NHS Croydon Clinical Commissioning Group. 3 Year Integrated Strategic Plan 2013 /16 & Operating Plan 2013 / 14

Transcription

1 NHS Croydon Clinical Commissioning Group 3 Year Integrated Strategic Plan 2013 /16 & Operating Plan 2013 / 14 FINAL VERSION Longer, healthier lives for all the people in Croydon Final Version: NHS Croydon CCG Page 1 of 112

2 Contents 1. Foreword NHS Croydon Clinical Commissioning Group Authorisation Our Approach to Public and Stakeholder Engagement Clinical Network Engagement Our Vision, Objectives and Values Objectives Achieve Financial Sustainability in Three Years Integrated Commissioning Collaborative relationships Mature membership organisation The Croydon Population We Serve Our Population Migration Ethnicity Deprivation Croydon Population; Health Needs Life expectancy at birth, Croydon electoral wards, Infant mortality numbers and rates Breast Feeding Childhood Immunisations Childhood Obesity Sexual Health Long Term Conditions Smoking Cessation Service Performance Housing and Homelessness Quality and Performance Quality and Performance Our Service Quality Priorities NHS England Performance Priorities NHS Constitution A focus will be particularly on the following 4 areas: NHS Outcomes Framework Domain 2 - Enhancing Quality Of Life for People with Long-Term Conditions Domain 2: Improving Access to Psychological Therapies (IAPT) Domain 2: Dementia Domain 3 - Helping People to Recover From Episodes of Ill Health or Following Injury Domain 4 Ensuring That People Have A Positive Experience of Care Domain 5 Treating and Caring For People in a Safe Environment and Protecting Them from Avoidable Harm Final Version: NHS Croydon CCG Page 2 of 112

3 6.10. Local Quality Premiums Quality Premium 1: Nine Diabetes Processes Quality Premium 2: MDT Case Management for People at Home Quality Premium 3: Reduction in Numbers of Admissions from Care Homes (Nursing) Safeguarding Safeguarding children and promoting their welfare Safeguarding adults and learning disabilities Adult Safeguarding Structure Patient safety Public Sector Equality Duty (PSED) Our Main Provider Landscape Transforming Our Services Levels of Service Provision Impact of Transformation Prevention Primary and Community Intermediate Hospital Our Improved Health Outcomes Measures Life Expectancy Supporting children and young people Independence A positive experience of care Health and Well-being Strategic Priorities Overall Prevention of Ill Health and Self-Care Long Term Conditions Overall Older People Adults Children and Young People Planned Care Primary and Community Urgent Care Medicines Management Measuring Our Improved Outcomes Carers Emergency Preparedness, Resilience and Response Business Informatics Quality Innovation Prevention and Productivity /14 QIPP Plan Medium Term QIPP Opportunity Final Version: NHS Croydon CCG Page 3 of 112

4 16.3. QIPP Delivery Risk QIPP Governance Finance Planning Planned Delivery In 2013/ Financial Plan 2013/14 (Including Key Assumptions) Key Bridging Movements from 2012/13 FCOT to 2013/14 Plan Triangulation of Finance and Activity Assumptions Key Capital Schemes Liquidity / Cash Flow / Cash Requirements Key Financial Risks and Opportunities in 2013/ Describe How You Will Manage Financial Risk Appendices Appendix 1 NHS Constitution Additional measures NHS England has specified for 2013/ NHS England 4 Mandated Measures Appendix 2 CCG Outcomes Indicator Set Appendix 3 Plan on a Page - Overview Appendix 4 - Commissioning Plan on a Page Final Version: NHS Croydon CCG Page 4 of 112

5 1. Foreword In producing the plan we have worked in partnership with the Health and Wellbeing Board to align our priorities and our vision of Longer, Healthier Lives for all the People in Croydon. The Joint Health and Wellbeing Strategy (Version 2.4) sets out 3 strategic goals; 1. increased healthy life expectancy and reduced differences in life expectancy between communities 2. increased resilience and independence 3. a positive experience of care We face many challenges over the coming years with growth in our population against tightening resources. We are determined that by implementing our transformation programme and by working closely with our commissioning partners, NHS England, the Local Borough of Croydon and neighbouring Clinical Commissioning Groups that we will maximise the resources available to us to ensure that we can continue to deliver high quality services to the populations we serve. Our Population and Health Challenges Both the very young and the very old need more care: o o The latest projections suggest that the number of people aged over 85 will increase by two thirds by The latest projections also suggest that there will also be more births, as more women of child bearing age move to Croydon. It s expected that the number of births will rise by around 10% over the next five years. Life expectancy is 9.5 years lower for men and 5.2 years lower for women in the most deprived areas of Croydon compared to the rest of Croydon. Circulatory diseases, cancers and respiratory diseases cause the majority of deaths which contribute to the gap in life expectancy Still births and early infant deaths are significantly higher in Croydon than in England or in London Croydon is in the bottom 10% of London local authorities for low birth weight babies Childhood immunisations rates for measles, mumps and rubella in Croydon do not compare favourably with other areas Levels of childhood obesity are worse than for England Sexual health continues to present challenges for Croydon which has comparatively high rates of diagnosis of Chlamydia, Gonorrhoea and Herpes and HIV Repeat abortions and late diagnosis of HIV Croydon performs significantly worse than the national average for end of life care Final Version: NHS Croydon CCG Page 5 of 112

6 Our Service Challenges Bottom 10% of lowest satisfaction rates to see a GP quickly Bottom percentile for patient experience at Croydon University Hospital for last 3 years Rates for emergency admissions are higher compared to other areas and are also higher than they were 3 years ago Rates of emergency readmissions to hospital within 28 days of discharge is significantly higher in Croydon than the national average Variable performance in meeting the A&E 4 hour waiting target Lead Responsibilities for Commissioning The Health and Social Care Act 2012 sets out different duties and powers for organisations in the new system. The overarching responsibilities for Croydon Clinical Commissioning Group, the London Borough of Croydon and the NHS England are described below. NHS Croydon Clinical Commissioning Group is responsible for commissioning health services to meet all the reasonable requirements of our population. NHS Croydon CCG: Responsible Commissioning Areas 1) Urgent and emergency care (including 111, A&E and ambulance services). Out of hours primary medical services except where this responsibility is retained under the GP contract. 7) Rehabilitation Services 2) Elective Hospital Care 8) Children s Healthcare Services (mental and physical health) 3) Community Health Services (such as rehabilitation services, speech and language therapy, continence services, wheelchair services, and home oxygen services, but not public health services such as health visiting and family nursing) 4) Other Community-Based Services, including (where appropriate) services provided by GP practices that go beyond the scope of the GP contract 5) Maternity and New-Born Services (excluding neonatal intensive care) 9) Services for People with Learning Disabilities 10) Mental Health Services (including psychological therapies) 11) NHS Continuing Healthcare 6) Infertility Services Table 1 Final Version: NHS Croydon CCG Page 6 of 112

7 Commissioning responsibilities of other organisations include: services commissioned by NHS England, include primary care, some public health services (e.g. public health services for children 0-5; screening and immunisation) and a number of specialised services; public health services commissioned by local authorities; and health protection services provided by Public Health England NHS Croydon Clinical Commissioning Group will work collaboratively with the local authority to deliver our joint priorities as set out in the Health and Wellbeing Strategy. The London Borough of Croydon will be responsible for commissioning most public health services. There are a number of key interfaces where we will work closely with local authority public health commissioners to achieve the best outcomes for our population. These include working together to: reduce the prevalence of smoking through primary prevention focused on schools and youth settings, enforcing tobacco control measures, and providing a range of services to help people quit smoking tackle overweight and obesity through promoting physical activity and a healthy diet across the life course and ensuring that appropriate weight management and treatment services for obesity are in place improve sexual and reproductive health by provision of advice, prevention and promotion, testing and treatment (including promotion of opportunistic testing and treatment in healthcare settings), and provision of high quality termination of pregnancy services The council is also responsible for commissioning adults and children s social care services. Croydon Clinical Commissioning Group and the London Borough of Croydon plan to establish an Integrated Commissioning Unit to progress jointly agreed initiatives. These include for example: Children and Young People Transformational Strategy for Long Term Conditions / Older Frail People Mental Health This plan highlights the interdependencies between each of the organisations to show how the priorities are aligned to meet the challenges that face us Dr Tony Brzezicki Paula Swann Chair Chief Officer Croydon CCG Croydon CCG Final Version: NHS Croydon CCG Page 7 of 112

8 2. NHS Croydon Clinical Commissioning Group Authorisation NHS Croydon Clinical Commissioning Group is pleased it has achieved authorisation, this is subject to 7 Conditions and 2 Legal Directions. The 7 Conditions relate to the following areas: 4 related to the financial position 1 related to a risk sharing agreement not being in place yet 2 related to Serious Incidents and early warning systems not being in place yet The 2 Legal Directions relate to the following areas: The development of the Clinical Commissioning Group s (CCG) Clear and Credible Integrated Plan, including but not limited to the CCG s financial modelling and implementation plan for 2013/14 The development of the CCG s project management capacity and governance structures for the purpose of delivering the QIPP (Quality, Innovation, Productivity and Prevention) Savings and Efficiency Plans NHS England noted particular strengths as follows: Strong leadership by the Clinical Commissioning Group team The GP networks demonstrate commendable good practice, involving learning, peer review and joint action Clear evidence of a step change in clinical involvement in commissioning Ambitious with high aspirations and the ability to see the bigger picture Strong partnership arrangements and relationship with the Local Authority (LA) Commendable succession planning for clinical leadership Action on health inequalities shows through our work NHS England (London) will provide external support until the end of April 2013 to support the development of: Detailed QIPP Plan for 2013/14 High Level QIPP Plans for 2014/15 & 15/16 Three Year Financial Improvement Plan Performance Framework & Improvement Strategy & Plan Final Version: NHS Croydon CCG Page 8 of 112

9 Quality & Safety Framework & Improvement Strategy & Plan We are confident that with the strong leadership we have in place the Conditions and Legal Directions will be lifted early in Final Version: NHS Croydon CCG Page 9 of 112

10 3. Our Approach to Public and Stakeholder Engagement NHS Croydon Clinical Commissioning Group, Communications and Engagement Strategy commits to ensuring that we regularly communicate and engage with our population, the wider health and social care community and our local stakeholders to maintain public trust and confidence in services for which we are responsible. The strategy also sets out how we will involve our population and stakeholders through the planning and engagement cycle (Croydon CCG Communications and Engagement Strategy, 2012). In developing the Integrated Strategic Operating Plan, the NHS Croydon Clinical Commissioning Governing Body has worked with Member Practices, Patients, Providers and the Public to develop the goals and priorities reflected throughout the plan. Please see Table 2 (below) for the events have been included in this. Final Version: NHS Croydon CCG Page 10 of 112

11 Stakeholder Engagement Topic Areas Dates Clinical Commissioning Group Open Meetings - All GPs, practice managers and practice staff invited Clinical Commissioning Group Open Meetings - All GPs, practice managers and practice staff invited Clinical Commissioning Group Open Meetings - All GPs, practice managers and practice staff invited Clinical Commissioning Group Open Meetings - All GPs, practice managers and practice staff invited Clinical Commissioning Group Open Meetings - All GPs, practice managers and practice staff invited GP and Stakeholder Open Meeting - All GPs and Wider Stakeholders Health and Wellbeing Strategy - Public and Stakeholder Consultation and Engagement Events Clinical Commissioning Group Stakeholder Event Invitees included GP s Local Medical Committee Local Pharmacy Committee Health Watch/Links Croydon Hospital Services LA representative from children s services The South London and Maudsley Mental Health Trust CCG Governing Body Meeting - Public and Stakeholder Primary and Community Strategy Workshop Long Term Condition Workshop Table 2 Topics discussed included Finance, NHS 111 Topics discussed included Urgent Care, QIPP, Better Services, Better Value (BSBV) Topics discussed included Finance, Community Respiratory Team, Risk Stratification, Ophthalmic, Urgent Care Topics discussed Integrated Strategic Operating Plan Topics discussed GP engagement strategy and QIPP, Effective Commissioning Intentions, BSBV, Cataracts, Reablement Integrated Strategic Operating Plan priorities discussed Health and Wellbeing Strategy, priorities aligned with Integrated Strategic Operating Plan, membership to Health and Wellbeing Board includes CCG Governing Body Members Influence and shape a local vision and set of priorities for the local health economy Early draft of Integrated Strategic Operating Plan discussed Topics discussed: CCG Vision, CCG Constitution Range of Stakeholders invited to workshop. High level principles and themes emerged Range of Stakeholders invited to workshop. High level principles and themes emerged to inform service models November 2011 January 2012 March 2012 May 2012 July 2012 September 2012 June to September th September th September th January th February 2013 Final Version: NHS Croydon CCG Page 11 of 112

12 3.1. Clinical Network Engagement Engagement with Stakeholders in agreeing the Plan has been through a variety of mechanisms and has been driven through the Clinical Leads Networks. Figure 1 shows the communication links within the CCG. The Six Clinical Networks which are geographically aligned are led by Clinicians who ensure that suggestions, views and ideas for service change are reflected back to the Governing Body. The GP Practice Open Meetings can be attended by any interested parties and are widely advertised; feedback from individual patients and patient participation groups are highlighted at these groups. CCG Governing Body Six Clinical Networks (Geographically Aligned) Clinical Leadership Group GP Practice Open Meetings Figure 1 Complaints and Compliments are also captured to feedback on priority areas for NHS Croydon Clinical Commissioning Group. As part of the Commissioning Support Unit (CSU) Service Level Agreement the Commissioning Support Unit will report on all complaints and compliments. The CSU is developing for the CCG a method for GPs to inform the CCG of any issues they have and these will be managed and reported to ensure the improvement in quality of services, but also to influence future commissioning plans. These are amalgamated with soft data (individual patient / public / professional feedback) collated by CCG Networks to inform service change needs. Final Version: NHS Croydon CCG Page 12 of 112

