Men or women Those from certain religions or with particular religious beliefs Currently in Bury there are a number of services and opportunities which serve to support the prevention and self-care agendas. A recent consultation exercise by Groundwork highlighted that in general the local population are not fully aware of these services and how to access them. Mental Health The data available in November 2011 indicates that there were 9,320 people on ESA / Incapacity Benefits (IB) in Bury. According to Quality and Outcomes Framework registers 2010/11 the prevalence of mental health in Bury is 0.9. This is compared to prevalence rate of 0.8 for England. Bury has a higher rate than the England average for emergency admissions to hospital for patients with mental health conditions. Bury s admission rate is (DSR*) per 100,000 whilst the England average is (DSR) per 100,000. * A DSR (Directly Standardised Rate) enables a comparison between different areas by applying local rates to a standard population. The Bury Health Survey 2010 results show a correlation between deprivation and the General Health Questionnaire, with the worst area at 32.9% and the best at 12.9%, with Bury average being 22.9%. The 2007 Health Survey shows an even stronger correlation between deprivation and self-esteem, with the best area at 21.6% having low self-esteem and the worst at 36.6%, with Bury average being 31.9%.This question was not asked in the 2010 survey. National and local anecdotal evidence suggests that people from black and minority ethnic groups, those from the Jewish community and many older people are less like to access primary care mental health services than the population as a whole. The detailed information NHS Bury Clinical Commissioning Group will obtain from the new Improving Access to Psychological Therapies (IAPT) data will provide the opportunity to understand service usage in a way that we have not been unable to do before. 18

19 One in six people over the age of 80 have a form of dementia and one in 14 people over the age of 65 have a form of dementia. In terms of local prevalence research published by the Alzheimer s Society [1] regarding the numbers of people on a dementia register, NHS Bury Clinical Commissioning Group is shown as being 54th out of 152 PCTs/CCGs in terms of prevalence of dementia [2]. Learning Disabilities Nationally it is estimated that up to 2% of the population have a learning disability. Within the borough of Bury this equates to approximately 3,640 individuals who have a learning disability. It is predicted by 2020 there will be an increase of 10% in people born with profound and multiple learning disabilities with associated complex health needs. suggests that people with learning disabilities are 58 times more likely to die before the age of 50 than the general population. The Department of Health estimate that 25% of these people will access specialist health services at different times of their lives, for Bury, this equates to approximately 910 individuals. It is therefore essential that both generic and specialist services are commissioned in a way that meets the specialist needs and requirements of those individuals with a learning disability Lifestyle Factors This section outlines the key lifestyle issues for Bury which have influenced development of the initiatives within the plan including: Alcohol Obesity Smoking Alcohol The binge-drinking rate (this is an Office for National Statistics synthetic estimate) for Bury is 25.1% and is above the England and North West averages of 20.1% and 23.3% respectively. This picture differs though for higher risk drinking (Bury 4.95%, England 7.11% and North West 7.3%) and increasing risk drinking (Bury 21.92%, England 20.77% and North West 22.7%). The rate of hospital admission for an alcohol specific condition for those under 18 is 78.25, above the England average of but below the North West figure of Mortality rates for males from chronic liver disease is 18.7 which is higher than the England average of but below the North West figure of 20.59, and the position is similar for females with 9.96 for Bury, 7.15 for England and for the North West Average. The crude rate of claimants of disability benefit whose main medical reason is alcoholism is for Bury, which is well above the national average of but is just below the North West average of According to the Bury Public Health Survey, 4.2% of Bury residents are problem drinkers, classified by CAGE (Cut-Annoyed-Guilty-Eye), internally used assessment instrument for identifying problems with alcohol), with a difference of 6.7 percentage points between the best and worst wards. There is a national positive correlation (r=0.52) between deprivation and alcohol related admissions to hospital. 19

