NHS Enfield CCG Commissioning Intentions 2015/16

NHS Enfield CCG Commissioning Intentions

2015/16

1 October 2014

For Publication

! Important note

These Commissioning Intentions are subject to further development, analysis and prioritisation with our clinical community, partners and population throughout the planning round and towards our 2015‐16 Operating and Delivery Plan.

NHS Enfield CCG Commissioning Intentions 2015-16 Page 1

Reader Information Document Title NHS Enfield CCG Commissioning Intentions 2015-16

Publisher NHS Enfield Clinical Commissioning Group

Owner Claire Wright – Head of Children's Commissioning

Approved by Graham MacDougall – Director of Strategy and Partnerships

Publication Date 30th September 2014

Expiry Date 31st March 2016

Overview The document contains the CCGs Commissioning Intentions for 2015-16 to support planning and engagement with providers and commissioning partners.

Information type Strategy & Planning

Secondary Info type: Finance, Policy & Performance, Communications

Primary Audience(s)

Existing & Potential Providers, NHS England

Member Practices, CCG Staff, Local Authority, Clinical Staff, Patients and the public.


Contents:

1. Introduction

2. Primary Care & Prevention

3. Integrated Care for Older People

4. Urgent Care

5. Planned Care & Long Term Conditions

6. Children & Maternity

7. Mental Health

8. Learning Disabilities

9. Community Services

10. Medicines Management

11. Quality & Safety

12. Contracting & Performance Issues

13. Concluding Remarks


1. Introduction

1.1. The Purpose of This Document This document details NHS Enfield Clinical Commissioning Group’s Commissioning Intentions for 2015-16. They are the product of on‐going engagement with our clinical community and stakeholders and represent our current planning and preparation for 2015-16. They primarily support provider engagement through the planning and contracting round and are a development of our Plans previously set out in “Our Commissioning Prospectus’, Enfield ‘Joint Health & Well-Being Strategy’ (JHWB) and both our 5-Year strategic vision and the North Central London 5 Year Strategic Plan.

We have an established Transformation Programme consisting of six individual programmes and a number of cross-impact initiatives. These Programmes will drive forward the changes that we need to see to health and healthcare in Enfield. This is linked to our shared responsibility to deliver our commitments in the JHWB Strategy and our partnership working with the London Borough of Enfield.

Our Transformation Programme has six programmes supporting the delivery of the CCG Strategic Goals and Corporate Objectives as well as supporting delivery for the key priorities set out in the JHWB Strategy. They are:

Prevention and Primary Care;

Integrated Care ;

Planned Care and Long Term Conditions;

Children, Young People and Maternity;

Mental Health, Learning Disability and Continuing Healthcare;

Unscheduled care.

In addition to the above, we have some cross-cutting initiatives aligned to our 6 programmes which include: Transformation of Community Services, Value Based Commissioning, Managing Demand (including Procedures of Limited Clinical Effectiveness [PoLCE] and Acute Productivity – including consultant to consultant referrals) as well as developing Locality Commissioning.

The CCG recognises the importance of quality in all its work and has embedded processes within the Transformation Programme to ensure that the planned service changes meet the requirements for high quality, safe services: i.e. we have put in place a robust Quality Impact Assessment (QIA) and monitoring process for our Quality, Innovation, Productivity & Performance (QIPP) Transformation programmes.

The following chapters provide a high level set of emerging commissioning intentions for 2015/16.They are divided between the six major programmes within the Transformation Programme areas with additional sections on:

Community services;

Medicines management;

Quality.


Work is on-going to develop these further, including:

Setting our likely activity and financial impact where known;

Proposed implementation date where known;

Proposed commissioning route (e.g. procurement, contract variation, etc.).

The information contained within this document is accurate at the time of publication. The intention is to share as much information with our providers as soon as possible in order to inform the contract negotiations for 2015/16. These commissioning intentions are part of ongoing discussion we have with all our providers throughout the planning year.

1.2. Background and Context Enfield CCG and our partners continue to make significant progress toward our vision and aims for the local NHS. Whilst we have been able to put in place some of the building blocks for change to secure safe, resilient and sustainable systems, we must now begin to accelerate the transformation of services and systematically improve the standards of care and outcomes our population experiences.

The CCG is committed to serving its population to ensure that the services it commissions meet their needs and provides value for money. We are very conscious that the financial challenge ahead of us remains significant and our focus for change is therefore on transforming services into systems that are able to deliver affordable coordinated, responsive and high quality care.

Working closely with the London Borough of Enfield and the Health and Wellbeing Board, we have spent most of the last year developing our Better Care Fund Plan around developing our integrated care system for older people with frailty/disability. The development of locality infrastructures managing locality populations is at the heart of what we are looking to develop across a range of populations.

We believe that we need to invest in systems that are able to consistently support delivery around self-care and self-management so that patients and carers become part of our care and case management model.

We know we need to be able to deliver a technical and information infrastructure to enable services to operate as a single system and to enable our patients and our commissioned services to become efficient at consulting with each other. Our vision for transformation is to co-create sustainable systems designed around the outcomes for our populations. We believe that is it critical to those systems that our providers are able to work together to provide care and case management to our populations based around our localities.

We are excited to take on this challenge but are fully aware of the continuing quality and productivity challenge (QIPP) that faces the NHS nationally and locally in Enfield. We know that the scale of the challenge in 2015-16 will be significant. Our current planning estimates the efficiency requirement to have risen from our initial planning assumptions to be in the region of £15 million.


Additionally, we are already making preparations for the changes in how the services will be commissioned and funded through our local ‘Better Care Fund” arrangements ’- where approximately £12.56m of our commissioning budgets will be commissioned jointly with the London Borough of Enfield through the Better Care Fund arrangements.

Our focus on greater integration predates this change in NHS funding, so we welcome this opportunity to work in further partnership with our Local Authority. We know integrated services will ultimately determine the future model of care for our population and is how we will respond to the complex and interrelated challenges facing us; improving outcomes; ensuring a safe transition to new models of care and securing financial sustainability.

As commissioners, we recognize that we need to work together to create an environment where we can build resilience for the whole system during a time of major transitions.

1.3. North Central London Health Economy Some issues that our local NHS faces are not unique to Enfield and so we have been working with the other CCGs within North Central London (NCL) as part of the NCL Strategic Planning Group. North Central London Health Economy is a system comprised of partners from Barnet CCG, Camden CCG, Enfield CCG, Haringey CCG, and Islington CCG who have come together to agree, refine and implement the following strategic intent: To drive improvement in the delivery of high quality, evidence-based and compassionate services, defined and measured by outcomes not process, to the population of north-central London. Our approach is:

A changed emphasis…

Developing a systematic approach to prevention

Earlier diagnosis of disease

Reducing inequalities in health outcomes targeting vulnerable groups

Encouraging individuals to take greater responsibility for their health

Supporting self-management of illness

Patients at the centre…

Compassionate, high quality, effective and efficient care pathways shaped by them

Care that is integrated and focussed around delivery of outcomes defined by them

Easy access to services delivered in ways and places convenient to them

Integration of care through…

Shared digital record for clinical records, data sharing, measurement and evaluation

Services to be commissioned and contracted in ways that drive partnership and integration

Financial sustainability through…

Clinically-driven focus on quality of services

Delivery of effective (evidence-based) and efficient (right first time) care Savings achieved through cutting the ‘cost of chaos


Our key areas of collaboration are:

We are currently working with the other four CCGs and our providers to refine the strategic plan.

1.4. Better Care Fund Plan We have worked closely with the Health and Wellbeing board (HWB) on the development of the Joint Health and Wellbeing Strategy, Better Care Fund plans and our strategic and operational plans. The London Borough of Enfield and Enfield CCG’s Better Care Fund is based on accelerating our progress to deliver the priorities and outcomes agreed by our Health and Wellbeing Board – and in particular – accelerating the integration agenda.

We are home to a larger than average population of young people, but our older population is also set to increase dramatically to over 16.6% of our population by 2032. For these reasons, and because of our particular demographic pressures, our plan is targeted at improving outcomes across four population groups. The population groups are:

I. Older People – focussed on those experiencing frailty and/or disability.

II. Working Age Adults – focussed on those with long term conditions.

III. Adults experiencing Mental Health.

IV. Children & Young People.

Current section 75 arrangements will need to be reviewed and updated in light of how the BCF will wish to operate and conduct its commissioning in the future.

•Vertical integration - Integrated Care Organisations•Horizontal Integration - VBC / Lead providers / outcome-based contracts (shared incentives to reduce cost of chaos)

•Health & Social Care - BCF (getting social care and health to deliver joined up care)

Integrated Care

•Simplify Urgent Care Systems•Patient NavigationUnplanned Care

•Convert Elective to Day-case•Non-elective to elective•Manage out-patient inefficiencies•QIPP / Productivity

Drive Efficiency

•Primary Prevention•Well-being•Healthy Environments•Self-care

Prevention

•Pathway Transformation•(manage supply through clinical navigation, efficient pathways and secondary prevention)

Reshape Care

•Federation (infrastructure, quality,consistency, investment)•Market exit•Provider Partnerships

Enhance Primary Care


1.5. Aims for 2015-16 Enfield CCG will set its corporate objectives for 2015/16 early in the new calendar year. These are likely to reflect the principles of the current year’ objectives, which are:

1. Deliver the 2014/2015 milestone objectives and outcomes set out in the Enfield CCG Strategic Plan.

2. Safeguard children and promote their welfare through effective safeguarding arrangements

3. Embedding the view of patients by way of engagement and consultation – on the work that we do.

4. Work towards delivery of financial sustainability by 16-17 in line with the CCG's medium term financial strategy.

5. Ensure that in 14-15 our services deliver on the requirements of the NHS Constitution, Outcome Framework and Quality Premium; where necessary in collaboration with partners.

6. Maintain and improve the quality of health services our citizens receive and ensure a strong focus on quality as services change.

7. To continue to develop the organisation focusing on: continuing to operate effectively as an independent organisation with local partners, operating collaboratively with the CCGs in NCL and succession planning and clinical leadership.

We will ensure that we work to deliver our corporate and strategic objectives and that these commissioning intentions support delivery.

We know there are specific underlying challenges in our local health economy that we must address next year and into the future including;

Deliver our targets for ‘18 week Referral to Treatment’ and ‘maximum 4-hour waiting-times’ in A&E;

Building robust safe and effective community services to drive care closer to home;

Substantial transformation of mental health services;

Delivering our national commitments for IAPT, Health Care Acquired Infections targets and Dementia diagnosis rates;

Delivering acute services in an affordable way that maintain sustainable services within an overall reduced ‘financial footprint’.

To continue to overcome these, our focus this year will be:

Continuing our path toward greater service integration and continuing to build high quality community services;

Ensuring greater patient and public engagement in all of our work;

Commissioning for outcomes for a range of our populations;

Reducing variation of practice across hospital sites and services;

Ensuring equity of access and outcomes

Ensuring continuity of care services for all patients but particularly those with complex and long‐term conditions;

Simplifying the urgent care system making it easier to navigate for patients removing overlaps and duplication;

Continue to re-focus on a number of key long term conditions across Enfield which are: cardiology, respiratory and diabetes as well as chronic multi skeletal conditions;


Securing and commissioning better communication between services;

Securing both quality and value from existing services and, where we are not, addressing this through formal service improvement or decommissioning;

To improve the mental health and wellbeing of the population in Enfield;

To improve recovery for adults with mental health problems in Enfield;

To achieve Parity of Esteem between mental and physical health;

Develop integrated care for children and young people through the development of locality working and Child Health and Wellbeing Networks;

Ensuring that we use technology and IT as accelerators of change.

1.6. Overall Commissioning Intentions This document sets out our commissioning intentions across all of our areas of work; however, we also have some overall intentions that will apply to all of our commissioned providers.

