DUDLEY CLINICAL COMMISSIONING GROUP BOARD …€¦ · 28-03-2019 · 3rd Floor Boardroom, ... expectations on commissioners and outlined a number of ways to redesign patient care

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DUDLEY CLINICAL COMMISSIONING GROUP BOARD

EXTRAORDINARY PUBLIC AGENDA

Thursday 28 March 2019 2.00pm – 4.00pm

Boardroom, 3rd Floor, Brierley Hill Health & Social Care Centre, Venture Way, DY5 1RU

QUORACY Meetings of the governing body will be quorate when four elected GP clinical members and two other governing body members (one from the lay members or secondary care doctor and one from the Chief Executive Officer, Chief Operating and Finance Officer or Chief Nurse are present, (provided that if the Chair is not present, then either the Chief Executive Officer or Chief Operating and Finance Officer must be present).

Time Agenda Item Attachment Presented By

2.00pm 1. Apologies

2.00pm

2. Declarations of Interest 2.1 To request members to disclose any interest they have, direct or indirect, in any items to be

considered during the course of the meeting and to note that those members declaring an interest would not be allowed to take part in the consideration for discussion or vote on any questions relating to that item. (Enclosed)

2.2 This meeting will be held in public and will be recorded purely as an aide memoir for the minute taker

to ensure an accurate transcript of the meeting, decisions and actions. Once the minutes have been approved the recording will be destroyed. All care is taken to maintain your privacy; however, as a visitor in the public gallery, your presence may be recorded. Should you contribute to the meeting during questions from the public, you agree to being recorded.

2.05pm 3.0 Financial Plan Enclosed Mr M Hartland

2.25pm 4.0 NHS Long Term Plan – Proposed Legislative Changes Enclosed Mr N Bucktin

2.45pm 5.0 Operational Plan Enclosed Mr N Bucktin

3.05pm 6.0 Constitutional Changes Enclosed Mr M Hartland

3.25pm 7.0 Corporate Objectives 2019/20 Enclosed Mr M Hartland

3.45pm

8.0 Date and Time of Next Meeting Thursday 9 May 2019 1pm – 4pm 3rd Floor Boardroom, Brierley Hill Health and Social Care Centre

A Glossary of terms is included at the end of the papers

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Declarations of Interest – Dudley CCG Board (JANUARY 2019)

Title First Name Surname Job Title Declarations of Interest

Mr Tony Allen Non-Executive Director Non-Executive Director – Shrewsbury & Telford NHS Trust Director – TNL Consulting Ltd

Mr Matthew Bowsher Chief Officer for Adult Social Care - Dudley MBC

None

Mrs Laura Broster Director of Communications & Public Insight

Director of Shrops Hire Solutions Ltd

Mrs Caroline Brunt Chief Nurse None

Mr Neill Bucktin Director of Commissioning

Non-Executive governor and Chairman of the Corporation, Heart of Worcestershire College (A general further education college which provides services for young people with special educational needs and disabilities of the sort commissioned from time to time by the CCG.) Member of Managers in Partnership

Mrs Stephanie Cartwright Director of Organisational Development, Transformation & Human Resources

In a personal relationship with Chief Executive Officer at Dudley CCG

Mrs Andrea Crew Chief Officer Healthwatch Dudley

None

Dr Jonathan Darby Clinical Executive Acute & Community Commissioning

Salaried GP - St Margaret’s Well Surgery Medical Advisor for BBC Drama, Birmingham Director Manor Abbey Investments Ltd Non-Executive Director for the Royal Wolverhampton Hospitals NHS Trust

Dr Ruth Edwards

Board Member Kingswinford, Amblecote & Brierley Hill Locality / Clinical Executive for Quality & Safety

GP Partner - AW Surgeries Shareholder, Future Proof Health Limited (via practice shareholding)

Mrs Emma-Kate Fletcher Interim Director of HR & OD

Sister is a GP at Rosemary Street, Mansfield, Notts Friend (Margaret Gildea) is Senior Independent Director at Derbyshire Healthcare /NHS FT

Dr Richard Gee GP Engagement Lead Appointed member of Dudley Group Foundation Trust Council of Governors

Miss Kate Green Integrated Plus Manager None

Dr Purshotam Das

Gupta Board Member Dudley & Netherton Locality

GP Partner at Links Medical Practice Shareholder, Future Proof Health Limited (via practice shareholding)

Dr Christopher Handy Non Exec for Quality & Safety

Chief Executive, Accord Group Visiting Professor at Birmingham City UniversityBoard Member of: - Black Country LEP Board - Redditch Co-operative Homes- Black Country Consortium- Walsall Housing Regeneration Agency - Direct Health - Eurohnet

Ms Deborah Harkins Chief Officer for Health & Wellbeing (Director of Public Health)

Employed by Dudley Council Visiting Professor at University Central Lancashire Member of Council of Association of Directors of Public Health

Mr Matthew Hartland Chief Operating & Finance Officer

Strategic Chief Finance Officer, Walsall CCG Strategic Chief Finance Officer, Wolverhampton CCG Director of Dudley Infracare Lift LTD Director of Infracare (Walsall and Wolverhampton) Limited Director of Whitbrook Management Company Member of Chartered Institute of Public Finance and Accountancy

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Title First Name Surname Job Title Declarations of Interest

Dr David Hegarty CCG Chair / Board Member Stourbridge, Wollescote & Lye Locality

GP Partner - Wychbury Medical Group Chairman of Black Country STP Clinical Leadership Group Partner is Director of Strategy at Worcestershire CCG Shareholder, Future Proof Health Limited (via practice shareholding) Shareholder with D C Corporation Ltd Council member- West Midlands Clinical Senate Member of LMC Member of BMA

Dr Tim Horsburgh Clinical Executive for Primary Care & LMC Representative

Salaried GP – Netherton Health Centre. Member of the Local Medical Committee Clinical Lead for SWITCH , CYP Drug Service GPSWI Clinical Lead CYP Commissioning Dudley CCG Designated Medical Officer Dudley CCG

Mr Alan Johnson Secondary Care Clinician None

Dr Rebecca Lewis Board Member Halesowen & Quarry Bank Locality

GP Partner – Feldon Practice Surgery Shareholder, Future Proof Health Limited (via practice shareholding)

Dr Mohit Mandiratta GP Board Member GP Partner – Feldon Practice Shareholder, Future Proof Health Limited (via practice shareholding)

Dr Stephen Mann Clinical Executive

GP Partner - Lion Health. Sister provides the Paediatric Triage Service Shareholder, Future Proof Health Limited (via practice shareholding)

Mr Paul Maubach Chief Executive Officer

Member of CIPFA Member of Managers in Partnership In a personal relationship with Director of HR & OD at Dudley CCG Chief Executive Officer, Walsall CCG

Mrs Helen Mosley Board Member Director, Wyre Community Trust

Dr Kiran Penumaka GP Board Member GP Partner at Quarry Bank Medical Practice

Dr Matthew Read Board Member Sedgley, Coseley & Gornal

GP Woodsetton Medical Practice Shareholder, Future Proof Health Limited (via practice shareholding)

Dr Fiona Rose Elected CCG Board Member for SCG Locality GP Lead Quality and Safety

GP - Northway Medical Centre Providing Educational Support to Effective Consulting Ltd on a Consultancy basis Husband works for Bham City Council in IT Director of Rose Medical consultancy - providing locum GP support to Future Proof Health Ltd Sister - Practising GP (Solihull/Norfolk)

Mr Martin Samuels Strategic Director - People, Dudley MBC

None

Dr Ruth Tapparo

GP Board Member and Clinical Executive for Finance, Performance & Business Intelligence

GP Partner - Three Villages Medical Practice Shareholder, Future Proof Health Limited (via practice shareholding)

Mr Stephen Wellings Lay Member - Governance

Wife employed by Dudley MBC Housing Department One Niece employed by DGFT as a nurse Member of CIPFA

Updated January 2019

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Date of Meeting: 28 March 2019

Report: CCG Financial Budgets for 2019/20 Agenda item No: 3.0

TITLE OF REPORT: CCG Financial Budgets for 2019/20

PURPOSE OF REPORT: To present baseline budgets for the financial year 2019/20

AUTHOR OF REPORT:

Mr J Smith, Head of Financial Management – Corporate Mr M Hartland, Chief Finance and Operating Officer

MANAGEMENT LEAD: Mr M Hartland, Chief Finance and Operating Officer

CLINICAL LEAD: Dr R Tapparo, Clinical Executive for Finance, BI & Performance

KEY POINTS:

Paper presented to Finance, Performance and Business Intelligence Committee and Governing Body for approval

All NHSE Financial metric and business rules met

Planned Revenue Surplus £11,691,000

QIPP/savings programme of £16,780,000 in 2019/20

Financial risk of up to £6.08m across the portfolio of CCG managed budgets. Mitigations identified resulting in net risk of nil.

RECOMMENDATION: The Committee/Governing Body is requested to approve the CCG budgets set out in the report.

FINANCIAL IMPLICATIONS:

See key points.

ACTION REQUIRED: Decision Approval Assurance

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DUDLEY CCG FINANCIAL BUDGETS FOR THE PERIOD 1ST APRIL 2019 TO 31ST MARCH 2020

CONTENTS 1. Introduction 2. Financial Overview 3. Financial Framework 4. Financial Plan 2019/20

4.1 Sources of funding 4.2 Financial structure 4.3 Planned Expenditure

4.3.1 Acute Services 4.3.2 Mental Health 4.3.3 Primary Care Development 4.3.4 Drugs & GP Prescribing 4.3.5 Continuing Healthcare 4.3.6 Community Services 4.3.7 Other Commissioning & Reserves 4.3.8 Corporate Services 4.3.9 Primary Care Co-commissioning

5. Long Term Financial View 2019/20-2023/24 6. Sustainability and Transformation Plan (STP) 7. New Model of Care / Vanguard 8. Better Care Fund 9. Quality, Innovation, Productivity, Prevention (QIPP) 10. Risk Management 11. Contingency/Non-Recurrent Expenditure Planning 12. Capital 13. Balance Sheet 14. Cash Limit 15. Recommendation

APPENDICES

1. Revenue Resource Limit 2. Financial Summary Report 2019/20

2a Financial Detail Report 2019/20 3. Mental Health Investment Standard 2019/20 4. Savings Plan / QIPP schemes 2019/20 5. Summary Sources & Applications Statement 2018 - 2020 6. Statement of Financial Position for 2019/20 7. Cash Plan for 2019/20 8. Budgets by Budget Holder 9. Contract Lead Commissioners 10. Better Care Fund Services 11. Long Term Financial Outlook 2019/20 to 2023/24

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1. INTRODUCTION

This paper sets out the proposed budgets of Dudley CCG for 2019/20. It provides an overview of the resource environment for the NHS and outlines key financial targets the CCG must achieve, together with an assessment of the financial risks to the CCG. The CCG has three financial statutory targets:-

to achieve revenue breakeven or better

to achieve capital breakeven against the capital resource limit

to achieve a breakeven on the cash limit.

The CCG is also expected to comply with the Public Sector Payment Policy (also known as the Better Payment Practice Code) which requires the CCG to pay 95% of valid invoices within 30 days of their receipt or the receipt of goods or services (whichever is the later) unless other payment terms have been agreed.

The CCG is also required to ensure that cash balances at month-end are within 1.25% of the cash requested and drawn down from NHS England.

The November 2018 Budget announced additional NHS revenue funding of £7.2 billion for 2019/20, which will increase funding for emergency & urgent care and elective surgery. In addition, for other core frontline services such as mental health, community and primary care services. An additional recurrent £1.25 billion, on top of the core revenue increase, is included to fund an increase in NHS employer pension contributions. Beyond this year revenue funding will rise by £34.4 billion over the 5 years.