20 Obesity In Bury in 2011, over 98% of Year 6 and Reception children were weighed and measured under the parameters of the National Child Measurement Programme. The obesity rates in Bury are comparable to those in the North West; however there appear to be considerably more obese children in year six compared to reception children. Furthermore, in both year groups more boys than girls have been identified as being obese. Currently 71% of the population of mothers initiate breastfeeding their babies. This decreases significantly by 6-8 weeks to 39.3%, and there is a stark differential in breastfeeding rates at 6-8 weeks between the most deprived ward (9% breastfeeding) and the most affluent (46% of mothers breastfeeding). According to the Bury Health Survey 2010, 3.92% of adults in Bury were participating in physical activity five times a week for 30 minutes or more at moderate intensity, the recommended level required for general health benefit. This proportion has decreased from 9.7% in However, the survey results also show that the percentage of adults undertaking no physical activity lasting 30 minutes or more (defined as inactive) was 16.51% in 2010, a decrease from 24.6% in Data from the Active People Survey shows Bury s levels of participation has increased from 20.8% in 2005/06 to 24.5% in 09/11(APS4/5). The challenge for Bury therefore, is to continue to increase the proportion of adults achieving the recommend levels of exercise, whilst encouraging those who are currently inactive to become more active. The areas with the highest levels of inactivity are predominantly the areas of highest deprivation and highest health inequalities. Smoking According to the Bury Health Survey, less than one fifth of adults in Bury now smoke (18.6%), compared to 21.6% in 2008, and 29.2% in Despite this significant improvement, the death rate from smoking related conditions remains higher than the England average. This is particularly apparent in lung cancer with Bury s death rate at (DSR) against the England average of (DSR). Smoking accounts for 320 deaths a year in Bury. The rates of smoking in pregnancy are lower than the North West (17.3%) but higher than national averages (13.2%) in Bury (16.9%) Population need summary The following summarises the findings from the analysis of demographic indicators, population health status, health needs and lifestyle: Health outcomes in Bury are poorer than nationally and in some cases than the North West. Lifestyle factors are a major contributor to this, as are the needs of people requiring support to take responsibility for their health. Prevalence is in line with North West average but outcomes in some areas are worse. The ethnic profile of Bury is changing with the most rapid growth in the Pakistani community. The three diseases which cause the highest mortality in Bury are coronary heart disease, stroke and cancer. Cancer treatment and access rates for screening are overall good, but there are groups who do not know how to access services and this may affect their outcomes. Lifestyle choices are a major cause of poor health and health inequalities in Bury. 20

21 Equality Target Groups are not consistently accessing available services and targeted community development work must be undertaken to improve this. Alcohol misuse is becoming a significant health issue for the population of Bury. Prevalence of hypertension will increase significantly as recording improves this will have an impact on prescribing costs. Mental health issues need to be detected early and supported to reduce worklessness. The ageing population will have a significant impact on the utilisation of health services and therefore prevention of ill health and enabling care to be provided at home needs to be a significant focus. NHS Bury Clinical Commissioning Group is committed to work with its partners and local people to make a difference to people s health and wellbeing by addressing the challenges and inequalities. 21

22 4. Health and Wellbeing In Bury The problems that contribute to health inequalities are complex and longstanding. It is clearly the role of the NHS to help everyone improve their chances of living longer and healthier lives. But the health service cannot eradicate these inequalities on its own. We recognise that involving local people, partners and providers in strategy development and the overall work of the CCG is critical if we are to be successful. Representatives from across the Bury community have come together to form the Shadow Health and Wellbeing Board, including a representative from the Bury LINK, Bury Public Health Team, Bury's Third Sector, Bury Metropolitan Borough Council and the NHS Bury Clinical Commissioning Group (CCG). The Health and Wellbeing Board is chaired by a NHS Bury Clinical Commissioning Group Governing Body GP. Our Governing Body will set the direction for the future design and delivery of local health care, social care and public health. The agenda includes the health and wellbeing of adults, children and families, as well as wider areas that impact on health such as housing, education and the environment. Underpinning aspirations: Engaging and empowering communities and individuals living and working in Bury to take responsibility for their own health and well-being. Working with individuals, families and communities to create the environment to enable them to make healthy choices. Reducing health inequalities by focusing on the needs of the most vulnerable, socially excluded and the most deprived communities. Preventing ill health and to work together to encourage independence and personal control. Working in partnership to identify real solutions to deliver improved health outcomes. Achieving change through social capacity and local capability by understanding, strengthening and utilising local assets and resources. 22