13 We will form strong patient participation groups and through our planned activities within the emerging Communication and Engagement Strategy we will ensure that we have mechanisms in place to continually engage and receive feedback from our patients and the public. Final Version: NHS Croydon CCG Page 13 of 112

14 4. Our Vision, Objectives and Values Through working with our Member Practices and our Public, Patients and Providers and through the development of the Health and Wellbeing Strategy, Croydon CCG has jointly developed the following Vision, Organisational Objectives, Outcomes and Priorities. Figure 2 Final Version: NHS Croydon CCG Page 14 of 112

15 4.1. Objectives Our 4 key organisational objectives are as follows: Achieve financial sustainability in three years Commission integrated safe, high quality services in the right place, at the right time Have collaborative relationships with the Borough to ensure an integrated approach Develop as a Mature Organisation Figure Achieve Financial Sustainability in Three Years The Integrated Strategic Operating Plan has been developed at a time of financial constraint. Croydon CCG has inherited a significant financial challenge ( 33m) from its predecessor organisation, Croydon PCT. This is in addition to the expected financial challenge ( 9m) that all CCGs face going forward (in-year pressures and movement from 1% to 2% surplus in 2014/15). The position is exacerbated by historical underfunding of the Croydon health economy and lack of pace of change in addressing this to meet the current needs of the local population. Croydon CCG is currently proposing a 19.9m deficit plan for 2013/14, in line with its ambition and corporate objective to achieve financial targets over a 3 year period. This is achieved from the recurrent baseline gap of 42m, through exemption from the surplus requirement and delivery of 14m QIPP schemes across Planned Care, Emergency Care, Continuing Care and Prescribing. London Borough of Croydon is also expected to manage a funding reduction of 26% over a four year period Integrated Commissioning Integrated safe, high quality services in the right place, at the right time. Through developing robust integrated pathways we will ensure that high quality services are delivered in the right place at the right time. Final Version: NHS Croydon CCG Page 15 of 112

16 Collaborative relationships The Integrated Strategic Operating Plan takes account of National Policy, example NHS Constitution, NHS England, National Outcome Framework Mandates, National Institute for Excellence and aligns to Local Strategies e.g. the Health and Wellbeing Strategy, NHS Croydon Clinical Commissioning Groups, Transformation Strategy, Prevention, Self-Care and Shared Decision Making Strategy, Primary and Community Strategy, the Urgent Care Strategy, and the Dementia Strategy. In addition to this it has also been informed by the Joint Strategic Needs Assessments including key topic chapters such as Depression in Adults. We will continue to link with Croydon Local Authority, Commissioning and Public Health to ensure alignment where relevant to, for example, their Community Strategy, the Children and Young People s Plan, the Housing Strategy and the Stronger Communities Strategy. Through our collaborative relationships with Croydon Local Authority, Commissioning and Public Health and neighbouring Clinical Commissioning Groups, we will ensure that we realise greater efficiencies, by reducing duplication and fragmentation so that we can deliver better services for less. By way of example, Croydon Clinical Commissioning Group is currently discussing and developing proposals for collaborative commissioning arrangements with our neighbouring Clinical Commissioning Groups, namely Lambeth, Southwark & Lewisham, to work in partnership to commission services from The South London and Maudsley Mental Health Trust. Final Version: NHS Croydon CCG Page 16 of 112

17 Mature membership organisation Figure 4 shows the organisational structure for Croydon Clinical Commissioning Group; we have clear organisational development and succession plans to give assurances that we will continue to consistently flourish as an organisation. Figure 4 Final Version: NHS Croydon CCG Page 17 of 112

18 Age group (%) 5. The Croydon Population We Serve 5.1. Our Population The first results of the 2011 census show that Croydon s population has grown more quickly in the last ten years than was projected by the Office for National Statistics (ONS). The usual resident population of Croydon was estimated to be 363,400 on 27th March This is 13,600 more people than was estimated by ONS in projections for 2011 based on the previous census (349,800), and 28,000 more people than in 2001 (335,100). If Croydon s population continues to grow at this rate, there will be over 390,000 people in Croydon by Age and Gender Nationally the population is ageing as life expectancy increases and the baby boomer generation approaches older age. Compared to other areas, however, Croydon has a relatively young population. The present high birth rate and effects of migration are expected to result in growth in some of the younger as well as older age groups in coming years. Age structure of Croydon s population compared with London and England, 2011 Census 90 and over Males Females 6% 5% 4% 3% 2% 1% 0% 1% 2% 3% 4% 5% 6% Population (%) Figure 5 - Source: 2011 Census Population and Household estimates for England and Wales, published 16/07/2012 In 2011 Croydon had a larger number of children aged under 5 and a larger number of people aged 45 to 64, compared with Croydon has the 5 th highest proportion of children aged 0 to 19 (26.9%) out of any London borough compared with London (24.5%) and England (24.0%). For people aged 20 and over, in general, Croydon has a younger population profile than England and an older population profile than London. Final Version: NHS Croydon CCG Page 18 of 112

19 Number In the next decade, the highest growth is projected to be in the age groups 0 to 14, 30 to 39 and over 55. Change in age structure of Croydon s population, 2001, 2011 and 2021 (projected) 35,000 30,000 25,000 20,000 Croydon ,000 10,000 Croydon 2011 Croydon 2021 (projected) 5,000 0 Age band Figure 6 Final Version: NHS Croydon CCG Page 19 of 112

20 Migration Approximately 18,000 people move into Croydon and 20,000 people move out of Croydon from elsewhere within the UK each year. Croydon s population is subject to a net north to south movement of people migrating from Inner South London to Outer South London and from Outer South London to South Eastern England. Croydon has 6,000-7,000 new immigrants from outside the UK per year and at least 3,000 emigrants. The main areas immigrants have been coming from in recent years are: South Asia (India, Pakistan and Sri Lanka: 2,300 people per year) Eastern Europe (Poland, Romania, Lithuania, Bulgaria, Hungary: 1,100 people per year) Certain countries in Africa (Ghana and Nigeria: 500 people per year) Final Version: NHS Croydon CCG Page 20 of 112

21 Ethnicity Over half of Croydon s population are from Black, Asian and minority ethnic groups, and the proportion is increasing over time. The publication of 2011 Census data will provide more accurate estimates of the proportion of Croydon s population in each ethnic group than the current data allows. The most common languages spoken by people in Croydon other than English are Tamil, Urdu, Guajarati and Polish. Figure 7 below shows projections based on data from Croydon general practices which will be less accurate than the census. Projected ethnicity distribution for Croydon s population based on recent trends in general practice data. 100% 90% 3.4% 3.6% 3.8% 9.4% 9.3% 9.1% 80% 70% 60% 50% 40% 30% 20% 10% 9.2% 8.5% 7.9% 4.7% 5.1% 5.3% 3.8% 4.1% 4.5% 8.2% 8.4% 8.4% 4.6% 5.1% 5.5% 7.6% 8.5% 9.3% 44.1% 42.6% 41.5% Other ethnic group Chinese Other Black Black African Black Caribbean Other Asian Bangladeshi Pakistani Indian Mixed Other White White Irish White British 0% Figure 7 - Source: Data from Croydon general practices, March 2009 to March These projections assume a linear trend within each 5 year age / sex band. Records with unknown ethnicity are excluded and White (not otherwise known) is included in the White British category. Croydon Council provides housing and subsistence to a relatively small number of adult asylum seekers compared to other London boroughs, but is responsible for 43% of unaccompanied asylum seeking children in London (440 in March 2011). Final Version: NHS Croydon CCG Page 21 of 112

22 Deprivation Croydon is more deprived in the north of the borough than in the south, and there are also areas of high deprivation in the east of the borough in Fieldway, New Addington and the Shrublands estate in Shirley. Figure 8 shows areas of deprivation in Croydon compared to England, 2010 Compared with super output areas in England Most deprived 5% Most deprived 10% Most deprived 20% Most deprived 30% Most deprived 50% Least deprived 50% Figure 8 - Source: Indices of Deprivation, Department of Communities and Local Government Final Version: NHS Croydon CCG Page 22 of 112

23 In recent years, compared with England as a whole, Outer London has been becoming more deprived, and Inner London more affluent. Between 2004 and 2010, levels of deprivation increased in Croydon more than in any other borough in the south of London. Croydon is currently the 19 th most deprived borough in London. If Croydon continues to grow more deprived at the same rate as recent years, by 2020 it will be the 12 th most deprived borough in London. Many of the risk factors for poor physical and mental health are associated with deprivation including poor housing, unemployment, poverty, poor education, and high crime Croydon Population; Health Needs It is in everyone s interests to ensure that people are able to maintain their independence and stay healthy throughout their lives. However, changes to the make-up of Croydon s population and lifestyle trends are likely to lead to more people needing care in the future. People are living longer and our population is ageing; the latest projections suggest the number of people aged over 85 will increase by two thirds by This is an important trend because we know that older people generally have more health problems and need to use health and care services more than younger adults. There will also be more births as more women of child bearing age move to Croydon; it is expected that the number of births will rise by around 10% over the next five years. The health of people in Croydon is mixed compared to the England average: Life expectancy for both men and women is higher than the England average. However, life expectancy is 9.5 years lower for men and 5.2 years lower for women in the most deprived areas of Croydon than in the least deprived areas Deprivation in the borough is lower than average, however 21,565 children live in poverty Over the last 10 years, all-cause mortality rates have fallen. Early death rates from cancer and from heart disease and stroke have also fallen An estimated 19.7% of adults smoke An estimated 24.3% of adults are obese There were 6,071 hospital stays for alcohol related harm in 2009/10 There are 408 deaths from smoking each year Breast and cervical cancer screening rates are both significantly worse than the national average Croydon is in the 10% worst performing areas for new cases of tuberculosis Final Version: NHS Croydon CCG Page 23 of 112

24 Life expectancy at birth (years) Life expectancy at birth, Croydon electoral wards, Heathfield Selsdon and Ballards Sanderstead Coulsdon East Bensham Manor Shirley Purley Fairfield Woodside Kenley Ashburton Coulsdon West Croham Men Upper Norwood Women Norbury Addiscombe West Thornton Thornton Heath South Norwood New Addington Broad Green Waddon Fieldway Selhurst Figure 9 - Source: Death registrations and mid-year population estimates, Office for National Statistics There has been little, if any, significant change in the gap in life expectancy between the most deprived areas and the least deprived areas between 1995 and Circulatory diseases, cancers and respiratory diseases cause the majority of excess deaths which contribute to the gap in life expectancy. Final Version: NHS Croydon CCG Page 24 of 112

25 Figure 10 shows the breakdown of the mortality gap between the most and least deprived quintiles by cause of death, Croydon Figure 10 - Source: London Health Observatory health inequalities intervention toolkit. Final Version: NHS Croydon CCG Page 25 of 112

26 Infant mortality numbers and rates Stillbirths and early infant deaths are significantly higher in Croydon than England or London and our performance compared to other areas has deteriorated. Croydon is in the bottom 10% of local authorities for low birth weight babies. Table 3, shows the overall infant mortality rate in Croydon has fallen over the last 5 years and is now close to the England and Wales average. Croydon England and Wales No. of infant deaths No. of still births No. of live births Infant mortality rate Still birth rate Infant mortality rate Still birth rate , ( ) 6.7 ( ) 4.7 ( ) 5.0 ( ) , ( ) 6.6 ( ) 4.6 ( ) 5.2 ( ) , ( ) 7.4 ( ) 4.3 ( ) 5.1 ( ) , ( ) 6.9 ( ) 4.6 ( ) 5.1 ( ) Table 3 - Source: Office for National Statistics Breast Feeding Breast feeding initiation and continuation is a real success in Croydon, although initiation rates did begin to slip in the last year. Increasing breast feeding will reduce childhood illnesses, which in turn will reduce hospital admissions in the under 1s. Infants who are not breast fed are more likely to become obese in later childhood, develop type 2 diabetes and tend to have slightly higher levels of blood pressure and blood cholesterol in adulthood. Final Version: NHS Croydon CCG Page 26 of 112

27 Percentage immunised by 2nd birthday Childhood Immunisations Childhood immunisations rates for measles, mumps and rubella in Croydon do not compare favourably with other areas and appear to be moving in the wrong direction. Percentage of children that received the first dose of MMR vaccine by their 2nd birthday, London boroughs 2010/11 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% 78% 76% 74% 72% 70% 68% 66% 64% 62% 60% Tower Hamlets Barnet Westminster Hillingdon Brent Teaching Harrow Waltham Forest Ealing Kensington & Chelsea Havering Islington Haringey Teaching Richmond & Twickenham Redbridge Kingston Bromley Greenwich Teaching Wandsworth Lambeth Croydon Hounslow Sutton & Merton Barking & Dagenham Bexley Care Trust Lewisham Newham Hammersmith & Fulham Southwark Camden Enfield City & Hackney Teaching England London Figure 11 - Source: The Information Centre for Health and Social Care Final Version: NHS Croydon CCG Page 27 of 112

