NHS Rushcliffe Clinical Commissioning Group …...RCCG Commissioning Strategy 2012-2015 2 Foreword Stephen Shortt Clinical Leader and GP Chair Sheila Hyde Lay Vice-Chair Vicky Bailey

NHS Rushcliffe Clinical Commissioning Group Commissioning Strategy 2012 – 2015

RCCG Commissioning Strategy 2012-2015

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Contents

Foreword 3

Executive Summary 4

1. Introduction 6

2. Mission, Vision and Values 8

3. Environmental analysis 10

4. CCG profile and case for change 12

5. Strategic objectives and improvement programmes 20

6. Domains 22

Clinical and multi-professional focus 23

Engaging with patients, carers and our community 27

Clear and Credible Plans 31

Governance, finance and commissioning 40

Collaborative Commissioning 44

Leadership 48

7. What will success look like? 49

8. Commissioning Intentions 2013-2014 50

Appendices:

Appendix 1. Associated documentation 59

Appendix 2. Financial Planning Assumptions 60

Appendix 3. Countywide QIPP work streams 61

Appendix 4. Financial Scenarios 62


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Foreword

Stephen Shortt Clinical Leader and GP Chair

Sheila Hyde Lay Vice-Chair

Vicky Bailey Chief Officer

Andy Warren Chair Patient Cabinet

From April 2013, NHS Rushcliffe Clinical Commissioning Group (RCCG) will be commissioning services for the population of Rushcliffe and the patients registered with member practices on the borders of the locality. The CCG will be different from any predecessor NHS organisation as it will consist of the member GP practices functioning together as a statutory NHS body. GP practices will have statutory duties as a CCG commissioner, while retaining responsibility for providing primary care services. As well as the challenges faced by any new organisation, over the next few years RCCG will have a significant Quality Innovation Productivity and Prevention (QIPP) target, which means that we will need to find ways to deliver high quality care for our patients in times of financial constraint. To achieve this, our strategy for the next three years will focus on supporting people to manage on-going conditions, improving mental health and wellbeing and supporting people to understand about how improvements to lifestyle can mean improvement in their health. RCCG will continue to have a proactive approach to health care management and over the coming years will continue to build on the successful integration of primary care with local health community teams. We plan to work with others, such as local acute trusts and the local authority, to extend the established integrated teams to include the Community Geriatrician, mental health services for older people and social work. The contents of this, the initial commissioning strategy for RCCG, reflects the joint input and endeavours of all parties involved in establishing the new organisation and leading it through the authorisation process to become a statutory NHS body. The early involvement of public and patients has strengthened the robust relationships that existed in the former Principia Partners in Health and this will form a strong foundation for the future development of RCCG.


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Executive Summary From April 2013 NHS Rushcliffe Clinical Commissioning Group will be commissioning services for the population of Rushcliffe, and the patients registered with the member practices on the borders of the locality. The CCG will be different from any predecessor NHS organisation as it will consist of the member GP practices functioning together as a statutory NHS body. This first Commissioning Strategy for RCCG describes our organisation’s mission, vision and values and outlines our clinical and organisational objectives up to 2015, as well as detailing our Commissioning Intentions for 2013-2014. Our vision is: Together patients, General Practitioners (GPs), other health professionals and partners will lead the transformation of local health services. Our culture of liberating thinking and encouraging innovation will enable us to approach improvements in health and wellbeing from a fresh and realistic perspective. We will work with partner organisations to develop opportunities to integrate services that are centred on the patient. Our commissioning decisions will drive improvements in the quality of services and we will increase productivity and efficiency through better use of people and funds. We will be a thriving local commissioning organisation, which acts within our health and local government community and is financially sustainable. In pursuing this vision, and based on local health need our clinicians and patient representatives have identified the following clinical objectives for RCCG:

1. Commission to improve the health of the whole population of our area with better quality of care and outcomes for all patients, in line with three priority areas:

Supporting people to manage on-going conditions

Improving mental health and wellbeing

Promoting prevention, early intervention and supporting people to make healthy lifestyle choices

2. Improve the quality of health services in relation to health inequalities, health outcomes, patient safety, access and patient experience.

RCCG believes that the key to making the improvements we want is for us to work differently as an organisation and for us to work differently with partner organisations. Our focus will be on clinical leadership and patient and public representatives working together to shape services. We will also develop our ability to influence the providers of services and we will work collaboratively with our neighbouring CCGs to make the best use of the available funding and the skills of our members.


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It is essential that we manage our statutory functions robustly and to do this we have a sound governance structure that will ensure that we meet the required standards for financial management, quality, safety and information governance. Within this Commissioning Strategy we have detailed our Commissioning Intentions for the year 2013/2014.


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1. Introduction NHS Rushcliffe Clinical Commissioning Group aims to achieve full statutory and regulatory status as a Clinical Commissioning Group by April 2013. This is in accordance with the Health and Social Care Act 2012. This document sets out the mission, vision and values of the organisation and provides clear strategic objectives for the organisation, through authorisation to become a statutory body and for the following two years. This strategy will provide the framework for our commissioning decisions and associated Improvement Programmes. RCCG is a new body, which has evolved from the former Principia Partners in Health (Principia) Practice Based Commissioning Group and Social Enterprise. That organisation has a history of inspirational clinical leadership, a ground-breaking approach to public and patient involvement, a reputation for innovative service design and for collaboration with partner organisations. While recognising that the CCG will be significantly different in its role and level of accountability, this is an invaluable platform on which to build. Member practices are committed to working collaboratively to meet the requirements of clinical commissioning as set out in the Health and Social Care Act 2012. The CCG is confident that this collective commitment, together with established clinical leadership and high calibre management support, will enable RCCG to lead transformational change locally. The CCG will inherit objectives, contractual commitments and financial legacy from NHS Nottinghamshire PCT and will have a statutory responsibility to make sure that existing plans are continued and delivered as detailed in the NHS Nottinghamshire Integrated Plan 2012/13. It is imperative that if we are to succeed we need to re-orientate our efforts from managing acute episodes to a greater focus on prevention and self-management, supported by genuinely integrated services. We will develop pathways that combine physical and mental health services, in recognition that for many patients their physical and mental health needs are inextricably linked. We will also be focusing on the management of those with long term conditions, particularly the frail elderly and those requiring palliative care. For us to deliver the magnitude of change required, and at the necessary pace, it is vital that the CCG builds on and embeds the joint work that has already been done with local government and other partners, to improve health outcomes for our constituent community. The CCG Governing Body is committed to the concept that the scale of change needed can only be achieved through health and local government partners working together systematically. RCCG aims to be radically different in its approach to making transformational change actually happen, so that we can demonstrate measureable improvements in clinical outcomes. We believe that we have the capability to lead and deliver


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transformational change by focusing our efforts on establishing an effective Commissioning System and on collaboration, influencing and relationship management. All commissioning decisions and associated improvement programmes will be based on a Quality, Innovation, Prevention and Productivity (QIPP) approach. This approach will be underpinned by robust financial and corporate governance, information management, systematic communication and engagement, and organisational development. Not unexpectedly, the Governing Body identified financial pressures as the greatest risk to the organisation and its sustainability. However, the strategic ambitions of the CCG and financial constraints are not viewed as conflicting. We believe that there is significant scope for improving quality and productivity, thereby reducing costs while improving the patient experience, and that financial risk can be managed with the risk management approach outlined in section 8.2. Primary care performance and influence will be pivotal in both transforming local services and managing expenditure and we are confident that through peer influence, the CCG will be able to bring about the necessary changes in individual and collective behaviour. In developing this strategy the opportunities and threats facing the CCG have been analysed to inform a strategy that aims to exploit opportunities and manage the risks to RCCG.


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2. Mission, Values and Vision 2.1 The mission statement, vision, values and strategic objectives have been

jointly developed by clinicians and patient representatives through the following approach:

Patient Cabinet (formerly the Patient Reference Group) meetings

Practice Patient Group (PPG) Chairs meetings

Joint patient and clinician Protected Learning Time (PLT) event in November 2011

Protected Learning Time event in February 2012

Clinical Cabinet meetings

Governing Body meetings They have also been shared with the wider population of Rushcliffe through the quarterly Rushcliffe Borough Council newsletter (Rushcliffe Matters) which is delivered to virtually every household in the area, and through other engagement events. The public have been invited to comment on the strategic objectives and to become involved in shaping health services locally.

2.2 Mission statement Our mission is to improve the health outcomes of people registered with a practice in NHS Rushcliffe CCG and other patients who live in the locality, by commissioning high quality and affordable health care services.

2.3 Values The values that lie at the heart of RCCG’s work are:

Quality Improving patient safety and the quality of services is integral to all our decisions, in all domains: safety, timeliness, equity, efficiency, effectiveness and patient centredness.

Affordability Be creative in planning and buying services to promote integration and make the most of available funding.

Inclusivity

Patients, and their carers, doctors and health professionals will make meaningful decisions together.

Local focus Listen to what local people tell us about their health priorities, and combine this with public health information and clinical expertise to inform our commissioning decisions.

Transparency

Communicate in an open and honest manner at all times. Respecting different points of view, encouraging healthy


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challenge and working with integrity.

Leadership Create a culture of trust and credible leadership - able to influence and be willing to be influenced, both collectively and individually.

Innovation Provide the environment where innovation is actively encouraged and new ideas explored.

2.4 Vision Our vision defines the mid to long term goals of the CCG:

Together patients, General Practitioners (GPs), other health professionals and partners will lead the transformation of local health services. Our culture of liberating thinking and encouraging innovation will enable us to approach improvements in health and wellbeing from a fresh and realistic perspective. We will work with partner organisations to develop opportunities to integrate services that are centred on the patient. Our commissioning decisions will drive improvements in the quality of services and we will increase productivity and efficiency through better use of people and funds. We will be a thriving local commissioning organisation, which acts within our health and local government community and is financially sustainable.