23 Our Pledges : Pledge 1: We will promote and develop prevention, early intervention and self-care We will help you to live well and prevent illness. We will show you how and will help you take better care of yourself, or someone you know. Pledge 2: We will reduce inequalities in health and wellbeing We know that there are social and economic reasons that have a negative impact on people s health and wellbeing. We will organise our local health and social care services to take account of these. Pledge 3: We will develop patient centered services We will simplify how health and wellbeing is created and delivered for you in Bury. We will make sure that you can access those services, in a timely way, and see that they are fair. We will put the patient at the centre of how services are delivered. Pledge 4: We will plan for future demands We recognise that the population is ageing and more care is needed. This will have an impact on us all. We will shape services so that future generations can have a better quality of health and wellbeing. Health and Wellbeing Board Priority areas: In recognition that there is an accumulation of positive and negative effects on health and wellbeing as we progress through life, in agreeing interventions to tackle our priority areas both the Clinical Commissioning Group Strategic Plan and the Health and Wellbeing Strategy underpin their thinking with the Marmont concept of five life course stages, depicted in Figure 16 below 1. Starting well good health for mothers and children 2. Developing well encouraging healthy habits to avoid harmful behaviour 3. Growing up well identifying, treating and preventing mental health problems and creating resilience and self-esteem 4. Living and working well - choosing lifestyles and behaviours that influence health and wellbeing 5. Ageing well supporting resilience through social networks and activity, providing protection from preventable ill health The priorities we will deliver in this strategy focus on improving the health and wellbeing of vulnerable individuals, families and communities in Bury, and underpins the Plans on a Page within the CCG Strategic Plan We will: Deliver added value through integrated action Work with people and organisations to recognize and realise their potential impact on community health and wellbeing Provide every opportunity and support for individuals and communities to take responsibility for their own health and wellbeing. 23

24 Starting Well: Ensuring a positive start to life for children, young people & families: Supporting positive and resilient parenting particularly for families in challenging situations, to develop emotional and social skills for children. Developing integrated services across education, health and social care which focus on the needs of the child in the community, as well as for growing numbers of children with the most complex needs. Creating positive opportunities for young people to contribute to the local economy and community. Developing Well: Encouraging healthy lifestyles and behaviors in all actions and activities: Increasing the number of adults and children with a healthy weight. Reducing the number of people who smoke. Reducing physical inactivity. Reducing harmful alcohol consumption. Promoting sexual health, reducing teenage pregnancy and improving outcomes for teenage parents and their children. Increasing the engagement of individuals and communities in taking responsibility for their health and wellbeing. Growing Well: Helping to build strong communities, wellbeing and mental health Implementing early interventions and accessible and appropriate services for mental wellbeing. Reducing homelessness and addressing the effect of changes in housing benefit on vulnerable groups. Minimising the negative impacts of alcohol, illegal drugs and associated anti-social behavior, on health and wellbeing. Reduce abuse and neglect - particularly domestic abuse. Living & Working Well: Promoting independence of people living with long term conditions: Ensuring that people with long term conditions receive appropriate healthy lifestyle support services. 24

25 Ageing Well: Supporting older people to be safe, independent and well: Preventative interventions which reduce unnecessary hospital admissions for people with long term conditions and improve outcomes e.g. through falls prevention, stroke and cardiac rehabilitation. Integrating services for frail older people, ensuring that we have strong community health and care services tailored to the individual needs of older people, which minimise the need for long stays in hospitals, care homes or other institutional care. Timely diagnosis and inter-agency services for the care and support of older people with dementia and their carers Figure 16 25

26 5. Commissioning In Partnership 5.1. North East Sector Partnership Approach The CCGs in the North East Sector of Greater Manchester are: Bury Heywood, Middleton and Rochdale North Manchester, and Oldham Together, the North East Sector CCGs have established a formal partnership underpinned by a partnership agreement. This formal agreement builds on the previously established arrangements in the North East Sector, with the aim of implementing a partnership approach to the commissioning of secondary care (hospital) services. A joint Commissioning Board has been established which has authority to make decisions in the best interests of CCGs across the North East Sector and staff are working collaboratively across the sector, with a view to moving to a rapid movement to a formal pilot of the Commissioning Support Unit Operational model of sector cooperation. The North East Sector Commissioning Board is responsible for: Review, planning, procurement and performance monitoring of agreed services to meet the health needs of Members populations as follows: Acute (hospital) services, (particularly the contract with Pennine Acute Hospitals NHS Trust) Mental health services Community services Cancer services To undertake reviews of services, manage the introduction of new services, drugs and technologies and oversee the implementation of NICE (National Institute for Health and Clinical Excellence) and/or other National guidance or standards relating to the services being commissioned. To coordinate a common approach to the commissioning of services from the defined providers. To manage the budget for commissioning the agreed services, be held accountable for its use, and develop financial risk sharing arrangements. To develop, negotiate, agree, maintain and monitor service level agreements/contracts for the specified providers. 26