It is the CCG’s responsibility to ensure we deliver the best possible health service within the funds available.

The financial plan builds upon the ‘The NHS Long Term Plan’ and additional supporting technical guidance issued in January 2019. The guidance sets out how these funds will be distributed and the expectations on commissioners and outlined a number of ways to redesign patient care to future proof the NHS for the decade ahead and will form the basis of the long term financial plan.

This plan describes how the CCG will fund the ambitions set out in our Operational Plan whilst meeting its duty to achieve financial balance.

2. FINANCIAL OVERVIEW

The CCG’s revenue start point baseline in 2019/20 is £504.3m. This consists of £454.6m core CCG funding; £43.0m for the procurement of primary care and £6.7m running costs. Despite what has been a more challenging year for the CCG, Dudley CCG is expected to meet its planned surplus of £13.6m in 2018/19 and carry this forward into 2019/20. The CCG has used current refreshed guidance from NHS England to plan anticipated resource increases within this plan. The budget book presented to the Committee and Governing Body identifies a balanced financial plan for 2019/20, with plans to achieve a surplus of £11.7m in 2019/20. This is in line with the control total set by NHS England and utilises £1.92m draw down of historic surpluses carried forward. It also reflects NHS England requirements in respect of key planning assumptions and business rules. The context within which the CCG will need to operate financially will be challenging, requiring effective reinvestment, caution and prudence. Stringent controls on expenditure and performance management will be required in order to ensure the CCG resources are directed to services providing maximum quality and value. For this reason a stringent financial framework will continue to operate in 2019/20 that embeds focus on the financial impact of all decisions made throughout the organisation.

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3. FINANCIAL FRAMEWORK

The 2019/20 financial year will be a more challenging financial year for the CCG, and the NHS as a whole, due to the changes placed upon CCG’s to support national and local NHS operational planning changes in the form of supporting Sustainability and Transformation Plans (STPs); transformation commitments of cancer services; the continuing transfer of funding to Dudley MBC for the Better Care Fund; the protection of mental health services to maintain the Mental Health Investment Standards; increasing pressure and demand on acute and primary care services; Procurement and implementation of the Multi-Speciality Community Provider (MCP); increasing Intermediate and Continuing Healthcare demand; risks relating to QIPP delivery and pressures on running costs due to new structures and both local and national priorities.

The Finance, Performance and Business Intelligence Committee and Commissioning Development Committee agreed a number of actions to reduce the financial risk moving forward, such as return to ‘invest to save’ principles for developments and service change; the development of an investment/disinvestment’ prioritisation tool for all services and the adoption of some financial recovery techniques including a robust efficiency plan.

Focus on the financial impact of all decisions made throughout the organisation will continue to be made by empowering commissioners and budget holders. Expanding commissioners and budget holders authority to commit resources, in line with budgets approved by the Governing Body in this Budget Book, is the approach. This will be supported, however, by robust performance monitoring and reporting at all levels of the organisation.

A key factor in implementing the financial governance model was the redefinition of the framework in which the CCG operates including the ‘streamlining’ of approval processes to enable commissioners/budget holders to commit resources and make the required service changes as efficiently as possible. The Scheme of Delegation empowers commissioners/budget holders to take full responsibility for their portfolio. Budgets by Budget Holder can found in Appendix 8. It is important for the Governing Body to recognise however, that with responsibility comes accountability. Management of a portfolio’s total financial position will continue to be delegated to the commissioner/budget holder and where appropriate responsible clinical lead. In addition, commissioners/budget holders will be responsible for the delivery of all QIPP and service change initiatives within their portfolio, and all performance and KPI’s metrics for such services. To aide this, a list of Contracts by lead commissioner has been constructed and can be found in Appendix 9 Commissioners/budget holders/clinical leads have been aligned with finance staff and other CCG staff who provide an enabling function.

The CCG in 2019/20 is changing its committee structures. Finance, Performance & Business Intelligence committee will become the Finance & Investment Committee with responsibility for establishing the financial framework for the CCG; ensuring the CCG meets its statutory financial duties; oversee budgets delegated to committees and directors; oversee the QIPP programme and manage financial risk regimes across the Dudley Economy and wider Black Country. Committees in the new financial year will be accountable to the Finance & Investment Committee and Governing Body for budgets delegated to them. This will include the responsibility for ensuring that break-even is achieved on collective delegated budgets. The CCG scheme of delegation is being amended to reflect this. A key change to the CCG’s scheme of delegation and approvals process in 2018/19 was necessary for the purposes of managing conflicts of interests whilst the CCG continues to develop and procure the MCP and continues to be implemented within the financial framework for 2019/20.

Appropriate committees will be required to approve plans for the forthcoming year for each portfolio. This includes: detailed budget plans and spend profiles; QIPP/service change programme for the year; Investment/disinvestment/decommissioning plans; plans for improvements in Constitution requirements and quality improvements. When these are approved, the implementation of schemes to deliver the plan will be approved with a significantly reduced process as long as the proposal is within predetermined tolerances. Committees will receive regular reports outlining financial performance against delegated budgets.

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The framework requires increased focus on QIPP delivery. Commissioners, budget holders and clinical leads are responsible, and will be held to account for the delivery of all QIPP schemes. In 2019/20 this will continue to include providers where appropriate. The scope of the current QIPP challenge programme is to be continued and utilise the day to challenge commissioners and linked finance staff collectively on all financial, QIPP, performance (and potentially quality issues) within their portfolio.

4. FINANCIAL PLAN 2019/20 4.1 Sources of Funding

The CCG will receive the majority of its funding from NHS England in the form of a resource limit. Appendix 1 provides a summary regarding the composition of the total resource limit the CCG is planning on receiving in 2019/20 and is summarised in the following table:

NHS England published notional 5 year allocations for specialised services in January 2019 at a local population (CCG) level. For Dudley in 2019/20 this shows £86.4m resulting in a total population budget of £602.4m. It is important for the Board to note however that £516.0m is the sum delegated to the CCG and is the statutory sum to be spent in 2019/20.

CCG PROGRAMME ALLOCATION

Recurring

(£000's)

Non Recurring

(£000's)

Total

Budget

(£000's)

CCG Starpoint 2018/19 Programme Resource Allocation 428,756 428,756

5.3% Growth 19/20 22,605 22,605

Specialised Services 1,001 1,001

Paramedic Rebanding 246 246

Ambulance Winter Funding 94 94

Anticipated 18/19 Surplus cfwd 13,611 13,611

CCG RUNNING COST ALLOCATIONRecurring

(£000's)

Non Recurring

(£000's)

Total

(£000's)

CCG Starpoint 2018/19 Running Cost Allocation 6,735 6,735

Running Cost Adjustment 7 7

PRIMARY CARE CO-COMMISSIONING ALLOCATION

Recurring

(£000's)

Non Recurring

(£000's)

Total

Budget

(£000's)

CCG startpoint 2018/19 Primary Care Co-commissioning Allocation 41,842 41,842

5.73% Growth 19/20 2,398 2,398

Centrally Funded Clincial Negligence Scheme for GP's (1,273) (1,273)

TOTAL 2018/19 PROGRAMME ALLOCATION 452,703 13,611 466,314

TOTAL 2019/20 RUNNING COST ALLOCATION 6,742 0 6,742

CCG RESOURCE LIMIT 2019/20 : PRIMARY CARE CO-COMMISSIONING 42,967 0 42,967

TOTAL CCG RESOURCE LIMIT 2018/19 502,412 13,611 516,023

PLANNED EXPENDITURE 504,332

SURPLUS / (DEFICIT) 11,691

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The financial plan submitted has been prepared taking into account NHS England specific business rules and assumptions around growth and inflation for 2019/20 and these are summarised in the table below.

The default position for all CCGs is the delivery of an in year break even position each year, subject to the agreement of any drawdown of prior year surpluses. In addition CCGs are required to maintain a minimum cumulative 1% underspend in 2019/20. The cumulative underspend must be the higher of 1% and the amount carried over from the previous financial year, subject to the approval of any drawdown. Typically the cumulative underspend will be funded through the return of the carry forward from the previous year, and will not need to be created from the current year’s allocation.

Business rules for this planning period state that there is no requirement for any portion of the CCG’s allocation to be spent non-recurrently in 2018/19, and further there is no requirement for a risk reserve to be held. CCGs are still required to set aside 0.5% of their allocation as a contingency and to demonstrate through the assurance process that they have adequate mitigations including deployment of their contingency to cover any risks to delivery of their plan. The CCG has historically retained its contingency uncommitted and is planned to remain uncommitted in 2019/20 plans.

£ Detail

516.0m Total Funding 2019/20

602.4m Total 'Place Based' Funding

86.4mNational resource allocation set by NHS England for Specialised Services

expenditure.

428.8m

National resource allocation set by NHS England for programme

(commissioning) expenditure which includes £1,923k increase for GP

Access.

6.7mNational resource allocation set by NHS England for administration

(running cost) expenditure.

Additional Allocation Adjustments as follows : £246k increase for the

Paramedic Rebanding, £94k increase for Ambulance winter funding and

an increase for specialised services transfer of £1,001k

1.3m

22.6m 5.3% Growth funding on programme resource allocation for 2019/20.

43.0mNational Resource Allocation set by NHS England for Primary Care

Commissioning expenditure

13.6m Projected surplus carried forward from 2018/19

Minimum 0.5% Contingency Fund Held 0.50%

1% Surplus Carry Forward 2.50%

Underlying Surplus 1.00%

Better Care Fund minimum contribution of 1.79% must be complied with 1.79%

Quality Premium must be applied to Programme Spend Achieved

All commissioners are required as a minimum to break even, subject to prior

agreement of drawdown of historic underspendsDrawdown agreed of £1.9m

Demographic Growth-local determination based on ONS age profiled

weighted population projections0.27%

Prescribing Inflation-expected range 4%-7% 6.50%

Mental Health Investment Standard - 6% 6.00%

Net QIPP Savings- greater than 3% 3.30%

Running Costs Remain within Admin Allocation (£21.05 per head of population for 2019/20)Achieved £19.17 per head of

population

NHS ENGLAND PLANNING ASSUMPTIONS & BUSINESS RULES CCG PLAN AS SUBMITTED

Business Rules

Growth & Inflation Assumptions

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Outlined in the next section are the proposed budgets for the CCG for 2019/20.

4.2 Financial Structure 2019/20 Financial management and reporting within the CCG has been on a ‘divisional’ basis reflecting key CCG responsibilities. Currently the main areas (categorised as per NHSE requirements) are:- 1. Acute Services – to reflect expenditure on Acute Commissioning, Planned and Urgent care, mostly

with NHS and independent providers. 2. Mental Health – to reflect the commissioning of Mental Health; Learning Difficulties; and Dementia

services 3. Primary Care Development – to reflect investment in membership support of Dudley GP member

practices including GP access funds. 4. Drugs and GP Prescribing – to reflect GP prescribing and drugs spend; and medicines

management and support. 5. Intermediate and Continuing Healthcare - to reflect expenditure on continuing healthcare and

intermediate care services. This includes both personal health budgets and payments to independent providers.

6. Community Services - to reflect the commissioning of Community and Children’s Services 7. Other – to reflect Safeguarding expenditure; property costs for commissioned services; Better

Care Fund transfer for Social Care Services; NHS 111 services; Reserves and Investments such as the contingency reserve, Risk reserve and target surplus for 2019/20.

8. Corporate Services – this represents the running costs of the CCG and contains the majority of CCG staff and establishment costs plus charges from the Commissioning Support Unit (CSU). In 2019/20 this budget equates to £21.05 per head of the CCG population.