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3. Environmental Analysis It is recognised that RCCG is applying for authorisation as a statutory body in a period of significant change not only within the NHS, but also externally. In agreeing the strategic objectives for the CCG in the period up to 2015, the CCG has identified and analysed the wider external environment in which it will be functioning, as well as national and local changes to the public sector. The key factors identified were:

3.1 Political

• Health and Social Care Act 2012 • Coalition government / General election 2015 • Local councils multi-tiered - County, Borough and City

3.2 Economic

• National and global recession • Opening of provider market and encouragement of competition

o Bargaining and influencing power of commissioners (individually and collectively)

o New providers of services • Changes to social care funding

3.3 Socio-cultural

• The CCG already has one of the oldest populations of the Nottinghamshire CCGs, and an ageing population that may be negatively affected by changes to the retirement age

• Increasing prevalence of Long Term Conditions • Increasing expectations of public service users • Increasing population and local housing developments • In general, the health of the population is better than England average • The prevalence of deprivation in Rushcliffe is lower than the England average,

but this obscures pockets of deprivation at LSOA level

3.4 Legal

• Statutory and public duties • Corporate risk and liability • Legal constitution and governance


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3.5 Environmental

• Sustainability • Fuel costs / power • Recycling


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4. Clinical Commissioning Group profile and the case for change 4.1 Member Practices The CCG is made up of 16 member practices which are grouped into three community wards: (not sure we should say ward here as different term in public health language – what about just communities). Some of the member practices operate from more than one premises: Central

• Compton Acres Medical Centre • Ludlow Hill Surgery • Gamston Medical Centre • Musters Medical Practice • Southview Surgery • St Georges Medical Practice • Trent Bridge Family Medical Practice • West Bridgford Health Centre

North

• Belvoir Health Group • East Bridgford Medical Centre • Radcliffe-on-Trent Health Centre

South

• East Leake Medical Group • Keyworth Medical Practice • Orchard Surgery • The Ruddington Medical Centre • Soar Valley Surgeries

4.2 RCCG is one of six CCGs in Nottinghamshire. It covers around 155 square miles (400 sq km) and commissions healthcare services for approximately 121,400 people, the majority of whom live in the Rushcliffe Borough Council area. The main population is based within West Bridgford, where approximately 36,000 of the Borough's population live. The remainder of the district is largely rural, with the population split between small towns and villages. The district health profile demonstrates the following:

• The health of people in Rushcliffe remains generally better than the England average

• Deprivation is lower than average, however 1,600 children live in poverty


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• About 11.8% of year 6 children are classified as obese lower than the England average

• The level of smoking during pregnancy across Nottinghamshire PCT is worse than the England average

• Life expectancy for both men and women is higher than the England average

• Life expectancy is 5.5 years lower for men and 5.7 years lower for women in the most deprived areas

• The incidence of malignant melanoma is higher than the England average albeit the actual number is small (23) and aggregated over 3 years

• Priority public health issues in Rushcliffe are smoking, obesity and alcohol

4.2.1 Smoking Smoking is the primary cause of preventable illness and premature death in England and the single biggest cause of inequalities in death rates. Smoking prevalence in the adult population is lower in Rushcliffe Borough (16.4%) than England (20.8%) or the East Midlands (21.1%). Around 1,300 deaths are attributable to smoking each year in Nottinghamshire. Prevalence of smoking in pregnancy is available at PCT level and for Nottinghamshire County it is significantly higher than the England average. Estimates provided in the APHO health profiles at local authority level reflect prevalence at PCT level. Given the low smoking rates in the general population of Rushcliffe, it is likely that the actual local rate of smoking in pregnancy is lower than the Nottinghamshire average. 4.2.2 Obesity Obese children are more likely to develop into obese adults and subsequently more likely to develop diabetes, colon cancer, hypertension (high blood pressure) and heart disease. Obesity also has an impact on psychological well-being. Although Rushcliffe has the lowest overall adult obesity prevalence in Nottinghamshire, adult obesity is high in specific wards in Rushcliffe: Cotgrave is in the higher than national average quintile for obesity. 4.2.3 Substance misuse: alcohol and drugs Alcohol misuse can lead to a number of health conditions and the long term effects of excessive alcohol consumption are a major cause of avoidable hospital admissions. In addition, alcohol has detrimental social and economic affects. The rate of alcohol-attributable admissions for residents in Rushcliffe is lower than in other parts of Nottinghamshire, but is increasing in line with the rest of the County. The proportion of the population estimated to be higher or increasing risk drinkers, although not significantly different from the England average, is the highest in the County. This has implications for appropriate early intervention services and future health issues for the population.


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Drug and alcohol misuse can prevent parents from providing their children with the care and support they need and greatly increases the likelihood that their children will grow up to develop drug or alcohol problems themselves. Rushcliffe residents have the lowest drug-related hospital admissions in Nottinghamshire. The following public health data has been derived from the Joint Strategic Needs Assessments for adults, older people and children and further supports our additional priority considerations and action areas. 4.2.4 Life Expectancy Given that overall health is good in Rushcliffe, it is not surprising that the overall life expectancy for males and females is higher than the England average. Life expectancy is however 5.5 years lower for men and 5.7 years lower for women in the most deprived areas. When looking at life expectancy at practice level, there is some variation between practices and an estimated 3 year difference in overall life expectancy between the registered populations of Compton Acres Medical Centre (77.4) and of Orchard Surgery (80.7), which is estimated to have the highest life expectancy within RCCG. The difference in life expectancy is more pronounced in females, with an estimated 4.5 year difference in life expectancy between the two practices. 4.2.5 Population growth Rushcliffe has the highest projected population increase overall in Nottinghamshire (13.24%) from 2010 -2025. The over-65 population in our area is expected to increase by 40% by 2025 (Rushcliffe district by 42%). 13.3% of households in Rushcliffe are single pensioner households and there is expected to be a 40% increase in this number between 2011 and 2025, with the potential increased level of need for social and health care support and the subsequent costs of this. This could have a severe impact on the levels of demand for services for frail older people and older people with long term conditions such as dementia. Rushcliffe has the fourth highest number of 0-19yr olds in the county, and is also projected to have the second highest increase in population in the period at 16%. The majority of the population are White British, though Rushcliffe has one of the highest Black and Minority Ethnic (BME) populations in the county in the 0-19yr old group, and the second highest percentage of non-white working age population (6%). The combination of projected 0-19yr old increase and relatively high BME communities suggests that appropriateness and access to health and social care services within this population will be a future consideration within Rushcliffe. Rushcliffe have the second highest projected increase in the 18-64yr old age group (5.6%) in the county. The increase is expected to be greater in males than in females.


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4.2.6 Long Term Conditions The prevalence of long term conditions is similar to the national average. In Rushcliffe, the most common long term conditions are hypertension (30,523), common mental health disorders (11,420), asthma (8,895), chronic kidney disease (9,399), diabetes (7,269), chronic back pain (5,927), coronary heart disease (4,918) and cancer (4,443). The most common cancer in women is breast cancer (1,201) and in men, prostate cancer (591). In Rushcliffe the incidence of malignant melanoma is significantly higher than the England average, however the numbers are small, approximately 25 per year. Unmet need is also particularly high in some of the long term conditions noted above. Conditions where there is a relatively high proportion of unmet need include dementia, hypertension, chronic obstructive pulmonary disease (COPD), chronic kidney disease and diabetes. There are currently expected to be 1,560 people living with dementia in Rushcliffe. In 2010/11 56% of sufferers were undiagnosed. The number of people newly diagnosed with dementia across Nottinghamshire is expected to almost double between 2010 and 2030. This is a significant challenge for health and social care delivery with direct costs to the NHS predicted to treble by 2030. 4.2.7 Mental Health Rushcliffe has the lowest estimated prevalence for common mental disorders and second lowest for psychotic disorders. However, this still represents a significant number of people affected by mental illness with over 11,000 people expected to suffer from common mental health disorders and just under 500 with severe mental health disorders. Rushcliffe’s population has a significantly lower mortality rate from suicide compared with the regional average. Children in Rushcliffe experience lower rates of admissions to hospital for mental health conditions compared with the rest of the county (47.1 per 100,000) and lower demand for CAMHS services. 4.2.8 Excess winter deaths 13% of pensioners in Rushcliffe live alone. Fuel poverty is the lowest in the county with only 3.86% of people aged 65 years and over having no central heating. Excess winter deaths were the second lowest in the county and lower than the East Midlands and England averages. However, neither of these was significant. Annual flu immunisation in patients aged 65+ years is 78%, the highest in the county. Fractured neck of femur admission in 64+ years age group is lower than the East Midlands and England averages. However, it has risen over the last year. Older people in Rushcliffe feel the safest in Nottinghamshire.


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4.2.9 The graph below shows that with increasing age an individual is more likely to have more than one health condition.

4.3 Population diversity Rushcliffe is the most affluent district in Nottinghamshire and has significantly lower deprivation than the England average; income deprivation affecting older people is the lowest in the county. This high proportion of affluence can mask pockets of deprivation that are spread across the district: Rushcliffe does have recognised child poverty ward areas. The table below reflects the district ward areas where child poverty is the highest. Child poverty is calculated by the number of children in families in receipt of either out of work benefits or tax credits. Low income is the most commonly used measure of poverty as it provides a broad indication of living standards and includes families experiencing poverty whilst also in employment.


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4.3.1 Child poverty in priority ward areas in Rushcliffe

Ward % of children in poverty 2008

% of children in poverty 2009

Cotgrave 19.6 18.7

Bingham West 15.5 16.5

Keyworth South* 13.5 12.6

Edwalton Village 12.1 16.2

Trent 11.3 11.9

Ruddington 10.4 10.1

* Lower super output area (LSOA) within Keyworth South has a child poverty figure of 36.8% 75% of the 16-64years population in Rushcliffe are in employment, compared to 71% across the East Midlands and 70% in the UK. However, there are differences between men and women aged 16-64years in employment in Rushcliffe: male employment is notably higher than the County average (81% Rushcliffe, 76% Nottinghamshire), but female employment is comparable with the County average (69% Rushcliffe, 68% Nottinghamshire). The latest unemployment figures indicate that Rushcliffe has the lowest unemployment rate (2.1%) across the county. Mosaic maps demonstrate which social group is dominant in a given area. Rushcliffe’s population has a high representation of ‘successful professionals living in suburban or semi-rural homes’ with further strong representation of ‘couples in comfortable modern housing’ and those with ‘strong local roots’. This district macro level profiling is useful but it can mask the more micro level deprivation spread which is consequently more prone to be hidden as a result.


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Reproduced with kind permission from Rushcliffe Insight

4.3.2 RCCG is committed to the principles that all its commissioning priorities are based on identified health needs and that commissioning decisions focus on addressing local inequalities. In agreeing our strategic objectives, broad aims were outlined to address the health needs as identified above, and in accordance with the Health and Wellbeing Strategy. These outline aims were then discussed and refined by the Clinical and Patient Cabinets. High level draft objectives were published and


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comments requested in a Rushcliffe Borough Council newsletter, sent to all households in Rushcliffe. The objectives were discussed and challenged further at a Governing Body development session, prior to finalisation and formal approval by the Governing Body. In delivering its ‘local’ objectives, the CCG will be contributing significantly to the collective delivery of strategic priorities for the whole of Nottinghamshire as identified in the Health and Wellbeing Strategy (May 2012), based on the refreshed Joint Strategic Needs Assessment 2012. The CCG has ensured that its own objectives articulate its contribution to the commissioning of services and improvement of outcomes across CCGs and sectors in Nottinghamshire, as well as locally. The CCG has also aligned its strategic objectives to meet the requirements of the NHS Outcomes Framework and the Public Health Outcomes Framework. The pending NHS Commissioning Outcomes Framework will be considered in the planned refresh of this document for 2013/14. Specific outcomes will be described in depth in the individual improvement programmes. The strategic ambitions of RCCG and financial constraints are not viewed as conflicting. RCCG believes that there is significant scope for improving quality and productivity, thereby reducing costs while improving the patient experience. By focusing on prevention and re-ablement, it is expected that there will be reductions on the current expenditure for secondary care services. The organisation has an established reputation for being innovative and bold in its contribution to pathway design and we will work closely with partners and other stakeholders to continue to develop high quality and cost effective clinical pathways. The CCG intends to develop its approach so that commissioning decisions will be more sensitive to the wider economic and social environment in which it will be functioning. We will work closely with local authorities to analyse key demographic and economic activity data and forecasts, so that we can more accurately predict where priorities and subsequent investments might be made for the best long term gain. This is an opportunity to ensure that investment is more specifically focused on key groups, for example, health and wellbeing priorities for young people or the newly retired.


