Bristol Clinical Commissioning Group. Operational plan 2014 to refresh

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1 Bristol Clinical Commissioning Group Operational plan 2014 to refresh 1

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3 CONTENTS Page Foreword 5 1 Introduction 6 Who we are 6 Our responsibilities 6 Purpose of Document 7 CCG vision 7 Our Principles 7 Strategic Priorities 7 Our commissioning intentions 8 How we make decisions 9 2 Plan on a Page Refresh 10 SECTION 1 Setting the scene for our plans 11 3 Background 11 Local Context 11 Bristol locality groups 11 Our main providers 12 National context 12 NHS strategic ambitions /15 successes and achievements 13 4 Developing 2015/16 priorities Gaining views on our 2015/16 priorities Financial context for our plans Health outcomes and health inequalities Benchmarking Performance Demand and capacity modelling Local issues for 2015/ Section 1 - Summary 49 SECTION 2 Capacity to deliver change 50 5 Building capacity to deliver change Primary Care Co-commissioning System Working Capacity and capability: programme management 53 SECTION 3 New Models of Care 54 6 Bristol Model of Care and Support Developing a new model of care Principles for developing models of care Information Technology strategy Workforce 58 SECTION 4 Our Delivery Programmes 59 7 Our Delivery Programme 59 3

4 7.1 The Planning Process and Governance Summary delivery programme Our QIPP Plans (Quality, Innovation, Productivity and Prevention) Cross cutting programmes Prevention Health inequalities Self-care Better Care Programme including personalisation Delivery Programmes: Steering groups Urgent care Long Term Conditions End of Life Care Planned care Mental health Learning disabilities Cancer Dementia, care homes and carers support Children s Maternity Medicines management Quality 107 Specific patient safety focused work 112 Patient experience 116 Evidence and Research Staff Health and Wellbeing Sustainability Risks and Mitigations for Plans Appendices 123 Glossary 4

5 Foreword I am pleased, as Clinical Chair of Bristol Clinical Commissioning Group, to be able to share our 2015/16 refresh of our five year and operational plan. This is the plan for the second year of delivery of our Five Year Strategic Plan. We have taken the opportunity this year to carry out a significant refresh. The Five Year Forward View has provided a useful challenge and driver to consider how we can work with our partners to deliver our vision for Better Health and Sustainable Healthcare for Bristol. I am clear that, despite the hard work and achievements of 2014/15, there is still much to do to improve outcomes and remove inequalities of outcomes for the people of Bristol. In many ways 2015/16 will be a very challenging year, both in terms of delivering against our financial challenge and tackling some entrenched performance issues, working with our providers and others in the system. I recognise the need to focus this year on these key priorities and to deliver high quality care within the resources available for the population we serve. I am clear that we can only do this through strong partnership working and Bristol CCG intends to play a full role in the system leadership required across health and social care, the voluntary sector and with patients and the public. Despite our challenges in 2015/16, it is really important that we do not lose sight of the need to make some radical changes to how we commission and design services for our population for the future. There will be increasing demands on our services and a continued financial challenge. I believe that self-care, prevention of ill health and promoting health and wellbeing are key to this, as well as innovative ways of working and delivering care. We are a clinically led organisation, and I am proud to say there are already exciting examples where GP primary care colleagues are working alongside community health and social care staff and acute clinicians to work in new ways at a local level, joining up services and putting patients at the centre of care. We will build on those examples and develop a model of care for Bristol that works at an individual, neighbourhood, community and cross Bristol level. I look forward to speaking and working with individuals and organisations in Bristol to deliver our plan for 2015/16. Dr Martin Jones Clinical Chair Bristol Clinical Commissioning Group 5

6 1 Introduction Who we are Bristol Clinical Commissioning Group is the organisation with responsibility for commissioning health services for the population of Bristol. We became a statutory organisation in April 2013, following authorisation by NHS England. We are a clinically led organisation of 55 GP practices. These practices are grouped into localities reflecting the distinct local needs and ambitions. A Governing Body oversees the organisation. Our responsibilities We are responsible for commissioning health care services to meet the reasonable needs of patients registered with Bristol general practices and unregistered patients living in the area, except for those services that the local authority or NHS England are responsible for commissioning, such as general practice and very specialised services. We are also responsible for commissioning services that will provide an emergency response to anyone present in the local area who needs it. In practice, we work very closely with NHS England (NHSE), Bristol City Council, providers of care, neighbouring CCGs (often referred to as BNSSG Bristol, North Somerset and South Gloucestershire), the patients and the public to ensure services in the health and social care system are joined up for the benefit of the communities and individuals we serve. The areas for which we are responsible include: Community health services such as district nurses, rehabilitation services, mental health, community services for children and young people Continuing health care Maternity services Services provided by hospitals including urgent and planned care Other urgent care services such as ambulance and GP out of hours services In 2015/16 we have applied to take on a Joint Commissioning role with NHSE which will allow us work with them to shape and deliver the primary care strategy and ensure better integration of plans and of services. This means we will form a Joint Committee with NHSE locally to make decisions about primary care commissioning. The scope for co-commissioning would be for primary medical care only (i.e. not dentists, pharmacies or opticians). 6