9. Primary Care – this represents the delegated responsibility of the CCG for the commissioning of Primary Care services to reflect GP Contract payments; Rent Reimbursements and Local Enhanced Services

In 2019/20 the delegation of responsibility for financial decision-making and performance to lead clinicians will continue. The detail of the disaggregation of budgets to this level will be finalised when the finance and activity information from associate CCGs has been received. In addition, during 2019/20 the CCG will categorise commissioning expenditure between Multispecialty Community Provider (MCP) and non-MCP and utilise the year as a shadow year prior to the MCP contract being awarded and commencing.

4.3 Planned Expenditure In deriving the expenditure plan for 2019/20 the CCG initially used the planning assumptions adopted by the STP which underpins the financial strategy submitted as part of the approved STP plan. The key assumptions relating to expected growth and inflation (Pre QIPP) are shown below.

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The budgets contained in this paper represent planned expenditure to maintain services and invest in agreed priorities set out in the CCG’s Strategic Plan. Detailed budgets are shown in Appendices 2a. A budget summary is shown below.

Programme 5.30%

Running Costs -0.74%

Delegated Primary Care 2.69%

Mental Health 6.00%

Learning Disabilities 3.70%

Community Services 5.30%

Ambulance Services 5.27%

Primary Care (Excl Prescribing) 2.69%

Prescribing 4.97%

Continuing Care 5.97%

Acute 5.93%

Estates 3.50%

Other 1.50%

Demographic Growth 0.27%

Tariff Inflation (included in above) 3.80%

Tariff Efficiency (included in above) -1.10%

Planning Assumptions 2019/20

Allocation Growth

Inflation & Growth Assumptions

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4.3.1 Acute Services

Budgets within this plan are based on latest negotiated positions with providers however may be subject to slight change. All offers meet 2019/20 NHSE growth requirements and are based on the revised 2019/20 prices. This includes significant increases in funding for emergency care resulting from the transfer of Provider Sustainability Funding (PSF) into emergency prices. CQUIN funding in 2019/20 will reduce from 2.5% to 1.25% with the balance being absorbed into the national and local tariff prices. The CCG is yet to agree all contracts where it acts as an associate, however latest offers are included in the plan.

4.3.2 Mental Health Services

CCGs are required to meet the Mental Health Investment Standard (MHIS) which stipulates an increase in planned expenditure above 2018/19 levels equivalent to the growth in allocation each year which is 6.0% in the case of Dudley CCG. The detailed analysis which supports the MHIS is shown in Appendix 3 with the summary information shown below.

WTE

Budget

Pay Budget

(£000's)

Non Pay

Budget

(£000's)

Income

Budget

(£000's)

Total Budget

(£000's)

Commissioning

Acute Services - 262,166 (129) 262,037

Mental Health Services - - 45,031 - 45,031

Primary Care Development 0 4,402 - 4,402

Drugs And GP Prescribing 14.54 216 53,672 (333) 53,555

Intermediate & Continuing Healthcare 19.85 886 23,768 - 24,653

Community Services - - 35,564 (373) 35,191

Other Commissioning 7.30 747 29,619 (12) 30,354

Surplus Target - - 11,691 - 11,691

TOTAL COMMISSIONING 41.69 1,849 465,912 (847) 466,914

Running Costs

Corporate Services 84.95 4,995 1,147 - 6,142

TOTAL RUNNING COSTS 84.95 4,995 1,147 - 6,142

Primary Care Co-Commissioning

GP Contract - 26,775 - 26,775

QOF - 136 - 136

Local Enhanced Services - 7,980 - 7,980

Premises - 4,621 - 4,621

Other 0.80 45 3,410 - 3,455

TOTAL PRIMARY CARE CO-COMMISSIONING 0 45 42,922 - 42,967

TOTAL 127.44 6,888 509,982 (847) 516,023

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Mental Health contract values have been agreed and the budget book reflects such contract values. In 2019/20 the contract with Dudley and Walsall Mental Health Partnership NHS Trust will predominantly be a block contract with cost and volume elements related to IAPT and Primary Care. This provides both the CCG and Trust with some financial certainty in the lead up to a new MCP model from 1 April 2020 whilst allowing both organisations to focus on developing the new care model.

4.3.3 Primary Care Development

The CCG intends to continue to invest in primary care initiatives within its control to ensure national and local initiatives are delivered, predominantly focussed on implementing the GP Forward View. The CCG baseline budget includes an allocation of £6 per weighted patient (£1.93m) to support the provision of extended evening and weekend access in line with GP Forward View (GPFV) requirements. This allocation is being invested in 2019/20 to commission an average of 35 additional minutes per week of extended access per 1,000 weighted patients on a locality basis, ensuring that General Practice Services are available 7 days a week including Bank Holidays. Further GPFV allocations will be received in 2019/20 to support the continued rollout of online consultation solutions for general practice, to provide training for administrative and clerical staff in practices. These allocations will be held at an STP-level, with Dudley CCG hosting this funding for the Black Country. The CCG will also commit £1.50 per patient in 2019/20 from Core CCG Allocations in support of Primary Care Networks.

4.3.4 Drugs and GP Prescribing

Forecast PPA prescribing data at month 9 has been used as the basis for the 2019/20 baseline, with an adjustment made to reflect the current cost pressure in respect of Price Concessions due to stock shortages, and an increase in Category M generic drug prices. Net inflation and ONS growth of 4.97% has been applied, with a further £4.23m identified as a QIPP target. Further expansion of the Prescription Ordering Direct team, along with a detailed work plan produced by Medicines Management team is intended to ensure the target is achieved.

4.3.5 Continuing Healthcare

Budget figures in the financial plan are based on growth including provider inflationary uplifts of 5.97%. This reflects the growth we have seen recently but still presents a risk if growth increases. The CCG will also continue to roll out Personal Health Budgets in line with national policy.

Mental Health Investment Standard (MHIS)

Required Mental Health Growth

Programme

Growth + 0.7%

2018/19

Outturn

2019/20

Plan

Growth in

MH Spend

MHIS

Achieved

Additional

investment

required to

achieve MHIS

Mental Health Investment Standard (including LD & Dementia) 6.0% 53,238 56,293 5.7% N/A N/A

Mental Health Investment Standard (excluding LD & Dementia) 6.0% 35,121 37,230 6.0% Y -

CYP and CYP Eating Disorders 2018/19 outturn 10.3%

CYP and CYP Eating Disorders 2019/20 plan 10.4%

Increase/Decrease in percentage 0.0%

CYP & CYP ED 2018/19 outturn adjusted for spend against non-recurrent allocations 5,529

CYP & CYP ED 2019/20 Plan 5,842

Increase/Decrease in CYP and Eating Disorders spend 312

Indicative CYP and Eating Disorders allocation in CCG baselines 114

Increase in CYP and ED spend in line with CCG baseline increases (18/19 corrected for

non-recurrent CYP allocation)Y

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4.3.6 Community Services

The CCG has contracted with Dudley Group FT to fund additional community activity in line with ambitions of the care model.

4.3.7 Other Commissioning and Reserves

In support of the financial planning assumptions made in the CCG’s financial plan, under mandate from NHS England the CCG is required to create a 0.5% contingency reserve and is to remain uncommitted at the start of the financial year and used to mitigate any risks that materialise during the year. The impact of planning guidance activity increases above the funding received has resulted in reductions to the CCG planned investment reserves with the balance used to create a risk reserve. Further analysis of other spend can be found in Appendix 2a, which includes the charge the CCG will receive for the premises costs associated with commissioned services space that are owned and maintained by NHS Property Services and Community Health Partnerships (in relation to LIFT buildings).

The planned surplus for 2019/20 is £11.7m, equating to 2.5% of recurrent revenue resource. This is in line with the control total set by NHS England and utilises £1.92m draw down of historic surpluses carried forward to be used on MCP transactional costs.

4.3.8 Corporate Services

This reflects corporate functions managed within the running cost allowance given to CCGs of £21.05 per head of population. ‘Running costs’ include any costs incurred that are not a direct payment for the provision of healthcare or healthcare related services, including all costs associated with the corporate and operational management of the CCG. In preparation for the 20% reduction in allowance CCG’s are required to achieve by 2021 a savings target of 10% has been set to be achieved in 2019/20 with costs closely being monitored against target. Appendix 2a illustrates the planned running costs for the CCG for 2019/20 which are based on current structures, adjusted for the impact of organisational change already incurred where appropriate. The agreed contract value for services to be purchased from NHS Greater East Midland and Arden Commissioning Support Unit (CSU) is also included in full. The running cost budget for the CCG is set to achieve a saving of £600k in 2019/20. Plans to achieve the target include the application of an additional cost improvement target across all departmental pay and non-pay budgets, a review of posts following changes in the governance structures of the CCG and ensuring all appropriate expenditure related to programme projects is charged against the correct programme allocation.

4.3.9 Primary Care Co-commissioning

The CCG acquired delegated responsibility for the co-commissioning of Primary Care services from NHS England on 1 April 2015. Growth of 2.69% has been applied to the 2018/19 allocation, an increase of £1.125m. The new GMS contract framework represents a significant change to General Practice payments, with a new central indemnity scheme being introduced alongside a new DES for the provision of services in Primary Care Networks, with additional support funding to practices. The combined cost of these commitments is outlined in the table below and results in a cumulative increase in costs of £1.509m. Overall this represents a shortfall of £384,000 compared to the notified allocation increase.

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National Contract Item Cost to CCG (£’000)

Global Sum Increase 366

Network DES - Clinical Director (£.51 per patient) 163

Network DES Payment (£1.76 per patient) 548

Network Additional Roles - Pharmacist 227

Network Additional Roles - Social Prescribing 205

GP Contract Commitments 1,509

This gap between allocation growth and mandated cost increases creates a pressure within the Co-commissioning budget, restricting the CCG’s ability to invest further in local initiatives. This pressure does not however affect the funding of the Dudley Quality Outcomes for Health Framework (DQOFH). This has increased by a further £230,000 in 2019/20 as a result of the reinvestment of the 2019/20 PMS premium. The scheme value now totals £7.12m, split between Co-Commissioning and Core CCG budget streams.

5.0 LONG TERM FINANCIAL VIEW 2019/20 - 2023/24 The CCG originally received its 5 year indicative allocations in January 2019. The allocations process uses a statistical formula to make geographic distribution fair and objective, so that it more clearly reflects local healthcare need and helps to reduce health inequalities. Dudley CCG has seen an impact of -1.32% from these changes within the revised allocation formula, a further breakdown is illustrated below.

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These allocations are part of the deployment of NHS England’s five-year revenue funding settlement, averaging 3.4% a year in real terms and reaching £20.5bn extra a year by 2023/24. Local assumptions have been made around running cost allocations for 2021/22, 2022/23 and 2023/24 Key points to note are:

The formula on which allocations are based have been updated to reflect the impact of changes outlined above.

Populations are now based on the average registered list for the most recent year, rather than the size of the list at the time of allocations. This is intended to better reflect cyclical patterns in some areas where there are large numbers of seasonal workers. Predicted ONS growth using age and gender specific population projections is then used to forecast the next 5 years allocations.

Revised allocations are to ensure no CCG in England is more than 5% away from their target core allocation. NHS England deem within 5% to be ‘reasonable and within appropriate statistical boundaries to conclude that an area is appropriately funded to meet health need’.

There has been included a ‘sparsity adjustment’ for remote areas

‘Place based’ allocations are included, noting no changes to the formula-based notional allocations for specialised services

Previously Community services need had not formed part of the allocations formula until now where needs have been estimated on a combination of the age and deprivation profiles in the local area.

A refreshed Mental Health and Learning Disabilities formula is being used exploiting new collections of IAPT activity and linking to both GP registration and diagnoses from the Healthcare Episode Statistics dataset.