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5. Strategic Objectives 5.1

The objectives of the CCG for the next three years have been developed by patient and public representation, including through the Patient Cabinet, and by members of the Clinical Cabinet, before approval by the Governing Body. They have been separated into clinical and organisational priorities. The clinical objectives are those which have been agreed jointly by patients and clinicians and are aligned to the CCG mission statement ‘to improve the health outcomes of people registered with a practice in Rushcliffe CCG and other patients who live in the locality, by commissioning high quality and affordable health care services.’ They have been communicated during drafting to the wider public through the Rushcliffe Borough Council newsletter, and comment was encouraged. These objectives are intended to cover the life span of our population from birth to death. This is a recognition that, by investing in prevention and supporting people to make better lifestyle choices, there will be longer term gains for the population, not only in better health outcomes for individuals, but in reduced demand for secondary care services.

5.2 Clinical Objectives

Commission to improve the health of the whole population of Rushcliffe CCG with better quality of care and outcomes for all patients, in line with three priority areas:

Supporting people to manage on-going conditions

Improving mental health and wellbeing

Promoting prevention, early intervention and supporting people to make healthy lifestyle choices.

Improve the quality of health services in relation to health inequalities, health outcomes, patient safety, access and patient experience.

Organisational Objectives

Establish the infrastructure to meet the statutory requirements for authorisation.

Ensure that the CCG has inspirational leaders with the skills, capabilities and personal qualities to create a culture which is innovative and pioneering.

Develop excellent relationships and directly influence providers, partners and other stakeholders as a catalyst to achieve clinical transformation.

Ensure all commissioning decision-making is underpinned by clinical and patient ownership/engagement

Ensure the CCG has capacity and capability to deliver value for money through robust financial management and improved productivity and efficiency within its budget


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The organisational objectives are those that will enable RCCG to proceed through authorisation to be established as a statutory body and to become a sustainable commissioning body, with the infrastructure and capability to deliver its clinical priorities.

5.3 In order for the CCG to deliver its objectives there are nine Improvement Programmes planned in key areas. Each programme has a Clinical Lead who will be responsible for its development and delivery. The programme aims, strategic intentions, planned impact and benefits are outlined in appendix xx. Each programme will have a detailed implementation plan which will describe planned benefits, enablers, contributing projects, measures of success, resource requirements, costs and risks. Improvement Programmes:

1. Health and Wellbeing, including children and young people 2. Elective Care 3. Non Elective Care 4. Long Term Conditions 5. Mental Health 6. Community Services 7. Primary Care 8. Prescribing 9. Commissioning capability

5.4 The CCG will have a responsibility to inform commissioning decisions made by the National Health Service Commissioning Board (NHSCB) regarding primary care services. Although it will not have responsibility for directly commissioning these services, it will have responsibility for attaining standards and improving primary care quality. The approach will be for the systematic improvement of quality across GP practices, led by our GP leads for Primary Care. For further detail of the CCG recommendations for primary care commissioning see Commissioning Intentions 2013/2014 (section 8)


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6. Domains RCCG has stated its strategic objectives and the Improvement Programmes that are being established to deliver these objectives. It is recognised that for us to have a measurable beneficial impact on the health and well-being of our population, we will need to approach the implementation completely differently from the smaller-scale and often slow pace of change to date. While this has been invaluable for forming relationships and for piloting change, for this ambitious new programme of improvements to be achieved, change will have to be of greater magnitude and speed. The application and implementation of innovative and proven redesign methodologies must be increased, and relationships with stakeholders need to be more productive. The CCG and its predecessor organisation have a strong track record of building productive relationships and piloting innovative service change, and we must ensure that we capitalise on this experience and learning. To ensure that the CCG has the capacity and capability to deliver long term sustainability and to fulfil future assurance expectations, it has considered the NHSCB’s Authorisation domains in the development of its strategic direction.


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6.1 Domain 1: Clinical and multi-professional focus 6.1.1 Clinical Effectiveness RCCG believes that Clinical effectiveness is about delivering the best possible care for patients, ensuring they receive the right treatment by the right person, in the right place, and at the right time, to deliver the best outcome. Monitoring and improving Clinical Effectiveness is dependent on a number of elements including:

• research evidence • guidelines and standards to identify and implement best practice • quality improvement tools, such as clinical audit, evaluation and rapid cycle

improvement • Clinical expertise and peer review

To ensure clinical effectiveness, the organisation will use the following to review and improve treatments and services:

• the views of patients, service users and provider staff • evidence from incidents, near-misses, clinical risks and risk analysis • outcomes from treatments or services • measurement of performance to assess whether the

team/department/organisation is achieving the desired goals • identifying areas of care that need further research • information systems to assess current practice and provide evidence of

improvement • assessment of evidence as to whether services/treatments are cost effective • development and use of systems and structures that promote learning and

learning across the organisation • contract management of providers

6.1.2 The member practices of RCCG are committed to working collaboratively to undertake clinical commissioning as set out in the Health and Social Care Act 2012 and to deliver the strategic objectives of the CCG. The expectations of this collaboration are detailed in our Membership Agreement. This Agreement seeks to build on the past work of Principia Partners in Health as we move to become authorised as a statutory body and to ensure that the relationships between individual member practices, and collectively as a CCG, are robust and fit for purpose. In signing the Agreement, practices are committing to working as part of the CCG to deliver its statutory functions and participating through the Membership and Clinical Commissioning Forums.


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The Membership Agreement outlines a set of principles as to how practices will engage in clinical commissioning. All practices have signed up to the Agreement, and have therefore agreed to abide by these principles.

Member Practices will work collegiately and with respect whilst accepting and appreciating individuality

Member Practices may wish to involve other CCG member practices in their recruitment in recognition of the member practice interdependency processes

Member Practices will work effectively with other GPs, including sessional and locum GPs, and with other professionals and practice staff, to influence commissioning decisions

Member Practices will support the clinical leads to ensure that decisions made are understood and implemented by the practice and owned by the community

Member Practices will endeavour to send as broad a range of GPs to CCG meetings as possible in order to disseminate the CCG vision and priorities

Member Practices will ensure that when making individual practice level commissioning decisions that the decision is based on evidence and contributes to the delivery of CCG priorities.

Member Practices will develop a thorough understanding of the needs of the practice

patient population to ensure that wider public health priorities for the community are identified and promoted with other local organisations in support of the Health and Wellbeing Strategy

6.1.3 The CCG has designated Clinical Leads, who serve in the Clinical Cabinet , and are responsible for defined priority areas. These clinicians work in different practices across the CCG, ensuring wide representation of practices and a diversity of skills and expertise. The Clinical Leads are responsible for developing and implementing the CCG’s Improvement Programmes. In addition, each GP practice has a Gateway Lead. These clinicians work at a speciality level and focus on joint work with secondary care colleagues to improve communication, understanding of pathways, and reduce unnecessary demand for secondary care services.


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An intended benefit of sharing clinical leadership is the ability for GPs to manage their CCG commitments, minimising time away from their practices, thus ensuring minimal impact on patients. The Clinical Cabinet was established in Autumn 2011, and is a committee of the Governing Body, providing a forum where collective knowledge of clinical service delivery and associated issues can be shared. The Clinical Cabinet includes three members elected by the membership to sit on the RCCG Governing Body. The CCG recognises how important sharing high quality clinical data is if it is to have shared responsibility for continuously improving clinical quality. Therefore, the CCG has worked closely with member practices to develop a monthly ‘Practice Pack’ which details key performance information and highlights specific areas needing attention. The format and content of this pack will be reviewed regularly to make sure that the data is of high quality and supports local improvement initiatives. Maintaining good communications with our GP practices, patients, public and stakeholders, is vital to the CCG’S success. A communications and engagement strategy is in place to support this.

6.1.4 Research The CCG is committed to promoting clinical research in fields that are of relevance to the services it commissions. In recognition of the key role that the CCG will have in supporting research, it pledges to:

encourage patient recruitment to, and participation in, research (where applicable this could include funding the treatment costs of patients)

ensure that commissioning decisions are underpinned by research evidence where available

work closely with our chosen Commissioning Support Unit to ensure that procurement and contracting processes enable rather than restrict our ability to support research or promote innovative redesign

support the dissemination and adoption of research findings and their application in practice

use contractual incentives to encourage providers to fund and implement research and to apply research findings

The CCG has inherited a well-established partnership arrangement with the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Nottinghamshire, Derbyshire and Leicestershire. This is a vehicle for working with partners to develop a framework and allied processes for promoting research in the future. Through its Research Delivery Support Unit, CLAHRC will work with CCGs and others to develop a sustainable way of delivering research and disseminating findings in the East Midlands.


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At the time of developing this strategy, national guidance on establishing Academic Health Science Networks is being developed. While the AHSN model is not yet clear the CCG would wish to be actively involved in working with any proposed local initiative.


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6.2 Domain 2: Engagement with patients, carers and our community 6.2.1 Patient Involvement The ethos of RCCG is that the patient voice is at the heart of local decision making. Engaging and communicating with patients, carers and the public is a top priority for the CCG to ensure they are directly involved in developing commissioning decisions that improve services and standards of care for everyone. Founded on the former Principia Partners in Health, the organisation is proud of the way patients are integrated throughout the organisation and in the decision-making process. Principia gained national recognition for its patient and public involvement (PPI). RCCG is committed to expanding on the successes of previous engagement work to ensure meaningful engagement with patients, carers, the public and all stakeholders continues to shape our work and local health services and to embed patient and public engagement at all levels throughout the organisation:

• Individual patient or carer making decisions with their clinician • Formal membership of CCG decision-making bodies • Patient representation on the Governing Body

Member GPs are committed to supporting patient choice and demonstrate this in their discussions with individual patients about care options; services will be commissioning in such a way that the patient has genuine choice about the services they can access locally. The Patient Cabinet will have a lead role in ensuring that patient choice is reflected in commissioning decisions. Patient groups have been instrumental in developing the PPI model for RCCG based on their experience of previous engagement approaches. The model aims to be comprehensive and representative of the diversity of the local population. It will provide a robust link between the Patient Participation Groups, Patient Forums and our wider Health Network. It also provides formal links between the Patient Cabinet, the Clinical Cabinet and the CCG Governing Body. In recognition of the importance of patient involvement in decision making, accountability and assurance, the Patient Cabinet is a committee of, and reports directly to, the Governing Body.