7 Purpose of document The purpose of this document is to set out our 2015/16 operational plan, year two of our refreshed five year strategy. This plan will address the approach we are taking to fulfil the vision set out in the NHS Five Year Forward View, whilst delivering the operational requirements for this year. We are doing this in the context of our delivery in 2014/15 and any additional issues or strategic requirements that have emerged since we set out our Five Year Strategy, including feedback from the public, patients, our members and partners in the health and social care system. CCG Vision Our vision as outlined in our Five Year Strategy is Better Health and Sustainable Healthcare for Bristol Our vision and strategic priorities are developed in line with the Health and Well Being Board s overarching health themes for Bristol; that it is a city: Filled with healthy, safe and sustainable communities and places Where health and well-being are improving Where health inequalities are reducing Where people get high quality support when and where they need it Our Principles We have 5 principles which will drive how we deliver our vision Clinically led Embracing the diversity of our communities Open and responsive Patients at the heart of all our decisions Working with partners across boundaries Strategic priorities In 2014/15 we reviewed the information we had about the needs and outcomes for our population. This was outlined in detail in our Five Year plan (2014/15 operational plan) and helped us to develop our strategic priorities as follows: Long term conditions: care closer to home Earlier cancer diagnosis Improved vascular outcomes (vascular disease is caused by inflammation and weakness of the veins and arteries) Managing growing demand for children s services 7

8 Understand and address inequalities in health Modernising mental health services Integrated working across health, social care and voluntary sectors These still stand but further work this year suggests we also need to prioritise: Joint work with partners on the alcohol strategy and other key preventative strategies and services Self-care, working with individuals, communities and providers Developing new ways of working and models of working, including primary care Personalisation of care Integration of services and care coordination These priorities all need to be addressed in the context of delivery of the NHS Constitutional standards and this requires us, in 2015/16, to: Deliver system performance Close the financial gap (ensure financial stability) Reduce unnecessary delays and waits Improve our achievement of key outcomes Reduce unnecessary variation Our commissioning intentions The CCG s commissioning plan will need to be affordable within the available resource and compliant with the national financial framework. It is important to note that the financial pressures are likely to be recurring and will therefore impact on the amount of resource available for investment in new priorities. We will also focus on tackling the delays for patients that result from the challenges to capacity and demand within our system. We expect to work collaboratively with our key providers and other partners to deliver a system that meets quality standards, is financially viable, based on robust research and evaluation evidence and is sustainable. This involves addressing the needs of our population and the best interests of the local health and social care system as a whole and its long term future. The focus of the CCG s commissioning intentions for 2015/16 are: to work with partners to develop those schemes which are designed to support our performance and financial challenge and the required whole system transformation and integration of services 8

9 to align our delivery programmes, such as urgent care, to the work we do with partners as part of the Better Care Programme (BCP) to achieve the key outcomes of a reduction in emergency admissions and days spent in the acute hospitals to strengthen approaches to self-care and personalisation of care to focus on reducing health inequalities and the needs of protected groups within our communities through meeting our public sector equality duty obligations. How we make decisions The CCG is a membership organisation which means that the local General Practices are all involved in making decisions about how we allocate funding. Our Governing Board includes clinicians, managers and lay representatives and ensures that decisions are made fairly and transparently. To support this process, we have a published prioritisation framework which looks at the following areas: National alignment ensuring we address the outcomes and standards we are expected to deliver Local alignment ensuring we address our strategic priorities, identified need and the views of patients and the population Outcomes improving outcomes important to patients and for the better utilisation of the health care system Scale of impact assessing the numbers of people affected Health inequalities addressing the gap in health and/or life expectancy Quality of evidence being clear about the robustness of the evidence for our proposals Process being clear how much they add to integration and are practical Sustainability addressing our sustainability objectives The outcome of this process is assured through a financial framework to ensure value for money. 9