An adjustment to take account of health inequalities and unmet need has been made to the allocations using the standard mortality ratio for those aged under 75.

The allocation formula continues to take account of unavoidable cost differences between areas by applying the Market Forces Factor (MFF) to all services except for prescribing.

Running cost allowances have been maintained in cash terms at the same amount as in 2018/19. In 2020/21, allowances are 20% lower in real terms than in 2017/18 after adjusting for the estimated additional pressure from the three year Agenda for Change pay deal. No changes have be made for population changes.

The table below from NHS England identifies the allocations, and associated metrics, for the 5 years indicated by NHS England. To note these tables have not been updated to reflect the latest Primary Care allocation changes relating to the GP contract and GP indemnity reduction however the growth assumptions remain the same. Further details of the CCG’s Sources and Applications statement for 2018/19 to 2021/22 is included in Appendix 5.

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* Based on Allocations as at month 9 2018/19

CCG 2018-19 2019-20 2020-21 2021-22 2022-23 2023-24

Allocation £k 426,906 451,775 469,631 487,875 505,795 523,219

Allocation per capita £ 1,410 1,462 1,515 1,567 1,617

Growth 5.30% 3.97% 3.90% 3.69% 3.46%

Per Capita Growth 5.02% 3.69% 3.63% 3.42% 3.20%

Target £k 445,821 463,799 482,512 501,069 519,170

Target per Capita £ 1,392 1,444 1,498 1,552 1,604

Opening DfT -0.71% -0.74% -0.75% -0.60% -0.45%

Closing DfT -1.26% -1.32% -1.24% -1.10% -0.93% -0.77%

Primary Medical 2018-19 2019-20 2020-21 2021-22 2022-23 2023-24

Allocation £k 41,842 44,240 45,884 48,057 49,746 51,505

Allocation per capita £ 138 143 149 154 159

Growth 5.73% 3.72% 4.74% 3.51% 3.54%


Target £k 44,796 46,281 48,323 49,916 51,587

Target per Capita £ 140 144 150 155 159

Opening DfT 2.24% 1.83% 1.45% 1.17% 0.94%

Closing DfT 1.63% 1.26% 0.87% 0.55% 0.34% 0.16%

DUDLEY CCG 5 YEAR ALLOCATIONS

Specialised 2018-19 2019-20 2020-21 2021-22 2022-23 2023-24

Allocation £k 80,228 86,442 91,998 98,095 105,091 112,864

Allocation per capita £ 270 286 305 326 349

Growth 7.75% 6.43% 6.63% 7.13% 7.40%


Target £k 82,365 87,503 93,159 99,654 106,896

Target per Capita £ 257 272 289 309 330

Opening DfT -4.11% -4.31% -4.49% -4.66% -4.80%

Closing DfT -4.52% -4.72% -4.89% -5.03% -5.17% -5.29%

Total Programme 2018-19 2019-20 2020-21 2021-22 2022-23 2023-24

Allocation £k 548,976 582,457 607,513 634,027 660,632 687,588

Allocation per capita £ 1,818 1,891 1,969 2,046 2,124

Growth 5.69% 4.32% 4.38% 4.21% 4.09%


Target £k 572,982 597,584 623,994 650,640 677,652

Target per Capita £ 1,789 1,861 1,938 2,015 2,094

Opening DfT -1.01% -1.10% -1.17% -1.12% -1.07%

Closing DfT -1.54% -1.65% -1.66% -1.61% -1.54% -1.48%

Running Costs 2018-19 2019-20 2020-21 2021-22 2022-23 2023-24

Allocation £k 6,735 6,742 5,946 5,922 5,898 5,874

Population 2018-19 2019-20 2020-21 2021-22 2022-23 2023-24

Population Projection 319,480 320,332 321,186 322,035 322,859 323,658

Population Growth 0.27% 0.27% 0.26% 0.26% 0.25%

Actual Forecast

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Key headlines from the above are:

The CCG has received a lower core growth percentage than neighbouring CCGs due to the population impact on the allocation formula (5.3% in 2019/20). For comparison purposes, Wolverhampton CCG received 6.07%, Walsall CCG 5.64% and Sandwell & West Birmingham CCG 7.04%.

Growth has increased by 3.3% compared to 2.0% in 2018/19.

Distance from target slightly increased from 1.26% in 2018/19 to 1.32% below target in 2019/20. This then reduces further to 0.77% in 2023/24

Primary care allocation growth of 5.73% in 2019/20, reducing to 3.54% in 2023/24

Primary care distance from target begins 2019/20 at 1.26% over target, but this reduces to 0.16% by 2023/24

In 2020/21, Running Costs allowances are 20% lower in real terms than in 2017/18 and remain fairly flat for future years

Population is expected to increase by 0.3% per annum A long term financial model has been developed that meets the required financial targets set out in the business rules, but also enables the quality of commissioned healthcare and outcomes for patients to be improved. The table below, which is an extract from the CCG financial plan submitted to NHS England, identifies the summary financial outlook for the CCG for 2019 to 2024, drawing attention to the key changes in income available to the CCG and how this will be utilised. Further detail of the key financial headlines for the CCG is illustrated in Appendix 11.

Revenue Resource Limit

£ 000 2018/19 (Month 9) 2019/20 2020/21 2021/22 2022/23 2023/24

Recurrent 477,412 502,412 520,093 540,486 560,071 579,230

Non-Recurrent 2,683 0 0 0 0 0

Draw Down

Surplus Bfwd 12,651 13,611 11,691 11,691 11,691 11,691

Total 492,746 516,023 531,784 552,177 571,762 590,921

Income and Expenditure

£ 000 2018/19 (Month 9) 2019/20 2020/21 2021/22 2022/23 2023/24

Acute 244,759 262,037 268,546 275,228 282,087 289,130

Mental Health 41,479 45,031 46,149 47,056 47,982 48,925

Community 32,313 35,191 36,413 37,669 38,969 40,313

Continuing Care 23,496 24,653 25,958 27,134 28,366 29,655

Primary Care 58,938 57,958 60,900 63,807 66,773 69,884

Other Programme 29,340 28,047 29,864 35,153 39,763 43,426

Primary Care Co-Commissioning 42,007 42,967 44,581 46,752 48,440 50,198

Total Programme Costs 472,333 495,883 512,411 532,799 552,379 571,532

Running Costs 6,802 6,142 5,340 5,310 5,280 5,250

Contingency 0 2,307 2,342 2,377 2,412 2,449

Total Costs 479,135 504,332 520,093 540,486 560,071 579,230

£ 000 2018/19 (Month 9) 2019/20 2020/21 2021/22 2022/23 2023/24

Surplus / (Deficit) in -Year Movement 960 -1,920 0 0 0 0

Cumulative Surplus / (Deficit) 13,611 11,691 11,691 11,691 11,691 11,691

Surplus/(Deficit) % 3.13% 2.5% 2.5% 2.4% 2.3% 2.2%

Surplus (RAG) GREEN GREEN GREEN GREEN GREEN GREEN

*Allocations to 2023/24 are indicative

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6.0 SUSTAINABILITY AND TRANSFORMATION PLAN (STP) Dudley CCG is a constituent member of the Black Country STP footprint consisting of the CCGs, NHS providers and Local Authorities of Dudley, Wolverhampton, Sandwell and West Birmingham and Walsall. The Black Country STP was published in Autumn 2016 and identified that the local NHS, described above, face a financial gap of up to £512m by 2021. The STP described how this gap could be mitigated, and such actions relevant to Dudley for the 2019/20 are included in our financial plan and this budget book. Dudley CCG will continue to participate in the STP in 2019/20 alongside the emerging Integrated Care System arrangements.

7.0 NEW MODEL OF CARE/VANGUARD

The CCG continues to procure a Multi-Specialty Community Provider with an expected go live date of April 2020. The CCG will not be in receipt of Vanguard / Value Proposition funding in 2019/20 as the national programme ended on 31st March 2018. NHS England have allowed the CCG to drawdown £1.92m from its historic surplus to cover the continued costs of the procurement process and to contribute towards the mobilisation and development of the MCP

8.0 BETTER CARE FUND

2019/20 represents the fifth year of the Better Care Fund Pooled Budget arrangements with Dudley MBC. The final value of the fund for 2018/19 was £77.7m. This includes the Local Authority contribution and the additional Improved Better Care Fund (IBCF) allocation. NHS England guidance on the Better Care Fund for 2019/20 is yet to be published. The proposed budget for next financial year therefore assumes similar requirements and funding assumptions. The indicative CCG contribution to the pool in 2019/20 is £44.1m. This includes the existing £5.4m CCG baseline funding being used for the protection of Adult Social Care services. The final value of the pool is still being discussed with the Local Authority, however a key part of these discussions is ensuring the level of discharges being planned within the BCF are adequate to support the predicted demand included within the Acute contracts for 2019/20 and that the system continues to make effective use of the IBCF. A key component of the agreement will be that all services the CCG funds as part of the BCF will contribute to the new care model and achievement of the nationally defined outcomes, and that appropriate performance metrics and monitoring protocols are implemented.

9.0 QUALITY, INNOVATION, PRODUCTIVITY AND PREVENTION (QIPP) A programme of service change has been established which will deliver the CCG’s QIPP target in 2019/20. The sum of £16.78m is the value required to meet CCG financial plan requirements and create recurrent headroom to fund future growth in activity and invest in new services. The main QIPP schemes in 2019/20 are emergency admissions from care homes, inpatient rehabilitation, prescribing and activities to be implemented through the RightCare programme such as MSK. A schedule of all schemes for 2019/20 can be found in Appendix 4. The QIPP plan equates to 3.3% of total commissioning resource in 2019/20. The CCG’s QIPP initiatives have been shared with providers and included in the contract activity plans where appropriate. It is important the QIPP target is achieved not only to achieve financial planning targets, but also to facilitate a recurrent shift in investment in anticipation of full implementation of the new care model.

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10.0 RISK MANAGEMENT The CCG will need to plan appropriately to manage in-year financial risk. A key determinant of this is

the ability to obtain early indications of adverse variations within budgets.

The diagram below illustrates the sensitivity of the main risks facing the CCG and the impact on the CCG’s £11.7m surplus target if the probability of those risks occurring increases or decreases from the base case level of the potential risk.

Outlined below are some of the key risks identified to date for 2019/20:-

QIPP delivery – The cash releasing target for 2018/19 (£16.99m) and 2019/20 (£16.8m) is extremely challenging and the extent of slippage against non-delivery of cash releasing savings is a significant risk to the CCG. QIPP PIDs have been developed however a risk of £2.3m slippage of efficiency savings has been identified following the risk profiling of the QIPP programme for 2019/20.

Acute contracts – continued rise in demand and increase in utilisation of all providers. There remains a risk regarding contracts yet to be agreed including contracts where Dudley is an associate. There will also be volatility due to the potential PBR nature of the contract that will need to be managed.

MCP procurement costs – unplanned MCP procurement costs could arise during the final stages of the procurement.

Prescribing budgets are based on 2018/19 outturn at month 9, but spend can be volatile and there is a potential risk of cost pressures from Price Concessions due to stock shortages arising. QIPP schemes in prescribing have been developed and amount to a net saving of £4.2m, whilst the schemes are good and the rationale is clear there is a risk they may be too ambitious.

Primary Care Contract – There is a risk that the Primary Care growth funding is over committed following the latest allocation reduction for National GP contract settlement and the creation of the national GP indemnity scheme.

Continuing Care – Further increase in demand for packages of care remains a risk. Notification of the Funded Nursing Care rates for 2019/20 are yet to be received.

10,00010,50011,00011,50012,00012,500

Other Risks

Mental Health Placements

Continuing Care

Primary Care Contract

Prescribing

MCP Procurement

Acute SLAs

QIPP Under-Delivery

Total Impact on Surplus / (Deficit) (£)Reduced Potential of Risk

Increased Potential of Risk

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Mental Health Placements – increased complex care packages grow above modelled assumptions.