Patient Cabinet: Part of formal governance structure of Rushcliffe CCG, providing input to the Governing Body on all PPI matters and ensuring that statutory and Governing Body requirements of being an NHS organisation are met and disseminated through the PPI structure

Patient Participation Groups (PPGs): Practice level groups in 14 of our member practices


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Patient Forums: the CCG has Forums for Cancer, Diabetes, 50+ Health, Mental Health & Well Being, Learning Disability and Carers

Active Group : Representation from each PPG, Patient Forum and external organisations

Health Network: Virtual network with over 850 individuals contributing views and opinions, and receiving continual information flows regarding services and plans

6.2.1.1 In addition to the formal mechanisms to involve patients directly in governance arrangements, RCCG is committed to wider information sharing and encouraging wider engagement to ensure that local health services are accessible, meet the health needs of the local community and reduce health inequalities. Through NHS Nottinghamshire County there is a service level agreement (SLA) with Rushcliffe Community and Voluntary Service. The SLA is to ‘work in partnership with Principia [now NHS Rushcliffe CCG] and NHS Nottinghamshire County to support involvement of the people of Rushcliffe, particularly those who the NHS has traditionally found ‘hard to reach’. The CCG also has a strong commitment to working with carers. It is recognised that carers are vital in managing patients in their own home. Working closely with colleagues in the local authorities, there will be further investment in initiatives to support carers, to make sure that their input is sustainable without it being detrimental to their own, or the patient’s, physical and mental health. We are already developing a wide range of communications channels to make sure all our public are familiar with the locally available health care services and are aware of the CCG’s strategic priorities, and to invite them to become involved in local decision making. This includes briefings, events, newsletters, online and digital media, and working with the local media. In addition, we continue to share and expand communication opportunities with partner organisations, for example, contributions to Rushcliffe Borough Council newsletters that are distributed to local households. Patient experience information enables RCCG to understand what it does well, and identify areas for improvement. Triangulation of data from complaints, compliments, stories and patient satisfaction surveys helps the CCG understand how the services it commissions can be improved. Further intelligence is obtained from the Patient Cabinet, and feedback of patient stories from practice staff. Patient stories are discussed at Governing Body meetings so that there is a better understanding of the emotional, social and psychological impact of commissioning decisions about local healthcare services on patients, their carers and relatives.


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Local organisations such as LINks and the local authorities provide further intelligence. RCCG, and its predecessor Principia, have a strong reputation for involving patients and the wider community in decision making.

6.2.2 Equality and Diversity RCCG is committed to ensuring that Equality and Inclusion is central to business planning, governance, staff experience, commissioning, service delivery and patient and communities outcomes. The new Equality Regulations require public bodies to publish relevant, proportionate information demonstrating their compliance each year and to set themselves specific measurable equality objectives every four years. Protected Characteristics

age

disability

gender reassignment

marriage and civil partnership

pregnancy and maternity

race

religion or belief

sex

sexual orientation Consideration of Equality & Diversity requirements will be included in all commissioning contracts and through monitoring of these contracts. RCCG will actively seek to work with members of the community and other CCGs to engage with people in the protected characteristics groups to ensure that they are actively involved with the setting of priorities for the CCG. We will encourage our staff to sign up as Equality & Diversity champions.

6.2.3 Communications Maintaining good communications with our GP practices, patients and stakeholders is vital to our success. A communications and engagement strategy is in place to support this, and will ensure we continue to have strong relationships with all partners and stakeholders. We will continue to inform all stakeholders about our commissioning plans to gauge their opinions and feedback, as part of our decision-making process. We are developing and utilising a wide range of communications channels, specifically tailored to our audiences’ needs, to inform them about our work and how they can get involved.


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6.3 Domain 3: Clear and Credible Plans

In developing clear and credible plans, RCCG is not ‘starting with a blank sheet’ as it will inherit responsibilities, legacy strategic objectives, and contractual and financial commitments from NHS Nottinghamshire PCT. Therefore, the CCG has ensured that its strategic objectives are aligned to existing PCT objectives, including those to reduce inequalities and improve quality, whilst ensuring that service performance and continuity, patient safety and financial sustainability are assured. RCCG will bring a fresh perspective to the implementation and delivery of these commitments. Through local knowledge, clinical leadership and direct patient involvement, RCCG aims to ensure that commissioning decisions genuinely contribute to an improvement in health outcomes for the population of our area. Our plans are developed with reference to the priorities articulated in the Nottinghamshire Health and Wellbeing Strategy (2012/2013). The CCG has worked alongside a range of partners to provide clinical input to the development of the HWS and is engaged with on-going work to plan for its implementation. The intention of the Health and Wellbeing Board is to take an iterative approach to the future development of the strategy, drawing on insights from the Joint Strategic Needs Assessment. Through representation on that board, the CCG will continue to enjoy opportunities to influence and be informed of newly emerging priorities. The CCG’s Commissioning Intentions for 2013/14 are detailed in section 8.

6.3.1 Financial Plans This Commissioning Strategy 2012-2015 is underpinned by a financial plan that aims to enable the optimisation of service provision by making full use of the resources available. RCCG recognises both the financial challenges over the next few years and the improvements required of services delivered. This Commissioning Strategy takes advantage of the strengths of RCCG and the broader health economy within which we operate. The national economy continues to experience significant financial pressures which are having long terms implications for funding across the public sector services. This presents a difficult planning environment in which to operate. In addition, 2012/13 budgets have been set by the PCT’s Professional Executive Committee based on historical spend, with a 20% movement to the estimated ’target share’ (of the CCGs’ total share of the PCT budget) while waiting for confirmation of the allocation of the CCG’s resources for 2013/14. RCCG is confident that there are opportunities to optimise the use of limited resources through service reconfiguration and improved contract management. Investment in service improvements will be funded by innovative approaches to increase productivity and efficiency, de-commissioning poorly used or redundant services, and through sourcing non-recurrent funding to pilot and develop services.


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We have planned to make available a 2% Transformational Fund to support the system changes that are planned for the coming years. In addition, we will continue to benchmark services against other comparable CCGs to ensure opportunities for savings and value for money are maximised. For Rushcliffe CCG the recurrent financial budget for 2012/13 and baseline financial plans for the two years 2013/14 and 2014/15 are as follows:

NHS Rushcliffe CCG

2012/13 Recurrent Budget (£m)

2013/14 Plan (£m)

2014/15 Plan (£m)

Enhanced Services 0.9 0.9 0.9 Healthcare Contracts 96.1 98.7 99.9 Corporate & Administration 4.5 4.8 4.9 Prescribing 17.5 18.4 19.3 Other Reserves inc Transformation 6.2 6.1 6.1 Contingency Reserve 0.6 0.6 0.6 Planned Surplus 0.4 0.4 0.4 QIPP Challenge 2013/2014 0.0 (2.4) (2.4) QIPP Challenge 2014/2015 0.0 0.0 (2.2)

TOTAL 126.2 127.5 127.5

Note: The 2012/13 budgets are net of the QIPP target. The assumption around zero growth is based upon NHS Nottinghamshire County PCT’s Financial Plan. In 2012/13 PCTs did receive minimum growth to meet Operating Framework commitments, which could be the position for 2013/14, but the expectation would be if low level growth was received it would come with additional commitments in the 2013/14 Operating Framework. Key considerations for future commissioning of services and the delivery of savings are:

• Continue the transition of services from secondary care into the community where clinically appropriate

• Reduce the costs of continuing care through the establishment of integrated services, thereby reducing avoidable hospital admissions, reducing the duplication of services and reducing delayed transfers out of secondary care

• Reduction of costs for mental health and learning disability services, through improved performance information analysis and monitoring, leading to better demand management, a reduction in variation and improved financial management (enabled by a change to payment by results)

• Working with providers to review current service configurations • Reviewing current contracts, payment mechanisms and monitoring to ensure

that the CCG is getting the best value for money for its population. Agree


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incentives and penalties for provider performance, and address existing disincentives

• Review south of county or countywide contracts, to which RCCG is committed by previous commissioning arrangements, to assess whether they are fit for purpose for the needs of the CCG population in terms of specification, activity and costs

6.3.2 Quality, Innovation, Prevention and Productivity (QIPP) RCCG views QIPP as a framework for all its commissioning decisions and improvement programmes. The Organisational Development (OD) Plan will consider the capacity and capability that will be required to support this approach. For example, it is expected that all CCG members have a basic understanding of proven service improvement methodologies, with some people having practitioner level improvement skills. This will ensure that the full benefits of pathway redesign are realised and that changes are sustainable, and outcomes measurable. Gaps in capacity and capability are addressed in the OD Plan. The CCG will also work to make sure that information is available in a format that is accessible to clinicians and enables them to review both qualitative and quantitative data on their performance. 6.3.2.1 Quality If the CCG is to achieve maximum value for money on healthcare, then the quality of services must be improved. As articulated in both our Values and in our strategic priorities, we are committed to continuously improving the quality of services, with patient safety and the quality of services being integral to all commissioning decisions. Quality Framework It is essential that quality is a key consideration, underpinning all commissioning decisions. The ability for commissioners to ensure that the services commissioned are of consistently high quality and cost effective is reliant on access to valid and timely data. RCCG is working to improve the health and wellbeing of its population with a specific aim to improve quality by delivering improved safety, effectiveness of services and improved patient experience. In essence this means continually monitoring the quality of all our provider organisations both in primary and secondary care. The overarching principle is doing the right thing first time and every time in both our commissioning and in terms of provider activities. The CCG will maximise its use


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of regional and national enablers, such as quality indicators, NHS Evidence and NHS Choices in the quest for quality. The three quality domains are:

• Patient Safety (the safety of treatment and care provided to patients) • Patient experience (the experience patients have of the treatment and the

care they receive) • Clinical Effectiveness (measured by both clinical outcomes and patient-

related outcomes). Acceptable Quality is only achieved when all three domains are met. To achieve a good quality service, the values and behaviours of those working in the NHS need to remain focused on patients first. An organisation that is truly putting patients first will be one that embraces and nurtures a culture of open and honest cooperation. The approach to achieving this is detailed in our Quality Strategy. Each improvement programme or specific QIPP scheme to be implemented by RCCG will identify the planned Quality and Equality impact. 6.3.2.2 Patient Safety The last decade has seen a number of key publications that have informed and shaped the patient safety agenda. Patient safety includes: Safeguarding Children and vulnerable Adults NHS commissioning organisations across Nottinghamshire will prioritise the safety and welfare of children and vulnerable adults across all commissioned and contracted services. The Children Acts of 1989 & 2004 outline statutory roles and responsibilities and duties relating to safeguarding and promoting the welfare of children for NHS organisations and partner agencies. These duties are summarised in Working Together to Safeguard Children (DH, 2010). The role of NHS Commissioners (DH, 2011) outlines a commissioner’s role in preventing and responding to neglect, harm and abuse to adults in the most vulnerable situations, including the commissioning services for women and children who experience violence or abuse. Infection Prevention and Control (IPC) All healthcare organisations are expected to minimise the risk of healthcare acquired infection to patients by complying with the Health and Social Care Act 2008: Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance.