10 Bristol Clinical Commissioning Group Plan on a Page 2015/16 Our principles Our mission Better Health and Sustainable Healthcare for Bristol Clinically led Embracing the diversity of our communities Open and responsive Patients at the heart of our all our decisions Working with partners across boundaries Our strategic priorities (5 year plan) Long term conditions: Care closer to home Earlier Cancer Diagnosis Improved vascular outcomes Managing growing demand for children s services Understand and address inequalities in health Modernise mental health services Integrated working across health, social care and voluntary sectors Additional 2015/16 priority areas: Alcohol and other key preventative strategies Self-care Personalisation of care Urgent care Planned care Long term conditions Mental health and Learning disabilities Cancer Dementia and care homes End of Life Care Children s and maternity Medicines management Key delivery programmes Deliver 4 hour target, GP support unit implementation at NBT; ambulatory care; reduced length of stay and delayed transfers of care Deliver referral to treatment targets, Referrals management support; Coding and data changes; DVT, Musculo Skeletal, ophthalmology pathways; Diabetes integrated model, reduced amputations, CVD and respiratory pathway; House of Care model of support Increased IAPT access and recovery rates; reduced out of area placements, delivery of parity of esteem targets, new LD pathway of care Deliver performance targets for diagnosis and treatment, Develop survivorship service proposal and early diagnosis; Deliver increase in diagnosis rates, dementia in reach and safe haven beds; care home support team; dementia wellbeing service End of life care coordination, anticipatory prescribing Recommissioned children s community service, improved mental health services, maternity services and pathways review Medicines optimisation, cost effective, quality prescribing schemes and waste reduction Focus for 2015/16 operational plan Deliver performance (NHS Constitution) Close the financial gap (ensure financial stability) Reduce unnecessary delays and waits Improve our achievement of key outcomes Reduce unnecessary variation Improve system resilience Cross cutting programmes 2015/16 Out of hospital model of care and support Better Care Programme Health inequalities 10 Prevention Self-care

11 SECTION 1 Setting the scene for our plans 3 Background Local context Bristol is the largest city in the South West and the seventh largest in the country. The resident population of Bristol CCG is 432,500. This population is served by a total of 55 GP practices. These practices are grouped into localities reflecting the distinct local needs and ambitions. Bristol Locality Groups NHS Bristol Clinical Commissioning Group (CCG) is based on three groupings of member practices: 11

12 Bristol South Locality Group Inner City and East Locality Group North and West Bristol Locality Group These groups are based on natural geographical boundaries, broadly matching the ward and neighbourhood partnership boundaries within Bristol City Council. In January 2011 the three Locality Groups agreed to form a single Bristol wide CCG. The locality group allows: local involvement of practices sharing similar populations and natural patient flows in the commissioning process meaningful engagement with and influence of the Joint Strategic Needs Assessment opportunity to link with community groups local patient and public involvement Our main providers The main providers from whom we commission care are: University Hospitals Bristol NHS Foundation Trust (UHB) North Bristol Trust (NBT) Bristol Community Health (BCH) South West Ambulance Service NHS Foundation Trust (SWASFT) Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) National Context The NHS Five Year Forward View was published on 23 October This sets out a vision for the future of the NHS and how it can meet the healthcare needs of the future. The document talks about the need for an increased focus on prevention, a focus on new models of care accompanied by the workforce and technology to support radical change and new partnerships with patients, communities and the voluntary sector. The Forward View into Action: Planning for 2015/16 contains the operational detail required for CCGs to develop their plans and to make a start in 2015/16 towards fulfilling the vision set out in the NHS Five Year Forward View. 12

13 The Better Care Fund, known in Bristol as the Better Care Programme (BCP), is about improving the quality of health and social care available to the public. It is about moving away from a sickness service, and towards one that enables people to live independent and healthy lives in the community for as long as possible by joining up services around the individual person and their individual needs. The requirements of the NHS Mandate and the NHS Outcomes Framework set out the outcomes that will be used to monitor health improvements in local populations. NHS strategic ambitions The seven ambitions for the NHS 2014/15 to 2018/19 which we will be seeking to address in our plans are: Securing additional years of life for the people of England with treatable mental and physical health conditions Improving the health related quality of life of the 15 million+ people with one or more long-term conditions, including mental health conditions Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital Increasing the number of people with mental and physical health conditions having a positive experience of hospital care Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in general practice and in the community Making significant progress towards eliminating avoidable death in hospitals caused by problems in care The additional three key measures identified in 2014/15 by NHS England were: Improving health by working closely with Public Health and through Health and Wellbeing Boards Reducing Health Inequalities Moving towards a parity of esteem around Mental Health 2014/15 successes and achievements In 2014/15 we established 11 delivery themes with agreed outcomes, a work programme and clinical leadership. Despite a challenging year in terms of performance, there have been achievements and foundations laid for work to be completed in 2015/16. Our planned interventions were outlined in Chapter 6 of our 2014/15 operational plan and five year strategy. Key achievements include: 13