Workstream Description

Cost Improvement Plans (CIPs)

We will expect all providers to share their CIPs with us in November for consideration for their impact on quality and safety of care. We aim to move towards a joint planning process for CIP / QIPP.

Improvements In Contract Management

We will continue to refine our systems to track the quality & performance standards to be delivered by our service providers, by means of setting and monitoring new locally designed KPIs, working in partnership with our commissioning support unit.

Improvements In Collaborative Commissioning

We will, in collaboration with other NCL CCGs, seek to implement new quality standards in provider contracts.

Value Based Commissioning: Older People with Frailty

Enfield and Haringey CCGs wish to implement the first stage of their work with the value based commissioning programme for Older People with Frailty in 2015/16. This will mean:

1. Focus on Royal Free Hospital, Barnet, Enfield & Haringey Mental Health Trust, Whittington Health and North Middlesex University Hospitals for 2015/16,

2. Focus on 65% of those aged 75 year and above to include pre-frail (50%) and frail (15%)

3. Deliver agreed set out outcomes and KPIs for 2015/16 for this population

4. 10% of activity and spend top-sliced from providers and contracted, via overarching contract, for delivery of the agreed outcomes and KPIs

5. Payment against outcomes is based on delivery across all providers


6. Providers achieve the 3.5% reduction of emergency admissions required for the Better Care Fund (to be agreed what % relates to this population)

7. CCGs and Providers will continue to work during 2015/16 to finalise and agree the activity and financial model associated with this population

8. Discussions to take place with primary care to align the integrated care investment of the £5 per head to the agreed outcomes

9. Discussions continue with London Boroughs of Enfield and Haringey about the potential for Enablement services to be part of the outcomes based model for 2015/16.

Data And Information

We will expect that all providers to develop the capacity to report and provide data on a site by site and CCG locality basis from 1st

April 2015.

We also expect our health and social care partners, including our service providers, will work together to develop an IT-based shared record solution and joint information governance framework that will enable professionals across these partners to view appropriate data and records of patients (with their consent) from different IT care systems to enable them to discharge their duty of care responsibilities in the delivery of integrated care.

Where the CCG has concerns around data quality, the CCG will require a Data Quality Improvement Plan which is jointly agreed with the provider during 2014/15 and expect full implementation of that from 1 April 2015. In this event, Commissioners expect the Trust to place substantial focus on the delivery of the Data Quality Improvement Plan.


2. Prevention & Primary Care

2.1. Strategic Objectives: We want to:

Help people to stay well and identify those who are unwell early and stabilise quickly;

Work with public health to reduce the unacceptable variations in life expectancy both adding years to life but also life to years;

Reduce variations in key clinical outcomes for our populations in particular better management of diabetes, respiratory conditions and cardiovascular disease;

Work with all our key partners to substantially support self-care and self- management and to build resilience within our patients, their carers and their communities;

Improve access to and reduce unwarranted variation in the quality and patient experience of primary care;

Work with the other CCGs in NCL, NHS England and our local GPs to commission and help support new models of primary care delivery focused on accessible care, co-ordinated care and proactive care and work towards the NCL CCGs having fully delegated commissioning of key element of primary care for 1 April 2016.

2.2. Background The role of GPs, and of general practice across the UK, is undergoing dramatic change. The Kings Fund reports that, internationally, primary care finds itself having to support health systems that struggle to meet the twin demands of constrained public spending as a result of the global economic recession; and many more people living with long term conditions.

Delivering the highest standards of primary care for patients is critical to our success, and delivering continuous improvement in our member practices is proving to be critical to a high performing system and achieving longer-term sustainability.

Our member practices have embraced a range of new and innovative processes, to create additional capacity in primary care, by providing respiratory training and equipment to the wider primary care team, encouraging patients to self-monitor via practice-based health kiosks, use of patient-centred technology to reduce unwanted appointments and enable patients to get more care and advice from Community Pharmacies through our ‘Minor Ailments Scheme’.

Enfield CCG is working with its general medical practices to support the establishment of two GP Network provider organisations to ensure sustainable provision over the coming years and to enable them assume more responsibility for service provision to a locality population, such as for the identification and management of people with long term conditions.

Enfield CCG is aiming to commission a range of extended services from the two emerging primary care provider networks that aim to enable practices to work together to deliver equity of access and outcomes. Enfield CCG is also aiming to commission integrated care, via multidisciplinary teams with other providers, focused around our locality populations of


children and young people, adults with long term conditions, adults with mental health issues and older people with frailty.

In addition, the CCG is supporting the further development of the four GP localities within Enfield led by the GP Board members within each locality. The aim of the localities is for GP practices to reflect upon the health needs and priorities for their geographical area and agree commissioning strategies for reducing unwarranted variation in health outcomes and resource utilization.

The CCG has also, as part of North Central London (NCL), submitted an expression of interest to NHS England for the co-commissioning of primary care services within Enfield and is further developing its proposals for 2015/16. As part of North Central London we are working with NHS England to develop our co-commissioning plans for primary care around accessible care, coordinated care and planned care with the aim to have fully delegated responsibility from 1st April 2016.

Enfield CCG is developing a vision for primary care services to guide our work over the next five years; where standards of excellence are achieved across the board, patients are at the centre of their own care and healthcare resources are allocated more effectively to drive better health outcomes.

2.3. Our Aims We will continue to work with the two emerging GP Network Providers (federations of

GP practices) so that they are able to collectively provide enhanced primary care services at scale to all Enfield’s patient population.

We will embrace co-commissioning of primary care services with NHS England and further explore how the CCG takes this forward.

We will work with our partners in Public Health to develop an over-arching Prevention Strategy.

We will work with GP locality leads for the four Enfield GP localities to reduce variation in A&E attendances, outpatient attendances, emergency admissions and primary care medicines management through developing local commissioning plans for each locality and implementing these.

We will develop a primary care quality improvement function within the CCG, based around our four localities, focussed on transforming primary care sustainability and resilience.

We will continue to work with the other CCGs of North Central London and NHS England to develop our co-commissioning plans for primary care.

We will facilitate the integration of prevention, self-care and self-management into the health care culture in Enfield by providing supportive infrastructure.

We aim to reduce the variations in key clinical outcomes.


2.4. Commissioning Intentions for Primary Care

Workstream Description Timescales

GP Provider Networks

Aim: To continue the CCG’s assurance process to support the establishment of two fully assured GP Provider Networks within Enfield.

Outcome Desired: GP Provider Networks to be commissioned to provide extended, integrated models of care for the management of people with long term conditions starting with diabetes.

For diabetes an increase in the diagnosis of those with type 2 diabetes and improvements in HbA1c rates, blood pressure and cholesterol.

Description / Change to service:

Provision of integrated services by emerging GP Provider Networks commencing with the management of long term conditions.

April 2015 onwards

Co-commissioning of Primary Care

Aim: To work collaboratively with our CCG partners across NCL and NHS England London Area Team to improve provision of out-of-hospital services for the benefit of patients and local populations.

Outcome Desired: To ensure that more optimal decisions are made about how primary care resources are deployed, to deliver greater consistency between outcome measures and incentives used in primary care services and wider out-of-hospital services and provide a more collaborative approach to designing local solutions for workforce, premises and IM&T challenges.


To create a joined up, clinically-led commissioning system which delivers seamless, integrated out of hospital services based around the needs of local populations.

October 2014 onwards

GP Localities Aim: Reduce variation in A&E attendances, outpatient attendances, emergency admissions and primary care medicines management through developing local commissioning plans for each locality and implementing these.

Locality Plans November 2014


Outcome Desired: Improvements across each of the four localities in the four identified areas in particular reducing unwarranted variation in activity levels and with a clear trajectory to meeting the London average.


This will be confirmed through the locality plans that are in development.


3. Integrated Care for Older People

3.1. Aims The aim of integrated health and social care is for people to be able to say that:

“I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me”

In order to do so, integration of health and social care means “the system will respond as a whole with the right intervention at the right time” (Enfield Better Care Fund Plan, 2014)

3.2. Background Enfield CCG has been working with patients, GPs, local authority commissioners and providers to develop a new model of care for older people. Our plans with the local authority for integration are therefore well advanced with our Better Care Fund priorities and plans agreed by the Health and Wellbeing Board.

Our vision for integrated care means all professionals and clinicians involved in patient care talk to each other and work together to plan for optimal care for, and with, the patient. This includes working within health, social care and voluntary sector services to develop multi-disciplinary teams across all sectors to ensure the appropriate high quality care is available for older people and patients with long term conditions. Our model of care operates within the following principles:

1. Focused on the patient, and those important to the patient. 2. Focused on the outcomes that are important to our patients. 3. Continually builds resilience within our patients, those important to our patients and

the communities in which they live. 4. Care delivery is based on the populations residing within our 4 localities, with care

delivery matching needs and outcomes for those different locality populations. 5. Providers across health and social care, across primary, community and secondary

care, work together to organise their care around the needs and outcomes of our patients in those localities.

6. Providers work within locality integrated teams (multi-disciplinary, multi-provider teams) to deliver the outcomes for our patients, calling on specialism as required to deliver the outcomes those locality populations.

7. Locality populations are stratified to ensure the appropriate level of planned assessment, intervention and stabilisation focussing on the achievement of patients’ goals in returning to their agreed normal.

8. Providers are commissioned to ensure collective responsibility for locality populations and their outcomes.

An analysis of the needs of older people in Enfield was undertaken in our Joint Strategic Needs Assessment (JSNA) in which the imperative to improve integration was identified as a key solution in conjunction with older people who told us the care system could be better shaped around their individual needs. Our BCF Plan indicates 50% of Enfield’s population aged 65+ years can be defined as “frail” or “pre-frail” (20,000), of which around 7,200 have the most complex cases and are at risk of hospitalization or intensive social care. Trends


associated with emergency admissions for older people show significant medium-term pressures if we continue with the current system, with a consistent increase in the number (and costs) of such admissions between 2010/11 and 2012/13. Longer-term, there are likely to be even greater pressures on the care system, with our older population set to increase to 17%, with even greater increases in long-term conditions such as dementia and stroke.

These trends will clearly impact on the current and future needs for intensive care for older people and is the fundamental reason for the implementation of our integrated care programme designed to service each of the 4 localities. Enfield CCG, the London Borough of Enfield Council and our care providers are also working together to improve care in peoples’ homes which will help reduce emergency admission rates.

3.3. Strategic Objectives: The Integrated Care Programme has the following objectives:

1. Better and more pro-active identification, tracking and reviewing of, and engagement with, patients across the whole-system, building resilience including developing a single point of access to support the pathway;

2. Improvements in people’s ability to make lifestyle choices that improve health & well-being and improvements in their capacity to self-manage care, conditions & lifestyles thus reducing future care needs;

3. Better coordinated & joined-up assessment, care planning, case management, treatment and care delivery, appropriately tailored to needs & preferences;

4. Ensure all elements of care system act as single system to provide care to individuals (avoiding duplication and fragmentation), with a range of public-, private- and voluntary-sector providers involved in delivery;

5. Reduced crisis-driven episodes of care & support, including reduced hospitalisation and less intensive care solutions, and ensuring nobody stays in hospital or care home longer than they need to;

6. Delivery of care will be planned and delivered in such a way that it always respects individuals’ dignity. Staff and organisations treat patients with empathy and respect;

7. Develop joint enabling solutions to deliver the above, including workforce development, IT system infrastructure and an estates strategy, across health and social care partners.

These objectives will be supported through the following actions:

We will fully commission the Integrated locality Teams.

We will review and commission primary care support to care homes, relationship Care Homes Team, OPAU and the impact of the Integrated Locality Teams.

We will re-commission specialist Palliative Care to ensure the service ties in with the overarching programme.

We will re-commission the OPAU based on evaluation and outcomes of service review.

We will move to a tariff, or other contractual mechanism, for OPAU and re-commission contractual arrangements on geographical boundaries; Haringey, Barnet, Herts.