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The Code provides the core elements that a healthcare organisation must meet in order to be registered with the Care Quality Commission. We will monitor to ensure that all our providers adhere strictly to this Code. Nottinghamshire Multi-Agency Safeguarding Hub (MASH) The MASH will act as the first point of contact for Social Care for safeguarding concerns regarding children and vulnerable adults. It will include representatives from Children’s Social Care, Adult Social Care, Police and Health working together at a central location. Virtual links will exist to other services and agencies such as the Probation Trust and housing. The MASH will receive safeguarding concerns from professionals as well as members of the public and family members. It is anticipated that a significant number of contacts will be addressed at an early stage by a new team of MASH Referral & Advice Officers who will be the first point of contact. Working under the close supervision of qualified Adult and Children’s social work professionals, Referral & Advice Officers will swiftly advise and signpost referrers to the most appropriate service, thereby filtering contacts and reducing the number of contacts being escalated to social work professionals inappropriately. As a result, better decisions will be made about what action to take and support will be targeted on the most urgent cases. Better co-ordination between agencies will be initiated leading to an improved service for children, adults and families. The MASH will also provide an advice line for professionals who have concerns about a child or adult. This will help clarify any causes of concern and provide advice on application of social care thresholds, or signpost to early intervention or other services as and when this is appropriate. 6.3.2.3 Innovation Innovation can be defined as ‘an idea, new to the NHS or applied in a way that is new to the NHS, which significantly improves the quality of health and care wherever it is applied.’ (Innovation, Health and Wealth, 2011). This includes applying an approach in a new context or organisation. RCCG will build on its reputation both locally and nationally for being innovative, and will focus not just on generating and adopting new ideas but in wider dissemination to make sure that the full potential benefits of innovation can be realised. RCCG will work closely with colleagues in our chosen Commissioning Support Unit to make sure that procurement processes and contract management enable, rather than inhibit, innovation. Robust financial and corporate governance arrangements will ensure that patient safety, quality and value for money are assured throughout the development, testing and evaluation of new ideas or services.


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6.3.2.4 Prevention The CCG has recognised that strategically it has a key role in commissioning services that support the prevention of illness. Although in some cases the improved outcomes may not be demonstrable for years, we believe that by investing in longer term prevention this will contribute to an improvement in the health of our population and to a more sustainable use of acute services in the future. Primary prevention already features in the plans for specific improvement programmes, eg Long Term Conditions. Where preventative work falls outside the scope of an existing improvement programme, it will be progressed through the CCG’s Health and Wellbeing improvement programme. Through its involvement in the Nottinghamshire Health and Wellbeing Board, and in the Rushcliffe Community Partnership, the CCG will work with partners to address prevention at population, community and individual levels. 6.3.2.5 Productivity Due to the anticipated 0% future growth in funding, it is expected that, unless the CCG commissions differently, there will be insufficient resources available to meet increasing demand, whilst also improving quality and prevention. Therefore, delivery of significant and recurrent financial savings is essential for the on-going financial balance of the CCG and to allow the delivery of our strategic objectives through the annual commissioning plans. To ensure long term financial stability it is essential that we understand the underlying financial position. RCCG has identified the required level of savings to be delivered through cost improvements and QIPP as follows: 2013/14 Target - £2.4m 2014/15 Target - £2.2m

QIPP Areas

2013/14 Indicative QIPP target £’ms

2014/15 Indicative QIPP target £’ms

Continuing Care 0.3 0.2

Prescribing 0.1 0.1

Acute 1.6 1.5

Mental Health & Learning Disabilities

0.2 0.2

Community Services 0.2 0.2

Totals 2.4 2.2


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The process to identify QIPP schemes to be delivered against these indicative QIPP targets will commence during Quarter 3 of 2012/13 and will take into account the full year impacts of current QIPP schemes plus the opportunity identified for new QIPP. This process will involve input from clinicians and other stakeholders as well as benchmarking referral and admission rates across other organisation and expected rates. The CCG’s Strategic Priorities will also inform the QIPP planning process. Delivering our financial plan will ensure resources are committed as effectively as possible, in the most appropriate manner, and that the commissioned services are delivered efficiently as possible, whilst maintaining and improving the quality of services provided to our patient population. It is notable that RCCG will be able to directly control some aspects of planned QIPP savings but there will be only limited ability to influence other aspects directly. RCCG is already working closely with neighbouring CCGs to jointly manage QIPP across the county. There are explicit, shared risk management mechanisms, with clear accountability and reporting mechanisms for the CCGs involved in collaborative commissioning.

6.3.3 Information Governance, Management & Technology (IGMT) The CCG recognises the pivotal role that information will play in its ability to deliver its strategic objectives. There is a shared resource for Information Governance, Management and Technology across the Nottinghamshire CCGs. A strategy has just been published; The Power of Information: An IGM&T Strategy for Nottinghamshire 2013-2017. This document has been endorsed by NHS Rushcliffe CCG, and it outlines the following principles about IGMT:

Use to fundamentally improve the health and outcomes for patients

Support commissioners in planning the most effective and efficient use of resources in delivering care to patients and the population as a whole

Core to the business of care because the benefits of information are potentially so great

Ambition for patients being able to access and share their own records which will help them make informed decisions about their own care

clinicians can use information to ensure they are delivering the best quality care which is aligned to agreed pathways

existing technology can be exploited to drive maximum efficiency from scarce resources and improve quality through innovation

Commissioning: Supports commissioners in planning the most effective and efficient use of resources in delivering care to patients and the population as a whole.

• Information used for planning is coordinated across the health and social care community and is easily accessible

• Information is linked to provide an integrated picture of service provision, quality and patient experience


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• Inequalities in health and variations in access to health services are understood and planned for in commissioning plans

Patients: Patient individual care records:

A change in culture and mindset, so that health and care professionals, organisations and systems recognise that the information in patient’s care records is fundamentally about them so that it becomes routine for patients to be able to access their own records online

Information used to drive integrated care – within and between organisations, and across the health, care and support sector as a whole

Patient electronic care records progressively become the source for core information used to improve their care, improve services and to inform research, etc. – reducing bureaucratic data collections and enabling patients and clinicians to measure quality

Information recorded once, at first contact, and shared securely between those providing care – supported by consistent use of information standards that enable data to flow whilst keeping confidential patient information safe and secure

Clinicians: use information to ensure they are delivering the best quality care, aligned to agreed pathways

• A culture of transparency, where access to high-quality, evidence-based information sourced and compared internationally, nationally and locally about the quality of care is openly and easily available

• An environment in which clinicians are encouraged and empowered to evaluate their decisions against the latest evidence and peer behaviour

• Information regarded as a health and care service in its own right, so that information helps reduce inequalities and benefits everyone

• An information-led culture where all health and care professionals, and local bodies whose policies influence health, take responsibility for recording, sharing and using information to improve patient care

Existing technology: exploited to drive maximum efficiency from scarce resources and improve quality through innovation

• The widespread use of modern technology to make health and care services more convenient, accessible and efficient

• Information systems built on innovative and integrated solutions and local decision-making, within a framework of national standards that will ensure that better quality information can move freely and safely around the system

RCCG will lead the whole IGM&T agenda on behalf of all the Nottinghamshire County CCGs and in doing so will:


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• Establish arrangements for the coordination of strategic IM&T planning across the Nottinghamshire health and social care community

• Migrate existing arrangements from the PCT into CCGs

• Support implementation of the Nottinghamshire IGMT Strategy

• Progress existing IM&T plans and maximise the benefits realisable from existing resources and infrastructure

The implementation of this strategy will be underpinned by robust governance arrangements in place across the health community to ensure CCGs collaborate with partners. Across Nottinghamshire CCGs there are already established appropriate, clinically-led, governance arrangements to set IGM&T strategy and review implementation. These arrangements will continue for 2013/14 and may be reviewed after this period.


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6.4 Domain 4: Proper constitutional and governance arrangements. 6.4.1 RCCG is committed to establishing and maintaining robust governance systems and structures, with transparency, accountability and probity at the heart of all decision making and subsequent implementation. The CCG is clinically led, with strong patient and public input, supported by experienced and capable managers. Member practices are represented via a Membership Forum, which nominates or elects clinical leads to a Clinical Cabinet and to the Governing Body. The Clinical Cabinet is a committee of the Governing Body, responsible for providing clinical leadership across designated areas and workstreams, and for ensuring the alignment of commissioning strategies and plans with the needs of our local population, local health and wellbeing strategies and our mission, vision and values. Strong patient and public input is assured by a Patient Cabinet, a committee of the Governing Body dedicated to focusing local views and input from the various public-facing structures in our area in the design and delivery of services, ensuring their voice is clearly heard by clinicians and managers. The CCG is confident that this model will secure a rigorous approach with appropriate experience, capacity and capability to assure effective governance of the CCG, whilst delivering effective commissioning activity to improve clinical quality and outcomes. The CCG has established a strong Governing Body:

• 3 GPs • 4 Lay members • Nurse • Secondary care clinician • Consultant in Public Health • 3 senior management members • Nottinghamshire County Council officer • Rushcliffe Borough Council officer

The Governing Body is well balanced, but with strong clinical leadership from GPs, nurse, public health and secondary care clinician, complemented by a significant lay membership and officer representation from both local authorities in our area, and supported by professional, experienced managers. The diverse perspectives of the Governing Body’s membership will be advantageous in delivering proper challenge, identifying opportunities for innovation and partnership working, and defining risk appetite.


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One of the GP members on the CCG Governing Body is also our representative on the Nottinghamshire Health and Wellbeing Board. This will prove an invaluable link for the CCG and will enable the direction of health care commissioning across Nottinghamshire to be influenced by both bodies in both forums, with ample opportunity to align objectives.

In addressing the objectives, plans and strategies, and performance and outcomes achieved by the CCG, the Governing Body will continue to develop its risk management approach, describing risk appetite and seeking assurance that risks to objectives, delivery, quality and safety, and financial stability and achievement of QIPP plans, are mitigated and managed against proper timescales under defined leadership. The Governing Body is accountable to its member practices, reflecting their views and engaging with them widely in discharging its duties, through a dedicated Membership GP lead and through the Clinical Cabinet and the Membership Forum (who will review its effectiveness and performance on an annual basis in a formal meeting). The Patient Cabinet will ensure that response, feedback and information, on CCG and governing Body activity, are fed back through its various channels to patients, public and representative groups.