14 Delivery of financial balance Delivery of enhanced services to care homes A clear model for supporting those with Long Term Conditions to be implemented from 2015/16 Development of our self-care strategy and implementation of elements of that strategy Support for carers Improved services for people with dementia Better utilisation of the Independent Treatment Centre for planned surgery Further development of support for GPs to refer to the right place first time for planned care and continued management of demand on acute services Recommissioned mental health services using an innovative service model and wide range of providers including the voluntary sector Establishment of Community Discharge Coordination Centres in both UHB and NBT The Section 136 suite is now accessible to all children and young people, including 16 year olds and under to provide an appropriate place for assessment and avoid the use of Police cells. More efficient use and management of medicines BPCAg The Bristol Primary Care Agreement, practices working together to support care closer to home for older people and those with Long Term Conditions Close whole system partnership working with the Better Care Programme Board 4 Developing 2015/16 priorities This is the second year of implementation of our five year strategy. We have taken this opportunity to reassess our context, performance, key priorities, programmes of work and mechanisms for delivery. 4.1 Gaining views on our 2015/16 commissioning intentions Feedback from patients, service users, carers and members of the public about local health services is a key building block in developing our commissioning plans. This information comes from a variety of sources, and in a range of different ways. For example, complaints and concerns from patients about their experience of local health services; involvement activities organised by the CCG to inform changes and developments to local health services; the specific opportunities provided for local people to comment on our commissioning plans and feedback provided by local people to partners such as Bristol Healthwatch. 14

15 The CCG has a patient and public involvement strategy which describes, in more detail, the arrangements that the CCG makes for ensuring that the views of local people actively contribute to, and inform the development of, our commissioning processes. Here is the link to the strategy: t_strategy.pdf The following is a list of some of the patient and public involvement source documents containing feedback from local people that we have drawn on in preparing our commissioning plans. Re-commissioning adult community health services pdf Re-commissioning children s community health services and child and adolescent mental health services t_1.pdf Re-commissioning adult mental health services Bristol-Final-Engagement-Report1-1-.pdf FINAL.pdf Involvement in commissioning We also involve service users directly in commissioning and redesign of services, including: We are setting up monitoring groups for all the new services and have written job descriptions and requested representatives from Bristol Independent MH Network (a service user forum group we fund and support through our service user development worker). We will be running regular service user monitoring visits with service user to service user monitoring of all services commissioned in Mental Health. There are Key Performance Indicators relating to service user involvement in all the new services. The system leadership has a service user and carer board and a service user director 15

16 post. All working groups including Crisis Concordat and street triage have service user representation. The cancer steering group has both service user and carer members on the group The children s steering group invited Bristol Parent Carers to nominate representatives to join their steering group. This organisation is commissioned by the local authority to seek out and represent the views of parents and carers, particularly those whose views are seldom heard. The maternity services steering group is fortunate in being able to work closely with members of Maternity Voices the local maternity services liaison committee. Process Our 14/15 plans and five year strategy outline the views expressed by the public, voluntary sector and member practices in relation to our plans. These views have also been taken into account when developing our 2015/16 plans but we have also carried out consultation specific to the commissioning intentions for this year and gained useful feedback. In October, we issued a set of high level commissioning intentions refreshed to include any new priorities including the impact of the Better Care Fund. This was followed swiftly by the release of the Five Year Forward View and co-commissioning guidance. Our intentions and our assessment of the opportunities for Bristol within the Five Year Forward View were then used as a basis for initial conversations with members, providers (Including the voluntary sector), partners in the Health and Wellbeing Board and the public. We published our intentions on our website and via a leaflet. We facilitated discussions at a number of events and meetings including those organised by Healthwatch and Care Forum (voluntary sector) and the Health and Wellbeing Board (HWB). An extraordinary meeting was also organised with the HWB to review the opportunities for closer working in Bristol, offered within the Five Year Forward View. This included healthcare providers across Bristol. Discussion of our commissioning intentions was a significant part of our annual members event and there was an opportunity to review progress, the context and prioritise areas for 2015/16. Our clinically led steering groups were also asked to review and reflect on priorities and identify any changes that should be made in their proposed programmes for 2015/16. This included input from public health leads who sit on those groups. This information was then fed into the Governing Body seminar and public discussions on priorities for 2015//16. The table below summarises the issues raised by member practices, the public and the voluntary sector. 16