We will review and re-commission a Fracture Liaison and Bone Health Service as


part of the wider Integrated Care Programme.

We will develop value based commissioning across the Integrated Care Pathway.

We will commission and procure voluntary community services specific to the care needs of the frail and elderly.

We will commission dementia services in line with service review which may include Dementia Hub in the community, Community Dementia Services and Admiral Nurses.

3.4. Commissioning Intentions for Integrated Care


Integrated Locality Teams - Community Health Services

Aim: To further implement Integrated Locality Teams.

Outcome Desired: Expected to increase numbers of people supported to match 7,200 people with frailty in Enfield, with additional investment supporting additional one-third on these patients.


Will need to be aligned as part of the wider recommissioning of Community Health Services.

1 April 15

Value-Based Commissioning for older people with frailty

Aim: Value-Based Commissioning for older people with frailty (likely to be top-slicing of existing activity-based contracts across NMUH, RF & BEH MHT).

Outcome Desired: Meeting outcomes will result in incentivizing provider(s) to deliver outcomes across the pathway linked to their existing contracts.


Expected to provide incentives to manage activity and outcomes and shifting activity away from secondary to primary care.

Will need to be aligned with other integrated care arrangements.

1st April 2015

Older People's Assessment Unit and NMUH Day Hospital (with Haringey CCG)

Aim: Recommission Multi-Agency OPAU and make commissioning decisions about Day Hospital.

Outcome Desired: Based on results of review, look to recommission multi-agency OPAU (health agencies involved are: NMUH; RF; BEH MHT) as a single system in Enfield.

Timescales of business cases to project boards and implementation date for provider.


A review will also be undertaken jointly between Enfield & Haringey CCG of the NMUH Day Hospital (and Ambulatory Care function) to determine future commissioning intentions associated with these services.


A new financial and contractual model will be required for the OPAU for 2015/16. ECCG will look to finalise our single system approach with our existing providers to re-develop existing services during 2014/15, hence phasing. Will also look to collaborate with Barnet, Haringey & Hertfordshire CCG on tariff, as % of patients from these areas.

The review of NMUH Day Hospital will explore a number of commissioning options for 2015/16 which may mean changes for the provision of this service.

Rehabilitation wards - bed-based provision

Aim: Key part of Integrated Locality Teams and needed to support integrated care pathway. Currently reviewing cross-agency intermediate care bed provision (across BEHMHT, NMUH & CF).

Outcome Desired: Expected to provide more efficient use of available beds as a resource to support an integrated care system with a single model for usage of non-acute beds.


Will need to be aligned as part of the wider recommissioning of community health services.

TBC

Dementia services - Admiral Nurses

Aim: Based on findings of end-to-end review, look to invest in admiral nurses in Enfield.

Outcome Desired: Identified as a service gap in provision - estimated to manage c. 60 cases at any one time.


TBC.

TBC but no earlier than Apr-15


Voluntary Sector Investment - Integrated Care Hub

Aim: This is a key part of Integrated Locality Teams and is needed to support the integrated care pathway.

Outcome Desired: Identified as a service gap in provision - estimated to manage some of the 7,200 most complex cases described above.


Review existing contracts via Section 75 and agree commissioning model for 2015/16.

1 April 15

Intermediate Care Services - bed-based provision

Aim: Explore the relocation of the Magnolia Unit on the Chase Farm site, if financially viable.

Outcome Desired: Expected to improve patient flow for intermediate care and rehabilitation.


There will be an interim solution until the redevelopment of the Chase Farm site is undertaken.

TBC


4. Urgent Care

4.1. Strategic Objectives: Our objectives for providing unplanned care services across Enfield reflect those set out in the NHS England Urgent and Emergency Care Review (2013):

To provide a highly responsive service for people with urgent care needs delivered as close to home as possible, minimising disruption and inconvenience for patients and their families.

Ensure those people with more serious or life threatening emergency care needs are treated in centres with the very best expertise and facilities in order to maximise the chances of survival and a good recovery. Much of the unscheduled care strategy will be delivered through the re-design and commissioning of effective integrated care.

In line with the NCL vision for unplanned care and the NHS England Urgent and Emergency Care Review we will refocus our efforts to achieve this through redefining unscheduled care services around five key elements along a clear pathway for patients:

1. Simplify Urgent Care Systems:

o Supporting self-care

o Provide much better and more easily accessible information about self-treatment options.

o Remove inefficiencies, overlaps and achieve greater integration, where practicable.

2. Patient Navigation: Help people with urgent care needs to get the right advice or treatment in the right place:

o Through the NHS 111 enhanced 24-hour, personalised priority contact service.

3. Providing a highly responsive urgent care service outside of hospital so people no longer choose to queue in A&E:

o We will provide access for patients to two primary care led urgent care centres with one based at Chase Farm Hospital and one based at NMUH which are GP led and can offer advice and treatment for patients who attend. We will continue to ensure that we have a strong and robust GP Out of Hours Service located within Enfield which can be accessed through 111 for patients who require advice and treatment outside of the usual opening hours of their GP practice.

4. Ensuring that people with more serious or life threatening emergency needs receive treatment in centres with the right facilities and expertise to maximise chances of survival and a good recovery.

o Through the implementation of the BEH Clinical Strategy we have ensured we have robust 24/7 consultant led and delivered A&E services based at NMUH and Barnet Hospitals which will focus on such patients and continue to develop their expertise.

o In addition, we are working towards Ambulatory Emergency Care (AEC), or ‘same day emergency care’ to ensure that, patients who are assessed as appropriate for AEC, are diagnosed and treated on the same day and then sent home with on-going clinical treatment and follow up as required.


5. Connecting the whole urgent and emergency care system together

o We are currently working together across Barnet, Enfield, Haringey, Camden and Islington to commission an integrated NHS 111 and OoH service delivered by a single provider to create a more streamlined service for patients.

4.2. Background The recently published Emergency and Urgent Care Review by Sir Bruce Keogh has highlighted that the majority of patients seeking care in A&E departments could be better cared for closer to home in a different care setting. We need to build a consistent offering of care to manage this demand across NCL with the following principles in mind:

a. Provide consistently high quality and safe care, around the clock, seven days a

week. b. Provide the right care in the right place, by those with the right skills, the first

time. c. Be easily understood by members of the public and professionals, particularly

where to access services appropriately. d. Deliver equitable services that are efficient and can meet demand appropriately. e. Minimise the number of different handovers and duplication involved in delivering

care as far as practicable, to ensure safe and smooth patient flow along the care pathway.

Approximately 40% of patients seeking care at A&E are discharged without treatment and there were over 1 million avoidable emergency hospital admissions in England last year. Enfield CCG A&E attendances increased in line with national population growth in 2012/13, whereas attendances increased disproportionately when compared with population growth in 2013/14 and is predicted to further increase disproportionately, based on current predictions in 2014/15.

There is also a particular concern around the growing numbers of patients who are admitted to hospital via A&E for less than one day. Together with managing and maintaining strong performance around national A&E targets (e.g. Maximum 4-hour waits); these challenges will need to be directly addressed.

During 2013‐14, whilst we have experienced rising demand for urgent and unplanned care from our changing population, our system has continued to work together to achieve our goal of providing an excellent standard of integrated emergency, urgent and proactive care to our patient population. In particular we have helped to establish the Urgent Care Centre at Chase Farm Hospital including the provision of ‘patient navigators’ to help people find their way around the system. We have also re-located the GP ‘Out of Hours’ Service adjacent to the Urgent Care Centre at Chase Farm Hospital so that Enfield residents have 24 hour access to urgent care.

In 2014/15 we will build on our achievements to date to develop a more integrated urgent care system across Enfield and more widely across NCL.


4.3. Our Aims: We are developing an Urgent Care Strategy within Enfield to ensure we create an integrated urgent care system of which we expect the main elements to be:

We will simplify the urgent care system making it easier to navigate for patients removing overlaps and duplication;

We will develop and procure an integrated 111 and Out of Hours service across the 5 CCG’s within North Central London;

We will carry out a review of our Walk In Centre to inform the future commissioning model as part of the wider review to inform the Urgent Care Strategy;

We will carry out a review of our Urgent Care Centres to inform and shape the future delivery model and commissioning approach for this service as part of the wider review to inform the Urgent Care Strategy;

We will continue to develop Ambulatory Emergency Care with both local acute providers including expansion on age range and agreement on tariff and coding;

We will develop a Direct Access Pathology Service Specification with agreement on turnaround times, pricing and savings across the 5 CCG’s within North Central London for against which we will commission all of our DA Pathology providers.

4.4. Commissioning Intentions for Urgent Care


Enfield CCG NMUH and CFH Urgent Care Centres

Aim: The aim of the project is to meet the urgent care needs of adults, young people and children, which cannot be met through self-care, primary care or community care through the ongoing development of Urgent Care Centres (UCCs) at the two local acute providers, namely Barnet and Chase Farm Hospitals (BCF) and North Middlesex University Hospital (NMUH). We will review the casemix of activity to better understand the needs of our communities.

Outcome Desired: Review UCC services with refreshed service specifications and commissioned models of care to maximize the impact for local people.


CFH

Review of the UCC service as part of a wider urgent care review across Enfield. Service specification updated to reflect a potential planned primary care pathway within the UCC and the co-location of the UCC and the Out of Hours Service.

TBC.


NMUH

Review of the UCC service as part of a wider urgent care review across Enfield. Update the UCC service specification following the review and work with the Trust on the best way forward in terms of commissioning the unit.

Enfield CCG Direct Access Pathology

Aim: The aim of this project is to improve the quality and efficiency of direct access pathology services for patients in Enfield as part of a wider piece of work across NCL through the use of contract mechanisms to improve efficiency across the providers locally.

Outcome Desired: Based on the outcomes of Modernising Pathology Services in London, a standard service specification and minimum data set across all pathology providers is being developed across NCL which will enable commissioners to understand exactly what is being purchased through contract and to be able to properly benchmark practice across the patch. It is anticipated that this will allow future efficiencies to be identified. It is also hoped to be able to negotiate a ‘best price’ approach to local tariffs for pathology services across NCL.


1. Gaining efficiencies through contract mechanisms.

2. To implement a standard specification for pathology services in 2015/16 across NCL.

3. To ensure implementation of a minimum data set (MDS) in line with the specification and ensure accurate data collection in 2015/16 across NCL.

4. To use the data collected through MDS to drive service re-design and accurate savings plans in 2015/16 across NCL.

5. To achieve cost benefits in 2016/17 being driven by achieving best price in local contracts across NCL.

Business Case and Service Specification December 2014.

Enfield CCG Ambulatory Emergency Care

Aim: The aim of the project is to continue to develop the best commissioning model for Ambulatory Emergency Care (AEC) for Enfield, to deliver a high quality service, improve upon patient outcomes and to further reduce the number of hospital admissions.

Review of current ambulatory care unit and admission activity by age and by HRG description


Outcome Desired: A new model for AEC development within Enfield includes an agreed tariff and way of coding activity in addition to an extension of scope of service to include patients over the age of 65 years particularly at Barnet Hospital where there is a larger cohort of older patients.


Agreement on activity coding and determine best practice tariff and local pricing in line with other ambulatory care services within NCL and Hertfordshire.

Develop and agree service specification, pathways and KPIs with both local acute providers.

Review and subsequently look to expand the AEC capacity with both local acute providers.

for each provider.

Development of best approach to coding of activity and a tariff price by March 2015.

Enfield CCG 111 and OoH Single Procurement

Aim: The aim of this project is to commission an integrated NHS 111 and Out of Hours (OoH) service, delivered through a single contract, to create a more streamlined service giving advice to patients on where to access urgent care in times of crisis. The single contract would be across the 5 boroughs within NCL: Barnet, Camden, Enfield, Haringey and Islington.

Outcome Desired: An integrated, single service provider model between NHS 111 and OOH as the optimum model to deliver the benefits of integrated urgent care. This model would deliver a seamless journey for the patient and access GP advice assessment in NHS 111.