6.4.2 Financial Risk Management Not unexpectedly, the Board identified financial management as the single biggest risk to the organisation and its sustainability. Apart from the national economic climate (see section 3 environmental analysis) there are risks specific to this CCG as


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described in below, however, the Governing Body is confident that these risks can be managed. The Governing Body recognises that the implementation of robust risk management procedures in support of the delivery of strategic objectives is essential. Risk management forms an integral part of the overall management process and is the responsibility of all staff. We have identified a number of risks that may impact on our ability to deliver our financial plan. These risks, the potential impacts and mitigating actions have been identified as part of the CCG’s Board Assurance Framework and will be managed as part of our Integrated Risk Management approach. Scenario planning has been carried out within the financial plans to understand the base case and best/worst case financial risks (see appendix 4). The key areas of financial risk for RCCG are:

1) Achieving financial balance with an underlying recurrent surplus based on a number of risks around:

Uncertainty of CCG allocations

Requirements of the 2013/14 Operating Framework

On-going recurrent cost pressures, e.g. activity levels higher than planned, increased expenditure in high cost/low volume cases, pressure arising from devolved budgets – ’in the baseline issues’

Delivery of QIPP not to required recurrent levels

Cost Pressures arising from County Council spending plans

Agreement of a risk pooling agreement

2) Achievement of the running cost target. The NHS Commissioning Board Authority published the indicative 2013/14 running cost allowances for proposed CCGs in May 2012. For Rushcliffe CCG this is an indicative figure of £3.11m. Financial risks will be monitored and managed through a variety of means including:

High level review of management accounts, budgets, medium term plans, forecasts, DH returns and annual accounts

Adherence to the finance standing orders, prime financial policies and scheme of delegation and reservation

Robust Service Level Agreements with the providers of financial services

Systems of internal control to ensure transactions are properly recorded and assets safeguarded

Independent review by Internal and External Audit

Rigorous approach to QIPP Work streams

Regular updates of the Financial Plan to reflect the previous year’s recurrent underlying position

Regular review by the Governing Body on the financial position and forecasts


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In addition to the CCG’s financial management plans outlined above, the PCT has provided for a contingency reserve of £0.6 M in each year.

6.4.3 Safeguarding Governance The governance arrangements for safeguarding adults and children are shared across all the Nottinghamshire County CCGs. The Safeguarding Committee is a joint committee hosted by NHS Newark & Sherwood CCG. Minutes and reports from the committee are delivered to the Governing Body as well as to the local safeguarding adults and children’s boards. The PCT’s Executive Lead currently attends both the adults and children’s local safeguarding boards; upon legal establishment of the CCG (and abolition of the PCT) appropriate continuing representation will be arranged.

6.4.4 Quality Governance Although individuals and clinical teams are at the frontline and responsible for delivering quality care, it is the responsibility of the Governing Body to create a culture within the organisation that enables clinicians to work at their best, and to have in place arrangements for measuring and monitoring quality and for escalating issues. The RCCG Governing Body will learn from mistakes and promote an environment where staff and patients are encouraged to identify areas for improvement. RCCG has developed its capability to proactively scan provider quality data and has added rigour to this process. Business intelligence, survey results, patient feedback, complaints, incidents and PALS contacts are combined to provide the CCG an overall picture of provider hotspots.


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6.5. Domain 5: Collaborative Commissioning How the CCG contributes to the development of the commissioning system and how it functions both as an individual CCG, and collectively with partners, will determine its ability to deliver clinical and organisational objectives. RCCG is part of a wider commissioning system that includes local government (social care, housing, education), other local CCGs and partner organisations. The ‘Commissioning System’ describes how commissioning decisions will be made from individual patient level through to the Health and Wellbeing Board and the NHS Commissioning Board. There are already well-established relationships between the former Principia and partner organisations. It is important that there is learning from these relationships and they are developed in a systematic way so that the CCG and local authorities capitalise on earlier joint work. As articulated in the CCG Vision, the CCG believes that for local transformation to happen, it is essential that an inclusive approach to all decision-making is embraced throughout the organisation. This will be reflected at every level in the CCG:

• Individual patient or carer making decisions with their doctor • Member practices involvement in and ownership of decisions • Formal patient and clinician membership of the CCG decision-making bodies • Clinical leadership and patient representation on the Governing Body • As a partner in the local CCG network • Active CCG participation on the Health and Wellbeing Board

RCCG is founded on the former Principia Partners in Health, which was a membership organisation and social enterprise. Therefore, we are able to draw on the six years of experience of that organisation which had established formal and informal mechanisms to make sure that patients and clinicians were fully involved in all decisions. RCCG will capitalise on the existing strong relationships and local and national networks. We are committed to working with partners to establish integrated commissioning. The precise model is still in development but priorities and commissioning intentions will be aligned as required through dialogue between the parties. The HWB will provide leadership through the Health and Wellbeing Strategy (HWS), based on the Joint Strategic Needs Assessment (JSNA), which has identified local priorities to improve outcomes:

Prevention: Behaviour Change and Social Attitudes

Children, Young People and Families

Adult and Health Inequality priorities The CCG Governing Body believes that the magnitude of change required can only be achieved through health and local government partners working together. In practice, the CCG will work with partners to develop integrated commissioning


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budgets and processes to enable the best deployment of resources. This will allow us to fundamentally change the way services are commissioned and delivered. By having joint budgets and processes we can enable transformational change rather than small scale changes that focus on the interface between different commissioning organisations. As part of a wide change movement, and supported by the HWB, RCCG will have a mandate and influence to implement changes more quickly and of a greater scale than would be feasible if working alone. It is expected that Integrated Commissioning Groups will be the main vehicle to deliver the HWS priorities. Our strategic objectives demonstrate the contribution that the CCG will make to support the achievement of improvements in the areas prioritised in the HWS. Through integrated commissioning, assets beyond the direct control of the CCG can be mobilised to support the delivery of improved outcomes for the local population. The CCG will work with partners to explore existing mechanisms that would enable integrated commissioning, for example section 75 agreements (shared budget agreements). The CCG is committed to transparency and sharing information with partners to inform mapping of services and spend so that there is a collective baseline for, and understanding of, the local economy. The CCG Governing Body believes that a key lever in changing behaviours will be the alignment of incentives for providers, and the removal of disincentives. We will use a variety of means to make sure that appropriate incentives are embedded across the health care system. Some of these will be through formal mechanisms for example:

• Contractual levers • Commissioning for Quality and Innovation (CQUIN) • Providers will be held to account for quality through regular quality scrutiny

panels • A ‘practitioner with special interest’ accreditation scheme is in place to

ensure consistent standards of competence regardless of care setting. • Leading Improvements in safety and Quality programme (LISQ), has been

commissioned from the NHS Institute for Innovation and Improvement to support our GP practices to improve the quality and safety of the services they provide.

The former Principia Partners in Health established a local ‘Success Scheme’ which will be continued by the CCG. This is a mechanism for providing financial incentives for innovative service development. This has not only rewarded success but has raised the profile of new schemes so that wider adoption of new practices is promoted. The purpose of the scheme is to:


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• Assist with delivery of the 2012/13 QIPP target • Encourage review and change of clinical practice • Maintain and promote innovation of elective pathways Through the Success Scheme each member practice has taken on leadership responsibility for a speciality area, for example, diagnostics. The practice leads on improvement work on behalf of the CCG to roll out best care across all GP practices. This also links to national GP contracts and the use of QOF to adopt elective and non elective pathways. The CCG is committed to expanding the Success Scheme to support the implementation of Improvement Programmes over the next three years. This is called the gateway lead In addition, there will be a focus on changing the behaviours of individuals, for example, through clinical shared learning sessions and peer review. The ability to influence others, both individually and collectively, will be vital to the implementation of improvement programmes and achievement of RCCG strategic objectives. In previous commissioning models the ability to influence providers directly, at a local level, was limited. We will be able to establish more direct and beneficial relationships with partners and providers. The benefits of more directly managed relationships will be:

• Access to shared information to identify changes in demographics which will affect health need

• Joint work to develop clinical pathways • Ability to have greater input in commissioner expectations of providers • Alignment of incentives to providers • Quicker identification of risks to delivery • Joint work to manage and share risk • Enabling the transfer of ideas across services and sectors

These relationships will need to develop at multiple levels and will need to be systematic to optimise influence without creating unrealistic demands on the capacity of CCG members. However, we are clear that while collaboration will be advantageous in optimising patient benefit and use of resources, it must not be allowed to constrain the ability of RCCG to be innovative or to implement change rapidly. The CCG will continue to develop effective relationships with the following:

• Patients and the public • Member practices • Local Authorities (Nottinghamshire County Council, Rushcliffe Borough

Council, Nottingham City Council) • Other Nottinghamshire CCGs • Providers (NHS, private providers and voluntary sector)


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• Productive Notts • The Greater East Midlands Commissioning Support Service • Voluntary and charitable bodies • CAMHS / Community paediatrics – why this in isolation • Richmond Group (representative group for local charities) • Rushcliffe Community Partnership • South Nottinghamshire Community Safety Partnership • Other allied sectors (leisure, education, police, housing) • Industry and academia

Systematic collaboration will allow the CCG to have a wider sphere of influence, both clinical and managerial, and this will be dependent on establishing open and honest relationships with partners, so that the CCG is assured that it is appropriately represented. There is an agreed Memorandum of Understanding for CCG governance with the other CCGs in Nottinghamshire County, and a memorandum of Understanding for collaborative commissioning with the CCGs in Nottinghamshire County and Nottingham City. RCCG is an active member of Productive Notts, which is a collaboration of organisations across Nottinghamshire and Nottingham City. It has a mandate to act across health and social care organisations and as such will be an effective means of implementing change across sectors and geographic localities. We acknowledge that we need to work with local authority colleagues to invest in longer term initiatives which may not deliver demonstrable benefits in the short term, but by changing behaviours should deliver substantial savings for the wider health and social care system, for example, by reducing demand for secondary care services, in the longer term. The Local Area Team (LAT) of the National Commissioning Board will cover the counties of Nottinghamshire and Derbyshire, and although the exact working mechanisms of how they will operate are still being determined, it is clear that we will need to work collaboratively as part of an overall commissioning system to support the LAT to deliver its direct commissioning responsibilities for the best clinical outcomes for patients, including large scale provider service re-organisations.