2018/19 Drawdown of historic Surplus – the associated risk of the drawdown of historic surplus from 2018/19 not being returned to the CCG but instead being retained to support centrally commissioned services.

Better Care Fund – guidance requiring the CCG to utilise funds in ways either already committed in contracts with providers or varying assumptions to those used in the CCG’s financial plan.

To mitigate the above risks the following actions will be implemented:-

Savings/QIPP Challenge – continuation of the QIPP challenge model, potentially expanding to other key performance indicators.

Acceleration of savings schemes originally identified for implementation in 2020/21.

Adoption of robust targeted financial performance management reporting at both CCG and practice/locality level.

Mandated contingency reserve to remain unallocated until October 2019 to mitigate pressures outlined above.

Delay and reduce any non-recurrent investment plans

Further disinvestment and potential decommissioning of existing services if required.

The CCG will work with Adult Social Care to agree appropriate risk sharing arrangements and mitigation through the Better Care Fund

Key milestones in MCP procurement to be adhered to reducing the risk of procurement drift.

External funding sources CCGs are required to identify any material risks to delivery of plans and show how these risks will be mitigated should they crystallise. It is the expectation of NHS England that CCG plans include sufficient mitigations to offset in full any anticipated risks.

11.0 CONTINGENCY/ NON-RECURRENT EXPENDITURE

In line with planning guidance a 0.5% contingency reserve has been established within the plan and is, as in prior years, prudently entirely uncommitted and is expected to fund any unforeseen pressures that the CCG may face or be required to fund during 2019/20. This will remain uncommitted in the first six months of the year and will only be released for investment in the second half of the year if it is not required to meet statutory financial targets or to mitigate risks. The CCG is no longer required to retain a non-recurrent spend reserve. Such funding is no invested recurrently in included in the plan. The CCG have always held the contingency reserve uncommitted at the beginning of the financial and has in the past been utilised to pump-prime QIPP initiatives, improving performance against contractual/quality targets, transitional support for providers, risk management and other relevant non-recurrent expenditure.

12.0 CAPITAL

CCG’s are not uniformly holders of capital assets. NHS England has, however, identified capital funding to support IT infrastructure. In addition to bids for revenue funding through the Estates and Technology Transformation Fund (ETTF), the CCG has submitted capital bids equating in total to

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£2,334,019 to support primary care IT initiatives, but are yet to be notified if it will receive further capital allocations in 2019/20.

13.0 STATEMENT OF FINANCIAL POSITION

Appendix 6 shows the forecast balance sheet position for 2019/20. 14.0 CASH LIMIT

The detailed forecast cash plan is shown in Appendix 7 and is based on the NHS England notified cash limit adjusted for expected receipts and anticipated revenue resource allocations.

15.0 CONCLUSION

The CCG has prepared a financial plan for 2019/20 that has been assured by NHS England. This budget book describes the detail, responsibility and accountability for individual budgets to meet the plan.

15.0 RECOMMENDATION

The Committee and Governing Body are requested to approve the budgets for the CCG for the 2019/20 financial year as set out in this paper.

J Smith Head of Financial Management – Corporate & Financial Planning M Hartland Chief Finance and Operating Officer March 2019

PROGRAMME

Recurring

(£000's)

Non

Recurring

(£000's)

Total

(£000's)

TOTAL 18/19 NOTIFIED RESOURCE ALLOCATION 427,395 0 427,395

Transfer for Vaccine Costs of Flu (£422,490 and Pneumococcal £19,272) (442) (442)

Market Rent 1 1

ST Oncology Allocation Transfer (6) (6)

Allocation Formula Difference (42) (42)

Alteplase Baseline (Birmingham Children’s) (29) (29)

Nephrology relating to UHB-QE (44) (44)

TOTAL 18/19 NOTIFIED RESOURCE ALLOCATION BASELINE 426,833 0 426,833

Growth 2019/20 (5.3%) 22,605 22,605

Paramedic Rebanding 246 246

Winter funding Ambulance Services 95 95

PMCF - GP Access Fund 1,923 1,923


TOTAL 19/20 NOTIFIED RESOURCE ALLOCATION BASELINE 452,703 0 452,703

Anticipated 19/20 Surplus cfwd 13,611 13,611

Total Anticipated Resource Allocation 0 13,611 13,611

RUNNING COSTS

Recurring

(£000's)

Non

Recurring

(£000's)

Total

(£000's)


Running Cost Increase 19/20 7 7


PRIMARY CARE CO-COMMISSIONING

Recurring

(£000's)

Non

Recurring

(£000's)

Total

(£000's)


1.93% Growth 18/19 784 784


5.73% Growth 19/20 2,398 2,398

Centrally Funded Clincial Negligence Scheme for GP's (1,273) (1,273)

Appendix 1: Revenue Resource Limit

Period : Baseline 2019/20

CCG RESOURCE LIMIT 2019/20 : ADMIN 6,742 0 6,742

CCG RESOURCE LIMIT 2019/20 : PROGRAMME 452,703 13,611 466,314

TOTAL CCG RESOURCE LIMIT 2019/20 502,412 13,611 516,023

CCG RESOURCE LIMIT 2019/20 : PRIMARY CARE CO-COMMISSIONING 42,967 0 42,967

WTE

Budget

Pay Budget

(£000's)

Non Pay

Budget

(£000's)

Income

Budget

(£000's)

Total Budget

(£000's)

Commissioning

Acute Services - 262,166 (129) 262,037

Mental Health Services - - 45,031 - 45,031

Primary Care Development 0 4,402 - 4,402

Drugs And GP Prescribing 14.54 216 53,672 (333) 53,555

Intermediate & Continuing Healthcare 19.85 886 23,768 - 24,653

Community Services - - 35,564 (373) 35,191

Other Commissioning 7.30 747 29,619 (12) 30,354

Surplus Target - - 11,691 - 11,691


Running Costs

Corporate Services 84.95 4,995 1,147 - 6,142

TOTAL RUNNING COSTS 84.95 4,995 1,147 - 6,142

Primary Care Co-Commissioning

GP Contract - 26,775 - 26,775

QOF - 136 - 136


Premises - 4,621 - 4,621

Other 0.80 45 3,410 - 3,455

TOTAL PRIMARY CARE CO-COMMISSIONING 0 45 42,922 - 42,967

TOTAL 127.44 6,888 509,982 (847) 516,023

Appendix 2: Financial Summary Report 2019/20

Period: Baseline 2019-2020

Appendix 2a: Financial Detail Report 2019/20


CommissioningWTE

Budget

Pay Budget

(£000's)

Non Pay

Budget

(£000's)

Income

Budget

(£000's)

Total Budget

(£000's)

ACUTE SERVICES

Acute Commissioning - 238,481 (112) 238,369

Ambulance Services - 11,968 - 11,968

NCAs - 3,403 - 3,403

Planned Care - 2,875 (17) 2,858

NHS 111 - 1,029 - 1,029

Urgent Care - 2,945 - 2,945

Winter Resilience - 1,465 - 1,465

ACUTE SERVICES TOTAL - 262,166 (129) 262,037

MENTAL HEALTH SERVICES

Mental Health Contracts - 27,339 - 27,339

Dementia - 110 - 110

Learning Difficulties - 8,677 - 8,677

Other Mental Health - 3,299 - 3,299

Child and Adolescent Mental Health - 5,606 - 5,606

MENTAL HEALTH SERVICES TOTAL - 45,031 - 45,031

PRIMARY CARE DEVELOPMENT

GP Practice Training - - - -

Primary Care IT - Programme - 1,465 - 1,465

GP Forward View - 1,923 - 1,923

GPwSI & Nurse Mentors 0 - - 0

Primary Care Investments - 1,014 - 1,014

PRIMARY CARE DEVELOPMENT TOTAL 0 4,402 - 4,402

DRUGS AND GP PRESCRIBING

Central Drugs - 2,082 (251) 1,832

Medicines Management - Clinical 4.47 216 708 (37) 887

Home Oxygen - 682 - 682

Prescribing - 50,199 (44) 50,155

POD 10.07 - 0 - 0

DRUGS AND GP PRESCRIBING TOTAL 14.54 216 53,672 (333) 53,555

INTERMEDIATE & CONTINUING HEALTHCARE

CHC Adult Fully Funded - 13,140 - 13,140

CHC Adult Fully Funded Personal Health Budgets - 1,802 - 1,802

Continuing Healthcare Assessment & Support 19.85 886 156 - 1,042

Funded Nursing Care - 4,224 - 4,224

Intermediate Care - 4,445 - 4,445

INTERMEDIATE & CONTINUING HEALTHCARE TOTAL 19.85 886 23,768 - 24,653

COMMUNITY SERVICES

Community Services - 27,588 - 27,588

Acute Childrens Services - 115 - 115

CHC Children - 613 - 613

CHC Children Personal Health Budgets - 316 - 316

Children Services - 6,933 (373) 6,559

COMMUNITY SERVICES TOTAL - 35,564 (373) 35,191

Appendix 2a: Financial Detail Report 2019/20


CommissioningWTE

Budget

Pay Budget

(£000's)

Non Pay

Budget

(£000's)

Income

Budget

(£000's)

Total Budget

(£000's)

OTHER COMMISSIONING

Better Care Fund - 12,707 - 12,707


Statutory Reserves - 6,949 - 6,949

Non Recurrent Reserve - - - -

Patient Transport - 1,592 - 1,592

NHS PS & CHP Property Charges - 3,010 - 3,010

Safeguarding 4.00 227 305 - 532

Integrated Clinical Leads 3.30 520 - - 520

Non Recurrent Programmes 0 301 - 301

Collaborative Commissioning - 19 - 19

High Cost Drugs - 54 - 54

Hospices - 778 - 778

Long Term Conditions - 1,284 - 1,284

Commissioning - Non Acute - (0) - (0)

Quality Premium Programme - - - -

Palliative Care - 770 (12) 758

Other 0 3,205 (12) 3,193

OTHER COMMISSIONING TOTAL 7.30 747 29,619 (12) 30,354

SURPLUS

Surplus - 11,691 - 11,691

SURPLUS TARGET TOTAL - 11,691 - 11,691


Running CostsWTE

Budget

Pay Budget

(£000's)

Non Pay

Budget

(£000's)

Income

Budget

(£000's)

Total Budget

(£000's)

CORPORATE SERVICES

Clinical Management 2.50 464 (28) - 437

Other Board 0.80 - 134 - 134

Organisational Development 1.00 78 58 - 137

CCG Management Team 7.00 975 (158) - 818

Communications & Engagement 7.05 208 126 - 334

Finance & Performance 20.70 1,023 176 - 1,199

Administration & Business Support 13.60 334 107 - 441

Commissioning 9.50 684 (1) - 683

Membership Development & Primary Care 5.00 319 (4) - 315

IM&T Support 4.00 147 224 - 371

Quality 7.00 393 48 - 441

Contracting 6.80 337 53 - 390

Governance - 240 - 240

Estates and Facilities - 207 - 207

Other Corporate Support Services 32 (36) - (3)

RUNNING COST TOTAL 84.95 4,995 1,147 - 6,142

Primary Care Co-CommissioningWTE

Budget

Pay Budget

(£000's)

Non Pay

Budget

(£000's)

Income

Budget

(£000's)

Total Budget

(£000's)