17 Issue Members Public Voluntary sector Integration x x x Improved Communication x x x Sharing information electronically x x x Better coordination x x x Clear plans that are shared and co-developed x x Prevention given more emphasis and more transparency of public health plans x x Reduce waits x x x Improve access to GPs/reduce pressure on GPs x x x Social prescribing/access to information and/or non-medical health and wellbeing services x x x More care closer to home (End of Life Care and Long Term Conditions) x x x Work with communities to deliver consistent selfcare messages x x Carers support x x Detailed feedback has been shared with the relevant delivery groups to inform their plans. 4.2 Financial context for our plans The financial plan is a refresh of year two of the previously published operational plan. The plan has been updated for revised resource allocations received, updated financial and activity modelling to deliver targets, local and national priorities and reflects other cost pressures that have been identified during 2014/15. 17

18 Bristol CCG has worked closely with health and Social Care commissioning partners and providers to ensure that the assumptions in our financial plans are communicated and aligned and to ensure the activity and financial plans are also aligned. Contracts with our providers and budgets are currently under negotiation. The national deadline for agreement of contracts is 31 st March. Financial Plan Key Headlines and Assumptions Bristol CCG received an additional allocation of 17m compared with the original 2015/16 plan, resulting in total growth of 27.3million. This allocation includes a recurrent element of 2.8million for operational resilience and capacity planning (ORCP) funding Bristol CCG has moved from a distance from target(dft) allocation of -4.42% to -2.83% (this is discussed in more detail below) The plan assumes return of surplus of 6.4m from 2014/15. This is higher than our planned surplus ( 5.2m) due to a rebate of 1.2m in relation to the CHC retrospective claims national risk pool. The financial plan is compliant with the NHS business rules of 1% surplus, 0.5% contingency, and 1% non-recurrent headroom. In negotiation with NHS England Bristol CCG is planning to deliver an increased surplus of 1.2% for 2015/16. CCG running costs budgets are within the Running Cost Allowance (RCA) of m. This includes a 10% reduction since 2014/15. Population growth of 1.1% has been included across the plan. This has been based on ONS estimates and has been validated by more detailed modelling. However, following national guidance non elective activity growth was increased to 3.6%. Delivery of the financial targets requires a net QIPP target of 23.6 million. This amounts to 4.2% of the total CCG allocation. The main drivers of the QIPP requirement are cost pressures of up to 7 million and service developments of 20.8 million. The most significant elements of this is the 18

19 funding required to achieve NHS Constitutional standards for Referral to Treatment and activity and contract disaggregation issues in mental health. Detailed work is being undertaken to validate and mitigate these pressures. Resource allocation Bristol CCG has received total funds of million. This includes 10.2million for CCG running costs and an assumption of 2.1million for capital grants. Bristol CCG has received an additional allocation of 17m since the previous planning assumptions were produced for 2015/16 bringing growth funding to 27 million. Target funding for CCGs are calculated based on population, age, geographical cost factors and deprivation. The indicative allocations for 2015/16 published in December 2013, showed that Bristol CCG was 23.9m or 4.42% below its target allocation. The NHS England policy, set out in the allocation paper from December, is to move organisations towards target as quickly as possible. This is because NHS England sees a clear relationship between over spending organisations and under target organisations Following the latest allocation, Bristol CCG is now 15.6m or 2.83% below its target allocation. CCG Additional Growth Original DFT Revised DFT ( m) Bristol % -2.83% North Somerset % -3.50% Somerset % -0.98% South Glos % -5.71% Total % -2.69% Summary Financial Plan Below is the Sources and application of funds statement. It can be seen that the planned applications and commitments of million exceed the sources by 23.6 million. The gap is funded by QIPP schemes which are planned to reduce expenditure by 17.0 million and there is 6.6 million of unidentified QIPP savings. The Total QIPP requirement of 23.6 million amounts to 4.2% of the CCG allocation. Although this percentage is in line with the South West Regional average for draft plans it is still in excess of what has previously been delivered in Bristol CCG. 19

20 The reason for the QIPP requirement is that the draft plan includes cost pressures of 7 million and 20.8 million of service developments. The largest component of these service developments is 11.1 million that is needed to commission additional acute services activity to reduce waiting times and deliver the Referral to Treatment target. In addition there are significant cost pressures on Mental Health. Further work is ongoing with providers to validate and mitigate the cost pressures, with the aim of reducing the overall QIPP target as well as agreeing realistic delivery plans. Further work is also ongoing to develop detailed QIPP plans to deliver the QIPP target. A summary of the QIPP programme for 2015/16 is shown at Appendix 5. 20