The economies of scale that could be delivered by the new service model proposed would also deliver savings to the commissioner through increased efficiencies and innovative working practices by the provider and streamlined management of the contract.


Develop a revised model of care for 111 and Out of Hours across NCL.

Commission through procurement an integrated model for 111 and Out of Hours to commence in April 2016.

Business Case and Service Specification December 2014.


Enfield CCG Urgent Care Strategy

Aim: The aim of this project is to develop a strategy for urgent care within Enfield which will provide a single 24-hour Urgent Care System to ensure that the patient is given the right care in the right place by those with the right skills, first time.

Outcome Desired:

The strategy will aim to create a more seamless urgent care system which will reduce inappropriate attendances at A&E and will deliver care as close to home as possible. We will simplify the urgent care system making it easier to navigate for patients removing overlaps and duplication;


Our objectives for providing urgent care services across Enfield reflect those set out in the NHS England Urgent and Emergency Care Review (2013):

For people with urgent care needs we should provide a highly responsive service that delivers care as close to home as possible, minimising disruption and inconvenience for patients and their families.

For those people with more serious or life threatening emergency care needs, we should ensure they are treated in centres with the very best expertise and facilities in order to maximise the chances of survival and a good recovery.

The aim of developing the strategy is to:

Meet the urgent care needs of the patient.

Offer a clear and simplified urgent care pathway.

Provide prompt care.

Ensure clear scope of service.

Enable clear governance and management responsibility for clinical quality and cost effectiveness.

Provide an appropriate environment.

Improve the patient experience whilst managing expectation.

A&E review – November 2014.

WIC review - November 2014.

UCC review – December 2014.

Urgent Care Strategy - March 2015.


The major component parts of the urgent care strategy are proposed to be:

A common core urgent care centre (UCC) specification developed for commissioning from existing or new providers.

A single 111 and Out of Hours (OoH) service model commissioned across the 5 NCL CCGs via procurement.

A common ambulatory care model of care and pricing structure for as many of the 5 NCL CCGs which wish to take part.

A review of Walk In Centres and their role in any future urgent care model across NCL.

Review and proposals for common approach across NCL (or as many CCGs as wish to join) to urgent primary care in and out of hours access including possible development of urgent access planned care appointment provided by GP networks.

Walk In Centre Aim: Review the current Walk in Centre in place in Edmonton including the clinical model.

Outcome Desired: Revised clinical model and service specification for a WIC and re-commissioning of the model.


Further details not known at this stage. Including whether procurement is required.

November 2014.


5. Planned Care & Long Term Conditions

5.1. Strategic Objective: We want to ensure that patients do not continue to face the confusion they currently experience by accessing a range of services across many different providers often in an unplanned way. Our vision for planned care and long term condition management is to deliver high quality, effective and integrated services safely in the right setting with the right professionals first time to ensure equity of outcomes for our population.

In order to address the above:

We will continue to re-focus on a number of key long term conditions across Enfield which are: cardiology, respiratory and diabetes as well as chronic musculo-skeletal conditions which will reduce variation in clinical outcomes.

We will implement a Lead Provider model, and will shift away from contracting with a range of providers across a care pathway to a focus on commissioning against a set of patient focused outcome measures for a whole care pathway developed in partnership with service users and providers.

We will work towards contracting processes that work together to deliver those outcomes.

We will continue to develop further the four GP localities within Enfield so as commission appropriate planned care services that can be provided on a local basis as required by the patient cohorts within that particular locality.

Through addressing this:

Earlier diagnosis with earlier interventions to deliver consistently better clinical outcomes.

Patient care will be much more integrated so patients will not have to visit lots of different healthcare professionals.

Patients will be more involved in their care and the choices that they have through shared decision making and goal setting.

Outcomes that patients feel are important to them will increasingly be how services will be held to account for delivery.

GPs and hospital doctors and nurses and others professionals will work together to improve care locally through four clinical networks within Enfield focussing on long term conditions like diabetes and COPD.

Most of the long term planned care strategy will be delivered through the re-design and commissioning of effective integrated care pathways.

5.2. Background We know that planning care properly leads to better clinical outcomes for patients and reduces the cost of health services. We are working hard to ensure that more patients receive care locally, closer to their homes without having to attend hospital.

During 2013-14 we have established new community service clinics for people with:


Chronic Pain Management.

Respiratory Illness.

Ear, Nose and Throat (ENT).

Urology.

Patients needing these services can be referred by their GP to clinics closer to home, rather than needing to attend hospital.

In addition, during 2014/15 along with a number of other NCL CCGs, we embarked on a rolling programme of reviewing clinical pathways in partnership with Royal Free Hospital. The first wave clinical pathways redesign schemes agreed commenced in 2014 and are:

1. Cardiology; 2. Gynaecology; 3. Urology; 4. Gastro-intestinal; 5. Dermatology; 6. MSK; 7. Respiratory ; 8. Hepatology.

The next wave of clinical pathways for redesign schemes agreed for 2015 are:

1. Ophthalmology; 2. General Paediatrics; 3. Diabetes; 4. Stroke and Rehab; 5. ENT and Audiology.

The CCG intends to work with all of its main providers around this programme during the remainder of 2014/15 and into 2015/16 to ensure that where possible the CCG has one set of commonly agreed clinical pathways for each clinical specialty.

During 2014-15, we will aim to further our plans by reviewing the whole care pathway for patients and develop integrated services which join up care across a range of providers and care settings and focus on ensuring key outcomes are achieved for patients with long term conditions and their carers who share the same condition and/or other common features.

The areas we are focusing on are:

MSK (musculo-skeletal);

Diabetes;

Respiratory;

Cardiology;

Gastroenterology;

Dermatology;

Ophthalmology;

Gynaecology.


5.3. Our Aims We will commission an outcomes based commissioning model through awarding a

lead provider five year contract for MSK planned care services (orthopaedics, rheumatology, pain management and physio).

We will commission a revised integrated model of care for cardiology which includes:

o Primary Care network based care package; o Community service which includes existing heart failure and cardiac rehab

services.

We will commission a revised integrated model of care for diabetes which includes a primary care network based care package working closely with the community service.

We will commission a revised integrated model of care for respiratory which includes a primary care network based care package working closely with the community service.

We will redesign and enhance Enfield’s current referral processes and referral management system for outpatient activity to streamline the current pathway including exploring the best mechanism for conducting clinical triage of outpatient referrals including PoLCE and managing acute generated outpatient activity.

We will continue to work with Royal Free and other CCGs to develop and roll out standardised clinical pathways for a range of clinical specialties and review revised clinical models and services which may need to be developed to implement these.

We will evaluate and build on learning from the joint CCG Gastroenterology Service pilot in 2014/15 to establish redesigned elements into acute contract to continue to make sustained improvements across the main care pathways and maintain reductions in/further reduce acute outpatient services demand.

We will streamline care pathways and develop a common community dermatology service specification and pricing model across the 5 NCL CCGs with the aim of commissioning new services across the NCL during 2015/16.

We will develop the best model for gynaecology planned care and commission a new integrated service for Enfield patients with the aim of providing more services closer to patients in the community and primary care and to deliver efficiency savings.

We will develop the best model for ophthalmology planned care and commission a new integrated service for Enfield patients utilising a lead provider model with the aim of providing more services closer to patients in the community and primary care and to deliver efficiency savings.

5.4. Commissioning Intentions for Planned Care & LTCs


Integrated Respiratory Services

Aim: The aim of the project is to further develop the Integrated Respiratory Services for Enfield to deliver a high quality service closer to the patient, improving patient outcomes, reducing hospital outpatient attendances, improving patient’s ability to self-

Final business case December 2014.


manage chronic conditions whilst offering value for money.

Outcome Desired: An integrated pathway for respiratory services across Enfield which sees more focus on prevention and early identification of patients with chronic respiratory conditions and a reduction in demand within secondary care.

Description / Change to service.

Contract variation with current three providers (ECS, NMUH & RF) to create enhanced integrated respiratory services whilst establishing GP provider networks and organising services around four localities.

Outpatient Referral Improvement

Aim: Redesign and enhance Enfield’s current referral processes and referral management system for outpatient activity to streamline the current pathway including working with acute providers to send any routine referrals back to the Enfield Referral Service (ERS) which have not been through it for triage; exploring the triage of C2C referrals through the ERS; and reviewing the triage process of referrals within the ERS.

Outcome Desired: The proposal outlined within the outpatient referral improvement business case is focussed on the following key aspects:

Options for improving referral processes through the use of IT solutions, such as e-Referral or other IT platforms.

Options on the Enfield Referral Management model and the best way to provide this.

Options for the best model for clinical triage may include both GP and consultant triage.

Create standardised outpatient referral proformas.

Utilise IT solutions to better communicate pathways to referrers and improve adherence of pathway navigation.

Develop a standardised and agreed referral mechanism across Enfield GPs.


The proposed improvements would aim to achieve the following benefits:

TBC


Improved equality of care through standardisation of working practices.

Promote consistency in the management of conditions and improve health outcomes.

Improved referral practice.

Improved working practices by reducing workflow variation.

Improved workflow performance.

Improved patient experience.

Improved end user experience.

In addition to the above key aspects, a separate piece of work is currently underway to review options around Procedures of Low Clinical Effectiveness (PoLCE) and whether the CCG should consider retaining this internally or look to outsource.

Ophthalmology Aim: The TPG decided that an integrated approach should be taken and is keen to explore how this can be achieved, including consideration of an 'accountable lead provider' model.

Outcome Desired: Currently, work is being done on the development of the business case. This will involve engaging with service providers, holding stakeholder workshops and working collaboratively with the providers on the way forward.

The intention is to develop an integrated model of care for Ophthalmology.


If a new model of care is proposed requiring procurement, a formal procurement process will be undertaken taking into consideration the current contract end date of October 2015 and impact on mobilisation and transition plans.

This option alongside others will be explored further in the business care, which will be expected to be finalised in December 2014/ January 2015.

1st Stakeholder workshop – September 2014.

2nd stakeholder workshop- November 2014.

Business Case December 2014/ January 2015.


Integrated Musculoskeletal (MSK) Procurement

Aim: Commission an outcomes based MSK commissioning model through awarding a lead provider five year contract for MSK planned care services (orthopaedics, rheumatology, pain management and physio).

Outcome Desired: An integrated MSK model of care which focuses on improve outcomes for patients across Enfield.


The intention will be that the lead provider will work with all current providers but that activity may change through greater productivity.

The new commissioning model will incorporate end to end pathway delivery across providers at all levels, managed by an Accountable Lead Provider (ALP) organisation, and includes the commissioning of a single point of referral triage in an Integrated MSK Service (IMS). The commissioned role of the ALP is leadership, management, coordination, delivery and improvement spanning primary care, community and acute services. The ALP will also be an MSK provider within the model.

All current providers have been given notice via letter in September 2014 for current services. Procurement is expected to commence in October 2015.

Procurement Committee to sign off PQQ documentation October 2014.

Contract commencement December 2015.

Gastroenterology Aim: The aim of the project is to develop the best commissioning model for gastroenterology services in Enfield delivering a high quality service closer to the patient, improving patient outcomes, reducing hospital outpatient attendances, streamlining access to diagnostic procedures, improving patient’s ability to self-manage chronic conditions whilst offering value for money.

Outcome Desired: Evidence suggests that lifestyle factors such as excessive alcohol consumption, smoking, inappropriate diet and intake of fatty food can lead to many gastrointestinal problems such as dyspepsia, gastritis, oesophageal reflux, liver disease, gastric cancer and bowel cancer.

Addressing behavioural life style factors may help in reducing incidence of gastrointestinal problems and hospital attendances related to

Service commencement – October/November 2014.

Service review of 1 year pilot – September - November 2015.