GP COMMISSIONED SERVICES

General Practice - GMS - 26,255 - 26,255

General Practice - APMS - 520 - 520

General Practice - PMS - - - -

QOF - 136 - 136


Premises Cost Reimbursement - 4,315 - 4,315

Other Premises Costs - 306 - 306

Collaborative Payments - - - -

Dispensing/Prescribing Drs - 235 - 235

Other GP Services 0.80 45 3,175 - 3,219

PRIMARY CARE CO-COMMISSIONING TOTAL 0.80 45 42,922 - 42,967

TOTAL 127.44 6,888 509,982 (847) 516,023

Appendix 3: Mental Health Investment Standard 2019/20


AcuteCommunity

ServicesContinuing Care

Primary Care

ServicesOther

Children & Young People's Mental Health (excluding LD) 5,324 5,324 5,630 5,630

Children & Young People's Eating Disorders 206 206 212 212

Perinatal Mental Health (Community) - - 428 428

Improved access to psychological therapies (adult) 1,191 1,191 1,440 1,440

A and E and Ward Liaison mental health services (adult) 536 190 726 552 202 753

Early intervention in psychosis ‘EIP’ team (14 - 65) 868 868 950 950

Crisis resolution home treatment team (adult) 2,762 2,762 2,844 2,844

Community Mental Health 4,297 4,297 4,424 4,424

Mental Health Act 109 109 112 112

SMI Physical Health - - - - N/C

Suicide Prevention - - - - N/A

Other adult and older adult - inpatient mental health (excluding dementia) 8,294 281 8,575 8,541 289 8,829

Other adult and older adult mental health - non-inpatient (excluding dementia) 5,112 136 5,248 5,253 92 5,346

Mental health prescribing 3,338 3,338 3,334 3,334

Mental health in continuing care 2,585 2,585 2,927 2,927

Sub-total - MH Services (exc LD & Dementia) 28,698 6,530 35,228 30,386 583 - 2,927 3,334 - 37,230 -

Learning Disabilities 8,573 4,170 12,743 8,827 4,419 13,246

Dementia 5,374 5,374 5,817 5,817

Sub-total - MH services (inc LD & Dementia) 42,644 10,701 53,345 45,031 583 - 7,346 3,334 - 56,293 -

Including LD &

Dementia

Excluding LD &

Dementia

2018/19 Spend of non-recurrent allocations (107) (107)

CCG MH weighted population (Oct 2018) 341,416

CCG Programme allocation for 2019/20 452,703

CCG MH planned spend as a % of CCG programme allocation 12.4%

Mental Health Investment Standard (MHIS)

Required Mental Health Growth

Programme

Growth + 0.7%2018/19 Outturn 2019/20 Plan

Growth in MH

SpendMHIS Achieved

Additional

investment

required to

achieve MHIS

Mental Health Investment Standard (including LD & Dementia) 6.0% 53,238 56,293 5.7% N/A N/A

Mental Health Investment Standard (excluding LD & Dementia) 6.0% 35,121 37,230 6.0% Y -

CYP and CYP Eating Disorders 2018/19 outturn 10.3%

CYP and CYP Eating Disorders 2019/20 plan 10.4%

Increase/Decrease in percentage 0.0%

CYP & CYP ED 2018/19 outturn adjusted for spend against non-recurrent allocations 5,529

CYP & CYP ED 2019/20 Plan 5,842

Increase/Decrease in CYP and Eating Disorders spend 312

Indicative CYP and Eating Disorders allocation in CCG baselines 114

Increase in CYP and ED spend in line with CCG baseline increases (18/19 corrected for non-recurrent CYP allocation)Y

Mental Health Services

(report against Mental Health Investment Standard)

2018/19 Outturn 2019/20

Reclassification from other plan categories Rationale for

zero in Plan

N/A or N/CCore Mental

Health

Reclassification

from other plan

categories

Total - 2018/19

Outturn for MHIS

Core mental

health - 2019/20

Plan

Total - 2019/20

Plan for MHIS

Appendix 4: Savings Plan / QIPP Schemes 2019/20


Main QIPP Programme PID Ref Description Targeted SavingCommissioning

Lead

2018/19

Plan

£000's

2018/19

FOT

£000's

2019/20

Plan

£000's

Fracture Liaison Service QPID002

Redesign of the existing falls service (currently commissioned by Public Health) to factor in a Falls and Fracture Liaison Service (FFLS) to deliver

Preventative and Proactive community service working with the practice based MDTs and developing a primary care falls risk register – a key means by

which patients will be identified.

FFLS will deliver supported discharge for admitted patients working with the consultant led acute service to identify admitted patients and ensure

sufficient support is available in the community.

The Team will work in conjunction with existing LA led service (non-clinical) and together will ensure the delivery of a Single Point of Access (SPA) across

Dudley Borough (This alone will deliver process efficiencies.

Emergency Admissions Tapiwa Mtemachani (450) (450)

Outpatient Demand Management QPID003

The CCG is seeking to build on the Demand Management Good Practice Guide by seeking practical alternatives to outpatient appointments. In so doing,

this will reduce demand on outpatient services which will reduce outpatient waiting times. Additionally, more patients will be managed in the

alternative settings such as in primary care or more appropriate community services.

As part of this programme, the CCG will implement a range of policies and procedures which are currently available but have not been fully utilised to

date. These include the following:

* Management of Aesthetic Surgery & Procedures of Limited Clinical Priority

* Advice & Guidance

* Consultant Letter Review

This will be part of a broader service review of the patient referral pathway where the CCG will seek to take out unnecessary steps in the process to

reduce demand on services, reduce outpatient waiting times and improve patient exprience.

Outpatient Attendances Mark Curran (750) (750)

Community Rehabilitation QPID005

Inpatient Rehabilitation has been identified as an outlier in terms of high costs for Dudley Group both locally and with other neighbouring

commissioners. Whilst some of this has been identified as a coding issue previous audits have identified that a considerable amount of rehabiltation

provided in the acute trust could be provided at lower costs and more appropriately in a community setting.

The project will aim to redesign community services and improve patient flow to ensure that patients can receive their rehabilitation in a more

appropriate community setting.

Rehabilitation Bed Days Jenny Cale (500) (500) (1,200)

Biosimilars QPID006

This project aims to work with DGNHSFT to manage the introduction of biosimilar drugs, using them in preference to their 'parent' complex molecule.

The transition will be managed by the specialists and will be led by the High Cost Drugs Sub Group which has oversight of this process.

During 2017/18 there will be 5 biosimilar molecules introduced into the Dudley Health Economy : Infliximab, Etanercept, adalimumab, rituximab and

abatacept. It is estimated that through applying gain share principles Dudley CCG will save £135K on successfully introducing these biosimilars.

The remaining £5K will be achieved through managing the introcution of biosimilar insulin Abasaglar during the course of the year.

High Cost Drugs Duncan Jenkins (125) (400) (400)




Lead

2018/19

Plan

£000's

2018/19

FOT

£000's

2019/20

Plan

£000's

Telemedicine in Care Homes QPID007

The urgent care admissions and ED attendances for nursing and residential care homes to secondary care have been increasing over the last 4 years. In

2015/16 there were 2213 Non-Electives (NELs) from care homes totalling £4,997,180.

Analysis of NELs from care homes in Dudley found that 61% of admissions occurred out of hours.

Analysis of the primary reason for admission has identified that significant numbers of admissions are for non-life threatening conditions that could be

managed in the community. Analysis of 952 admissions between April and September 2015 identified that 57% fall under ‘diagnosis not classifiable, local

infection, respiratory conditions, urological conditions and gastrointestinal conditions’. This supports the notion that a referral to a bespoke care home

clinical urgent care response service is appropriate to assess these conditions as an alternative to hospital.

The care home sector is under great pressure, brought about by a combination of the impact of the new living wage, CQC inspection regime, and

recruitment issues into both trained and untrained roles in the sector. A local survey of care home providers found that 12 out of 25 were looking to sell

or close their business.

There is currently a lack of an alternative to out of hours call handling and support for care home providers other than 111. This is an issue also raised by

the care home providers where the conveyance to hospital of a resident was not the desired outcome of the initial OOH call to 111.

The above factors are all drivers to look at alternative ways of supporting care home residents and preventing unnecessary admissions to hospital. This

has included looking at the other vanguards that are supporting care homes.

• Airedale telemedicine is an existing successful reactive service, with care and nursing homes using installed technology to connect via secure video link

24/7.

• Airedale has had a demonstrable impact on reductions on non-elective care

Emergency Admissions Andrew Hindle (589) (522)

Prescription Ordering Direct QPID009

• Local savings estimates, based on the size of Dudley CCG using the Coventry and Rugby model are in the region of £4M per annum.

• The POD is essentially a call centre which handles requests for repeat prescriptions in place of a GP Practice repeat prescription ordering system;

standard questions are asked at the point of requesting a repeat prescription and prescriptions are only passed to the GP Practice for issue if deemed

necessary by the trained call handler.

• This is an optional service provided for patients allowing them to order their repeat medications via a call centre manned by qualified operatives

• The Coventry and Rugby POD has resulted in a 6% decrease in the total number of prescription items issued by the GP Practice and a 4% decrease in

the number of dispensed items compared to the previous year. There has been a 9% decrease in items/ASTROPU which accounts for list size movement

and equates to a cost saving to the CCG of approximately £2M.

• This concept and business case is supported by the Prescribing Sub Committee

• The POD model has been used to establish a Dudley POD which opened in October 2016 serving two practices, it is the intention this will roll out to

three practices by March 2017 and then will roll out to further practices during 2017/18

• This project is expected to have a positive impact on the prescribing budget, in terms of managing waste medicines

• This project fits in line with the Vanguard Medicines programme, is both an exciting and innovative opportunity for Dudley CCG to explore different

methods of patients accessing medicines

Prescribing Clair Huckerby (204) (181) (659)

Practice Based Pharmacist Interventions QPID010

The PBP service has recently been expanded through resources provided by the Vanguard programme value proposition:

‘Increased provision in primary care and better management of LTCs requires extended and enhanced use of pharmacy in general practices. This will

include medicines reviews focusing on patients with complex chronic care needs (e.g. for people with dementia, for those with multiple LTCs) and other

tasks currently carried out by GPs where there is scope for safely shifting the provision of this care.’

Investment of £278k has been made to extend the PBP service from 400 to 665 hours per week. This builds on the EPIC programme which provided an

additional 110 hours per week up to September 2016, the £278k therefore funding an additional 375 hours per week.

Service evaluation has demonstrated that the service is overall cost saving both in terms of prescribing efficiencies and GP time saved. The latter is an

important strand in capacity and workforce planning in primary care.

We believe that the optimal level of provision of pharmacist input into practices has not yet been reached. The team has consistently demonstrated that

stepped investment releases proportionate savings, providing a highly favourable return on investment.

Evaluation of the service in 2015 (based on 400hrs per week PBP time) has demonstrated the following outcomes:

• Annualised savings of £1.8m

• Avoidance of 1,800 GP appointments

• Saving of 1,900 hours of GP time which would have been spent on medicines related activities

Prescribing Clair Huckerby (2,244) (2,164) (3,316)




Lead

2018/19

Plan

£000's

2018/19

FOT

£000's

2019/20

Plan

£000's

Primary Care Mental Health Reconfiguration QPID013

The mental health primary care team is mainly made up of two professional groups. Namely RMN nurses and IAPT therapists. NHSE guidance has

confirmed that only IAPT therapists can contribute to achieving nationally required standards for IAPT. The number of therapists has been increased (

with additional investment) to ensure those national targets for access and outcome can be achieved. As a consequence, the role of the nurse has

changed although the size of this cohort remains mostly unchanged.

The proposal is:- 1) to re-evaluate the role of the nurse in this team. 2) To model demand and capacity within the whole team. 3) redesign services

offered by the nursing co-hort of this team.

Contributory initatives:- redesign of EAS, MHUCC and CRHT to provide a 24 hour assessment service.