21 Sources Recurrent Non-Recurrent Total 14/15 Baseline Allocation Running Cost allocation Growth Winter Resilience funding Return of Headroom allocation from 2013/ Better Care Fund ETO allocation Return of Surplus Capital Grants Total Sources Applications Recurring expenditure Recurrent QIPP /15 Outturn pressures Running Costs CQUINs achieved / Prior Year CQUIN CQUIN provision Better Care Fund Cost Pressures Service Developments Non-Demographic Growth Demographic Growth Inflation Efficiency Reserves 0.5% Committed Uncommitted Total Headroom Reserve Subtotal reserves Commitments against reserves accounted for as service developments / cost pressures Total Planned Applications Total QIPP Total Planned Applications post-qipp % The table below shows the current draft application across the main budget areas. 21

22 2015/16 Area Budget Acute and Specialist Care Community Services 63.0 Continuing Healthcare 27.4 Medicines Management 66.0 Mental Health and Learning Disabilities 71.6 Primary Care Contracting 7.0 Support Costs 3.4 Urgent Care (Out of Hours) Services 6.7 Running Costs 10.2 Reserves Managed Programmes and Headroom 4.5 Contingency reserve 2.8 QIPP Surplus 6.9 Grand Total

23 4.3 Health outcomes and health inequalities The Bristol population Bristol has a resident population of 432,500 (mid 2012 ONS estimate), with 80,700 children under 16 (18.6% of the population), a working age (16-64 yr. olds) population of 294,600 people (68.1%), and 57,200 older people over 65 (13.2%). This is a significantly younger age profile than the national average which can be seen in the population pyramid charts below: Population Pyramid Mid-2013 Bristol, City of age Female Male 0 6,000 4,000 2, ,000 4,000 6,000 population Median age is 33.5 count 23

24 Deprivation is higher than the national average with 60,665 people in Bristol living in areas that are amongst the most deprived 10% in England and 1,630 people living in the most deprived 1% of areas in England. Nearly 20,000 children live in poverty. Half of Bristol s population lives in areas that are in the 40% most deprived parts of England. 35% 30% 25% Bristol 20% 15% 10% 5% 0% ONS Quintile 1 (most deprived) Quintile 5 (least deprived) 16% of the Bristol population (68,640) describe their ethnicity as black or minority ethnic (BME), higher than the 14% average for England & Wales, and increased significantly from 8.2% in Across the city, by CCG locality, the BME population ranges from 7.4% in South Bristol and 12.1% in North & West to 30.6% in Inner City & Bristol East locality (shown separately as 21% East & 40% in the Inner City). Within Bristol s over 65 year old population, only 5.2% (2,930 people) are from BME groups, compared to the all-age average of 16%, and for children (0-15), the Bristol average is 27.8% BME. 24

25 Health in Bristol The population of Bristol, in general, has worse health outcomes than that of England overall. The Bristol Joint Strategic Needs Assessment has provided us with a refreshed review of the needs of the population of Bristol. Key headlines are: Life expectancy in general is rising but people are spending longer living in poor health Inequalities in life expectancy still persist in Bristol 25

26 By gender, there are different patterns of health outcomes, core outcomes for men are worst in the inner city and for women in outer North and West of Bristol We expect the population to grow by 10% by The number of children is expected to grow by 15% and older people by 14%. The health of the children in Bristol reinforces patterns of health inequalities that we see in adults The key wider determinants that we know affect health outcomes are as follows in Bristol: The difference in the number of children living in poverty is almost 10 fold between areas There has been a rise in the number of children in social care and with Special Educational needs. Long term conditions: Primary care data for Long Term Conditions shows higher numbers recorded in Bristol South and outer North and West for most conditions and some in inner city. People in Bristol with Learning Disabilities have an increased number of health conditions and significantly worse health profile 16.7% of the Bristol population have a limiting long-term illness or disability which is lower than national (17.9%) There has been some improvement in the lifestyle factors that affect the health of the people of Bristol, for instance overall smoking prevalence is falling, but: Only 1 in 3 people in Bristol take regular exercise Adult obesity is increasing (around two thirds of residents are obese or overweight) Alcohol remains a significant issue in Bristol. There has been a rise in alcohol related hospital admissions for women, increased alcohol problems for older people and high rates of alcohol specific hospital admissions and premature mortality (liver disease) amongst men. 26

27 Public Health Outcomes Framework 2014 ( Overarching indicators Life expectancy at birth in Bristol is similar to national levels for females, but significantly worse for males (78.3 years males, years females). However, both male and female life expectancy does continue to rise. For healthy life expectancy at birth Bristol s figures are lower than England average but are not significantly different. There is an 8.4 year gap for males between the most deprived and most affluent areas in Bristol, for females it is 4.9 years. Wider determinants of health Compared to England, Bristol does not perform particularly well on these outcomes; in particular, many related to childhood children in poverty, pupil absence, first time entrants to the justice system and year olds not in education, employment or training. Health Improvement Bristol s outcomes are mainly similar to England, however a number of outcomes are significantly worse: breast and cervical cancer screening rates are worse than the England average and are showing no sign of either improving. NHS Health Check rates are also lower. Bristol performs significantly worse than England for hospital admissions for injuries due to falls both for people aged and people aged over 80. Although 27