28 Prevalence Childhood Obesity Levels of childhood obesity in Croydon are worse than for England, although there has been a slight improvement for Reception Year children. However, nearly a quarter of Year 6 children are classified as obese. This is likely to lead to long term health problems for them as they grow older including diabetes, heart disease and some forms of cancer. Prevalence of childhood obesity, in school reception year 'R' and year 6, Croydon, London and England 2009/10 30% 25% 24.06% 24.02% 20% 20.08% 19.59% 20.38% 17.02% 15% 10% 11.39% 12.31% 10.71% 10.93% 10.46% 9.17% 5% 0% Croydon London England Year R boys Year 6 boys Year R girls Year 6 girls Figure 12 - Source: National Obesity Observatory and National Child Measurement Programme Final Version: NHS Croydon CCG Page 28 of 112

29 March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec Under 18 conception rate per 1, Sexual Health Sexual health continues to present challenges for Croydon which has comparatively high rates of diagnoses of Chlamydia, gonorrhoea, herpes and HIV. Croydon compares particularly badly in terms of repeat abortions and late diagnosis of HIV infection. Teenage pregnancy has been a challenge for Croydon; a continuing focus on this issue, however, has led to some real reductions in teen conception rates. Under 18 conception rate, Croydon, London, England (rolling quarterly averages) Rolling Quarterly Average Figure 13 - Source: Office for National Statistics Croydon London England Final Version: NHS Croydon CCG Page 29 of 112

30 Number Long Term Conditions It is expected that many more people will be living with long term health conditions in the future. By this we mean health problems that are present for over a year or more, such as Diabetes, Heart Disease, Respiratory Problems, Asthma and Epilepsy. People often have more than one of these conditions, especially as they get older. Three out of every five people aged over 60 suffer from a Long Term Condition and as the population ages, this proportion is likely to rise. People with long term health conditions are the most intensive users of health services. They make up around 31% of the population, but account for 52% of GP appointments and 65% of planned hospital appointments. Projected number of long term conditions in Croydon s population, ,000 30,000 25,000 20,000 15,000 10,000 5, Year Chronic kidney disease (total) Chronic kidney disease (diagnosed) COPD (total) COPD (diagnosed) Dementia (total) Dementia (diagnosed) Diabetes (total) Diabetes (diagnosed) Stroke/TIA (total) Stroke/TIA (diagnosed) Figure 14 - Source: Projections based on data from Croydon general practices In the future many people who have Long Term Conditions will need better organised care, closer to home, to help them self-manage their conditions and live as independently as possible. This is especially important, given that social trends such as the increase in single-person households and people living further from their extended family may mean many people won t receive the support they need from family members and loved ones. Final Version: NHS Croydon CCG Page 30 of 112

31 Smoking Cessation Excellent progress has been made in Croydon in supporting people to stop smoking. For the first time in seven years, Croydon not only met, but exceeded, its quit smoking targets. However, smoking is still the single largest cause of preventable illness and premature death and contributes more than any other identifiable risk factor to inequalities in life expectancy. There is still much work to be done in turning around alcohol related crime, drug offences and increasing physical activity levels Service Performance Croydon is in the bottom 10% of areas for satisfaction with ability to see a GP quickly. Croydon performs significantly worse than the national average for end of life care. Rates for emergency hospital admissions are higher compared to other areas than they were three years ago. Croydon's performance for emergency admissions for conditions normally requiring an outpatient appointment has also deteriorated. The rate of emergency readmissions to hospital within 28 days of discharge is also significantly higher in Croydon than nationally Housing and Homelessness Housing and homelessness represents a significant and growing challenge for Croydon now and in the coming years. The roll out of self-directed support has successfully reversed the trends of the previous three years and increased self-directed support to social care clients. There has been a recent deterioration in delayed transfers of care in Croydon. Final Version: NHS Croydon CCG Page 31 of 112

32 6. Quality and Performance Clinical Commissioning Group Quality Profile - Please click on PDF icon to view / print Adobe Acrobat Document Figure 15 Final Version: NHS Croydon CCG Page 32 of 112

33 6.1. Quality and Performance NHS Croydon Clinical Commissioning Group (CCG) consistently aims to ensure it commissions health services that are safe, that employ best clinical practice and offer information to inform patients choice in how, when and where they receive their health care services. We believe that by embedding quality in our commissioning processes and communicating and engaging with the public and patients who use our commissioned services, Croydon CCG can facilitate an honest dialogue about health, health services and patient needs and views critical to effective and responsive care. Our processes and governance arrangements for managing quality assurance scrutiny and dialogue with providers is crucial to ensure quality is monitored, improved and maintained. Our working relationship with the South London Commissioning Support Unit (SL CSU), embedding clinical engagement and CCG Board leadership of this agenda and evolving programme of work will develop and strengthen our governance and assurance we derive on the quality of the services we commission. In the way that we work, NHS Croydon CCG will embody the principles of accountability, putting the patient first in everything we do as championed by the Francis Report Recommendations. 1 The CCG will also work with providers to embed these principles, to establish agreed levels of quality and encourage the development of service innovation and improvement. To do this we have established a Quality Sub Committee of the Integrated Governance and Audit Committee, and have a number of operational quality meetings as set out on the next page. The CCG will also be a member of NHS England Local Quality Surveillance Team, which will provide a forum for sharing quality intelligence. 1 Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry, 6 th March, 2013 Final Version: NHS Croydon CCG Page 33 of 112

34 Governing Body Remuneration Committee Integrated Governance and Audit Committee (governance, audit, quality, PPI patient safety) Quality Sub Committee Finance Sub Committee (finance and recovery) Senior Management Team Director of Finance and Recovery (Chief QIPP Operational Finance Officer) Board Senior Management Team Chief Officer Director of Commissioning Strategic Transformation Board Prescribing Committee NICE Sub Committee Clinical Leadership Group Director of Governance and Quality Quality Monitoring Group 4 Clinical Quality Review Groups Chief Nurse Safeguarding Governance Group Commissioning Support Management Task and Finish Groups CSU SI assurance and Review Group Figure 16 Final Version: NHS Croydon CCG Page 34 of 112

35 It is recognised that there is significantly more quality information about the acute providers than there are for other providers. A key issue for the CCG will be about working with NHS England in developing indicators for all our Providers. We also know that there are some quality indicators at Croydon Health Services NHS Trust, our main acute and community provider that show that we need to work together to identify the quality improvement priorities. We need to ensure our levels for change are aligned to support these improvements such as Commissioning for Quality and Innovation (CQUIN s), Local Enhanced Services (LES) and the Quality Premiums Our Service Quality Priorities Key sources of information provide an overview of the performance and quality of services with in providers. We know that at our main acute and community provider, Croydon Health Services NHS Trust that: Standard mortality rates continue to fall compared to previous years Staffing levels are increasing Maternity services are improving Also external review of services has shown very good: Experience of cancer patients Stroke service Haemoglobinopathy service There are some areas however that we know need improvement including: Patient Safety Reducing the number of Clostridium Difficile incidences Increasing VTE Assessments Reducing the number of pressure ulcers Improving Patient Experience overall Some service areas need improving such as Ophthalmology Services and Diabetes Waiting times need to improve for specific specialities to be seen in 18 weeks Final Version: NHS Croydon CCG Page 35 of 112

36 Our urgent care services include our GPs, Urgent Care Centres at the hospital site, Purley and New Addington, and the emergency department at Croydon University Hospital. We know A&E waiting times targets needs improving. For our main mental health provider South London and Maudsley NHS Foundation Trust we know patients feel involved in planning their own care. We also know however those improvements are needed to: reduce the risk of violence and aggression on some in-patient units. reduce the waiting time for some more specialised services such as Increased Access to Psychological Therapies (IAPTs) For each of these areas of improvement the CCG is working with the provider to develop robust recovery action plans, with clear trajectories for when they will achieve appropriate standards NHS England Performance Priorities NHS Croydon CCG will strive to meet all the requirements within the NHS Constitution (please see Appendix 1) and the NHS Outcomes Framework (NHS OF) (please see Appendix 2). In addition to this NHS England has set out the following national quality measures taken from targets and / or Domains within the NHS Constitution and / or the NHS Outcomes Framework. These areas are described in Section and NHS Constitution A focus will be particularly on the following 4 areas: (a) maximum 18-week waits from referral to treatment, (b) maximum four-hour waits in A&E departments, (c) maximum 62-day waits from urgent GP referral to first definitive treatment for cancer, (d) maximum 8-minute responses for Category A red 1 ambulance calls Table 4 (below) outlines the current challenges in meeting these targets and the actions in place to mitigate this. Final Version: NHS Croydon CCG Page 36 of 112

37 NHS Constitution Performance Area Month 8 Actions to Address A&E 4 Hour Wait: A&E target (All Types) 95.16% Green A&E target (type 1) 91.1% Red Whole system urgent care management and review Whole system urgent care monitoring with conference calls, three times a week, and the weekly Recovery Board; A&E specific implementation plan Recovery of this target is expected by the end of quarter 1 of 2013/14 however it will require continued focus to ensure sustainability. Referral to Treatment Indicators: Referral to Treatment Time (RTT) nonadmitted patients compliance RTT incomplete pathways patients compliance Numbers waiting on incomplete RTT Cancer Indicators: Cancer first treatment 62 days wait: GP urgent referral Cancer first treatment 62 days wait: Screening referral Maximum 8-minute responses for Category A - red 1 ambulance calls Table 4 Green Incomplete Amber Incomplete RED 80.4% Amber 88.6% Amber Red An external review by the Intensive Support Team undertaken on 17 January 2013, with specific action plan to be developed. Additional funding has been sourced to clear the backlog of people waiting, and an action plan for sustainable performance is in development. Full recovery is expected by the end of quarter 1.. The majority of breaches are in urology where there are quite a few treatment options and trials some with significant side effects. The CCG will be analysing breaches over the past year to ensure systematic learning and change in process being undertaken. A deep dive into the reason for this poor performance will take place during quarter NHS Outcomes Framework There are 5 domains within the NHS Outcomes Framework. The priority areas for 2013/14 are as follows: Domain 1: Preventing people from dying prematurely: Under 75 mortality from cardiovascular disease (NHS OF 1.1) Under 75 mortality from respiratory disease (NHS OF 1.2) Under 75 mortality from liver disease (NHS OF 1.3) Under 75 mortality from cancer (NHS OF 1.4) Final Version: NHS Croydon CCG Page 37 of 112

38 6.4. Domain 2 - Enhancing Quality Of Life for People with Long-Term Conditions Baselines (NHS OF 2.3 (1)) Unplanned Hospitalisation for chronic ambulatory care sensitive conditions aged 19 and over. The volumes are low as the technical guidance is restricted to certain ICD10 codes Figure 17 Final Version: NHS Croydon CCG Page 38 of 112

39 Baselines (NHS OF 2.3 (II)) Unplanned Hospitalisation for asthma, diabetes and epilepsy in under 19 s. The volumes are low as the technical guidance is restricted to certain ICD10 codes Figure 18 Final Version: NHS Croydon CCG Page 39 of 112

40 6.5. Domain 2: Improving Access to Psychological Therapies (IAPT) Baseline (NHS OF 2): Enhancing Quality of Life for People with Mental Illness. Table 5 shows the proportion for 2013/14 of the people that enter treatment against the level of need in the general population i.e. the proportion of people who have depression and/or anxiety disorders who receive psychological therapies. The number of people who receive psychological therapies The number of people who have depression and/or anxiety disorders (local estimate based on Psychiatric Morbidity Survey) Proportion % Table Domain 2: Dementia Baselines (NHS OF 2.6): Enhancing Quality of Life for People with Dementia. Table 6 shows the Dementia diagnosis rate for Croydon CCG in 2013/14 and 2014/15. i) Dementia diagnosis rate are you aiming for in 2013/14 and 2014/15: Period Number of people diagnosed Prevalence of dementia % diagnosis rate 2013/14 1,733 3, % 2014/15 1,915 3, % Table 6 Final Version: NHS Croydon CCG Page 40 of 112

41 6.7. Domain 3 - Helping People to Recover From Episodes of Ill Health or Following Injury Emergency admissions for acute conditions that should not usually require hospital admission (NHS OF 3a). The volumes are low as the technical guidance is restricted to certain ICD10 codes Figure 19 Final Version: NHS Croydon CCG Page 41 of 112

42 Domain 3 - Helping People to Recover From Episodes of Ill Health or Following Injury Emergency admissions for children with lower respiratory tract infections (NHS 3b). The volumes are low as the technical guidance is restricted to certain ICD10 codes Figure 20 Final Version: NHS Croydon CCG Page 42 of 112

43 6.8. Domain 4 Ensuring That People Have A Positive Experience of Care Roll out of Friends and Family Test according to nationally agreed roll out plan and national timetable Maternity Services by end of October 2013 and additional services (to be defined) by end of March And to choose from the following ONE objective on improving experience of hospital services: Patient experience for Acute Inpatient care Patient experience of A&E services NHS Croydon CCG has chosen the additional objective of measuring patient experience of A&E services Domain 5 Treating and Caring For People in a Safe Environment and Protecting Them from Avoidable Harm Incidence of healthcare associated infection: Methicillin-resistant Staphylococcus aureu (MRSA) (NHS OF 5.2.i) Incidence of healthcare associated infection: Clostridium difficile (C. difficile) (NHS OF 5.2.ii) Croydon CCG is striving to reduce the incidences of C. difficile; table 7 shows the reduced target number of incidences of C. difficile for Croydon CCG in 2013/14. Organisation \ Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total CUH Croydon CCG Table 7 Final Version: NHS Croydon CCG Page 43 of 112