Mental Health Service

redesignTrish Taylor (300) (200)

Running Costs QPID014

A 1% CIP across all running costs departmental budgets is to be applied equating to an cost savings of £68,000, £15,404 saving has been achieved from

the reprocurement of commissioning support unit services via the LPF framework and £11,976 has been identified as slippage against recruiting to

permanent posts within the CCG structure.

Reduction from CCG

Running CostsJames Smith (266) (266) (600)

Rightcare - Respiratory QPID015

Analysis of the Right Care data pack demonstrates that Dudley is an outlier in terms of respiratory activity. Dudley CCG and Dudley Group NHSFT have

agreed that this requires a joint clinical review, informed by external clinical challenge, in order to derive a service model capable of reducing the

number of unecessary admissions. This will be jointly led by the CCG Chair and the Dudley Group NHSFT Medical Director with support from the Office of

Public Health and a respiratory physician from a neighbouring provider.

Emergency Admissions Andrew Hindle (250) 0

Rightcare - MSK QPID016

The Right Care Commissioning for Value Packs (RCCV) have identified Musculoskeletal (MSK) emergency admissions as an outlier amongst the peer

group CCGs in the pack.

The CCG is seeking to build on the RCCV and the Demand Management Good Practice Guide by seeking practical alternatives to emergency admissions.

In so doing, this will reduce demand on inpatient services which will reduce inpatient capacity, reduce 'unnecessary' treatments and support Referral to

Treatment times. Additionally, more patients will be managed in the alternative settings such as in primary care or more appropriate community

services.

As part of this programme, the CCG will implement a range of policies and procedures which are currently available but have not been fully utilised to

date. These include the following:

* Management of Aesthetic Surgery & Procedures of Limited Clinical Priority

* Advice & Guidance

* Consultant Letter Review

This will be part of a broader service review of the patient referral pathway for MSK where the CCG will seek to take out unnecessary steps in the

process to reduce demand on services, reduce emergency admissions and improve patient exprience.

This process will be overseen by the Clinical Strategy Board. A Clinical Working Group is already in place but it's terms of refernce will be revised to

ensure that the identified challenges are met.

Emergency Admissions Mark Curran (1,244) (261) (1,110)

Premises QPID019 / Q181933

Schedules of accommodation for all Dudley wide premises have been reviewed, amended and agreed with local providers Billing schedules and cost

reviews have been completed and reductions in costs have been applied FMC and Coseley Family Health Centre leases have

been terminated. Ridge Hill site has been disposed of Challenges made to NHSPS and CHP relating to the costing schedules

in particular the Business Rates and VAT issues Utilisation reviews have been carried out independently and findings reported back to the

Estates Ops Group August: Workstreams have been set up prioritising Ladies Walk utilisation, Lower Corbett Site under-utilisation

and potential disposal of dilapidated buildings and Ridge Hill LD centre future use following the decision to stop inpatient referrals to the centre, and

looking at the potential of utilising Busheyfields to deliver a step down facility

Infrastructure Philip Cowley (670) (1,679)

Urgent Care Centre QPID024 / Q181915

UCC service commencement on 1st April 2015. Savings are attributable to the diversion of patients away from ED and to the UCC for primary care

assessment and treatment. The current interim premises arrangements mean that the full aspirations of the UCC contract and forecast savings cannot

be realised. The new premises solution should be completed by November 2017, which should mean a further 6.5% of patients streamed to UCC

Urgent Care Jason Evans (1,003) 0 (603)

Non Emergency Patient Transport QPID026 / Q181944

Non Emergency patient transport within the Dudley and Wolverhampton area was re-procured in early 2016 for service commencement in October

2016. The re-procurement process allowed for efficiency savings due to a change in the way charges were calculated. The new contract charges non

emergency patient transport based on a weighted mileage scheme across all CCGs within both contracts. The weighted mileage calculation has released

some savings in 2017/18 in comparison to charges received through the previous contract

Urgent Care Jason Evans (85) (85)




Lead

2018/19

Plan

£000's

2018/19

FOT

£000's

2019/20

Plan

£000's

High intensity Users QPID027 / Q181943Highest users of the urgent care system are identified and bespoke care plans are developed. This has been successful in other parts of the country,

notably BlackpoolUrgent Care Jason Evans (300) (130) (470)

Secondary Care Drugs QPID028 Discounts on high cost drugs v spend in previous years High Cost Drugs Clair Huckerby (400) (1,329) (1,000)

Procedures of Limited Clinical Priority Q181901 Enforcement of decommissioning Policy Decommissioning Mark Curran (1,285) (1,793)

Ophthalmology Q181904 Community Minor Eye Conditions AQP Right Care Mark Curran (64) (62)

Urology Q181906 Management of emergency UTIs Right Care Taps Mtemachani (500) (385)

Paediatric Triage and Follow Up Outpatient Q181911/13 GP peer assessment of referrals to Acute and follow up activity Outpatient Attendances Linda Cropper (100) (92) (151)

Non Obstetric Ultrasound Q181910 Reduction of inappropriate diagnostic requests Outpatient Attendances Mark Curran (232) (14) (150)

Dermatology Q181912 GPwSI to triage dermatology referrals Outpatient Attendances Mark Curran (50) 0 (50)

Pain management Q181914 Decommissioning injections in secondary care Outpatient Attendances Andrew Hindle (200) (200) (143)

Ambulance Turnaround Q181917 Reducing ambulance turnaround delays using the UCC Urgent Care Jason Evans (150) 0 (200)

Excess Bed Days Q181918 Reducing XSBD by reducing delayed discharges Urgent Care Jason Evans (954) (739) (190)

Dementia Q181921 Reduce spend per placement for dementia careContinuing Healthcare

PlacementsJenny Cale (75) (152)

Hospice at Home Q181929 Commission home based hsopice care as alternative to acute admission Urgent Care Andrew Hindle (50) (17) (103)

Community Nursing Q181930 Skill mix of community teams and reduced tissue viability equipment cost Community Nursing Taps Mtemachani (300) (712)

Colonoscopy Q181938 Reduction of scopes using improved pre-testing Diagnostics Duncan Jenkins (50) (30) (20)

Daycase to Outpatient Procedures Q181945 Transfer of care setting in partnership with Acute Elective Care Mark Curran (639) (284) (495)

Emergency Coding Q181949 Financial impact of Trust recoding activity in 2017/18 Urgent Care Matt Gamage (1,643) (2,195)

Ridge Hill Q181950 Decommissioning of surplus bed Mental Health Matt Gamage (948) (948)

Contract Reviews Q181952 Decommissioning of external contracts through prioritisation / reduced activity Private Sector Contracts Matt Gamage (167) (472) (1,375)

Admissions Units Q192005 Reduction of inappropriate activity in shorts stay units such as the Paediatric Assessment Unit Urgent Care Geraint Griffiths-Dale (750)

IAPT LTC Q192008 Reduction in secondary care acute activity through IAPT for people with a long term condition Urgent Care Trish Taylor (300)

Care Homes Q192016 Reduction in emergency admissions from a care home thorugh improved proactive support by the care homes team Emergency Admissions Andrew Hindle (1,533)

Continence Q192022 Gain share agreement in relation to more efficient prescribing of continence products Community Products Sarah Knight (250)

Emergency Flat Activity Q192024 Contracting for flat emergency activity Emergency Admissions Geraint Griffiths-Dale (960)

Advice and Guidance Outpatient Reduction Q192025 Reduction in outpatient attendances expected through the increased use of advice and guidance Outpatient Attendances Mark Curran (750)

TOTAL (16,787) (17,012) (16,778)

Appendix 5: Summary Sources and Applications Statement for 2018/19 - 2019/20


2018-19 2019-20

Recurring

Non

Recurring TOTAL Recurring

Non

Recurring TOTAL

£'000 £'000 £'000 £'000 £'000 £'000

Baseline Commissioning Allocation 421,389 2,451 423,840 445,108 445,108

Baseline Running Cost Allocation 6,735 67 6,802 6,742 6,742

BCF Allocation 7,446 7,446 7,595 7,595

Primary Care Co-Commissioning Allocation 41,842 165 42,007 42,967 42,967

In Year Allocations 12,651 12,651 13,611 13,611

Total Baseline Allocation 477,412 15,334 492,746 502,412 13,611 516,023

New Sources / Reduction of FundsSurplus c/f 12,651 12,651 13,611 13,611

DH Growth - Core 8,207 8,207 23,606 23,606

DH Growth - Other Policy Commitments 3,533 3,533 0 0

DH Growth - Primary Care 784 784 1,125 1,125

Notified Allocations 0 2,683 2,683 0 0 0

Total Income 12,524 15,334 27,858 24,731 13,611 38,342

Application of Funds

Growth / Demographics 9,320 9,320 11,065 11,065

Contract Inflation 11,092 11,092 18,131 18,131

Pressures/Commitments/Savings

Acute Cost pressures 3,294 377 3,671 3,509 3,509

Charge Exempt Overseas Visitors 630 630


Tariff Change Impact 2,887 2,887

IR Changes & HRG 4+ 3,947 3,947 0

Ambulance Service 153 153 341 341

Non Contract Activity 200 200 0

Primary Care 784 408 1,192 1,125 300 1,425

Community Services 690 31 721 222 222

Continuing Care 364 364 250 250

Learning Difficulties 170 170 0

Mental Health 811 97 908 305 305

GP Transformation 476 476 482 482

GP Access 1,923 1,923 1,923 1,923

HSCN 154 154 98 98

Prescribing 414 414 324 324

Premises 180 180 250 250

Running Costs 57 57 -593 -593

IT Strategy 50 250 300 301 301

Funded Nursing Care 600 600 0

Value Proposition Investments / MCP Procurement 875 875 250 1,920 2,170

GP IT 200 5 205 250 250

CAMHS TCP 171 645 816 118 118

Relaxation of 1% Non Recurrent Business Rules -4,717 -4,717 0

New DH Policy Commitments 3,533 1,817 5,350 0

Other 759 759 1,068 2,500 3,568

Total Expenditure 32,357 6,773 39,130 42,284 6,373 48,657

Gap -19,833 8,561 -11,272 -17,553 7,238 -10,315

QIPP Schemes -16,987 -16,987 -16,780 -16,780

Price Efficiencies -7,896 -7,896 -5,226 -5,226

Total Efficiencies -24,883 0 -24,883 -22,006 0 -22,006

Surplus / (Deficit) 5,050 8,561 13,611 4,453 7,238 11,691

Appendix 6: Statement of Financial Position for 2019/20


2018/19

Outturn

(£000)

SoFP March Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

AssetsNon Current Assets

Opening Balance

Depreciation

Additions

Long Term Receivables

Total Non Current Assets - - - - - - - - - - - - -

Current Assets

Inventories

NHS Trade and Other Receivables 1,340 290 50 120 230 203 246 322 271 308 495 401 1,657

Non NHS Trade and Other Receivables 1,567 2,525 3,182 3,285 3,451 3,327 2,654 3,264 2,962 2,873 3,256 2,477 2,119

Cash and Cash Equivalents 45 176 138 244 221 89 248 143 139 169 215 202 38

Total Current Assets 2,952 2,991 3,370 3,649 3,902 3,619 3,148 3,729 3,372 3,350 3,966 3,080 3,814

Total Assets 2,952 2,991 3,370 3,649 3,902 3,619 3,148 3,729 3,372 3,350 3,966 3,080 3,814

LiabilitiesNon Current Liabilities

Borrowings

Deferred Income (non current)

Provisions (non current) (141) (141) (141) (141) (141) (141) (141) (141) (141) (141) (141) (141) (141)

Trade and Other Payables (non current)

Finance Leases (non current)

Total Non Current Liabilities (141) (141) (141) (141) (141) (141) (141) (141) (141) (141) (141) (141) (141)