28 hospital admissions for falls are high, hip fractures for the same age groups are lower in Bristol than in England as a whole. Health Protection Bristol is significantly worse than England for uptake of a number of key vaccinations (see glossary) Hib/Men C booster in 2 and 5 year olds, MMR, HPV and flu vaccination for at risk individuals. Flu vaccinations for people aged 65yrs+ are significantly better than England. Healthcare and premature mortality Bristol s premature mortality (under 75s) is worse than England for some causes, although overall premature mortality is falling. Premature cancer mortality, in particular for males, is significantly worse than England and shows no sign of catching up with the national average. Also premature mortality due to liver disease, in particular in males, is significantly worse than England. PYLL amenable to healthcare Although Bristol is not above benchmark on PYLL due to coronary heart disease, these conditions cause about a third (32%) of all PYLL in Bristol. Stroke accounts for a further 11%, so these vascular causes account for 43% overall. Further improvements on the current positive trend in cardiovascular PYLL will be needed to reduce the total burden of PYLL in Bristol, given that these causes account for such a large proportion of PYLL amenable to healthcare. PHE modelled PYLL amenable to healthcare, Bristol CCG 28

29 The stack graph shows that the directly standardised rate of PYLL amenable to healthcare in Bristol is higher than the rate for England. Pneumonias contribute approximately 7% of PYLL amenable to healthcare in Bristol a much smaller contribution than cardiovascular disease and cancers. Projections by Public Health England (PHE) suggest that PYLL due to pneumonia are reducing very slowly and not nearly as quickly as England trajectory, i.e. the gap is widening. The rate is higher than expected, compared with England, but there is more statistical uncertainty around the modelled projections between now and 2018, given relatively smaller numbers involved. The key preventive approaches to reducing PYLL in Bristol include primary, secondary and tertiary prevention of harm from smoking, alcohol, lack of physical activity and poor diets. Early diagnosis of cancers and increased identification and management of cardiovascular risk factors are key secondary preventive actions. The CCG Plan includes action to address these at city and locality levels, with targeting of high need groups. We have an agreed PYLL Quality Premium Prevention plan and governance structure to support progress and monitor improvements. We also propose a much stronger oversight of premature mortality including PYLL via the HWB and are considering our approach with public health. This approach includes those new indicators outlined within the 2015/16 framework. Health inequalities within Bristol Inequalities within Bristol in health-related indicators, disease prevalence and in health outcomes at CCG locality and sub-locality level are summarised in and the graph and tables below. 29

30 Determinants of Health Inner City and East Inner City and East (Inner City) Inner City and East (East) North and West North and West (inner) North and West (outer ) South Bristol 1 Deprivation Smoking at the time of delivery Breastfeeding continuation 5 A* to C GCSEs Children in poverty Not in employment, education or training Out of work claimants Disability claimants Regular cycling Fruit and veg consumption Regular exercise Elderly living alone Smoking households

31 Health outcomes Inner City and East Inner City and East (Inner City) Inner City and East (East) North and West North and West (inner) North and West (outer) South Bristol 14 Male Life Expectancy Female Life Expectancy Premature Mortality Cancer mortality CHD mortality Respiratory 19 disease mortality 20 Childhood overweight and obesity (yr ) 21 Adult overweight and obese 22 Teenage conceptions Low birth weight Bad or very bad health Limiting Long Term Illness Alcohol admissions Stroke admissions CHD admissions Respiratory illness admissions The table below explains the indicators used in the two tables above. 31