Review report disseminated and decision on future services to be commissioned – December 2015/January 2016.


gastrointestinal diseases ranging from dyspepsia to oesophageal cancer.


The pilot is expected to commence at the two local acute providers between October and November 2014. A service review will be conducted between September and November 2015 to inform decision making on future service delivery.

Continue to work with existing local providers to agree an enhanced service model that works for Enfield and is delivered across an integrated partnership of providers in primary, community and secondary care.

Integrated Diabetes Service

Aim: The overall aim for the integrated diabetes programme of care is to coordinate, promote, and ensure equity of outcomes across communities via a single point of access, the provision of a comprehensive range of high quality, cost effective integrated health services for people with diabetes and their carers.

Outcome Desired: The proposed four-pronged approach to management of diabetes in Enfield will be outcomes based:

1- Primary care and prevention and early detection.

2- Enhanced initial management of diabetes (including self-management).

3- Integrated based multidisciplinary diabetes care.

4- Diabetes emergency pathway optimization.


Enfield CCG wishes to provide a commissioning statement of intent for 2015/16 structured around the strategic domains as outlined within the case for change.

Tier One services

1. Primary prevention and early identification

2. Enhanced initial management of diabetes through Networks (including self-management)

Due to the fact that the GP Provider Networks have not yet been established, it was decided

Final Business Case November 2014.


that we will pilot the network based diabetes service within the South East locality for the next six months (commencing late October 2014). It is our intention to roll the scheme out to all four localities across Enfield during 2015/16.

Tier 2 services

3. Enhanced Community Diabetes Service

4. Diabetes Hypoglycaemia Management Service

Tier 3 services

Secondary care services - insulin pump management, antenatal diabetes, acute diabetic foot care, nephrology (joint renal clinics CKD 4 and 5), transition from adolescent, inpatient, co-morbidities, complex diabetes and paediatrics.

Integrated Cardiology Services

Aim: The overall aim of the cardiology programme of care is to ensure that there is seamless and patient centered delivery of cardiology services with emphasis on driving prevention (including secondary prevention), self-care management and reduction of inequalities. Enfield CCG would like to develop a much more integrated system where appropriate care is provided to patients closer to home.

Outcome Desired: An integrated pathway for cardiology services across Enfield which sees more focus on prevention and early identification of patients with chronic cardiology conditions and a reduction in demand within secondary care.


A phased approach to the integration of cardiology services in Enfield is to be considered, namely:

1) In 2015/16 decommission the current community cardiology services and co-create a better integrated community multidisciplinary cardiology service and commission via a competitive procurement.

2) In 2015/16 commission GP Provider Networks to deliver Network based cardiology care package for all four localities across Enfield working with the

Final business case December 2014.


proposed community service to deliver a shared set of outcomes.

3) In 2016/17 review existing services commissioned with a view to tendering for a Prime Contractor/Lead Provider to commission a fully integrated cardiology service in a ‘Whole System Approach’, delivering services at a locality level via an outcome based commissioning model in 2017/18.

A business case is being developed to explore this further.

Community Dermatology Service

Aim: Streamline care pathways and develop a common community dermatology service specification and pricing model across the 5 NCL CCGs with the aim of commissioning new services across the NCL during 2015/16.

Outcome Desired: A streamlined pathway of care for planned care dermatology across NCL with a common service specification for a community based service.


Community dermatology service specification across NCL with common pricing structure and outcome measures to commission providers.

Business Case and service specification November/December 2014.

Community Gynaecology Service

Aim: Develop the best model for gynaecology planned care and commission a new integrated service for Enfield patients with the aim of providing more services closer to patients in the community and primary care and to deliver efficiency savings.

Outcome Desired: A streamlined pathway of care for planned care gynaecology across Enfield with a revised service specification for a community based service.


A business case is being developed looking at options around commissioning for planned care gynae services. This is expected in January 2015.

Business Case to be developed January 2015.


Planned Care Clinical Pathways (Royal Free)

Aim: Continue to work with Royal Free and other CCGs to develop and roll out standardised clinical pathways for a range of clinical specialties and review revised clinical models and services which may need to be developed to implement these. Explore with other acute providers adopting the same clinical pathways.

Outcome Desired: Standardised clinical pathways for planned care across Enfield and the wider health economy for a number of key clinical specialties.


During 2013/14 along with a number of other NCL CCGs we embarked on a rolling programme of reviewing clinical pathways in partnership with Royal Free Hospital. The first wave clinical pathways agreed commenced in 2014 and are:

Cardiology,

Gynaecology,

Urology,

Gastro-intestinal,

Dermatology,

MSK,

Respiratory

Hepatology The next wave of clinical pathways agreed for 2015 are:

Ophthalmology

General Paediatrics

Diabetes

Stroke and Rehab

ENT and Audiology

The CCG intends to work with all of its main providers around this programme during the remainder of 2014/15 and into 2015/16 to ensure that where possible the CCG has one set of commonly agreed clinical pathways for each clinical specialty.

First set of clinical pathways: November 2014.


6. Children & Maternity

6.1. Strategic Objectives: To ensure that every child has the best start in life, regardless of where they live in Enfield.

6.2. Background We know that we face a number of challenges:

Enfield's population has an unusually large proportion of younger people. In 2012, just over one fifth (21.23%) of residents were aged 15 or below. This is the fourth greatest proportion in London, and above the London average of 19.0% and the England average of 17.7%.

The health and well-being of children in Enfield is mixed compared with the England average. Infant and child mortality rates are similar to the England average.

The level of child poverty is worse than the England average with 33.7% of children aged under 16 years living in poverty.

Children in Enfield have worse than average levels of obesity. 13.3% of children aged 4-5 years and 24.4% of children aged 10-11 years are classified as obese. 63.6% of children participate in at least three hours of sport a week which is better than the England average.

The MMR immunisation rate is lower than the England average. Immunisation rates for diphtheria, tetanus, polio, pertussis and Hib in children aged two are lower than the England average.

In 2013/14 there was an increase in mental health in-patient stays for young people services from 1450 OBDs (overnight bed days) in 2012/13 to 2144 OBDs in 2013/14.

Enfield has higher than the London average of hospital admissions as a result of self-harm.

We want all children in our borough to realise their full potential, helping them to prepare from an early age to be self-sufficient and have a network of support that will enable them to live independent and healthy lives. This means that every child must have the best start in life, regardless of where they live in Enfield.

We want to break down the barriers between services and develop, deliver and commission a range of integrated services from pregnancy through to adolescence and beyond which deliver the national pledge. Effective universal services based on the Healthy Child Programme must be supported by targeted services that have a lasting impact particularly on the most vulnerable, in order to prepare for the responsibilities of adulthood and build up resilience for the future.

We will support all stages of childhood, pre-birth, infancy, pre-school and through school, with the aim of releasing the potential in all children. Educational attainment is recognised as being a key to achievement of long-term health and wellbeing.


6.3. Our Aims We want to:

Listen to children, young people and families, and ensure that they are at the heart of decision making, with the health outcomes that matter most to them taking priority.

Develop integrated care for children and young people through the development of locality working and Child Health and Wellbeing Networks.

Improve outcomes for children and young people with mental health problems and decrease admissions and lengths of stay to inpatient units. Building resilience and early identification and intervention in childhood and adolescence is key to reducing later morbidity.

Improve outcomes for children with disabilities, and their experience of services, through implementation of the Children and Families Act.

Improve the experience of transition.

Improve the experience of maternity services through implementation of care pathways associated with the maternity PbR tariff and a focus on quality and early access.

6.4. Commissioning Intentions for Children & Maternity


Development of Child Health and Wellbeing Networks

Aim: Improve outcomes for children and young people through the development and implementation of Child Health and Wellbeing Networks. Initial priority to set up and run itchy, sneezy wheezy clinics, and to implement a revised asthma care pathway.

Outcome Desired: Further development of child health and wellbeing networks.

Aims of the networks

o Improved knowledge and awareness with regards to wider public health messages through targeted health campaigns and integrating this as part of the overall model.

o Better clinical outcomes and improved life chances for children through co-produced and coordinated care management that incorporates the wellbeing and aspirations of children along with the needs of their medical condition.

o Reduce unscheduled care, inpatient admissions and paediatric outpatient referrals.

o Better management, including self-management, of long term conditions.

TBC


o Build resilience and support emotional wellbeing.

o Increase knowledge, confidence and skills across the whole system with an improved ability to navigate the system with ease.

o Innovative and co-designed solutions to patient information needs, including the use of technology.

o Financial savings across the system.

o Better experience of services.


Model for child health and wellbeing networks has been subject of ongoing engagement, and development has been supported by a clinician led multiagency group. Possible BCF investment in 2015/16.

Perinatal Mental Ill-Health

Aim: The CCGs recognise that there is a need to improve the pathway for women with perinatal mental ill-health before conception, during pregnancy and birth and in the postnatal period. This pathway needs to be clearly defined and be communicated with greater effectiveness. It needs to include referral processes; access and policy development.

Outcome Desired: During 2015-16 commissioners will require Maternity Units and Adult Mental Health Services to work together, and with commissioners and GP's to develop a clear pathway for women and their families affected by perinatal mental illness. This will require collaboration with other organisations currently providing support services for example counselling, CAMHS, Parent infant services, Family Nurse Partnership, alcohol and drug services, family support, domestic violence services, bereavement services and those provided following traumatic birth experiences. There also needs to be clear links to safeguarding, adult and children’s social services.


Providers are asked to participate in the planning and mandatory training required ensuring that LETB funding (Health Education England Training) allocated to support increased awareness, communication,

On-going


assessment, identification, care planning and treatment is most appropriately utilised. Trusts are also requested to release staff to undertake such initiatives. Current funding is for this financial year (2014-15), however it is hoped further funding can be obtained for 2015-16.

Trusts are requested to examine the feasibility of joint clinics (obstetric and psychiatry), where these do not currently exist. In addition maternity services should consider the appointment of a specialist midwife for perinatal mental health. CCG wants each Trust to have a lead Obstetrician and for perinatal mental health.

Assurance around implementation of the best practice diabetes tariff

Aim: Ensure effective implementation of the best practice diabetes tariff.

Outcome Desired: Assurance required


TBC

TBC

Review Paediatric Assessment Unit at Chase Farm

Aim: Review Paediatric Assessment Unit at Chase Farm.

Outcome Desired: Assess effectiveness of unit and impact on outcomes after one year.


TBC

TBC

Caesarian Section Rates

Aim: Ensure caesarian section rates across all providers are in line with NCL averages and expectations for the local population.

Outcome Desired: Improve Barnet Hospital caesarian section rate (move out of the top quartile in the country).


TBC

TBC

Implement pathway for women with complex social needs

Aim: Implement care pathway for women with complex social needs.

Outcome Desired: Reassurance that women are receiving the services that trigger the intermediate maternity tariff.

Description / Change to service: HRG to be confirmed.

Immediate.

You're Welcome Aim: Implement the You’re Welcome TBC.


assessment

Outcome Desired: ensuring services are more accessible to young people.


The You're Welcome standard assists services to improve accessibility to young people.

NCL Clinical Dashboard for Maternity Services

Aim: Monthly submission of requirements of the NCL Clinical Dashboard.

Outcome Desired: Consistency & improvement in reported quality indicators for maternity services.

Description / Change to service: Currently differs across providers.

Immediate.

Early Access And Birthing Options

Aim: Meet the national early access targets and provide birthing options.

Outcome Desired: Improved outcomes and experience of maternity services.


90% of all women should be booked by 12 weeks and 6 days. Performance differs across providers. Assurance that women are provided with birthing options.

Timescales of business cases to project boards and implementation date for provider.

Children with Special Educational Needs and Disabilities

Aim: Implement the Children and Families Act and Care Act.

Outcome Desired: Improved outcomes and experience of service for children and young with Special Educational Needs and Disabilities, and their families.