44 6.10. Local Quality Premiums Croydon Clinical Commissioning Group has identified the following three Local Quality Premiums for 2013/14: Quality Premium 1: Nine Diabetes Processes Quality Premium 1 relates to Domain 2 of the NHS OF: Enhancing Quality of Life for People with Long Term Conditions. All patients should receive nine crucial tests from their GP at an annual review of their diabetes management. These include measurements of weight, blood pressure, smoking status, a marker for blood glucose called HbA1c, urinary albumin, serum creatinine, cholesterol, and tests to assess whether the eyes and feet have been damaged by diabetes. These tests are essential to ensure that diabetes is controlled and if left unchecked, diabetes can lead to blindness, kidney failure and increase the risk of developing cardiovascular problems such as heart attacks and stroke. Measure: Numerator 10,094, Denominator 18,352 to ensure that 55% of registered people with Diabetes will receive nine care processes at annual review Quality Premium 2: MDT Case Management for People at Home Quality Premium 2 relates to Domain 2 of the NHS OF: Enhancing Quality of Life for People with Long Term Conditions. Within the Transformation Programme of Care we aim to ensure that people only attend hospital when needed. By identifying people through the risk stratification model we will identify people who are most vulnerable and who require additional timed support by either a single professional approach or a Multi-Disciplinary Team to ensure that they remain as in optimum health as possible. Measure: Numerator 152 with a high risk level of need. Denominator 21,660 (0.7% of population over 75) will have a Multi-Disciplinary Team Case Management Care Plan Quality Premium 3: Reduction in Numbers of Admissions from Care Homes (Nursing) Quality Premium 3 relates to Domain 3 of the NHS OF: Helping People to Recover from Episodes of Ill Health or Following an Injury Within the Transformation Programme we aim to ensure that people only attend hospital when needed. By supporting Care Homes (nursing) with a rapid response team it is expected that it will negate the need for an older person to be admitted to hospital by supporting the person and the Home with expert nursing and medical advice to prevent the person needing admitting. This will ensure that the older person does not need to leave a place where they feel safe and familiar and Final Version: NHS Croydon CCG Page 44 of 112

45 will be particularly important to people with a diagnosis of dementia and /or nearing end of life and have chosen their place of death as the Care Home. Measure: Numerator a reduction of 90 people being admitted inappropriately as an emergency admission from Care Homes (nursing) Denominator 1,095 (8.2% of emergency admissions from Care Homes) Safeguarding Safeguarding children and promoting their welfare NHS Croydon Clinical Commissioning Group will be directly employing safeguarding adult and children nurse designates. The designated doctor employment will continue through a Service Level Agreement with Croydon Health Services NHS Trust. Figure 21 demonstrates the governance structures the CCG will have in place to enable it to assure its responsibilities are carried out robustly. Local Authority CCG Governing Body Accountable Officer Clinical Lead GP Children s Safeguarding Board Chief Nurse Figure 21 Figure 21 shows: The CCG Governing Board is accountable for safeguarding. The Accountable Officer will be accountable for safeguarding The Chief Nurse on the Governing Body will have delegated responsibility for ensuring the CCG carries out its safeguarding statutory duties effectively. The Chief Nurse will act as the representative on the safeguarding boards. The GP Governing Body member will have a responsibility for GP leadership The Integrated Governance and Audit committee will have the oversight of quality including safeguarding and will be accountable to the Board. Final Version: NHS Croydon CCG Page 45 of 112

46 The chart below demonstrates the management structures and resources (to be confirmed) the CCG will have in place to enable it to manage its responsibilities robustly. Integrated Governance Team Day to day line management Professional line management Chief Nurse Quality and Safeguarding link Head of Safeguarding (Children's Designated Safeguarding Nurse) Designated and Named Professional Children s Safeguarding Nurse Designated GP Figure 22 In Figure 22: The Chief Nurse will provide the day to day line management and clinical professional supervision of the safeguarding team. They will also provide the safeguarding supervision for the designated professionals. Designated professional leads and named leads will be resourced to carry out the necessary duties. For the first time a designated GP lead will be appointed. Recognising the need for improving adult safeguarding and in anticipation of adult safeguarding guidance in relation to adult safeguarding becoming statutory the CCG will also resource for the first time dedicated designated adults safeguarding nurse The Designated Doctor for Children s Safeguarding and Child Death will be hosted by Croydon Health Service NHS Trust but remain accountable to the Chief Nurse. Current external clinical supervision arrangements will apply. The safeguarding team will continue to be based locally and a Croydon only focused resource CCG Safeguarding Responsibilities Final Version: NHS Croydon CCG Page 46 of 112

47 Safeguarding adults and learning disabilities CCGs will need to demonstrate that they have appropriate systems in place for discharging their responsibilities in respect of safeguarding adults and learning disabilities including: Local Authority CCG Governing Body Accountable Officer Clinical Lead GP Adult s Safeguarding Board Chief Nurse Figure Adult Safeguarding Structure Integrated Governance Team Day to day line management Professional line management Chief Nurse Quality and Safeguarding link Head of Safeguarding (Designated Safeguarding Nurse) Designated and Named Professional Adult s Safeguarding Nurse Figure 24 Final Version: NHS Croydon CCG Page 47 of 112

48 Patient safety Patient Safety is a priority for NHS Croydon Clinical Commissioning Group (CCG). Within the Service Level Agreement with the Commissioning Support Unit (CSU) the portfolio of services the CSU will provide to the CCG as part of the Core Service offering (the Core Services ) will include: Governance Key Activities Figure 25 Final Version: NHS Croydon CCG Page 48 of 112

49 7. Public Sector Equality Duty (PSED) NHS Croydon Clinical Commissioning Group published their reports on the Equality Delivery System (EDS) with key objectives and action plans for delivering EDS within its commissioning activities. This report provides an update on the status of equality impact assessments of the QIPP Schemes; progress being made with the implementation of the EDS action plan locally and at cluster level; future responsibility for equality and diversity function. As the Commissioning Support Unit (CSU) will be providing equality and diversity service to the CCG, the continuity of the implementation of the EDS will be expected to be overseen by the CSU Equality & Diversity Lead working in conjunction with commissioning leads at borough level. Therefore, progress reports on the embedding of EDS into mainstream commissioning activities will be expected from the CSU. The Action Plan has been populated to show progress with implementation of some of the actions to date A draft implementation plan is being developed to support the commissioning leads to embed EDS into mainstream commissioning activities. Implementation would follow a pragmatic approach ensuring that data and information collection reflect how we are meeting the needs of our service users in relation to the 9 characteristics and that this links with the equality impact assessment completed for that service. EDS will be included as a standing agenda item on the Clinical Quality Review (CQR) Groups. The intention is to use the forum to report on outcome of the implementation process Following the development of an implementation plan, 1-1 meetings will be set up with leads to talk through the process Healthwatch will be supporting us in the implementation process Progress reports will be submitted to Senior Management Team (SMT) / CCG Board and South West London (SWL) Cluster Equality Impact Assessments (EIA) - QIPP Schemes As part of a baseline quality assurance assessment of the QIPP Schemes, project leads also carried out equality impact assessments on the schemes. Impact assessment was completed for 24 QIPP schemes. All EIAs submitted to the Quality team were reviewed and returned to project leads with comments (where relevant). Final reviews and sign off of EIAs were done by the senior commissioning managers for each scheme. All EIAs are kept on file and will be submitted to cluster when requested for publication. Final Version: NHS Croydon CCG Page 49 of 112

50 Outcome of the equality impact assessments: All QIPP schemes will require monitoring and follow up in line with the requirements of the equality delivery system (EDS) Service leads to use the EDS as an enabler in monitoring the impact of service provision to users. The implementation process for EDS should take this into account Outcome reporting of EDS monitoring on a quarterly basis. This will be done through the CQR Groups Yearly review of completed equality impact assessments or as and when a service is redesigned or changed, to ensure that the service continues to meet the requirements of the users and to note any gaps The EIA exercise included refresher training and guidance sessions to service leads on the equality duty of the organisation and the importance of EIA in mainstream commissioning and planning. Further training on EIA and the EDS were provided by SWL cluster during May this year. Handover of Equality and Diversity by SWL Cluster: A meeting to handover the equality and diversity function has been organised by cluster to take place on 5th October Due to absence of an E&D and Patient and Public Engagement (PPE) lead, the Head of Quality will be attending this meeting and will feedback to the Director of Governance and Quality and SMT/CCG Board. The future of transgender healthcare Event on 25 September 2012 Milestones / Key Actions 1 Obtain draft Croydon CCG Organisational/Commissioning Strategy to embed Equality and Diversity Achievement Date 21 June Prepare draft Equality and Diversity Strategy 19 July Approve Equality and Diversity Strategy 9 August Prepare Equality Objectives for 2013 onwards taking into consideration those carried forward from Stakeholder Engagement/ Consultation regarding Equality and Diversity Strategy and Equality Objectives 6 Publish Croydon CCG Equality Objectives and Equality and Diversity Strategy by 13 October August September October 2013 Table 8 Final Version: NHS Croydon CCG Page 50 of 112

51 8. Our Main Provider Landscape Table 9 outlines the contract values for NHS Croydon CCG 2013/14 Provider Overview of Services Provided 2013/14 Value ( 000) GP Member practices LES / DES A proportion of member practices also provide Local Enhanced Services (LES), Direct Enhanced Services (DES) TBC CUH Acute Trust CUH Hospital Services 142,693 Other Acute Trusts All other hospital services 220,696 Croydon Community Health Services (CHS) Croydon Care Homes (Nursing) Delivered through clinics or care in people s own homes including care delivered in a residential care home. Services provided by CHS include adult and children s nursing, rehabilitation, therapies. In Croydon there are currently 279 Residential Care Homes (August 2012). 91 independent Care Homes offering nursing. These provide funded nursing component and care for people meeting NHS Continuing Healthcare eligibility 24,584 4,200 Intermediate services Some of which are offered as part of Any Qualified Provider, providing intermediate services closer to home, for example gynaecology and dermatology. 5,867 Voluntary sector Urgent Care An extensive range of voluntary sector help to support us in delivering our health priorities. Including St Christopher s A range of urgent care services which consist of a GP Led Centre Walk in Centre, Purley Urgent Care Centre, Virgin Front End Urgent Care Centre and New Addington Minor Injury Unit. 3,898 6, NHS 111 direct access service 834 Urgent Care Pharmacy Pharmacy First Minor ailment scheme 173 South London & Maudsley NHS FT Offer comprehensive care for people with a mental health need as an inpatient, outpatient or support in the community 37,738 Private Sector High cost placements for people with complex and long term mental health needs. 5,139 Learning Disability Includes High Cost Placements 5,480 Continuing Healthcare High cost placements for people with complex health needs 14,931 St Christopher s Hospice Table 9 The main provider for our population who need Hospice care support. See above 1,326 Final Version: NHS Croydon CCG Page 51 of 112

52 9. Transforming Our Services The Transformation Programme in addition to achieving improvements in quality outcomes is also expected to reduce an over reliance on hospital services, with the effect of people feeling more empowered to manage their own condition and more provision of care carried out in the primary and community setting. To ensure that there is choice available in other settings, we will need to transform the way we deliver services at the intermediate and primary and community setting. The aligned strategies to achieving this are the: Transformation Strategy Prevention, Self-Care and Shared Decision Making Strategy. Primary and Community Strategy Dementia Strategy Urgent Care Strategy, Beginning to End Long Term Condition pathways, Dementia, Diabetes, Cardiology, Respiratory and Cancer for all Adults and Children. Children s Primary Prevention Strategy Children s Early Intervention Programme One of the biggest areas of service change will be within Primary and Community Services. NHS Croydon CCG has developed 6 Geographical Networks with populations up to 80,000. The Geographical Networks supported by Public Health and Commissioning functions will understand their communities by knowing: Pockets of deprivation Prevalence of ill health, example numbers of people with long term conditions People who are vulnerable including those with a Mental Health Diagnosis, People with a Learning Disability, Older People and Children and Families needing additional support How health resources are utilised within their localities With this intelligence the Geographical Networks will be able to be more proactive in directing services to: Preventing ill health we know with areas of deprivation comes more health needs Self-care programmes to empower people to manage their long term condition and avoid exacerbations Final Version: NHS Croydon CCG Page 52 of 112

53 To identify through soft intelligence within practices and community services and through risk stratification people who would benefit from a Multi-Disciplinary / Professional Case Management approach to their care The services will therefore align around the 6 Geographical Networks with the GP Practices being a central point for understanding populations within each network. Each Geographical Networks will offer: Risk Stratification and MDT Case Management for vulnerable people Older People, Adults and Children Rapid Response GP / Pharmacy First Health Visitors / District Nurses / Community Matrons / Community Psychiatric Nurses (CPN s) / Nurse Consultant / Specialists / Midwives / Therapists aligned to Networks Whole System Pathways for referral on to Intermediate Care e.g. Urgent Care Centres Step Up / Step Down Service Provision Planned Care Appointment Services example Gynaecology, Ears Nose and Throat Final Version: NHS Croydon CCG Page 53 of 112

54 Geographic Network Population 1 Mayday 70,615 2 Thornton Heath 51,841 3 Woodside / Shirley 55,565 4 New Addington / Selsdon 50,280 5 Purley 69,259 6 East Croydon 80,010 Figure 26 Final Version: NHS Croydon CCG Page 54 of 112

55 9.1. Levels of Service Provision Our Provider services are mapped across 4 main levels, Hospital, Intermediate, Primary and Community and Prevention and Self - Care Services. A range of Providers work within all 4 levels to meet the health needs of Croydon population. Figure 27 Final Version: NHS Croydon CCG Page 55 of 112