32 1 Average ward rank within Bristol (out of 35) for IMD 2010 income component. 2 Mothers smoking at the time of delivery (% of all maternities - Local NHS maternity providers), Children totally or partially breastfed at 6 8 weeks (% of all children with valid status recorded - Child health records), KS4 Pupils achieving 5 A* to C grade GCSEs or equivalent - % of all KS4 children (Bristol City Council), % Population aged 0-15 living in income deprived households (IDACI index 2010) 6 Young people aged 16 to 18yrs not in education, employment or training - % of population 16-18yrs (Connexions), % of Working Age Population Claiming as Job Seekers (Dept of Work and Pensions), Feb % of Working Age Population Claiming Benefits for Disability (Dept of Work and Pensions), Feb Percent respondents who ride a bicycle at least once a week (Bristol Quality of Life Survey), Percent respondents who have 5+ portions of fruit or veg per day (Bristol Quality of Life Survey), Percent respondents taking exercise at least 5 times a week (Bristol Quality of Life Survey), % of population aged 65yrs and over who live alone, Census Percentage of respondents who live in households with a smoker (Bristol Quality of Life Survey), Life expectancy at birth for males, in years, Life expectancy at birth for females, in years, Deaths from all causes, under 75 years, standardised mortality ratio (SMR >100 above average expected) 17 Deaths from all cancer, under 75 years, standardised mortality ratio (SMR >100 above average expected), Deaths from coronary heart disease, under 75 years, standardised mortality ratio (SMR >100 above average expected), Deaths from respiratory diseases, all ages, standardised mortality ratio (SMR >100 above average expected), National Child Measurement Programme School Year Results - Year 6 Overweight and Very Overweight % (NCMP), 2012/13 21 Percent of respondents who are overweight and obese (Bristol Quality of Life Survey), Teenage conception rate per 1,000 (females 15-17yrs) - Teenage Pregnancy Unit (ONS), Low birthweight births (<2500g) - % of all livebirths (ONS), % of people in bad or very bad health (Census 2011) 25 % of people who had a limiting long-term illness or disability (Census 2011) 26 Alcohol-attributable admissions rate per 1,000 population aged over 16yrs (Hospital Episode Statistics), 2010/11 27 Emergency hospital admissions for stroke - Standardised admission ratio (SAR >100 above average expected), 2006/ /11 28 Emergency hospital admissions for coronary heart disease - Standardised admission ratio (SAR >100 above average expected), 2006/ /11 29 Emergency hospital admissions for respiratory illness - Standardised admission ratio (SAR >100 above average expected), 2006/ /11. 32

33 Long Term Conditions People with Long-term health problems or Disability 16.7% of the Bristol population have a limiting long-term illness or disability (71,700 people), lower than the 17.9% national average. Locally, 8.1% (34,600 people) state their daily activities are limited a lot. % people (all ages) with a Long-term health problem or Disability (2011) - CCG sub-locality areas 4.6% 6.5% 6.7% 7.2% 8.1% 9.1% 9.6% 10.0% 8.7% 9.5% 9.7% 9.8% % Daily activities limited a lot % Daily activities limited a little N & W (inner) Inner City Bristol average Bristol East South N & W (outer) The chart (split by a lot and little ) highlights that within Bristol this varies from 11.3% in North & West (inner) to almost 1 in 5 people in North & West (outer) (19.8%) & South (19.3%). The map shows the total percentage by Bristol ward. Source: ONS 2011 Census Numbers of people with a Long-term health problem or Disability (2011) - CCG Locality 30,000 25, Daily activities limited a lot 20, Daily activities limited a little 15, Daily activities limited a lot 10, Daily activities limited a little 5, Daily activities limited a lot 0 Inner City & East South North & West 0-15 Daily activities limited a little Further analysis by age highlights: Half are working age adults (51%), and 45% are older people over 65; another 4% are children. 33

34 South has the highest number with a long-term health problem or disability in each age category. North & West (inner) has the lowest area percentage in each age group. % of relevant population whose day-to-day activities are limited - by age and CCG sub-locality areas Bristol East Inner City South N & W (inner) N & W (outer) 40% 35% 30% 25% 20% 15% 10% 5% 0% % limited a little % limited a lot % limited a little % limited a lot % limited a little % limited a lot There are differentials by area across different long term conditions, see below: 34

35 Those with Learning Disabilities are also disproportionately affected, see the chart below: Our inequalities plan, therefore, seeks to address health inequalities across Bristol, between localities and within localities and also within specific groups. 35

36 NHS Outcomes Framework The national planning document Everyone Counts: Planning for Patients 2014/15 to 2018/19 set out a framework that put commissioning for outcomes at the heart of commissioning. Seven Outcome Ambitions were set that also mapped to the existing NHS Outcome Framework domains. NHS Outcome Framework 5 Domains 1. Preventing people from dying prematurely 2. Enhancing quality of life for people with long term conditions 7 Outcome Ambitions 1. Securing additional years of life of people of England with treatable mental and physical health conditions 2. Securing additional years of life of people of England with treatable mental and physical health conditions 3. Helping people to recover from episodes of ill health or following injury 4. Ensuring that people have a positive experience of care 5. Treating and caring for people in a safe environment and protecting them from avoidable harm 3. Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital 4. Increasing the proportion of older people living independently at home following discharge from hospital 5. Increasing the number of people having a positive experience of hospital care 6. Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in general practice and in the community 7. Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care Our plans for 2014/15 were aligned to delivery of these outcomes and during planning for 2015/16 we reviewed our performance against monitoring measures to identify priority areas for further improvement. Our insight pack highlighted areas 36

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