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6.6. Domain 6: Leadership RCCG is founded on a pre-existing culture of clinical leadership. It has adopted a distributed leadership model to ensure that clinical leadership is embedded across the whole health system. With GPs and other clinicians assuming responsibility and accountability for delivering health commissioning it is essential that the strategic objectives and associated Improvement Programmes are owned and led by clinicians generally. CCG clinical leads have a key role in influencing the behaviours of clinical colleagues. In particular, there is an expectation that they will lead by example and will be receptive to informed challenge about their own behaviours. In support of this, we have worked closely with primary care colleagues to develop ‘Practice Information Packs’ which are sent out to each practice on a monthly basis and highlight areas of significant variation in performance. Regular ‘Protected Learning Time’ events are already established and will continue as they are invaluable for sharing innovation and discussing clinical issues. The content of these sessions is informed by the strategic objectives and associated Improvement Programmes and is agreed by clinicians. These sessions will be aligned to the organisational development plan. Establishing and maintaining the capacity and capability of the CCG will be paramount to its sustainability and is reflected in the strategic objectives. This is recognised as a risk in the Board Assurance Framework and it will be a challenge to develop the organisation while maintaining the annual running costs within the required limits of £25 per capita of population. However, the CCG is fortunate in having established, high calibre clinical leaders and managers who are committed to working together to develop the CCG. There is a recognition that for distributed leadership to be sustainable there must be investment in supporting the development needs of potential future leaders and in succession planning. Everyone in RCCG needs to have a basic understanding of the expectations and statutory requirements of the CCG and their own contribution to the authorisation process, and longer term sustainability of the organisation. The Organisational Development Plan outlines how the CCG plans to support the development of individuals to optimise their collective contribution to the delivery of the organisational objectives. Members will be supported to gain a basic understanding of proven service improvement methodologies, supported by others with practitioner level skills. This will enable Improvement Programmes to optimise the input of resources for the benefit of patients, with a QIPP approach being second nature to CCG members. The specific workforce needs will be dependent on the functions that the CCG has sole responsibility for, those it shares and for those that are outsourced.


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7. What will success look like? RCCG has deliberately developed an ambitious strategy as a framework for its commissioning decisions and its Improvement Programmes. The implementation will be challenging but the Governing Body is confident that we have the vision, capability and influence to work with partners to deliver transformational change. The aim of the CCG is to achieve the following: By April 2013

• Authorisation as a statutory body • Ownership and commitment to deliver strategic objectives by all member

practices, management support and Governing Body • Evidence of public and patient support for the CCG Strategy • Improvement Programmes set up and working to defined timescales and

measureable outcomes • Improved and more inclusive mechanisms for public and patient involvement

By April 2015

• Measurable and demonstrable improvements in clinical outcomes • A record of patient involvement at individual level and in wider CCG decision

making • A record of clinical leadership in the redesign of services and pathways • Shared pathways with clear accountability for delivery • Mechanisms to support integrated commissioning are established, with

evidence of successful commissioning with partners • Sustainable financial position securing the future viability of the CCG

8. Commissioning Intentions 2013-2014

The following underpinning principles have been considered in the development process, NHS Rushcliffe CCG will commission:

Responsive, personalised, accessible local services based on need recognising equality, diversity and choice

Promote opportunities for the development of services in settings that are close to patients’ homes

Services that promote recovery and sustainable independence

The most effective and efficient services in response to national and local priorities NHS Rushcliffe CCG’s 2013/14 commissioning Intentions have been informed by: The health needs of our population NHS Rushcliffe CCG Strategy 2013-15 The Health & Wellbeing Boards Joint Strategic Needs Assessment refresh 2012 NHS Rushcliffe CCG Public Health Profile 2012 NHS Operating Framework 2012/13 The NHS Outcomes Framework 2012/13 NHS Rushcliffe CCG Communication and Engagement strategy Shared (6 Nottinghamshire CCG) CCG Strategic Outline Commissioning Intentions 2013/2016 The Quality, Innovation, Productivity and Prevention (QIPP) agenda


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Commissioning Intentions Why we chose this What we are trying to achieve What we are doing Lead Name

1) Health and Wellbeing (Links to other programmes: Non-elective, LTC, Community Services, Primary Care, OD and Capability) Each top tier and unitary authority now has its own Health and Wellbeing Board. Board members will collaborate to understand their local community’s needs, agree priorities and encourage commissioners to work in a more joined up way. As a result, patients and the public should experience more joined-up services from the NHS and local councils in the future. NHS Rushcliffe CCG is represented on the HW Board. NHS Rushcliffe has identified shared priorities with the Health & Wellbeing Board.

1.1) Patients involved in management of their care (3.3)

1.2) Improve the personalisation of care (3.2)

1.3) Strengthen and promote population health (4.2)

1.4) Clear leadership for professionals (2.3)

1.5) Secure sharing of clinical records and information between professionals involved in patient’s care (9.5)

1.6) Shared pathways of care with clear responsibility at each step (3.2)

1.7) Strong management of integrated services, with clear accountabilities and governance (3.2)

1.8) Incentives for prevention and early management (4.1)

The commissioning activities which will deliver this improvement programme are identified in the programmes: Non-elective, LTC, Community Services, Primary Care, OD and Capability. The four QIPP themes, Quality, Innovation, Productivity and Prevention are intrinsic to the overall delivery of the commissioning intentions.

HWB Clinical lead Dr J Griffiths Public health Lead Jonathan Gribbin

2) Elective care NHS Rushcliffe CCG has an outpatient 1st appointment standardised rate that is above that of neighbouring CCGs. Comparison against National Benchmarks

2.1) An agreed programme of utilisation review and management so that patients and GPs have a clear reason for referral Quality

2.2) Further development of clinical

Gateway Leads These roles have been developed and re-commissioned via the NHS Rushcliffe CCG Success Scheme. As part of this on-going programme, referral protocols, education needs

Clinical lead Dr M Jelpke Management lead Charlotte Lawson-Braley Practice Manager Lead Andrea Younger Patient lead Ian Thompson


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Why we chose this What we are trying to achieve What we are doing Lead Name

demonstrates the volume of outpatient 1st attendances is higher than expected levels. There has been 1.5% growth in referrals if 2010-11 is compared against 2011-12. At practice level, there is large variation between rates of referral, which is highlighted to Clinicians through the production of Monthly Practice Information Packs.

leadership roles, Gateway leads in the following specialities: – Mental Health – Gynaecology – Gastroenterology – Osteoporosis – Radiology – Colorectal – Respiratory – T&O upper & lower limbs – Rheumatology – Endocrine & Diabetes – Ophthalmology – Dermatology – Paediatrics – ENT – Urology Innovation

2.3) Streamlined pathways, which are commissioned and available to all GPs Productivity

2.4) Localise services where it will maximise the patient experience Quality

identification, self-management support and pathway development activities will be undertaken. Clinical Education NHS Rushcliffe CCG has an establish programme of clinical education. This programme will continue to support delivery of our intentions.

Finance lead Stephen Andersen Information lead Robert Taylor

3) Non-Elective Care, including Emergency Admissions and readmissions. Emergency admissions continue to grow rapidly. There are still more than 2 million unplanned admissions a year for

3.1) Reduce the number of unnecessary emergency admissions to hospital Productivity

3.2) Design and deliver a primary care and community service

Primary Care Review of primary care capacity and capability EMAS Implement and actively manage EMAS non conveyance protocol Integrated Team Coordinate support

Clinical lead Dr Tim Daniels & Dr Nick Foster Management lead Helen Griffiths Patient lead Andy Warren Finance lead Stephen Andersen Information lead Robert Taylor


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people over 65, accounting for 68 per cent of hospital emergency bed days, and the use of more than 51,000 acute beds at any one time. Locally there continues to be a steady rise in the number of non- elective admissions, however overall spend on activity is reducing. Despite this, the increase in admissions translated into an £1.1m (6.6%) overspend, against a plan of £16.8m, for the period April 2011 to February 2012. The case mix of the actual activity is in line with the plan, which highlights that the over spend is linked to the volume of activity rather than its complexity. Urgent care services can be highly fragmented and can generate confusion. A commitment to provide an integrated service across the required sectors and providers remains a high priority for the CCG.

system specification that enables unplanned care to be delivered in a planned and coordinated manner wherever possible Quality

3.3) Involve patients in the management of their own care Innovation

3.4) Provide timely access to primary care and the management of how people choose to access emergency care also remains critical to the success of this agenda Prevention

to care homes across integrated team: one practice/one care home; community geriatrician and community matrons to work with care homes with highest emergency admission rate Community Services CHP to systematically review patients over the age of 65 following emergency admission by telephone contact and or home visit and consider admission onto virtual ward with the aim of reducing readmissions Social Care Working in partnership with Social Care and hospital providers CCGs will develop a new range of services designed to safely and effectively rehabilitate patients

4) Long Term Management Long term conditions are those conditions that cannot, at present, be cured, but can be controlled and managed

4.1) To implement a chronic care model to: Help prevent or delay long term conditions where possible, Improve quality of life

Disease Registers Development of centralised disease registers Risk Stratification Implementation of risk stratification tool to replace

Clinical lead Dr N Fraser Management lead Helen Griffiths Patient leads identified for each work stream:


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by self care, medication and other therapies. They include diabetes, asthma, and chronic obstructive pulmonary disease. Of these, many patients live with a condition that limits their ability to cope with day-to-day activities. There is a significant challenge to proactively meet the health needs of approximately one third of the population have at least one LTC; 50% people over 60 years of age have an LTC; there is a predicted 60% increase in the number of people with 3 or more LTCs over a 10 year period (2006-2016). The DH is expected to publish its Long Term Conditions strategy in late 2012.

and independence for people with long term conditions Prevention

4.2) We wish to prevent people dying prematurely Quality

PARR + Specialist support We will commission more specialist support and advice to patients and GPs locally and improve management of patients Gold Standards All patients to be in receipt of evidence based intervention: development of five ‘Gold standard for LTC’ to be available at each GP practice iv development of systematic approach to annual reviews/checks including housebound patients Self-Care Standardise self-care management including anticipatory care plans; self-care plans; a range of self-care resources and models of delivery Tele health Introduce tele health medicine locally Interview Techniques Lead clinicians to be trained in motivational interviewing techniques Performance management Implementation and performance management of Home Oxygen service pathway Prevent people dying prematurely

Diabetes Nigel Lawrence COPD Wayne Chambers Heart failure Paul Midgley Finance lead Stephen Andersen Information lead Robert Taylor


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The Nottinghamshire CCGS will work proactively with the LA and other key stakeholders to address risk factors associated with lifestyle choices Cancer we will continue to work with the local cancer networks to ensure the provision of excellent and accessible cancer treatment EOL We will develop services that enable a significantly greater proportion of people who choose to die at home to avoid a hospital admission during their last months of life

5) Mental Health & Emotional Wellbeing Mental ill health is widespread; at least one in four people will experience a mental health problem at some point in their life, and at any one time 1 in 6 of the adult population in England will be experiencing a mental health problem. Good mental health is central to an individual’s quality of life and economic success. In addition,

5.1) Reduced high spend OATS Productivity

5.2) Prevent delayed transfers of care Quality

5.3) Reduce intensive care use Productivity

5.4) Increase accessibility of rehabilitation service Quality

5.5) Manage increases in Autism Spectrum Disorders (ASD) Quality

5.6) Manage the introduction of AWP, IAPT but also improve accessibility around choice

Practice Packs for Mental Health We will produce performance information packs for every GP practice in order to raise awareness of specific mental health and learning disability issues as well as allowing practices to compare and contrast behaviour between themselves Self-care We will initiate a bid for funds to procure the ‘Living Life to the Full’ programme which consists of self-care and support discs for patients with anxiety and

Clinical Cabinet lead Dr Nick Page Gateway Lead Dr Nick Page Management lead Vicky Bailey Patient lead Adan Walker Finance lead Stephen Andersen Information lead Robert Taylor


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having a mental health problem increases the risk of physical ill health. Severe and enduring mental illness has a significant impact on the physical health of those affected as well as high service and societal costs. Emotional wellbeing is essential to enable people to do well in life, and is important across all stages of life. Emotionally resilient individuals are able to build and maintain better relationships with family and friends providing an essential skill in personal achievement and better health and wellbeing.