56 9.2. Impact of Transformation Figure 28 Final Version: NHS Croydon CCG Page 56 of 112

57 9.3. Prevention Figure 29 Final Version: NHS Croydon CCG Page 57 of 112

58 9.4. Primary and Community Figure 30 Final Version: NHS Croydon CCG Page 58 of 112

59 9.5. Intermediate Figure 31 Final Version: NHS Croydon CCG Page 59 of 112

60 9.6. Hospital Figure 32 Final Version: NHS Croydon CCG Page 60 of 112

61 10. Our Improved Health Outcomes Measures Within our overarching Strategy we have 4 main health outcomes that we aim to achieve: Increased healthy life expectancy and reduced differences in life expectancy between communities Supporting children and young people to achieve their full potential Increased independence A positive experience of care Life Expectancy Improving life expectancy and reducing differences in life expectancy between communities We will focus on: Working with our partners in Public Health to support the key priority areas around prevention and early detection of illness Working with our Local Authority partners to support key priority areas around health promotion Supporting children and young people Supporting children and young people to achieve their full potential and have a great start in life We will focus on: The development and implementation of a joint Primary Prevention Strategy to support; Reducing the numbers of low birth weight babies Reducing infant mortality Improving initiation and duration of breast feeding Emotional health and well being Child and family health and life chances Final Version: NHS Croydon CCG Page 61 of 112

62 10.3. Independence Everybody will have the opportunity to have optimum health throughout their life and proactively manage their health and care needs with support and information. We will focus on: Earlier detection and intervention to reduce the impact of ill health Working with Public Health ensuring people are informed of life choices and the impact on health, supported by development of our prevention and self-management strategy Ensuring people are fully informed of options available to them when making any decisions about current and future health care needs Introducing risk stratification to identify people who would most benefit from integrated case management to reduce the impact of illness on their wellbeing Rolling out Telehealth so that people can manage their long term condition with support when needed A positive experience of care We will focus on: Commissioning high quality services and through proactive performance management will act on areas of concern Providers regularly reporting on patient and carer satisfaction survey and acting through contract levers where improvements can be made Ensuring that people know what services to use and when People, including those involved in making decisions on care, will respect the dignity of the individual and ensure support is sensitive to the circumstances of each individual. Final Version: NHS Croydon CCG Page 62 of 112

63 11. Health and Well-being Strategic Priorities Through our involvement with developing the Health and Wellbeing Strategy and working with our stakeholders we have identified 9 strategic priorities. Our main focus in delivering our priorities will include an emphasis on the prevention of ill health and supporting people to manage their conditions well. We will ensure that through developing integrated pathways that people are seen in the right place at the right time. This section describes the priority areas and how we intend to tackle the priorities throughout 2013/14, including how we are aligned with the Public Health and London Borough of Croydon commissioning intentions in each of the areas Prevention of Ill Health and Self-Care 11.2 Long Term Conditions Overall 11.3 Older People 11.4 Adults 11.5 Children and Young People 11.6 Planned Care 11.7 Primary and Community 11.8 Urgent Care 11.9 Medicines Management Please see Appendix 3 for Overall Plan on a Page and please see Appendix 4 for Commissioning Plan on a Page which includes high level activity ambitions. Please note that for all programme areas, forecast 2012/13 activity has been shown with no growth added. Average tariffs have been used. All activity and tariffs are pre-the split of HRG (Healthcare Resource Groups) activity which will transfer to NHS England under the Identification Rules (IR) Final Version: NHS Croydon CCG Page 63 of 112

64 11.1. Overall Figure 33 Final Version: NHS Croydon CCG Page 64 of 112

65 11.2. Prevention of Ill Health and Self-Care Figure 34 Final Version: NHS Croydon CCG Page 65 of 112

66 11.3. Long Term Conditions Overall Figure 35 Final Version: NHS Croydon CCG Page 66 of 112

67 11.4. Older People Figure 36 Final Version: NHS Croydon CCG Page 67 of 112

68 11.5. Adults Figure 37 Final Version: NHS Croydon CCG Page 68 of 112

69 11.6. Children and Young People Figure 38 Final Version: NHS Croydon CCG Page 69 of 112

70 11.7. Planned Care Figure 39 Final Version: NHS Croydon CCG Page 70 of 112

71 11.8. Primary and Community Figure 40 Final Version: NHS Croydon CCG Page 71 of 112

72 11.9. Urgent Care Figure 41 Final Version: NHS Croydon CCG Page 72 of 112

73 Medicines Management Figure 42 Final Version: NHS Croydon CCG Page 73 of 112

74 12. Measuring Our Improved Outcomes Croydon Clinical Commissioning Group with the support of the Clinical Commissioning Unit will regularly review its performance against NHS Constitution, NHS Outcome Frameworks and against locally set targets. The embedded pdf document shows the Baselines for NHS Outcome Framework where data is currently available. NHS Operating Framework Performance Baselines: Adobe Acrobat Document Figure 43 Final Version: NHS Croydon CCG Page 74 of 112

75 13. Carers National Policy Background The Carers and Disabled Children Act 2000, states that all carers aged 16 or above, who provide a regular and substantial amount of care for someone aged 18 or over, have the right to an assessment of their needs as a carer. This assessment is carried out by Croydon Local Authority to see if they can offer any support to aid in the role of caring. If there is more than one carer providing regular care in your household, both carers are entitled to an assessment. The local authority also has a responsibility to make sure a young carer s own wellbeing is looked after and that they receive the necessary support. A 16 or 17 year old who cares for someone, even for a limited period, may be entitled to an assessment. If a parent or carer/guardian has responsibility for a disabled child, the needs as a carer are assessed under The Children Act 1989 and the family has a right to a family needs assessment. The carers specific rights include the right to an assessment, the right to a direct payment if entitled to assistance, and employment rights such as flexible working.local authorities must make available a range of breaks for the carers of disabled children. The policy context, however, goes much further in its recognition of what central government and other statutory bodies should do to help and recognise the role of informal carers. Case for Change: Needs Demographic, economic and cultural trends are all pointing the way towards greater levels of informal caring within our society: The number and proportion of people who need care are growing, as are the proportion who need more extensive levels of care: The older population is growing. Moreover, longer life expectancy is not yet matched by better health expectancy and we are seeing higher levels of age related conditions such as dementia and circulatory and respiratory diseases. We can also expect increased level of demand for suitable, appropriately adapted or supported housing. The population of both younger adults and children with disabilities and long term illnesses is growing as life expectancy increases through medical advances. Increasing numbers of children have autistic spectrum disorders, conduct disorders, and behavioural issues. The general household survey indicated that 22% of carers cared for 50 or more hours a week in 2010, compared with 10% in Final Version: NHS Croydon CCG Page 75 of 112

76 Increasing life expectancy is fundamentally changing the profile of our society. The ratio of working people to people of retirement age has fallen from 5:1 in the 1940s to 4:1 today, and will fall further to 2:1 by This presents us with a major financial challenge and the government appointed Dilnot Commission is currently considering how the country can afford social care. At the time of the 2001 census, there were 29,400 people in Croydon who were providing regular unpaid care for family members or friends who are sick, frail or disabled, these people are known as carers. Carers are protected under the Equality Act 2010 by association of the person they care for because of their age or disability. Data on disabled children in Croydon is available on the I Count Disability Register. This data shows geographical spreads, age group and category of disability. This is a voluntary register and we currently have approximately 1,200 families who have registered their children. Over the past 30 years the disabled population has grown by 62%. Children aged 0 to 16 have formed the fastest growing group in the U.K. There has been a significant rise in the number of children with complex health needs and autistic spectrum disorders. Government population projections indicate that the number of older carers has increased by 250 over the last 10 years to 5,000 although there are no estimates for the number of carers under 65. We can expect that the state will increasingly look to families and society to take on the responsibility for caring for older people. And it is likely that vulnerable people may well wish to pursue informal caring arrangements, perhaps backed up by relatively low cost community based care, rather than high cost residential care. At the same time as this demographic impact, the cost of care is increasing and the global economic downturn has pushed the government into significant reductions to public spending with local authorities everywhere seeking financial efficiencies. We know that most vulnerable people would rather stay at home than move into residential care. Technological developments e.g. home aids and telecare as well as appropriate local housing provision are making that a far more realistic option than in the past. Self directed support also facilitates the staying put at home choice. However, as more people remain at home, the more likely they are to call on family and friends for at least some of their care. This, together with the message of the Big Society that we should find our own solutions, is likely to significantly increase the number of carers. Nearly a third of carers in our survey said that they need a bit or a lot more support hours or days than they were being offered (slightly higher in Croydon than the London average). Croydon Carers Strategy 2011 to 2016 is a strategy that was led by Croydon Council working in alignment with Croydon Clinical Commissioning Group, BME Forum, service managers and the Croydon Carers Partnership Group (CPG). The CPG brings together carers, providers of services for carers and statutory organisations. We have taken into account the results of the national consultation with carers and the findings of a local survey of carers undertaken in December Final Version: NHS Croydon CCG Page 76 of 112

77 The statutory sector is not the only provider of funding for carer services, and our thanks go to those third sector providers who raise their own funds and co ordinate the work of volunteers to ensure a decent level of local provision. We recognise the invaluable contribution of carers who give up their precious time to share their views on services in Croydon through the partnership groups and through other events and consultation opportunities Informal carers: people who look after their relatives, friends and neighbours when they are vulnerable through old age, disability or long term conditions and illnesses are important, and equal partners, in our society. They save the state money by providing the care which would otherwise be the responsibility of local authorities or the health service. A report in 2011 by Carers UK and University of Leeds calculates the value of care provided by carers in the UK to be a staggering 119bn per annum. This replaces the previous 2007 calculation of 87bn. Croydon has about 30,000 carers, 5,000 of those providing more than 50 hours of care each week. The saving to the public purse locally is in the region of 541 million a year. This replaces the previous 2007 figure of 400 million. Carers enable the people they care for to remain at home rather than move into residential care. This way, they are more likely to live full, safe, healthy and even longer lives, affording them their dignity and independence. Some carers cope very well with their caring responsibilities and are determined that they themselves provide support to their loved ones. But others need help whether because their caring responsibilities are very onerous impacting on many aspects of their lives, or because they too are vulnerable, frail, sick or disabled. It is in the interests of those carers, of the people they look after, and of the state, that we provide carers with timely help and support, and sometimes just recognition, to help them to carry on caring. According to the 2001 census, there are 30,000 people in Croydon providing regular unpaid care for sick, frail or disabled family members or friends. POPPI (Projecting Older People Information) estimates suggest that in 2011, there were 5,000 carers aged 65 or older. A national survey of carers in contact with adult social services found that approximately one quarter of carers were looking after someone with dementia (Ref. Personal Social Services Survey of Adult Carers in England , Health and Social Care Information Centre, 2010). Croydon s Integrated Carers Strategy of is an update of the previous strategy of It is aligned with the current government s 2011 refresh of the National Carers Strategy: Recognised, valued and supported: next steps for the Carers Strategy. The draft strategy recognises the valuable input of carers and aims to support carers by providing information, support, advocacy and respite breaks as appropriate. Young Carers in Croydon The 2001 census also reveals that there were more than 700 carers under 25, (including 555 aged five to 14) 3. Information from Croydon Young Carers Project gives us a picture of what it means to be a young carer. A young carer may begin their caring role from the age of 5 onwards. Bullying is Final Version: NHS Croydon CCG Page 77 of 112

78 still a serious concern; younger children are unable to go to school if their parent is too ill to take them; taking a family member to an appointment can take precedence over taking a break or attending activities; some are experiencing bereavement following the loss of one parent and having to cope with the frailty of the remaining parent. BBC survey of secondary school pupils published in November 2010 reveals that the National Census 2001 data of 175,000 young carers (aged 18 and under) in the UK could be a vast underestimation. The survey estimates that there could be as many as 700,000 young carers in the UK. Locally, we can see that there is an increase in sibling care, particularly for siblings suffering from autism and attention deficit hyperactivity disorder. Carers may themselves be ill, frail or disabled, and they themselves could fall within the protected groups under the Equality Act The 2010 survey of adult carers found that: 26% have a long term illness 24% a sight or hearing loss 21% a physical disability 11% a learning disability or mental health problem (some had more than one of these characteristics) In other words, the carers are not so very different from the people receiving the care. In some cases family members are looking after each other, for example a daughter with a learning disability and her elderly mother. 9% said they were in bad or very bad health. Indeed, the caring role can cause or exacerbate health problems. The (national) general household survey in 2009/10 found that 52% reported that their health had been affected, 42% said their personal relationships, social life or leisure time had been affected, and 26% their ability to take up or stay in employment. Not surprisingly, 72% of those providing 20 or more hours of care a week reported poor quality of life. There is a significant correlation between carer burden and increased use of mental health services Working with Health and Wellbeing Board, NHS Continuing Healthcare Personal health budgets are currently being piloted in the NHS in England, with over 2,700 participants across 20 sites. A number of sites are piloting personal health budgets with people eligible for NHS Continuing Healthcare. In October 2011, the Secretary of State for Health announced that subject to the evaluation, by April 2014 everyone in receipt of NHS Continuing Healthcare will have a right to ask for a personal health budget, including a direct payment. This will form part of a broader rollout of personal health budgets to people with long term health conditions. A personal health budget is an amount of money that is allocated to an individual to allow them to meet their health and well-being needs in a way that best suits them. At the heart of a personal Final Version: NHS Croydon CCG Page 78 of 112