27 To work in partnership with other commissioners across Greater Manchester and the North West and act as lead commissioner where agreed. Principles upon which the Commissioning Board is based: The Commissioning Board will support member CCGs in working to achieve financial stability. The Commissioning Board will support Member CCGs in striving to reduce the inequalities in access to and delivery of services for the populations the Member CCGs serve. The Commissioning Board will utilise the funds made available to it by Members, commission agreed services and support its management costs in a transparent and cost effective way, ensuring that the financial risks to individual Members of unforeseen or unplanned activity are minimised. Commitments made by the Commissioning Board will be binding on all Members. In commissioning and procuring services, the Commissioning Board will support member organisations to comply with all applicable statutory duties. The Commissioning Board will review, plan, develop and monitor the agreed services in partnership with clinicians, providers and service users. The Commissioning Board will maintain close working links with service providers, clinical networks and other commissioners or commissioning groups, fora and partnerships. A standard facilitation/arbitration procedure will apply should disputes between Members arise. The North East Sector Commissioning Board (CB) is the body mandated by the four North East Sector CCGs as set out in the North East Sector Partnership Agreement. Delivery at a North East Sector Level is underpinned by two work streams Programme Level Development Boards (DB) with a focus on the development and implementation of new projects and work streams to improve health outcomes and/or the efficiency of delivering those outcomes. Operations and contracting with a focus on contract, quality and performance monitoring and taking action to address performance issues will become the responsibility of these groups. In addition, the North East Sector Commissioning Board has support teams as follows: Clinical assurance - to support systems redesign (currently CAG) 27

28 Clinical support - to support resolution of performance issues (CAG) Project management resources to ensure the delivery of system redesign work streams 28

29 Figure 17 29

30 5.2. Greater Manchester Transformational Change The Healthier Together Programme, led by NHS Greater Manchester aims to work with partners in the NHS, Local Authority and voluntary sector to co-design a clinically-led strategy that puts forward options for new ways of providing health and care services in Greater Manchester in a number of priority areas. The programme is increasingly being viewed within the context of whole system public sector reform across Greater Manchester. Clinically led work streams have been established in the following areas: Primary care Long term conditions Urgent and emergency care Acute medicine Cancer, surgery Cardiovascular disease Women and children s issues To define the case for change in each area based on quality standards, outcomes and current practice to identify the scope of programme. Formal consultation on the cases for change is due to begin in April Joint Commissioning Arrangement with the Local Authority NHS Bury Clinical Commissioning Group and Bury Local Authority have a well-established track history of jointly commissioning to secure the highest quality health and social care services to meet needs of the population within available resources. The NHS White Paper contains a vision for the future of the NHS that aims for a less insular and fragmented (NHS), that works much better across boundaries, including with local authorities and between hospitals and practices. We aim to continue with our whole systems approach to health and social care, and have joint strategic leadership arrangements with the Local Authority to ensure partnership working and to oversee joint commissioning arrangement to deliver improved outcomes for patients and better value for money in key priorities areas: Child health and wellbeing The Children s Trust Board arrangements were introduced in the Children's Act The principle behind these arrangements was that stronger partnerships, greater integration of services and a shared purpose for all those working with children, young people and families would lead to better services. These arrangements will be reviewed regularly in the light of a changing national and local picture, and our vision is that the Health & Wellbeing Board will eventually set the priorities and strategies to improve health and wellbeing across all ages. Through our joint Children s and Young People Plan 2011/14 we aim to: 30

31 Improve the lives of families with multiple needs. Ensure that all children and young people experience parenting that keeps them safe, healthy and ready to learn. Ensure that all young people make a successful transition to adulthood. Bury Safeguarding Children Board The Bury Safeguarding Children Board ensures that agencies are protecting children from harm and safeguarding their wellbeing. Bury Safeguarding Children Board (BSCB) is the forum for agreeing how services, agencies, organisations and the community safeguard children and improve their wellbeing. Mental Health and Learning Disabilities Health and Wellbeing We have well established joint commissioning arrangements for Mental Health and Learning Disabilities with joint decision making panels to ensure that appropriate packages of care are in place for all. Bury Metropolitan Borough Council's Adult Care Services Department and NHS Bury Clinical Commissioning Group are currently working with partners to co-produce a Joint Mental Health Commissioning Strategy for the borough. The strategy will outline our vision and commissioning intentions for mental health services for the future, in line with the priorities in the national mental health strategy 'No Health without Mental Health'. This strategy will be underpinned by the Mental Health and Learning Disability Plan on a Page contained within this Strategy. 31