Innovation

depression. This work is in line with the quality and productivity indicators in QOF QIPP We will continue to participate in the Nottinghamshire County-wide QIPP programme for mental health and learning disability services and will ensure that we contribute to schemes locally

6) Community services To help deliver our Non-Elective and LTC work programmes around the integration of care it is vital that we commission community services that can meet and respond to both the unplanned care and long term condition agenda.

6.1) Further development of integrated teams to support primary and acute care in the management of patients Innovation

Single point of access Implementation of a single point of access for adult care MHSOP Enhance interface between community services and MHSOP through referral pathway and potential of joint case management /clinics Children & Young people review of children and young people’s services

Clinical lead Dr Lynn Ovenden/Kate Robertson Management lead Helen Griffiths Patient lead Sandra Teece and Kate Mcloughlin Finance lead Stephen Andersen Information lead Robert Taylor


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to ensure meets the needs of the local population. Build on the work of the children gateway lead (Dr Bakula Patel) to improve advice for simple conditions

7) Primary care (Links to Non-Elective care improvement programme) Primary care is the first access point to the NHS and accounts for some 90 per cent of NHS activity. For this reason, improving access to primary care and the range of services is a high priority.

7.1) Increase range of high quality services Quality

7.2) Provide timely access to primary care and the management of how people choose to access emergency care also remains critical to the success of this agenda Quality

QOF Practices to consider using data intelligence whether the pattern of demand of 'avoidable' attendances at A&E, from the practice data, and the capacity provided by the practice for same day contacts/consultations seem to match, i.e., whether same day access to clinicians in the practice is appropriate and whether any conclusions can be drawn between current provision for same day contacts and the pattern of 'avoidable' A&E attendances.

Clinical lead Dr I McCulloch, Dr Ram Patel Management lead Caroline Stevens Patient lead TBC Finance lead Stephen Andersen Information lead Robert Taylor

8) Prescribing NHS Rushcliffe CCG has an annual prescribing budget of around £16m. Without input into prescribing, with increasing financial pressures and the continued growth of the amount of medicines prescribed, this budget can easily become overspent.

8.1) To ensure that NHS Rushcliffe CCG comes within its prescribing budget in 2013/14 and delivers good quality prescribing for patients within Rushcliffe an evidence based, cost effective prescribing plan will be developed and implemented across the practices within Rushcliffe using the Primary Care Prescribing Team Productivity

Prescribing Plan NHS Rushcliffe CCG will develop a prescribing plan targeting specific areas of prescribing including adherence to local and national guidelines, e.g. COPD guidelines, medication reviews with face to face contact at patient level using pharmacist prescribing skills, as well as simple switches, e.g. generic switches, to ensure cost effective prescribing.

Clinical lead Dr A MacDonald Management lead Beth Carney Patient lead Rupert Earl, Michael fanthorpe Finance lead Stephen Andersen Information lead Robert Taylor


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9)OD and Capability Continuing to develop organisational structures and systems that enhance opportunities for staff to improve patient care and the health and wellbeing of people in Rushcliffe will be pivotal to our success.

9.1) Ensure organisational structure reflects both DOH guidance and the values of the organisation Quality

9.2) Improve use of informatics for business efficiencies Productivity

9.3) Need to have strong process in place to ensure commissioning is based on best clinical practice and health intelligence Quality

9.4) Move to robust contract management to achieve QIPP

9.5) Secure sharing of clinical records and information between professionals involved in patient’s care Innovation

9.6) Ensure all clinicians have access to relevant decision support and clinical information tools Quality

Data Implement new Practice Packs Performance Management Implement new performance management reports to Clinical Cabinet and Governing Body to include integrated report for performance and quality Health Information Complete Proof of Concept for integrated health information for dementia, falls and UTIs Commissioning Tools Migrate existing commissioning tools to a single health portal across Nottinghamshire CCGs Online Records Start implementation of providing patients with Online Access to their GP Records Summary Care Records Complete implementation of Summary care Record deployment in primary care Guidelines Provide a central repository for local guidelines and pathway descriptions enabling clinicians to ensure they are managing patients in the most effective manner Risk Stratification Enhancement of

Clinical lead Dr Sean Ottey Management lead Andy Hall Patient lead Ian Blair Finance lead Stephen Andersen Information lead Robert Taylor


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existing systems to provide multi-disciplinary teams the ability to assess and stratify the level or risk for patients being readmitted to hospital Clinical Decisions The provision of more granular information to support clinicians in examining variations in clinical behaviour through clinical audits Clinical variation The ability for GP Practices to normalise reported clinical variations by considering differences in working patterns and expertise of individual clinicians LTC Early provision of data sharing across organisations to support Long Term Conditions and End of Life care Finance Data Presentation of information on the quality and cost implications of pathway choices for patients

Appendices: APPENDIX 1: Associated documentation This Strategy has been written as an overarching framework for the period 2012 to 2015. It has not duplicated information contained in the allied documents which have been referenced. It should be noted that RCCG works in collaboration with Nottingham North & East CCG and Nottingham West CCG, therefore some of the plans and policies listed below are joint documents covering the three CCGs.

Document title

RCCG Constitution RCCG

Membership Agreement RCCG

Board Assurance Framework RCCG

Communications and Engagement Strategy 2012 -2013 RCCG

Finance and QIPP Plan RCCG / NNECCG / NWCCG

Equality and Diversity Strategy RCCG / NNECCG / NWCCG

Information Governance, Management and Technology Strategy

Countywide

Public Health Memorandum of Understanding Countywide

Quality Strategy 2012-2013 (Draft) RCCG / NNECCG / NWCCG

Safeguarding Strategy 2012-2013 (Draft) RCCG / NNECCG / NWCCG

Collaborative Commissioning Arrangements Memorandum of Understanding

Nottingham City and Nottinghamshire County CCGs

Collaborative Governance Arrangements Memorandum of Understanding

Nottinghamshire County CCGs

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APPENDIX 2: Financial Planning Assumptions (in line with the PCT’s Financial Plan) Resource Limit - the CCG’s financial plans for 2013/14 onwards are based on an estimated ’target share‘of 15.77% as agreed for the 2012/13 budget setting. Allocation Growth – the CCG is assuming 0% real growth for the 2 years 2013/14 and 2014/15. Surplus – the CCG is planning to deliver 0.3% of it Recurrent Revenue Limit (RRL) in 2013/14 and 2014/15. Transformational Funds – the CCG is planning to make available 2% of the RRL available from recurrent resources which will be allocated on a non-recurrent basis to support the significant changes that will be undertaken within the health community to deliver the health service transformation required. Contingency Reserve - the CCG has included 0.5% of its RRL as a recurrent contingency reserve within the financial plan for each financial year to mitigate against risk. Inflation Uplifts – the following base case inflation planning assumptions are included which are consistent with the current operating framework, national tariff arrangements and local health economy agreements:

Uplift Assumptions 2013/14 2014/15

Service Level Agreements (SLAs) Net (1.8%) (1.8%) CQUIN 0.00% 0.00% Prescribing (Gross before QIPP) 5.00% 5.00% PCT HQ Budgets (Gross before QIPP) 2.20% 2.20%

Pay Award Inflation 0.00% 0.00%

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APPENDIX 3: Countrywide QIPP work streams

Management and Admin Nottingham University Hospitals (NUH) (excl specialised commissioning)

Estates and Assets

Sherwood Forest Hospitals Trust (SFH) (Including community / excl specialised commissioning)

Continuing Care Mental Health and Learning Difficulties

Specialised Commissioning

Community - SFH (now in SFH Programme)

Prescribing

Community – County Health Partnerships

Primary Care Community - Other

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APPENDIX 4: Financial Scenarios.

The baseline financial plans for the two years 2013/14 to 2014/15 are based on planning

assumptions which are consistent with the current operating framework, national tariff

arrangements and local health economy agreements and in line with the Nottinghamshire

County PCT’s Financial Plans assumptions.

The CCG has worked through two further financial planning scenarios in terms of possible

worst case and best case financial environments. This includes changes to the assumptions

around PBR and Prescribing uplifts, allocation growth and QIPP targets and could see the

QIPP challenge in 13/14 range between £2.1m (1.7%) and £4.1m (3.2%) and in 14/15 range

between £1.9m (1.5%) and £3.9m (3.1%).

The best case would allow the CCG to invest more in health improvement areas which would

increase the pace of implementation and enable our vision to be delivered more quickly.

The worst case scenario would require a review of all investments including invest to save

schemes and ultimately require disinvestment/activity reductions in further areas.

We will continue to develop the financial scenarios to enable us to manage any changes

from the announcement of CCG allocations and the publication of the 2013/14 Operating

Framework. This will also enable us to use our processes to prioritise to maximise health

gain for any given resource available and understand the challenge of our QIPP plans. Below

shows how we will manage any changes to our base case financial plans:-

Position improves

Position worsens

PlannedSurplus £0.4m

Accelerate Non-recurrent investments

Non-recurrentIM&T and OD Programme

Pump-primeinvest to save

schemes

Delay any pump-primeinvest to save

Bring forwardnext year's QIPP

programme

Stop any low priority

developments

Review Balance Sheet Flexibilities & Risk of Increasing

Reserves

Review Balance Sheet Flexibilities & Risk of Decreasing

Reserves

Documents

NHS Rushcliffe Clinical Commissioning Group …...RCCG Commissioning Strategy 2012-2015 2 Foreword Stephen Shortt Clinical Leader and GP Chair Sheila Hyde Lay Vice-Chair Vicky Bailey