79 health budget is a care plan which sets out the individual s health (and social care) needs and includes the desired outcomes, the amount of money in the budget and how this will be spent. The care plan has to be agreed between the individual and the professional, before being checked and signed off by the NHS. Personal health budgets potentially offer greater integration of health and social care for both individuals who need care and their carers, and better partnership working between the NHS and local authorities. Personal health budgets and NHS Continuing Healthcare provides more information about the recent Government announcement and how these budgets are relevant to people receiving NHS Continuing Healthcare and how personal health budgets change the NHS Continuing Healthcare pathway As part of the mandate to NHS England, enhancing quality of life for people with long term conditions, the proposal is that by April 2015, CCGs will be ready to offer personal health budgets to other people with long term conditions likely to benefit from the increased choice and control offered by the new personal health budget model. This comes on top of the requirement to offer personal health budgets in NHS Continuing Health Care from April NHS Croydon Clinical Commissioning Group is working towards ensuring that they meet their obligations to offering personal health budgets, as it is acknowledged that this will benefit both the person and the carer by giving them the flexibility to secure services in the way that would be most beneficial to them Although the statutory responsibility for providing a carers assessment lies with the Local Authority, the NHS Croydon Clinical Commissioning Group has a responsibility to ensure that Providers are aware about signposting responsibilities for a carers assessment when assessing patients needs Milestones / Key Actions Achievement Date 1 Personal Health Budgets offered to people agreed as eligible for NHS CHC 1 st April Working with LA to raise awareness for carers of rights to an assessment 1 st Oct 2013 Table 10 Final Version: NHS Croydon CCG Page 79 of 112

80 14. Emergency Preparedness, Resilience and Response Joint work to update and strengthen the way the revised health system will plan and respond to incidents and emergencies is nearing completion. Health response partner agencies including the NHS England, Public Health England (PHE) and Department of Health (DH), working with local government and the Local Government Association (LGA) will ensure the safe transition to new Emergency Preparedness Resilience and Response (EPRR) arrangements into the health and care system from April Recent transition developments include: System assurance exercises to provide assurance of the cross-agency effectiveness of the new EPRR system are being held in each region. The first exercise was held on 7 November 2012 in Cleveland for the northern region and will be followed by exercises in the Midlands and East region (23 January) and the Southern and London regions (6 February). Geographical boundary maps for NHS England Area Teams, PHE centres, Local Health Resilience Partnerships (LHRPs) and Local Resilience Fora (LRF) are now available. NHS England has published guidance for area teams, including a checklist of the preparations required in order for each area team to take over responsibility from PCTs as part of transition. The LGA recently led a stocktake exercise, to allow local authorities to review their progress in taking over transferred public health responsibilities, including EPRR. The 100 percent return revealed very good progress, with 95 percent of localities expecting a successful and safe transition. Where authorities have local challenges of particular concern, LGA is ensuring sector-led support. PHE expects to lift and shift the majority of Health Protection Agency staff with EPRR responsibility shortly. This includes specialist emergency planning staff. The roles and responsibilities of the CCG in relation to EPRR derive from the Civil Contingencies Act (CCA) 2004 and the Health and Social Care Act 2012 (s46 relates to emergencies). Health Emergency Preparedness, Resilience and Response from 2013: Summary of the principle roles of health sector organisations (DH, July 2012, Gateway 17820) identifies the principle organisational roles and responsibilities of CCGs related to EPRR. Please outline assurance that the CCG and Providers of NHS Services are properly prepared to cope with emergencies and to monitor their compliance. Final Version: NHS Croydon CCG Page 80 of 112

81 Include assurance that the CCG will: Ensure contracts with provider organisations contain relevant emergency preparedness, resilience (including business continuity) and response elements; Support NHS England in discharging its EPRR functions and duties locally; Provide a route of escalation should a provider fail to maintain necessary EPRR capacity and capability; Fulfil the responsibilities as a Category 2 responder under the CCA; Maintain business continuity plans for their own organisation; Be represented on the LHRP (either on their own behalf of through representation by a lead CCG); Appoint an individual who is responsible for the preparedness and response of that organisation. As lead commissioners for acute Trusts, it is anticipated that CCGs will also have a role in managing surge pressures, especially during the winter months, which may include authorising ambulance service diverts when hospitals can no longer take admissions. In addition as lead commissioners for community services it is also anticipated that CCGs will be expected during a major incident to authorise the mobilisation of community staff and to liaise with Local Authorities. Milestones / Key Actions 1 Agree a workable model with NHS England for a 24/7 on-call function for surge pressure management within the SW cluster area managed by the CSU to begin from 31st January Identify appropriate staff to fulfil the 24/7 on-call function for major incident and liaise with Emergency Planning, Performance and Contracts colleagues to ensure appropriate training is made available, equipment is provided (e.g. pagers, phones, ipads etc.) and on-call documentation and contact information is up to date 3 Identify an accountable emergency officer to assume executive responsibility and leadership for EPRR and business continuity management. 4 Review and update / develop business continuity plans for the CCG that define critical functions and include response arrangements for mitigating the loss of key premises, staff, IT or suppliers in the event of an internal disruptive event. 5 Confirm that existing and future contractual arrangements with provider organisations contain relevant clauses outlining the role of the provider in the response to emergencies and requirements for provider organisations to maintain appropriate business continuity plans. Achievement Date 25 January 2013 By 31 January 2013 End of January 2013 End of February 2013 Mid-March 2013 Final Version: NHS Croydon CCG Page 81 of 112

82 Milestones / Key Actions 6 Ensure CCG plans, arrangements and activation mechanisms are in place that allow it to support the response to emergencies through the mobilisation of local provider resources 7 Seek assurance that the CCG is suitably director level represented at London Health Resilience Partnership (LHRP) meetings, and ensure that communication channels are in place that allow the two-way sharing of EPRR information between the CCG s accountable emergency officer and CCG Lead person(s) representing all CCGs at the LHRP. 8 Ensure that the CCG is engaged in local resilience planning through close partnership working with the NHS England EPRR Area Team, and is suitably represented at planning groups such as Borough Resilience Forum meetings. 9 Develop an annual work programme to reduce risk and implement any lessons learnt from exercises and incidents relating to EPRR. The programme should be linked to the National Risk Assessment (NRA) and Community Risk Register (CRR). 10 In conjunction with NHS England EPRR Team, seek assurance that provider organisations have detailed, comprehensive and tested resilience arrangements to respond effectively to an emergency and have business continuity management processes in place to maintain critical functions during a disruptive event. 11 Ensure that the CCG has suitable up to date plans in place for the management of threat specific incidents such as severe weather; industrial action; CBRN; and pandemic flu and arrangements for regular reviews of the plans on a yearly basis and following exercises or incidents. 12 Incorporate an EPRR risk section into any organisational risk registers which links to the locally identified risks such as flooding or pandemics 13 Ensure key staff are aware of plans and are suitably trained in the response required by them in an incident. This should include update training when plans or response requirements change. 14 Have arrangements in place to provide a suitable environment to manage a significant incident or emergency (an ICC). 15 Develop an exercising and training plan to meet the duties as a category 2 responder and participate fully in Borough and NHS England exercises to ensure plans are tested through a six monthly communications exercise; a desktop exercise once a year; and a major live or simulated exercise every three years. This includes providing debrief reports for incidents and exercises. Achievement Date Mid-March 2013 End March 2013 End March 2013 End April 2013 End June 2013 End June 2013 End June 2013 End August 2013 End April 2013 End August 2013 Table 11 Final Version: NHS Croydon CCG Page 82 of 112

83 15. Business Informatics There are two key components to the NHS Croydon Clinical Commissioning Groups approach to ensuring it has appropriate informatics capability and capacity during transition and beyond: Business Intelligence and Information and Communications Technology (ICT) services purchased as scale from the South London CSU Working collaboratively with South London CSU to evolve informatics capability in future Business Intelligence and ICT Services Purchased At Scale from the South London CSU South London CSU is providing both Business Intelligence and ICT support for the CCG during the transition period. The scope of these services is as follows: Performance reporting and data management > performance measurement of provider quality and delivery against Key Performance Indicators (KPI s) and the Commissioning Outcomes Framework, as well as advanced analytics and bespoke reporting services. CCG ICT > Key services such as , telecoms, central storage and access to the data warehouse. Primary Care ICT > Providing GPs with Information and Communications Technology (ICT) to carry out day to day work effectively, as per General Medical Services (GMS). Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS) contract In order to provide continuity of service during this transition period the CSU has not only been recruiting to its structures (over 80% of posts are now filled), it has also been line managing the legacy Cluster staff since 1 November 2012, many of whom will officially be part of the CSU from 1 April The CSU is now delivering the informatics service in shadow form governed by the Service Level Agreement (SLA) signed by the CCG on 30/11/2012. Working Collaboratively With South London CSU to Evolve Informatics Capability In Future The CCG continues to work with the CSU to deliver a data warehouse and reporting capability to support our acute commissioning during the next 12 months. In parallel the CSU has been working on a three year Business Intelligence strategy to deliver a greater level of sophistication in performance reporting and data management. In order to deliver this strategy we will work with the CSU to focus on delivering: Strategic data warehouse solution: in 2013 the CSU will be going out to procurement for an enterprise data management and analysis capability. This will be done in conjunction with the development of the London Data Management Integration Centres (DMIC) and the CCG will provide input to the requirements. Final Version: NHS Croydon CCG Page 83 of 112

84 Commissioning Intelligence Model (CIM): the three year strategy being worked up in conjunction with the CSU is aligned to the CIM, so that informatics capability is able to answer the critical questions for commissioners. Capability and processes: both the CSU and CCG will invest in development of our people and enhancing our processes so that our knowledge and expertise evolve in step with technologies, technical tools and commissioning intelligence requirements. Training programmes are already under way for the foundation data warehouse. Data Management Integration Centres (DMIC): we will ensure the CSU is proactive in leading the London DMIC development, which will be critical to delivering cost effective data management, as well as enabling commissioners across the capital to share information in a consistent way. Developing and Delivering GP Practice Level Information During 2013/14 we will be working work with the CSU on enhancing the information provided to GP practice level. This includes: GP Practice Level Dashboards: South London CSU has instigated a project to develop a tool to provide information at GP practice level, which: o o o o Contains secondary Care focus, using SUS data, refreshed monthly Shows activity by Specialty and function; e.g. inpatients and outpatients Has the ability to drill down to a patient level Managed centrally by the CSU with a link to the data warehouse to which Croydon CCG already has direct access The key milestones for delivery are: Initial scoping meeting to assess high level requirements Complete Complete scoping and detailed customer requirements Complete Integrate with existing data warehouse April 2013 Build and test April 2013 Pilot roll out May 2013 Develop, build and release next version June 2013 to September 2013 Implementing the John Hopkins ACG Risk Stratification software, which includes: o o Integration of primary and secondary care data on a patient specific basis Costs for both primary and secondary care activity Final Version: NHS Croydon CCG Page 84 of 112

85 o o o o o Integrated utilisation activity e.g. no. of times individual patients have attended primary care, A & E, emergency admission, outpatient attendance and suchlike Trend analysis; diagnostic profile; detailed analysis via hypercube; trend Analysis Identification of patients with Chronic Diseases and no activity Ability to support other initiatives such as Chronic Disease Management and Telehealth Potential for practice comparisons (using non PID data) Improved Flexible Reporting The Business Intelligence service provided by SL CSU will give the CCG improved reporting in the short term, with greater levels of flexibility. This capability is being developed during Q4 2012/13 and includes: Centrally managed data warehouse containing SUS data, SLAM data Common reporting platform across South London with unified global PODs Improved benchmarking capabilities Access to a suite of standard reports for acute contract management Flexible reporting tools and data cubes, including Cognos and PerformancePoint Secure CCG sand-pit area for local analysis of data sets All access provided through a secure user Portal An Achievable Trajectory for Providing Summary Care Records The provision of Summary Care Records has started in NHS Croydon Clinical Commissioning Group and the current status is as follows: CROYDON SCR UPLOADS REMAINING NUMBER OF SURGERIES 64 INPS Vision EMIS LV EMIS PCS isoft Synergy Emis WEB Total Table 12 Final Version: NHS Croydon CCG Page 85 of 112

86 The trajectory for implementation of the remaining 38 practices during 2013/14 is: Figure 44 - Implementation will be complete by 31 March 2014 A proposal for giving patients on-line access to their medical records, starting with their GP records This will be achieved in EMIS practices by implementing EMIS Access which allows patients to book appointments, request repeat prescriptions and view results. The implementation of EMIS Web is a pre-requisite for this functionality. In practices where Vision is used this will be achieved by implementing Vision 360 On-line services which allows the same functionality. In Croydon CCG there are 36 practices on EMIS. 2 of these have already been migrated to EMIS Web with a plan in place to migrate the remainder by 31 March 2014, including the 5 practices still using isoft Synergy. There are 21 practices using Vision. There is a plan in place to implement Vision 360 by 31 March In conjunction with the migration to EMIS Web, plans for implementing patient access technology will be formulated this year and will ensure the following are covered: Communications support from SL CSU to help with the engagement with patients Training materials for practices provided by Training and Change Managers Patient forums to understand any challenges or blockers to using the functionality Assessment of Information Governance issues with a plan to address these In December 2013 a business case will be submitted to secure funding to rollout the required functionality, with implementation to start in April 2014 and planned to complete by March The implementation will include practice communications literature to inform patients of the functionality. Final Version: NHS Croydon CCG Page 86 of 112