32 6. Provider Landscape This section outlines the provider landscape within Bury identifying the key challenges facing commissioners. The provider landscape for Bury patients is made up of community and primary care, secondary acute (hospital) care, tertiary services (specialist hospital services), the Ambulance Trust, mental health and independent and third sector providers (such as Spire Hospitals). Figure 18 (below) summarises NHS Bury Clinical Commissioning Group providers and the current proportionate investment into the relevant provider services Secondary Care The majority of our secondary care activity (78%) is undertaken by the Pennine Acute Hospitals NHS Trust. The Trust is based across four sites; Fairfield General Hospital, Oldham, North Manchester and Rochdale. This configuration was reviewed through the Healthy Futures Programme, resulting in major reconfiguration: Centralisation of inpatient vascular services to the Royal Oldham Hospital Transfer of acute surgery from Rochdale Infirmary to the Royal Oldham Hospital Planned day case surgery from the Royal Oldham to Rochdale Infirmary Transfer of acute surgery from Fairfield General Hospital to North Manchester General Hospital Planned surgery from North Manchester General Hospital to Fairfield General Hospital Centralisation of inpatient breast services to North Manchester General Hospital 32

33 Emergency orthopaedics from Fairfield General Hospital to North Manchester General Hospital Transfer of elective orthopaedics from North Manchester General Hospital to Fairfield General Hospital More positive change will result from the Healthier Together review (Section 6.2.Greater Manchester Transformational Change). The challenge for NHS Bury Clinical Commissioning Group and local providers is to enhance services for local residents whilst enabling these moves within the defined timescales. NHS Bury Clinical Commissioning Group continues to prioritise the urgent care agenda and in particular accident and emergency attendances and non-elective (unplanned/emergency) admissions. Accident and emergency attendances have reduced year on year since 2009/10, and non-elective admissions have seen a reduction of over 200 during 2011/12. These improvements are also aligned to the successful achievement of the 95% A&E 4 hours target, an achievement attained through whole system coordination and joint working. This reduction has been underpinned by the successful reablement pilot implemented through the Local Authority and the Pennine Care NHS Foundation Trust. The re-ablement service. Children s inpatient secondary care services are commissioned from a number of Trusts. A paediatric observation and assessment unit at Fairfield General Hospital (within Pennine Acute Hospitals NHS Trust) delivers up to six hours of care to children and young people that do not require a hospital admission. Inpatient facilities are delivered on the Oldham and North Manchester Pennine Acute sites, and specialist services are delivered at Central Manchester NHS Foundation Trust. However, a review of commissioning arrangements for paediatric inpatient facilities is required due to the increasing number of admissions and attendances at the Royal Bolton Foundation Hospital Trust Independent Sector Provision Greater Manchester is participating in the Phase 2 of the national independent sector contract between the Secretary of State for Health and independent sector providers (in this case Care UK). The national independent sector programme aims to help provide the extra clinical capacity needed to deliver swift access to treatment for NHS patients; spearhead diversity and choice in clinical services for NHS patients; stimulate innovative models of service delivery and drive up productivity. The contract with Care UK is a seven year contract which commenced in February Services are provided from mobile clinical units which visit sites in Bolton, Denton, Longsight, Oldham, Rochdale, Salford and Trafford. The Clinical Assessment and Treatment Service, also known as CATS, provides a full clinical assessment of patients and subsequent treatment or onward referral to secondary (hospital) care where this is indicated. Five specialties are provided, these are: general surgery, ear, nose and throat, musculoskeletal (muscles and bones), gynaecology and urology. The contract provides for an average of 85,000 referrals every year. 33

34 Care UK continue to perform well in terms of national and local quality performance indicators where they are monitored against 35 individual Key Performance Indicators including clinical quality and treatment by timeframes. In addition, local independent sector providers are available as a choice for patients through Choose and Book (an electronic booking system) as an alternative to traditional secondary care (hospital) providers. Figure 19 below shows the split of provider on the basis of patient choice for their first booking. Figure Mental Health Pennine Care NHS Foundation Trust is the main provider of inpatient and community services for NHS Bury Clinical Commissioning Group s population. Mental health commissioning is undertaken through a joint commissioning arrangement, managed through the Mental Health Partnership Board acting on behalf of NHS Bury Clinical Commissioning Group and Bury Metropolitan Borough Council. This is led by the Director of Adult Care Services. Primary care based mental health services have seen substantial expansion and investment over the last four years, with additional Clinical Psychologists employed, as well as the development of a Primary Care Mental Health Team. Currently, there is a lack of robust activity information for mental health services, which requires the majority of the services to be commissioned as a block contract. Block contracts make modernisation of services across pathways of care more challenging. NHS Bury Clinical Commissioning Group is moving to a currency model for mental health (in line with national policy), following a recent benchmarking exercise. We have increased the information requirements within the contracts to assist planning for future years. In addition, we are using national programmes such as Choice of mental health provider as a level for change. 34