Work with commissioner, the Local Authority and other providers to deliver the new Act, including support for the Local Offer, the single assessment and planning processes, and implementation of Education, Health and Care plans (EHC).

To work with commissioners to ensure where possible EHC Plan requirements are met from existing resources.

Ongoing.


Child & adolescent Mental Health Services (CAMHS)

Aim: Implementation of the CAMHS Action Plan following agreement to the new Joint Commissioning Strategy for CAMHS.

Outcome Desired: Improve outcomes for children and young people with mental health problems and decrease admissions and lengths of stay to inpatient units.


The Joint Commissioning Strategy is a three year strategy. There has been BEH MHT involvement in its development. Some of recommendations involve staff members working differently, and proof of efficiencies and improved outcomes will be required.

1 April 15.

CAMHS Aim: Involvement of young people in the design and delivery of the service

Outcome Desired: Improved outcomes and experience of services. Reduction in DNA’s.

Description / Change to service: Extension of current practice.

1 April 15.

CAMHS Aim: Develop an Enhanced Behaviour Support Team for young people with behavioural problems.

Outcome Desired: Improved outcomes including reduction in need for residential placements.


The expanded team will work with the Joint Services for Children with Disabilities, local schools, parents and Cheviots Children’s centre.

Possibly funded through the Better Care Fund 16/17.

Preparation in 15/16.

CAMHS Aim: Extend the early intervention in psychosis service to focus more on adolescents.

Outcome Desired: Improved outcomes including reduction in need for inpatient admission.


Possibly funded from the Better Care Fund 16/17. The current care pathway will need to be redesigned in co-production with young people and families.

Preparation in 15/16


CAMHS Aim: Further develop a mental health service for children leaving care.

Outcome Desired: Ofsted has identified mental health provision for young people leaving care as a gap in provision. Potential to improve outcomes.


The expanded team will be developed in conjunction with Kratos and the Heart Team.

Possibly funded from the Better Care Fund 16/17.

Preparation in 15/16.


7. Mental Health

7.1. Strategic Objectives The strategic objectives that will deliver the required improvements are summarised below:

To improve the mental health and wellbeing of the population in Enfield.

To improve recovery for adults with mental health problems in Enfield.

To achieve Parity of Esteem between mental and physical health.

7.2. Background This section sets out Our Vision for the Mental Health and Wellbeing of Adults in Enfield and what will be different over the next 5 years.

There will be a strong focus on service quality, recovery & enablement and improved outcomes delivered through effective partnerships. There will be improved access to:

Support to maintain mental health and wellbeing for all.

Early diagnosis and intervention.

Substantial focus on recovery and enablement.

Information about services and support.

Evidence based assessment, treatment and support.

Housing with flexible support.

Support by GP’s and in community settings.

Good quality support for people during acute phases of illness.

Support to find meaningful occupation or employment and to maintain income.

Support to develop meaningful relationships and participations in community activities.

Support to address both mental health and physical health needs.

Support for carers.

There will be more:

Control and choice in care planning.

Effectively co-ordinated care.

Of a community presence for adults with mental health problems.

Involvement of service users in decisions about services and support.

Effective use of resources in secondary care, with care targeted at those who need access to specialist services the most.

Attention to the mental health and wellbeing of carers.

Attention to faith and cultural beliefs.


There will be less:

Stigma and discrimination associated with mental health problems.

Inequity in mental and physical health and wellbeing.

Avoidable harm and injury.

Time spent away from their homes by adults with mental health problems.

And fewer:

Avoidable crises and admissions to hospital.

Adults with mental health problems who feel alone and unsupported.

Adults with mental health problems who are excluded from the communities in which they live.

As with mental health services nationally, services for adults with mental health problems in Enfield are not sufficiently focused on recovery. Significant action is needed to enable adults with mental health problems to maximize their potential. One of our many priorities is to implement a stepped up recovery model for those in our population with mental ill-health.

7.3. Our Aims: Enfield Clinical Commissioning Group (Enfield CCG) has developed a Joint Mental Health Strategy (JMHS) with the London Borough of Enfield. The overall aim of the Enfield Joint Adult Mental Health Strategy is to address the safety, effectiveness and patient/client experience and therefore to improve the quality of services.

We will commission mental health services that focus on recovery and enablement.

We will review the current RAID services at NMUH and Barnet Hospital and consider whether to continue commissioning these services.

We will review our current IAPT Service and consider whether to re-commission this via procurement and/or expand further.

We will review our current spot purchased rehabilitation services and consider whether to procure a service.

We will consider the development of a primary care service model for mental health.

We will consider commissioning a CBT for people with Asperger's and autism.

We will review the Big White Wall Project and consider future funding of this service.


7.4. Commissioning Intentions for Mental Health


IAPT Aim: Increased activity

Outcome Desired: To achieve national targets for access.


IAPT is a national programme aimed at implementing NICE guidance for depression and anxiety disorders

National guidance defines the population considered appropriate for IAPT services which in Enfield equates to 35,258 people and sets a target for access to the service. The current access target is that by the end of the 2014/15 financial year the number of patients entering IAPT services should be equivalent to 15% of the eligible population (i.e. 15% of 35,258). The Enfield IAPT Service has been commissioned to treat 10% of the target population in 2014/15. Enfield CCG wishes to increases its commissioned IAPT service in 2015/16 to meet the national target of 15% of the target population. The CCG is mindful that, despite IAPT services being open to all adults, there is a considerable under representation of older people amongst the population accessing IAPT. It is believed that 25% of people over the age of 65 living in the community have symptoms of depression serious enough to warrant intervention, but only a third of them discuss it with their GPs, and only half of those get treatment, primarily medication.

In addition to providing increased access to the general range of psychological therapies for older people the CCG will also require the IAPT service to develop strategies to address the issues identified as barriers to access for older people. Enfield CCG, in collaboration with London Borough of Enfield, has been working with its providers to develop integrated health and social care teams managing locality populations of older people. There will be core team with access to wider MDT when required by the population. It is the intention that IAPT services for older people are part of that wider MDT. The level of resource required will depend on the locality population needs.

1 April 15


Crisis Response Home Treatment Teams(CRHT)

Aim: To be determined by service review

Outcome Desired: Tri-Borough Initiative


Our 2015/16 commissioning intentions will be informed by the outcome of the CRHT review currently underway. We also intend to agree and monitor crisis response times in 2015/16.

1 Oct 15

Community Mental Health Teams

Aim: To be determined by service review

Outcome Desired: Tri-Borough Initiative


Using the model of review piloted in the CRHT’s we wish to review the effectiveness and productivity of the CMHT’s particularly in view of the high proportion of caseloads not on CPA. We intend to work with the Trust to understand the impact on quality of care and to plan, where appropriate, the safe discharge of some of this activity back to primary care.

1 April 15

Liaison Psychiatry/RAID (Royal Free Hospital Barnet /North Middlesex University Hospital)

Aim: Reduction of investment (Service only partly funded by Enfield CCG).

Outcome Desired: Establishment of an equitable funding basis for the service.


Enfield CCG is committed to improving the quality of care for people with mental health needs presenting in acute services. A review of the quality and financial benefits of the existing investment in Mental Health/RAID Liaison Services at Royal Free Hospital Barnet and North Middlesex University Hospital is currently being carried out with other funding North Central London CCG’s.

The CCG’s believe the review has identified benefits accruing to acute partners from the introduction of Liaison Psychiatry/RAID which suggests there is a dialogue to be had about sharing the costs of ongoing funding for the service. A second element of the dialogue would be the extent to which CCG’s outside NCL are deriving cost-free benefits from the investment by NCL CCG’s into the service and how an investment proportionate to actual usage of the service can be achieved.

6 months


Big White Wall Aim: Investment. Current access funded by Regional Innovation ceases 31.3.14.

Outcome Desired: Support Network


Enfield CCG obtained additional funding from the NHS Regional Innovation Fund for a pilot programme in 2014/15 with Big White Wall to supplement the service commissioned from IAPT.

Big White Wall is an online early intervention service, developed in collaboration with the Tavistock and Portman NHS Foundation Trust, which provides a clinical pathway to enable people experiencing psycho-social distress to self-manage the improvement of their mental health and wellbeing.

Anyone over 16 registered with an Enfield GP can access the Big White Wall through inputting their postcode on the website www.bigwhitewall.com (no referral is necessary) to gain immediate access to:

The Support Network

This is the baseline service of Big White Wall which offers:

o Peer and community support 24/7 o Safe, anonymous support o Trained counsellors (called Wall

Guides) online at all times o Community, group and 1:1 peer

therapy o Clinical tests and a broad range of self-

care resources.

Guided Support

These are structured group programmes to support people with specific issues:

o Topics include anxiety, depression, smoking, obesity, substance abuse, and wellbeing

o Groups run for four to eight weeks o Members select their own groups after

joining the Support Network.

Big White Wall also provides Live Therapy - this is one-to-one counselling or CBT, delivered online by BWW’s fully trained and accredited therapists. To access the Live Therapy patients need to

1 April 15.


complete an on-line assessment which confirms their need for Live Therapy and have a supporting GP referral.

The pilot programme has demonstrated the popularity of Big White Wall with the Enfield population – as at 30 September 2014 the uptake against target stood at 100% (the highest proportion of all the CCG’s involved in the trial programme).

Investment is required by the CCG to ensure ongoing access for the Enfield population at the end of the trial period.

Dementia services - Memory Service

Aim: Based on findings of end-to-end review, look to redesign/ recommission Service in collaboration with primary care and emerging network development.

Outcome Desired: Likely to be an increased number of people diagnosed with dementia and better VFM - expectations are unit price per patient improves, but may be added investment


We will look to finalise our review and implement a single system across primary & specialist MH services in 2015/16. Final model needs to be discussed.

1 April 15

Older People's Long Stay Functional Beds

Aim: review provision of functional mental health beds.

Outcome desired: commission more community based beds and facilities (e.g. nursing homes).


TBC.

6 months


8. Learning Disabilities

8.1. Strategic Objectives Our high level vision for providing health services for people with learning disabilities is aligned to the principles of the Department of Health White Paper Valuing People dated 2001-09. We know that the number of people living in Enfield with a learning disability is likely to increase in the next 10 years due to a range of factors. We will continue to address this through the interventions set out below.

8.2. Background The Enfield Integrated Learning Disabilities Service (ILDS) is an integrated specialist health & social care service for people with learning disabilities living in Enfield. The service is provided in partnership with the NHS Enfield Clinical Commissioning Group (ECCG) through our Section 75 Agreement and is managed by Enfield Council. The service is fully integrated with a single core learning disabilities specialist assessment, support plan and review function undertaken by the most appropriate health or social care professional.

We are in the process of developing a local needs assessment that is based upon prevalence and local information that will set out our priorities for the next 3 – 5 years. This will form part of the boroughs Joint Strategic Needs Assessment (JSNA). We are committed to developing a clear set of commissioning intentions that underpins Enfield’s clear commitment to delivering good quality, safe, personalised services that promote choice and control locally and in the community.

The commissioning intentions that are being developed at present will be aligned to the principles of; Valuing People Now dated 2009 first published in 2001 and the Winterbourne View Concordat 2012, Mental Capacity Act including Deprivation of Liberty, Vulnerable People’s Act, Equality Act, Human Rights Act, Autism Act, Health and Social Care Act, Personalisation and Carers Services and Recognitions Act amongst others (this is not an exhaustive list).

In Enfield we have approximately 850 people with learning disabilities and their families, at any given time, in contact with the Health and care services we commission.

We know that the number of people living in Enfield with a learning disability is set to increase in the next 5 years as a result of:

Growing number of children and young people with complex and multiple disabilities

A sharp rise in the reported numbers of school age children with autistic spectrum disorders who have a learning disability

Increases in the life expectancy of people with learning disabilities with many more people living into older age as a result of improvements in health care

People with learning disabilities are developing age related conditions such as dementia that require specialist interventions

A growth in the number of people with learning disabilities who are choosing to live in Enfield from other areas.