87 Business Intelligence Supporting Roll Out Of 111 and Directory of Services As the provider for its 111 services, SL CSU will provide information required for the monthly Department of Health returns (via UNIFY2). This includes: Monitoring A&E activity at Trusts covering the 111 area that the CCG is responsible for, monitoring and reporting on activity in Urgent Care Centres, Walk-In Centres and GP Out of Hours in order to monitor the impact that the 111 service is having on NHS urgent care Providers. Monitoring and quality assuring and signing-off the monthly minimum data sets that are submitted by the 111 Providers. In addition to these mandatory central returns, SL CSU will also collate and process the daily SITREP data that is sent by the 111 Providers and upload the analysis to the Urgent Care extranet portal. The reporting will include trend analysis and activity monitoring as well as dissemination of national benchmarking and feedback from the 111 pilots across the country. Final Version: NHS Croydon CCG Page 87 of 112

88 16. Quality Innovation Prevention and Productivity /14 QIPP Plan Croydon CCG is developing plans to meet a QIPP target of 14m for 2013/14 compared with the 2012/13 target of 25m (Month 10 report forecasts achievement 21.2m). The table below gives a high-level summary of the latest position of the 2013/14 QIPP Plan where m of saving opportunities (net of re-investment costs) have been identified to date. However, these savings have been risk-adjusted at this time due to the fact that the projects are in the planning stage at present, so the assumptions are subject to change. Following risk adjustment, the revised net savings total currently identified is m, leaving a further 0.006m to find; there is also risk relating to possible slippage etc within schemes already identified. Plan as agreed by Governing Body on 26 March 2013 NET SAVING Opportunity ( 000) Risk Weighting NET SAVING Total ( 000) Identified Schemes with PIDs 11,925 90% 10,732 Schemes in Development (High Level Assumptions only) 4,349 75% 3,268 TOTAL 14,000 Table 13 - High-Level Summary of 2013/14 QIPP Plan as agreed 26 March 2013 A number of the schemes identified to date in Croydon s 2013/14 QIPP Plan are either savings made through contract efficiencies or full year effects (FYE) of projects implemented in 2012/13 or before. New initiatives have also been developed that include: Service Redesign schemes that plan to move activity from the acute setting into the community Demand Management schemes that are designed to reduce the number of patients referred into acute services inappropriately The review of all patients in Mental Health and Learning Disability Placements to ensure they are in the most suitable place of care The operational workstreams to support Croydon CCG s Transformation Strategy Further QIPP schemes have been identified and high-level assumptions made about the net savings they could achieve in 2013/14. However, these are being developed and verified, and are subject to further refinement. The total net saving forecast relating to these schemes stands at 3.262m following risk adjustment. The CCG continues to work to identify additional projects/initiatives for implementation in 2013/14 to to provide additional savings to meet any inyear shortfall in the current plan. Final Version: NHS Croydon CCG Page 88 of 112

89 16.2. Medium Term QIPP Opportunity Croydon CCG has committed to achieving financial recovery and sustainability over the next 3 years, from 2013/14 to 2015/16. To achieve this, a key element for the CCG to deliver is significant change in the delivery of care to reduce the demand on acute services in both elective and non-elective activity. As previously stated Croydon CCG is signed up to achieve Croydon s QIPP target of 14m in 2013/14. To support the targeting of QIPP delivery projects, a benchmarking exercise has been carried out to identify opportunities at CCG and Practice level for developing and taking forward and has been incorporated in an Opportunities Report. The benchmarking has taken into account both programme budgeting and national efficiency benchmarks, and variation in practice. The identified opportunities are summarised below: Benchmarking Efficiency / Opportunity m 2013/14 Good Practice m 2014/15 Best Practice Transforming m 2015/16 Transforming m A&E Attendances Outpatients Non Elective Admissions Maternity 1.5m Continuing Care Length of Stay Diagnostics Elective inc ECIs Mental Health Prescribing in all settings Opportunity 24.5m m 18.0m 15.0m 13.5m Table 14: Source: Benchmarking Opportunitie paper, November The CCG has engaged external clinical support to review the benchmarked opportunity on the latest available data, draw on best practice from other health systems, and inform the QIPP ambition for 2014/15 and 2015/16 to meet financial recovery and sustainability objectives. Final Version: NHS Croydon CCG Page 89 of 112

90 16.3. QIPP Delivery Risk Croydon has had considerable success in the last two years in delivering significant QIPP savings: 2011/12 ( 17m outturn) and 2012/13 ( 20.2m Forecast Outturn FOT). The table below details the main risks and mitigations that face the QIPP challenge: RISK Lack of Project/ Commissioning Manager resource to cover the full scope of change. Vacancies and the use of interim staff have meant there is a risk to project continuity and delivery Lack of buy-in from local Croydon Health Services to the specific service changes the CCG is proposing across planned and unplanned care. MITIGATION The CCG is seeking to mitigate this risk through developing an Integrated Commissioning Unit with the Local Authority and recruiting to vacancies To address this risk, QIPP governance was reviewed and the Acute Task Group has been set up to convene on a monthly basis to triangulate acute and QIPP issues with Croydon QIPP Project Managers and the ACU. For 2013/14, the CCG has specifically negotiated QIPP schemes into the contract (planned care), or with a contractually agreed in-year date for resolution. This includes using Activity Planning Assumptions (APAs) and Local Quality Requirement (LQRs) schedules in the contract. Lack of engagement of GP members into the referral management services (CReSS) and referring to the Intermediate Services (eg ENT, Gynaecology, Dermatology, MCATS and CORS) and taking up the Enhanced Services aimed at reducing emergency admissions (eg LTC and GP Support for Care Homes) To address this risk, the Planned Care Commissioning Team market the Intermediate Services to GPs in a number of ways including presentations at the Clinical Leadership Group and GP Network meetings, bulletins in the equipped newsletter and targeting GP Practices with low referral rates etc. The Older Adults Commissioning Team are working with the GPs and LMC to understand the reasons for poor uptake of the Enhanced Services and to develop alternative models to encourage more GP support of the schemes Table 15 Final Version: NHS Croydon CCG Page 90 of 112

91 16.4. QIPP Governance Croydon CCG utilises a Programme Management Office (PMO) approach to support QIPP delivery by implementing and managing controls and assurances. Overarching PMO principles are detailed below: The QIPP Delivery/PMO team is being expanded from 2.0 WTE to 3.0 WTE to further support the organisation in the development and delivery of QIPP schemes The CCG has an agreed governance structure that ensures transparency in reporting and resources are directed to those schemes most at risk. A multi-disciplinary approach, including clinical leadership is at the heart of problem solving and delivery Project workbooks are in place for managing all material projects through the PMO. Workbooks for 2013/14 projects require sign-off from the Responsible Director, Clinical Lead, Finance Lead and Public Health Lead (as appropriate) to ensure a greater level of engagement, buy-in and governance Equality Impact Assessments (EIAs), Risk Registers with mitigating actions and Milestone Trackers are completed by Project Managers for each scheme The PMO has a robust scrutiny process, which includes monthly meetings with all Project Managers to review and discuss progress and performance of each scheme PMO reports consisting of financial dashboards and a written update are submitted monthly to the Croydon CCG Senior Management Team and the South London Commissioning Support Unit (CSU) The PMO operates a continually rolling programme it supports Commissioners in the identification and development of new schemes to bridge the gap of lost savings where projects have underperformed/slipped in-year and ensures future saving plans are in place The PMO routinely reviews other local and National QIPP schemes that are available to identify opportunities that may be suitable for implementation in Croydon. The PMO then works with the appropriate Commissioners to develop the idea into a PID (Project Initiation Document) Croydon CCG has implemented the QIPP Operational Board (QOB) to increase rigour, scrutiny and support to the QIPP Programme. The QOB is chaired by a GP and comprises the Director of Commissioning, Director of Finance, Public Health Consultant, Head of PMO and Project Managers. It meets weekly to review progress of all QIPP projects on a rolling basis and helps to identify risks, unblock obstacles that the Project Managers are facing and provide support where necessary. It also reviews plans for 2013/14 QIPP projects for challenge and sign-off. Strategic themes from the QOB are reported to the Croydon CCG Senior Management Team for early discussion and action as appropriate (i.e. projects experiencing significant loss, data validation issues, ACU, contracting, recruitment etc). Final Version: NHS Croydon CCG Page 91 of 112

92 In addition, the Croydon CCG Head of QIPP Delivery and PMO chairs the bi-monthly South London QIPP Leads meeting to maintain and broaden the networking links on QIPP and share best practice ideas to maximise delivery as efficiently as possible. Final Version: NHS Croydon CCG Page 92 of 112

93 m from Target 17. Finance Planning A more detailed analysis of the 2013/14 Financial Plan is contained in the accompanying paper entitled Detailed 2013/14 Financial Plan (April 2013) Planned Delivery In 2013/14 The CCG inherits from its predecessor organisation, Croydon PCT, with the following significant factors: Below-target allocation position (one of five in London) Population and need growth higher than projected/funded (2011 census v 2011 projections) by another 5%, materially worsening the distance below target on allocations. Financial challenge identified in 2011/12 of 42m and underlying recurrent deficit at the end of 2012/13 of 36m adrift of operating plan targets ( 18.2m recurrent deficit plus 18m shortfall on operating plan targets (2% headroom and 1% surplus). Local acute provider with deteriorating financial position and poor quality reputation /12 Distance from Target ( m) - London PCTs ( 867m > Target) (10.0) (20.0) London PCTs Figure 45 Final Version: NHS Croydon CCG Page 93 of 112

94 The PCT has delivered QIPP programmes of 17m in 2011/12 and 20m in 2012/13 to address this challenge. However, the CCG sized the financial challenge in the Medium Term Financial Strategy (October 2012) and agreed, as one of its four corporate objectives, to achieve financial recovery and sustainability over three years (to 2015/16). The financial challenge in 2013/14 alone is 42m financial challenge (before QIPP) to meet operating plan targets, as outlined below. Source of 2013/14 Financial Challenge ( 42.1m Before QIPP) 13/14 Pressures, 4.8m, 11% 2% Headroom, 8.2m, 20% Inherited Deficit (84% of PCT Deficit), 15.2m, 36% 2% Surplus, 8.2m, 19% Allocation Errors, 5.7m, 14% Figure 46 Of this 42m, 33m is attributable to inherited historical performance from Croydon PCT. The new challenges that all CCGs face are in-year 2013/14 pressures ( 4.8m) and moving from 1% to 2% surplus by 2014/15 ( 4.1m) The key focus is development and delivery of a 14m (3%) QIPP programme, with identified schemes, and the procurement of external support to strengthen delivery of those schemes. The CCG Opportunities paper has identified key efficiency opportunities over a three year period. The net QIPP savings identified to date range from 10m - 14m depending on risk rating (refer Section 5) The net planned financial position is a 19.9m deficit ( 42.1m, less exemption from 2% surplus ( 8.2m) less 14.0m QIPP) and is summarised in the next section. Final Version: NHS Croydon CCG Page 94 of 112

95 17.2. Financial Plan 2013/14 (Including Key Assumptions) The draft 2013/14 Plan (is summarised below) in graphical and tabular format: 2013/14 Expenditure Profile ( 425m) Running Cost/Excl, 11.8m, 3% Reserves, 18.4m, 4% Mental Health/LD, 54.0m, 13% Primary Care, 49.4m, 12% Acute Services, 240.1m, 56% Out of Hospital Care, 50.7m, 12% Figure 47 Total 2013/14 m Allocated Resources Application of Funds Acute Out of Hospital Care 50.7 Primary Health Care Services 49.4 Mental Health Services / Learning Disability Services 54.0 Running Cost Allowance 9.1 Other incl Running Cost Exclusions 2.7 Reserves & Contingencies Local Reserves (activity/specialist transfer) 8.2 2% Transformation & Risk Reserve Contribution to SWL Risk Pool % Contingency 2.0 Total Spend (incl 14m QIPP across service lines) Planned Deficit 19.9 Table 16 Final Version: NHS Croydon CCG Page 95 of 112

96 Key risks to delivering the proposed deficit control total for 2013/14 are as follows: Underlying activity/cost growth on acute (planned for 3.7%) Completing development and improving deliverability of 14m QIPP programme Delivery of the 14m QIPP Programme Technical allocation adjustments including specialised commissioning, primary care and premises Continuing Care restitution claims Key opportunities to deliver improved patient care through more efficient processes are: Harnessing the benefits of a local integrated acute/community provider Development of an Integrated Commissioning Unit with our Local Authority Development of integrated health and social care pathways through a local Strategic Transformation Board Development of geographically-based GP Networks with devolved indicative resource budgets and QIPP schemes Harnessing the Business Intelligence capabilities of the South London CSU Final Version: NHS Croydon CCG Page 96 of 112

97 The key planning assumptions underpinning the plan are as follows: Description Assumption Allocations Growth +2.3% (+ 9.2m) Inflation/Provider CIPs PbR Tariff Deflator Non-PBR Price Deflation -1.3% (+2.7% inflation - 4.0% CIPs) -1.3% (same as PbR) Non Acute NHS Price Deflator -1.3% Non NHS contracts / placements +2.0% Running Cost Pay +1.0% CQUIN 2.5% - no change from 2012/13 Growth assumptions (pre QIPP impact): Acute +3.7% Out of Hospital/Mental Health +1.5% Prescribing +5.0% (script growth) Continuing Care +5.0% Table 17 The following assumptions are also fundamental to the plan Non-Elective Threshold Adjustment (NETA): Assessed at 3.4m from 12/13 FOT, assumed to be invested in community and primary care to support transformation of Long Term Conditions care pathways. Detail being agreed with local partners including Croydon Council, CHS (integrated provider) and LMC Non-Elective Readmissions rebate: To be reinvested in emergency care QIPP schemes as in 2012/13. No additional release of funds expected, therefore no additional investment planned Reablement Funds: Although the predecessor PCT did not recurrently invest these resources in reablement, the CCG is considering invest to save QIPP schemes for Long Term Conditions that may also be consistent with the reablement agenda. Indeed, successful reablement schemes funded from the Health and Social Care allocation may well be extended Risk Sharing: SWL CCGs have agreed to share financial risk on an in-year basis (where risks are unknown and not planned for) and programme costs of service transformation Final Version: NHS Croydon CCG Page 97 of 112

98 17.3. Key Bridging Movements from 2012/13 FCOT to 2013/14 Plan The waterfall diagram below highlights the key bridging movements between the 2012/13 PCT Forecast Outturn position at Month 10, to the draft 2013/14 plan. The key steps in the bridge are as follows: PCT Recurring deficit ( 18.2m), including Non Elective Threshold Adjustment (NETA) Distribution of PCT recurring deficit across receiver organisations CCG Opening Recurring Deficit ( 15.5m) Allocations adjustments and corrections ( 5.2m) and specialist commissioning CCG Growth allocation ( 9.2m) 2013/14 planning assumptions (inflation, provider efficiency, growth in demand) Operating Plan targets (0.5% contingency, 2% non-recurrent headroom and 2% surplus) 2013/14 Challenge ( 42m) QIPP identified investment and gross savings (net 14m) Current proposed control total of 19.9m deficit These assumptions are broadly in line with the base case of the CCG Medium Term Financial Strategy, with adverse movement on allocations, non-elective threshold principles and level of QIPP identified. Final Version: NHS Croydon CCG Page 98 of 112

99 PCT 12/13 FOT (M9) Reverse Risk Share Benefit Other NR (NETA, CQUIN etc) PCT 12/13 Recurrent Position Public Health Transfer NCB Transfer *NCB Specialist Commissioning CCG OPENING RECURRENT Allocation Adj/Errors Allocation Growth Inflation Provider CIPs (4%) Demographic/Demand Growth 0.5% Contingency 2% N/R Headroom 2% Surplus NET QIPP CHALLENGE (OP Plan) Relief on 1% Surplus (NCB) QIPP Gross Savings QIPP Investment (above NETA) Net Planned Financial Position 26/3/13) SLA Negotiation Pressures Correction for Allocation Errors Minimise Pressures/Reduce Reserves Net Planned Financial Position (30/4/13) ( 8.2m) 8.2m ( 2.0m) ( 8.1m) 1.0m ( 1.0m) 3.7m 0.0m ( 5.2m) 16.7m ( 2.7m) ( 5.8m) 4.8m ( 9.2m) 9.2m ( 10.3m) 13.5m ( 15.5m) 0.0m ( 9.0m) ( 18.2m) ( 15.5m) ( 42.1m) ( 19.9m) ( 19.9m) 5.0m 0.0m Croydon CCG Waterfall : 12/13 -> 13/14 Draft Plan ( 5.0m) ( 10.0m) ( 15.0m) ( 20.0m) ( 25.0m) ( 30.0m) ( 35.0m) ( 40.0m) ( 45.0m) Figure 48 Final Version: NHS Croydon CCG Page 99 of 112

100 17.4. Triangulation of Finance and Activity Assumptions The CCG has been working closed with the Specialist Commissioning Team from NHSE, Croydon Health Services NHS Trust, and South London and the Maudsley Mental Health Services NHS Trust to triangulate activity and finance assumptions in the plans. Heads of Terms for all key contracts have been signed in early May The specialist commissioning transfer remain under further review given the complexity of the changes. Final Version: NHS Croydon CCG Page 100 of 112

101 17.5. Key Capital Schemes The key capital requirements for the CCG are as follows: Type Owner of Capital Scheme Descriptions Local SL CSU IT capital to support the relocation to joint offices with London Borough of Croydon Strategic capital: Immediate Strategic capital: future Table 18 Croydon Health Services Croydon Health Services Investment in local A&E and Maternity services at A&E to address quality issues and expected increase flows from changes arising at South London Healthcare Investment in CHS emergency and maternity services if is shortlisted as a hot site in the Better Services Better Value business case Liquidity / Cash Flow / Cash Requirements Given the significant financial challenge and risks facing the CCG, all revenue-based allocation corrections and risk sharing drawdown must be cash backed to ensure NHS and non-nhs creditors continued to be paid within public sector payment targets. The CCG will need 19.9m cash support for the control total deficit of 19.9m. This represents 5% of cash outflow and based on the drawdown arrangements for CCGs, need to be resolved well in advance of March 2014 when the risk of insufficient cash would arise. It should be noted that additional cash will be required to settle significant PCT provisions, e.g. Continuing Care Restitution claims, as these are settled in 2013/14 and subsequent years by the CCG. The continuing care restitution provision for Croydon PCT is expected to be between 2m - 5m. Final Version: NHS Croydon CCG Page 101 of 112

102 17.7. Key Financial Risks and Opportunities in 2013/14 The following narrative is documented further in the DRAFT Detailed 2013/14 Financial Plan with financial risk and mitigation values tabulated. Key financial risks are: Risk Risk Mitigation Risk Value m Risk Rating Max /14 SLA negotiations with acute, community and mental health providers (cost pressures, PbR, deflator, QIPP) Due to transition and transfer of functions (specialist commissioning arrangements in particular), it has taken longer than normal for key issues to emerge and be managed. At this stage the CCG is still working towards Heads of Terms by 28/3/13, with the key caveat being finalisation of QIPP which is linked to the 30/4/13 deadline for the Clear and Credible Plan. Key risks are: - Service developments (St Georges) - Impact of PbR changes (maternity and unbundling) - Agreement on levels of activity/cost growth - Agreement on impact of community/primary care investment on acute volumes (QIPP savings) 9m 25 Growth in demand for acute services CCG has established geographic GP networks to manage devolved indicative budgets at network and practice level CCG has in place a demand manager/referral management service to improve the quality and appropriateness of referrals (CReSS) CCG is establishing a long term conditions programme as part of the QIPP programme +1% = + 2.6m CCG has budgeted for 3.4% growth/cost pressures 20 Allocation corrections not agreed CCG has raised these issues with NCB London Finance team promptly following publication of allocations CCG considers these to be factual errors in the allocations that collectively are material to the financial position of the CCG CCG recognises that the Public Health adjustment and shortfall cannot be corrected and is not pursuing this ( 1m) Nil as assumed within deficit position Strengthening 14m QIPP Programme External support and review from PwC has been commissioned Additional mental health benchmarking analysis is being undertaken CCG has worked with CSU to draw together relevant benchmarking data to identify QIPP and transformation opportunities over 3 years QIPP Delivery/PMO is being expanded from 2.0 WTE to 3.0WTE to support commissioning team 4m 25 Final Version: NHS Croydon CCG Page 102 of 112

103 Risk Risk Mitigation Risk Value m Risk Rating Max 25 Leading South London QIPP Leads Network to maximise sharing of successful schemes and ideas. Croydon CCG Chair the group Exploring the development of LHE wide PMO, including Reablement and Transformation of Long Term Conditions Deputy Director of Strategy to started in March 2013 Technical adjustments for Specialist Commissioning and acute transfers to NCB (emergency dentistry) and LA (sexual health) London CCGs working with Specialised Commissioning to identify pressures and realign across London where possible to avoid minimise impact on CCGs ACU rerunning relevant data by trust and triangulating with Trust analysis Unknown 20 Delivery of QIPP in-year (20% risk on programme = 4m) Increase PMO establishment form 2.0 WTE to 3.0 WTE Bring reablement projects into the discipline of the PMO Growth in demand for non-acute (eg continuing care, prescribing, mental health etc) (each+1% = 1.4m) CCG actively case managing continuing care cases with CCG clinical input and greater scrutiny of funder (MH, LD, older people, children) CCG has an excellent track record in delivering prescribing efficiency and expects to continue with a further 3% QIPP impact in 13/14 Development of efficiencies in MH care is a particular focus for clinical commissioners - with a focus on reduction in use of acute beds. Further benchmarking information on SLaM is being procured. Croydon is also leading on the establishment of joint commissioning arrangements with Lambeth, Southwark and Lewisham 4m 20 Cashflow in March 2014 As noted above, working to a deficit control total and the risk on settling continuing care restitution claims means the CCG will need cash support in March m - 22m 20 Table 19 Final Version: NHS Croydon CCG Page 103 of 112

104 17.8. Describe How You Will Manage Financial Risk In addition to the CCG s general governance and risk management processes, there are a number of mechanisms in place to manage risk, in line with NHSCB guidance: All provisions and reserves are excluded from individual budgets in favour of centralised control and application The demographic and residual growth reserves (acute and non-acute) have been created to mitigate against the risk of increased demand in service areas caused generally as a result of population and demand growth The contingency ( 2m, 0.5%) reserve is, as in prior years, entirely uncommitted and is expected to contain any unforeseen pressures that the CCG may face or be required to fund during 2013/14 The 2% headroom ( 8.2m), is committed to fund service transformation programme costs (Better Services Better Value, 1.3m), the balance currently held as contingency against risks The CCG is also entering into a financial risk sharing agreement, subject to Governing Body approval, to share risk with other SWL CCGs on in-year unknown risks. The detail of this can be supplied on request The CCG has also engaged PwC to support it to strengthen QIPP savings schemes and their delivery Final Version: NHS Croydon CCG Page 104 of 112

105 18. Appendices Appendix 1 NHS Constitution Appendix 2 - CCG Outcomes Indicator Set Appendix 3 - Plan on a Page Overview Appendix 4 Commissioning Plan on a Page Final Version: NHS Croydon CCG Page 105 of 112

106 18.1. Appendix 1 NHS Constitution Expected rights and pledges from the NHS Constitution 2013/14 (subject to current consultation) including the thresholds the NHS England will take when assessing organisational delivery Referral To Treatment waiting times for non-urgent consultant-led treatment Admitted patients to start treatment within a maximum of 18 weeks from referral 90% Non-admitted patients to start treatment within a maximum of 18 weeks from referral 95% Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral 92% Diagnostic test waiting times Patients waiting for a diagnostic test should have been waiting no more than 6 weeks from referral 99% A&E waits Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department 95% Cancer waits 2week wait Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP 93% Maximum two-week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected) 93% Cancer waits 31 days Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers 96% Maximum 31-day wait for subsequent treatment where that treatment is surgery 94% Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regimen 98% Maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy 94% Cancer waits 62 days Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer 85% Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers 90% Final Version: NHS Croydon CCG Page 106 of 112

107 Maximum 62-day wait for first definitive treatment following a consultant s decision to upgrade the priority of the patient (all cancers) no operational standard set Category A ambulance calls Category A calls resulting in an emergency response arriving within 8minutes 75% (standard to be met for both Red 1 and Red 2 calls separately) Category A calls resulting in an ambulance arriving at the scene within 19 minutes 95% Mixed Sex Accommodation Breaches Minimise breaches Cancelled Operations All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the patient s treatment to be funded at the time and hospital of the patient s choice. Mental health Care Programme Approach (CPA): The proportion of people under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care during the period 95%. Table 20 Final Version: NHS Croydon CCG Page 107 of 112

108 18.2. Additional measures NHS England has specified for 2013/14. Referral To Treatment waiting times for non-urgent consultant-led treatment Zero tolerance of over 52 week waiters A&E waits No waits from decision to admit to admission (trolley waits) over 12 hours Cancelled Operations No urgent operation to be cancelled for a 2 nd time Ambulance Handovers All handovers between ambulance and A & E must take place within 15 minutes and crews should be ready to accept new calls within a further 15 minutes. Financial penalties, in both cases, for delays over 30 minutes and over an hour. Table 21 Final Version: NHS Croydon CCG Page 108 of 112

109 18.3. NHS England 4 Mandated Measures Domain Measures that are suitable for both in year and annual assessment Measures that are suitable for annual assessment only In Quality Premium Preventing people from dying prematurely None Potential years of life lost (PYLL) from causes considered amendable to healthcare Under 75 mortality rate from cardiovascular disease Under 75 mortality rate from respiratory disease Under 75 mortality rate from liver disease Under 75 mortality rate from cancer Potential years of life lost (PYLL) from causes considered amendable to healthcare Enhancing quality of life for people with long term conditions Helping people to recover from episodes of ill health or following injury Combined measure of Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s and 2 measures from domain 3. Combined measure as above with Emergency admissions for acute conditions that should not usually require hospital admission Emergency admissions for children with LRTI Emergency readmissions within 30 days of discharge from hospital Proportion of people feeling supported to manage their condition Health-related quality of life for people with long-term conditions Dementia Diagnosis Rates Patient Reported Outcomes Measures (PROMs) for elective procedures: i)hip replacement, ii)knee replacement, iii)groin hernia, iv)varicose Veins Combined measure of Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s Emergency admissions for acute conditions that should not usually require hospital admission Emergency admissions for children with LRTI Ensuring that people have a positive experience of care Patient experience of i GP Services ii GP Out of Hours services Friends and family test Patient experience of hospital care (needs attribution to CCG ) Patient experience measure Treating and caring for people in a safe environment and protecting them from avoidable harm Incidence of healthcare associated infection: MRSA Incidence of healthcare associated infection: C. difficile None Incidence of healthcare associated infection: MRSA and C. difficile Table 22 Final Version: NHS Croydon CCG Page 109 of 112

110 18.4. Appendix 2 CCG Outcomes Indicator Set Figure 49 Final Version: NHS Croydon CCG Page 110 of 112