An increase in the number of people with learning disabilities living in the community who meet the eligibility criteria for Continuing Health Care

Over the next 18 months we will be transitioning people with very complex and


challenging needs who have been in out of area hospitals back to the community ( DoH Transforming Care: a response to Winterbourne View 2012)

As well as developing a local needs assessment, Health and Social Care are working collaboratively to review Enfield’s learning disabilities service user pathway.

8.3. Our Aims: In line with Valuing People Now, we are committed to delivering community focussed

services for people with learning disabilities. Therefore, we intend to develop the local market and the universal offer to respond to the needs of older people and young people with learning disabilities especially with regards to the provision of day opportunities and supported living services.

We are currently implementing our joint Autism Framework. We will be going through a procurement process to commission an autism co-ordination function that will responsible manage the local autism steering group and implementing our joint framework

We will be seeking to further reduce admissions to learning disabilities specific assessment & treatment services. Over the last 2 years, we have reduced admissions significantly from 9 on average to 2 by investing in community intervention that is provided by the Integrated Learning Disabilities Service. Due to this success, we will need to commission a range of alternative community options that provide holistic support to people with learning disabilities who are experiencing mental health problems and / or are in crisis.

We will continue to work in partnership with primary care services to improve access to DES health checks for people with learning disabilities, as we view this as a means to address health inequalities experienced by people with learning disabilities and promote good health and wellbeing.

We will focus on the outcomes that are important to our patients and their carers.

8.4. Commissioning Intentions for Learning Disabilities


Day Opportunities Hub

Aim: Work with the London Borough of Enfield (LBE) in the development of community day opportunities hub for young people (18 – 25 years old)

Outcome Desired: people can take part in structured activities on a sessional basis


Services move to a wellbeing and independence type sessional community model rather than traditional styles of ‘day care’ that is provided 5-days a week basis.

1 April 15

Supported Living Services

Aim: Work with LBE in the development of a range of supported living services that promote

1 April 15


greater independence, choice and control

Outcome Desired: make good use of community resources, use assistive technology, telehealth and innovative solutions as part of the service delivery model.


Shifting the focus from people with learning disabilities with complex needs and behavior that can prove challenging at times living in restrictive care settings that are out of area to offering a range of housing options that promote greater opportunities for independence, choice and control.

Personal Health Budgets

Aim: Establish / enhance services for PHB / DP

Outcome Desired: Services that can be purchased by using Personal Health Budgets and Direct Payments


Moving from the spot contracting to service user being enabled and supported to manage their own budget which promotes personalisation and greater choice and control

1 April 15

Reviewing the diagnostic and support pathway for adults with high functioning autism

Aim: review the diagnostic and support pathway for adults with high functioning autism (such as Asperger’s)

Outcome Desired: commission a small scale local service for screening, diagnosis and post-diagnosis support


To develop a clear diagnostic and therapeutic support pathway for adults with high functioning autism through a single provider model and to provide this service locally.

1 April 15

Specialist Housing And Support

Aim: As part of our Transforming Care Programme, work with LBE in their commissioning of a small scale service (no more than 3 placements) of specialist housing and support in the community for people with high needs who have behavior that proves challenging at times. Some of these people will

1 April 15


be at risk of re/offending.

Outcome Desired: This service will work in partnership with our community intervention service to resettle people who have been discharged from Out of Area Treatment services back to the Enfield Community.


The specialist supported living service will offer holistic, personalised care and support services to people with learning disabilities with complex needs. The service will work with individuals and their support and social network to identify and de-escalate triggers for challenging behavior and reduce cyclical episodes of crisis to support independence and prevent admissions.

Adults with learning disabilities

Aim: reduce further avoidable admissions to assessment & treatment for people with learning disabilities

Outcome Desired: reduced avoidable admissions by delivering targeted integrated community intervention.

Description / Change to service: shifting resources away from assessment & treatment services to providing rapid response community intervention that prevents people from falling into crisis

1 April 15


9. Community Services

9.1. Strategic objective We want to build robust, safe and effective community services to drive care closer to home

9.2. Background Currently Enfield CCG commissions’ community services from BEH MHT and we intend to re-commission these services.

9.3. Aims We want to redesign community services so that the right models of care are in place for different populations, ensuring that services are more personalised, more focussed on outcomes and more integrated with other provider services.

1. We want more services to be provided locally in a more joined-up way GPs in Enfield work together in four local areas. We want to plan community services around these four geographical areas so that they work as a network to support GP and hospital services better in the future. We want more services to be provided in the community or at home. We want different providers to work to support patients to stay as well as they can at home or in the community wherever possible.

2. We want services to be targeted towards smaller population groups with similar health needs.

If services are delivered to smaller population groups, we believe that they will better understand and support the personal health needs and goals of patients. The population groups we want to focus on are:

3. We also want health services to deliver better long-term health outcomes for patients

We want to implement outcomes based commissioning, with initial priority given to older people

CHILDRENUniversal services for children and young people such as Health Visiting and School Nursing

Children with additional needs including:

Children with special educational needs and disabilities

Complex and end of life care

Looked After Children

Safeguarding

ADULTSOlder adults with complex health needs

(from prevention to end-of-life care)

Younger adults with long-term conditions

(from prevention to end-of-life care)

Adults requiring short episodes of care such as wound care or nursing after an operation

Adults with learning difficulties

SEXUAL HEALTHSelf referral and

treatment services for teens and adults


9.4. Commissioning Intentions for Community Services


Community Health Services

Aim: Re-Commissioning of Community Health Services.

Outcome Desired: Expected to provide more productive use of available resources to support additional number of patients, e.g. for intermediate care services.


Will need to be aligned with other integrated care arrangements and Value Based Commissioning across integrated care pathways. There is potential for re-investment.

6 months

District Nursing Aim: Review of District Nursing service to assess relationship and pathway with PCSS and impact of additional investment.

Outcome Desired: Review pathway to ensure that there is no duplication in the services provided and that additional investment is impacting on service delivery and patient outcomes.


TBC

Develop brief in 14/15 commence in Quarter 1

Delays in Transfers of Care

Aim: Reduce delays in transfers of care from secondary care services and then maintain appropriate levels of performance.

Outcome Desired: Reduction of Occupied Bed Days

Description / Change to service: To be determined.

TBC

Community Health Services 2

Aim: Revised service models to be implemented by population and delivered in Locality Teams

Outcome Desired: Community services will work aligned to the 4 localities in an integrated approach with provider partners; the right care, right place, at the right time principles, highlighting that the population based localities are pivotal in achieving improved health within our populations and that integrated community provision is key to system resilience and delivering increased care closer to home.

In place from 1st April 2015.



The Integrated Locality Teams are in development but it is our expectation that they will be fully implemented and operational by 1st April 2015

Fracture Liaison and Bone Health Service (Enfield Falls Programme)

Aim: Based on results of review of Falls Programme, look to recommission Programme to incorporate its function fully into integrated care pathway supporting future demand & improving productivity

Outcome Desired: Likely to be synergies in bringing disparate falls management functions together. Expectations are unit price per patient improves, but may be added investment


We will look to review existing service & contract in Nov-14, with recommendations for future commissioning. Will look to work with provider to make changes in last 4 months of year as part of phasing

1 April 15

Parkinson’s Service

Aim: We aim to transfer the Parkinson’s Nurse to an acute provider to ensure continuity, quality and supervision of service.

Outcome Desired: The community service will be overseen and supervised by an acute provider; however, the service will continue to be delivered in the community


TBC.

TBC.


10. Medicines Management

10.1. Strategic Objectives The projects objective is to improve patient access to appropriate treatments and deliver clinical and cost effectiveness within the financial budget for prescribing. It plans to deliver a savings target of £1.1 million in 14-15.

GP practices will be encouraged to prescribe more cost effectively and to take ownership of their prescribing budget. Treating the maximum number of patients as possible, with the most effective medicines, in the most appropriate setting whilst prioritizing patients with the most needs, is our primary objective.

10.1. Background Enfield CCG has had a medicines management service operating since 2000. Following the setting up of CCGs the spend on PBRexc drugs has been managed by the Acute medicines service at the Commissioning Support Unit (CSU). The Acute Medicines Management service is seeking to review the use of PBRexc medicines to ensure their use is consistent with NICE and also to maximize cost effectiveness, enabling the maximum number of patients to be treated. This work demands liaison between CSU Medicines Management, CSU Contracts and Acute trusts Medicines Management and Contracts.

Primary care Medicines Management focusses on the quality and cost effectiveness of GP prescribing. This is achieved by medicines management pharmacists meeting with GPs and agreeing changes to be made. Practices are incentivized to make changes.

The Medicines Management team liaises with acute trusts via the Joint Formulary Committee in order to influence medicines included in formularies. The Medicines management team use prescribing data to identify practices that may be outliers in prescribing and try to link this to patient outcomes.

10.2. Our Aims • We will work with primary care through the newly created Primary Care Medicines

Management leads to reduce variation in the use of primary care medicines

• We will continue with the incentive scheme with primary care on medicines management

• We will work with community pharmacists to encourage self-care and patient education

• We will work with secondary care to review PbR excluded drugs


10.3. Commissioning Intentions for Medicines Management


We will work with primary care through the newly created Primary Care Medicines Management leads to reduce variation in the use of primary care medicines.

Aim: Currently primary care medicines management pharmacists work to support practices to improve quality and cost effectiveness of prescribing. CCG is proposing to appoint GP Locality leads to support the medicines management team in challenging high cost and poor quality prescribing.

Outcome Desired: This should enable a closer link to be established between prescribing performance, hospital admissions and patient outcomes leading to a reduction in variation in use of medicines.


Plan to employ more prescribing adviser support to practices to advise further on quality and cost effectiveness of prescribing. Continue to fund dietician post to ensure appropriate use of oral nutrition.

Throughout 2015/16

We will continue with the incentive scheme with primary care on medicines management

Aim: Prescribing Quality and Saving Scheme has encouraged practices to improve quality and cost effectiveness of prescribing.

Outcome Desired: as above.

Description / Change to service: Plan to continue with this in following year

Throughout 2015/16

We will work with community pharmacists to encourage self-care and patient education.

Aim: Minor ailments scheme has encouraged patient to not attend their GPs for minor ailments, leading to improved GP access.

Outcome Desired: Plan to set up a healthy living pharmacy in East of Enfield


The Healthy Living Pharmacy (HLP) framework is a tiered commissioning framework aimed at achieving consistent delivery of a broad range of high quality services through community pharmacies to meet local need, improving the health and wellbeing of the local population and helping to reduce health inequalities.

Throughout 2015/16


We will work with secondary care to review PbR excluded drugs

Aim: Currently CCG pays Acute trusts for many NICE PBR excluded drugs with no clear audit to check we are being charged correctly.

Outcome Desired: Plan to put in place an audit of NICE PBR excluded drugs with aim of recouping any mischarges.


CCG plans to work more closely with Acute trusts via CSU Contracts, Acute Medicines Management Team and Joint Formulary Committee to influence choice of PBR excluded drugs used. Continue to fund Joint Formulary Committee with other CCGs and Acute trusts.

Throughout 2015/16


11. Quality & Safety

11.1. Strategic objectives As commissioners of healthcare locally, we must ensure that quality and safety are central to everything that we do, fulfilling our statutory responsibilities in relation to the NHS constitution, clinical governance and improving both health care and health outcomes locally.

We are committed to quality and safety and we continuously monitor and measure it in all our contracts. Patients expect to receive high quality, clinically effective and compassionately delivered care and this is also their right under the NHS Constitution.

As it is fully recognised that patient-centred quality is everyone’s business, the CCG publishes annually a Quality Strategy to set out a vision for how clinician led and evidence based continuous improvement in all commissioned services is achieved. Our Quality Strategy is above everything, about people.

11.2. Background Our Quality Strategy is for all the people of Enfield and aims to provide everyone with the care and compassion they want and need by enabling their voice to be heard and then commissioning services with them that are amongst the safest and most effective in the NHS, and that this is provided reliably to every patient, every time.

In recent years, key reports such as Francis, Keogh, Berwick as well as Clwyd and Hart have enforced the need for transparency and constant vigilance around the quality of NHS care. We have embedded the learning from these reports and take a thorough approach to reviewing the quality of services using three sets of indicators – key performance indicators, patient outcomes and quality metrics.

Key performance indicators o Including measures like access and response times.

Patient outcomes

o Including type of treatment offered and outcome measures.

Quality metrics o Including monitoring complaints, serious incidents, compliments, staff and

patient surveys.

Our performance indicators, which the CCG has set to address the key issues within the local health community, are to improve access to primary care, diagnosis of dementia and reduce hospital readmissions. We will review performance reports at every Governing Body meeting.


11.3. Our Aims Our aims are centred on

Commissioning services that are safe and continually improving

Effectively Engaging stakeholders

Outcome monitoring with remedial action taken as necessary

To monitor these aims and sets of indicators, we routinely use of the core domains of quality as set out in the CCG Governing Body approved Quality Strategy, namely patient safety, patient experience and clinical effectiveness, to monitor quality improvement and standards of care provided.

This is supported by a series of measures to ensure we meet out statutory obligations:

• Having in place an appropriate supporting governance infrastructure, to support its statutory duties and ensure that quality improvement is identifiable, measurable, and effective. This includes clear roles and responsibilities of senior CCG staff including safeguarding leads, supporting quality staff from the North East London Commissioning Support Unit (NELCSU), and a structure for committees to monitor progress under the Governing Body which has primary responsibility for quality.

• Maintain partnerships with stakeholders, such as NHS England in managing primary care.

• Inform service re-design and commissioning intentions through service user, carer, stakeholder (such as Healthwatch) feedback, peer group reviews, early warning signs, and pathway visits in response to CQC inspections and other soft intelligence received on quality and safety.

• Embedding processes within the Transformation Programme to quality assure service specification and thus ensure that the planned service changes meet the requirements for high quality, safe services – i.e. we have put in place a robust Quality Impact Assessment (QIA) and monitoring process for our QIPP Transformation programmes.

• Monitor indicators through our contract quality group using dashboards and exception reports. Monthly monitoring of contractual quality schedules includes incident and serious incident monitoring, infection control and breaches of mixed sex accommodation.

• Meet all main providers on a monthly basis to receive direct quality assurances through a meeting called Clinical Quality Review Groups (CQRGs), taking action where quality and safety is found to be compromised. The CCG also participates in key provider committees such as infection control and safeguarding.

• Continue to run an internal system (called Quality Alerts) where our member practices can feed in soft intelligence which acts as an early warning system.

• Announced and unannounced walk the pathway visits also provide further assurance on the quality of care being delivered to patients. These are undertaken on a regular basis, in consultation with providers, by GP clinical leads for the service along with NHS managers.


11.4. Patient Safety We fully understand the recommendations from the Francis Report (Department of Health 2013), and will seek assurance from providers that we commission to ensure:

Fundamental standards and measures of compliance are always met;

They demonstrate openness and candour;

They promote and provide compassionate, caring and committed nursing;

They promote strong healthcare leadership;

They provide information and data that is transparent to service users and the public. Our Quality Strategy also reflects the key findings of the Francis, Berwick and Winterbourne View reports through implementation of a specific Patient Safety Implementation Plan and supporting policies associated with management of incidents and serious incidents.

11.5. Commissioning Intentions for Quality & Safety


Patient Safety

Aim: Commissioned services that are safe and continually improving. Outcome Desired: CCG is appropriately and effectively assured on the quality of services it commissions. Description / Change to service: a series of actions designed to reflect recommendations of Francis, Keogh and Berwick reports: commissioning structure re-arrangements:

Regular reports (through Clinical Quality Review Groups) of assurance against provider’s own action plans in response to Francis, Keogh, Berwick and Clwyd-Hart.

Regular reports for assurance against other reported issues, including external stakeholders, e.g. Health Service Ombudsman

Review and response to soft intelligence/early warning “quality alerts” as and when escalated.

Provider routinely meets reporting expectations as defined by work plans for Clinical Quality Review Groups (CQRGs) – including incidents, serious incidents, healthcare acquired infections, access and response times.

Ongoing throughout the year – business as usual through CCG contract management.


Patient Experience

Aim: Effectively Engaging stakeholders. Outcome Desired: CCG is appropriately and effectively assured on the quality of services it commissions Description / Change to service: a series of actions to reflect improvement in design of methods to collect and respond to patient feedback and other soft intelligence on quality:

Provider reporting and assurance on complaints themes and trends, compliments and patient experience surveys.

Review and response to soft intelligence/early warning “quality alerts” as and when escalated.

Ongoing throughout the year – business as usual through CCG contract management

Clinical Effectiveness

Aim: Outcome monitoring with remedial action taken as necessary. Outcome Desired: compliance in line with performance and quality schedules incorporated into provider contracts. Description / Change to service: a series of actions to reflect improvement in governance infrastructure which ensures that quality improvement is identifiable, measurable, and effective:

Super Clinical Quality Review Group (CQRG) with Barnet Enfield and Haringey Mental Health Trust (for which the CCG is lead commissioners) with appropriate change to terms of reference and forward plan reflecting findings from contract quality review.

Reporting through Clinical Quality Review Groups of audit programmes, informed where appropriate by CCG audit wants and needs.

CCG reviews of governance processes associated with pathway visits (“Walk the Pathway”) that providers participate in and are reported through Clinical Quality Review Groups (CQRGs).

Ongoing throughout the year – business as usual through CCG contract management, both providers and North East London Commissioning Support Unit (NELCSU)


12. Contracting & Performance The section highlights a number of issues or routine data requirements that the CCG wish to introduce or change. As with the rest of the document, these items should be read in conjunction with the commissioning intentions letters issued by the CSU on behalf of commissioners.

At the time of writing, we are awaiting full details of the 2015/16 NHS Standard Contract, Payment by Results rules and tariffs, the National Operating Framework and Outcome Measures and any other expectations of NHS England. However, the CCG intends to agree contracts that incorporate the key requirements of these documents.

The CCG will use all available contract levers during 2015/16 to ensure performance remains in line with agreed standards. General contracting principles, including expected additional requirements to the standard terms of the contract, will include:

12.1. Data Requirements Enfield CCG Contract Monitoring Group has identified a number of data sources the CCG require to be captured from all NCL providers in 15/16, including:

• Maternity booking data by provider by CCG

• OP Referral data by provider by specialty by CCG and by practice

• Activity recorded by site code.

• Improve robustness and consistency of data across all providers.

These items should be delivered at the same time as SLAM data.

12.2. Quality, Safety and Performance Standards Providers will be expected to comply with all national quality, safety and service performance standards, including Serious Incidents, Infection Control and Safeguarding. Providers must adopt any new and recommended standards of best practice and evidence-based working including the principles and outcomes of the Francis Report, Keogh Review, Berwick Report and the Winterbourne Review. Assurance will be sought on the quality of service provision through announced and unannounced visits.

Providers will be expected to make further progress towards delivering the Safer Staffing recommendations highlighted by the Keogh review, including staffing and skill mix levels and training standards for nursing, medical and other staff involved in the provision of services. Providers will be required to report front-line staffing levels to the CCG on a monthly basis.

Providers will be expected to report against the agreed metrics in the NHS Outcomes Framework; Everyone Counts and take remedial action where performance is demonstrated as below the national expected level.

Localised quality standards, performance indicators and outcome measures as determined by the CCG will be agreed with Providers to improve specific areas of quality which are of current concern.


The CCG will develop and agree national and local CQUINs with Providers, setting stretching targets to drive quality improvements and service change in priority areas. This will include the development of whole system CQUINs to promote integrated working. Providers will be expected to continue to implement actions in place as a result of the delivery of the 2014/15 CQUINs. ECCG will be looking to develop mechanisms to release a proportion of CQUIN monies upon demonstration of the continued roll out of good practice.

All providers will be expected to demonstrate their broader organisational engagement with clinical networks and their key work areas including any relevant data submissions and audit requirements.

Providers will be required to implement the Prevent agenda requiring healthcare organisations to work in partnership to contribute to the prevention of terrorism by safeguarding and protecting vulnerable individuals who may be at a greater risk of radicalisation.

12.3. Activity and Finance We will seek to work jointly with providers to manage capacity in line with our financial envelopes. To support this we expect the full engagement of providers to support service change and redesign in the development of cost effective pathways and in relation to the implementation of the Better Care Fund.

Productivity and performance standards will be agreed with providers, linked to the QIPP agenda across the local health and social care system. Providers will be expected to deliver CIPs which will be quality impact-assessed by the CCG as part of formal sign off. We expect to move to a joint process for the development of CIP and QIPP.

We will adhere to PbR tariff unless local tariffs are specifically negotiated; this may include where a service has been the subject of a jointly agreed transformation programme project. PbR rules regarding counting and coding will be followed to ensure that parity of coding and charging exists across all providers.

The CCG intends to adopt any PbR mandatory tariff items including Best Practice and any new PbR terms which link the tariff to delivered outcomes; where providers claim for a best practice or outcome based tariff, they will need to clearly demonstrate that requirements are being delivered to receive payment. The CCG will continue to work with non-acute providers to develop tariffs and currencies that enable us to move from block contracts to services commissioned on a cost and volume basis, and delivered on an outcome basis.

Risk sharing arrangements will be agreed in contracts that mitigate the risk of in year changes to the cost of activity; this will include shifts in case mix and coding and any outcomes of the unbundling of activity from tariffs.

All contracted activity, whether PbR or Non-PbR, will require reporting at an individual patient level to allow for validation and receive payment. The CCG will stipulate minimum data sets and requirements that providers will need to comply with to ensure that data supplied is in a consistent and standardised format and can be attributed to practices.

Enfield CCG wishes to explore moving to long-term contracts - which will not be PbR-based and therefore will need to develop new financial models for longer-term delivery.


13. Concluding Remarks Overall 2015-16 will be another challenging year. We will focus on improving patient experience, delivering value for money and ensuring excellent clinical outcomes, but by planning for the longer‐term, we can have confidence that we will continue to deliver for patients.

NHS Enfield CCG Commissioning Intentions sets out our commissioning priorities (including our QIPP schemes) for 2015/16. It has been informed by the feedback received from our GP members, the public, the Enfield Joint Strategic Needs Assessment and the Enfield Health and Wellbeing Strategy.

We welcome our shared responsibility to deliver the JHWB Strategy and our shared commitments working closely with the London Borough of Enfield.

We will continue to develop our six transformation programmes as well as cross-cutting programmes which include: Transformation of Community Services, Value Based Commissioning, Managing Demand and developing Locality Commissioning. We will work together to create an environment where we can build resilience for the whole system during a time of major transitions.

As part of the North Central London Health Economy Strategic Planning Group, we will drive improvement in the delivery of high quality, evidence-based and compassionate services, defined and measured by outcomes not process, to the population of North-Central London.

This document summarises our Commissioning Intentions for 2015/16. It is a framework for how we intend to commission local health services during the next two years. Our Commissioning Intentions have been developed to show how we intend to make best use of our available resources to ensure that Enfield people receive high quality, safe health services that meet their needs and are good value for money.

We will only be successful if we can continue to work effectively with our member practices; build on our strong collaborative working with the local authority, health care providers, NHS England and NCL; and work in partnership whilst with our local communities, Healthwatch and voluntary/ third sector organisations.

Enfield CCG Commissioning intentions for 2015/16 represent an ambitious commissioning plan; but we believe that it is only by being transformational in our approach that we will be able to respond effectively to the significant challenges facing the NHS.

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Documents

NHS Enfield CCG Commissioning Intentions 2015/16