Current Liabilities

Borrowings

Deferred Income (current)

Provisions (current) (1,097) (1,097) (759) (739) (719) (640) (640) (640) (640) (640) (620) (605) (690)

Trade and Other Payables (current) (28,684) (27,974) (26,207) (27,691) (28,739) (30,040) (30,316) (28,873) (28,643) (28,511) (29,034) (29,442) (28,487)

Finance Leases (current)

Total Current Liabilities (29,781) (29,071) (26,966) (28,430) (29,458) (30,680) (30,956) (29,513) (29,283) (29,151) (29,654) (30,047) (29,177)

Total Liabilities (29,922) (29,212) (27,107) (28,571) (29,599) (30,821) (31,097) (29,654) (29,424) (29,292) (29,795) (30,188) (29,318)

TOTAL ASSETS EMPLOYED (26,970) (26,221) (23,737) (24,922) (25,697) (27,202) (27,949) (25,925) (26,052) (25,942) (25,829) (27,108) (25,504)

Taxpayers' Equity

General Fund (26,970) (26,221) (23,737) (24,922) (25,697) (27,202) (27,949) (25,925) (26,052) (25,942) (25,829) (27,108) (25,504)

Retained Earnings (Accumulated Losses)

Revaluation Reserve

Other Reserves

TOTAL ASSETS EMPLOYED (26,970) (26,221) (23,737) (24,922) (25,697) (27,202) (27,949) (25,925) (26,052) (25,942) (25,829) (27,108) (25,504)

2019/20 Plan (£000)

Appendix 7: Cashflow for 2019/20


2019/20 April May June July August September October Nov Dec January February March Total

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Receipts

Balance b/fwd 45 176 138 244 221 89 248 143 139 169 215 202

BACS 100 100 100 100 100 100 100 100 100 100 100 100 1,200

CHAPS -

NHS England-Drawdown 35,200 36,600 37,000 37,000 36,500 36,700 37,500 38,500 37,800 38,000 38,600 39,360 448,760

NHS England-Drawdown additional -

Other 1,480 50 50 50 50 50 50 50 50 50 50 50 2,030

PCS Payments Reimbursements -

VAT 50 50 50 50 50 50 50 50 50 50 50 50 600

Capital Receipts -

Prescribing & Home Oxygen 4,129 4,480 4,195 4,454 4,420 4,484 4,610 4,399 4,653 4,507 4,477 4,748 53,555

Total Receipts 41,004 41,456 41,533 41,898 41,341 41,473 42,558 43,242 42,792 42,876 43,492 44,510 506,145

Payments

Creditors NHS 25,790 25,030 26,688 26,757 26,736 26,534 27,475 27,920 27,542 27,901 28,023 28,742 325,138

Creditors CHAPS -

BACS 10,019 10,917 9,516 9,576 9,135 9,247 9,370 9,893 9,538 9,363 9,898 10,092 116,564

Salary 300 300 300 300 300 300 300 300 300 300 300 300 3,600

Pensions 80 80 80 80 80 80 80 80 80 80 80 80 960

Tax & NI 150 150 150 150 150 150 150 150 150 150 150 150 1,800

GP Pensions 330 330 330 330 330 330 330 330 330 330 330 330 3,960

Standing Orders /Direct Debits - 1 - - 1 - - 1 - - 2 - 5

PCS Payments -

Other -

Payable Orders 30 30 30 30 100 100 100 30 30 30 30 30 570

Prescribing & Home Oxygen 4,129 4,480 4,195 4,454 4,420 4,484 4,610 4,399 4,653 4,507 4,477 4,748 53,555

Total -Expenditure 40,828 41,318 41,289 41,677 41,252 41,225 42,415 43,103 42,623 42,661 43,290 44,472 506,152

Balance c/fwd 176 138 244 221 89 248 143 139 169 215 202 38

Appendix 8: Financial Budget Summary - Budgets by Budget Holder (at total contract value)

Period: Baseline 2019-20200.035

WTE

Budget

Pay Budget

(£000's)

Non Pay

Budget

(£000's)

Income

Budget

(£000's)

Total Budget

(£000's)

Gross QIPP

Programme

ANDREW HINDLEDementia - - 110 - 110 - Home Oxygen - - 682 - 682 - Community Services - - 27,588 - 27,588 (250)Hospices - - 778 - 778 - Long Term Conditions - - 1,284 - 1,284 - Palliative Care - - 770 (12) 758 - Local Enhanced Services - - 1,850 - 1,850 -

TOTAL - - 33,062 (12) 33,050 (250)

ANTHONY NICHOLLSContracting 6.80 337 53 - 390 - Procurement - - 1 - 1 -

TOTAL 6.80 337 55 - 392 -

CAROLINE BRUNTSafeguarding 4.00 227 305 - 532 - Quality 7.00 393 48 - 441 - GP Practice Training - - - - - - GP Forward View - - 1,923 - 1,923 - GPwSI & Nurse Mentors 0.00 0 - - 0 - Practice Engagement LES - - 1,014 - 1,014 - Membership Development & Primary Care 5.00 319 (4) - 315 - GP Mentor Support - - 15 - 15 - General Practice - APMS - - 520 - 520 - General Practice - GMS - - 26,255 - 26,255 - QOF - - 136 - 136 - Local Enhanced Services - - 7,980 - 7,980 - Premises Cost Reimbursement - - 4,315 - 4,315 - Other Premises Costs - - 306 - 306 - Collaborative Payments - - - - - - Dispensing/Prescribing Drs - - 235 - 235 - Other GP Services 0 45 3,175 - 3,219 -

TOTAL 16.80 984 46,223 - 47,207 -

JASON EVANSAmbulance Services - - 11,968 - 11,968 (200)NHS 111 - - 1,029 - 1,029 - Urgent Care - - 2,945 - 2,945 - Winter Resilience - - 1,465 - 1,465 -

TOTAL - - 17,407 - 17,407 (200)

JENNY CALECHC Adult Fully Funded - - 13,140 - 13,140 - CHC Adult Fully Funded Personal Health Budgets - - 1,802 - 1,802 - Continuing Healthcare Assessment & Support 19.85 886 156 - 1,042 - Funded Nursing Care - - 4,224 - 4,224 - Intermediate Care - - 4,445 - 4,445 -

TOTAL 19.85 886 23,768 - 24,653 -

LAURA BROSTERCommunications & Engagement 7.05 208 126 - 334 -

TOTAL 7.05 208 126 - 334 -

LINDA CROPPERChild and Adolescent Mental Health - - 5,606 - 5,606 - Acute Childrens Services - - 115 - 115 - CHC Children - - 613 - 613 - CHC Children Personal Health Budgets - - 316 - 316 - Children Services - - 6,933 (373) 6,559 -

TOTAL - - 13,582 (373) 13,209 -

MARK CURRANNCAs - - 3,403 - 3,403 - Planned Care - - 2,875 (17) 2,858 - High Cost Drugs - - 54 - 54 - Patient Transport - - 1,592 - 1,592 -

TOTAL - - 7,924 (17) 7,906 -

Appendix 8: Financial Budget Summary - Budgets by Budget Holder (at total contract value)

Period: Baseline 2019-20200.035

WTE

Budget

Pay Budget

(£000's)

Non Pay

Budget

(£000's)

Income

Budget

(£000's)

Total Budget

(£000's)

Gross QIPP

Programme

MATTHEW HARTLANDCommissioning Reserve - - 6,949 - 6,949 (856)Non Recurrent Reserve - - - - - - NHS PS & CHP Property Charges - - 3,010 - 3,010 - Non Recurrent Programmes - 0 301 - 301 - Surplus 0.00 - 11,691 - 11,691 - Clinical Management 2.50 464 (28) - 437 - Other Board 0.80 - 134 - 134 - Finance & Performance 20.70 1,023 176 - 1,199 - Governance - - 240 - 240 - Estates and Facilities - - 207 - 207 - Corporate Costs & Services - - (52) - (52) (600)Apprentice Levy 0.00 32 - - 32 - IM&T Support 4.00 147 224 - 371 - Primary Care IT - Programme 0.00 - 1,465 - 1,465 -

TOTAL 28.00 1,667 24,318 - 25,984 (1,456)

NEILL BUCKTINBetter Care Fund - - 12,707 - 12,707 - Collaborative Commissioning - - 19 - 19 - Integrated Clinical Leads 3.30 520 - - 520 - Commissioning Team 9.50 684 (1) - 683 - Acute Commissioning - - 238,481 (112) 238,369 (10,660)Learning Difficulties - - 8,677 - 8,677 - Central Drugs - - 2,082 (251) 1,832 - Medicines Management - Clinical 4.47 216 708 (37) 887 - Prescribing - - 50,199 (44) 50,155 (4,213)

TOTAL 17.27 1,420 312,872 (444) 313,848 (14,873)

PAUL MAUBACHCCG Management Team 7.00 975 (158) - 818 -

TOTAL 7.00 975 (158) - 818 -

STEPH CARTWRIGHTOrganisational Development 1.00 78 58 - 137 - Administration & Business Support 13.60 334 107 - 441 -

TOTAL 14.60 412 165 - 577 -

TRISH TAYLORMental Health Contracts - - 27,339 - 27,339 - Mental Health Services – Adults - - 1,951 - 1,951 - Mental Health Services - Collaborative Commissioning - - 106 - 106 - Mental Health Services – Not Contracted Activity - - 213 - 213 - Mental Health Services – Other - - 755 - 755 - Mental Health Services - Specialist Services - - 274 - 274 - Mental Capacity Act - - - - - -

TOTAL - - 30,638 - 30,638 -

TOTAL 117.37 6,888 509,982 (847) 516,023 (16,779)

Appendix 9: Contract Lead Commissioners


Provider Contract Type Lead

Commissioner A&E

Non

Electives

Electives/

DaycasesOutpatients

Mental

Health/LD

Ambulance

Services

Community

ServicesOther CQUIN Total

The Dudley Group Acute/Community Neill Bucktin 10,723 69,213 33,278 41,181 25,673 44,402 2,806 227,275Dudley and Walsall Mental Health Mental Health Trish Taylor 30,595 382 30,978Black Country Partnerships Community/LD/Mental Health Linda Cropper 6,967 5,821 160 12,947West Midlands Ambulance Ambulance Geraint Griffiths 11,820 148 11,968Univerity Hospital Birmingham Acute Mark Curran 373 2,622 2,019 1,538 1,536 101 8,188The Royal Wolverhampton Acute/Community Mark Curran 478 2,429 1,398 1,318 883 786 91 7,384West Midlands Hospital Acute Mark Curran 5,034 1,831 182 88 7,136Sandwell & West Birmingham Acute/Community Geraint Griffiths 540 994 723 1,762 224 1,466 71 5,780Royal Orthopaedic Acute Mark Curran 86 2,226 408 526 41 3,287Urgent Care Centre Other Geraint Griffiths 2,945 2,945Birmingham Women's & Children's Hospital Acute Linda Cropper 109 1,099 536 487 930 40 3,201NHS 111 Other Geraint Griffiths 1,029 1,029Worcestershire Acute Acute Mark Curran 170 205 164 171 166 11 887South Staffordshire and Shropshire MH Mental Health Trish Taylor 152 2 154Heart of England FT Acute Mark Curran 51 172 136 124 78 7 568Birmingham and Solihull Mental Health Mental Health Trish Taylor 327 4 331University Hospital North Midlands Acute Mark Curran 11 27 57 24 122 3 245Walsall Healthcare Acute & Community Mark Curran 40 120 58 53 14 36 4 325Shrewsbury & Telford Acute Mark Curran 28 85 182 33 24 4 357Robert Jones & Agnes Hunt Acute Mark Curran 12 182 44 49 4 291Birmingham Community NHS Trust Community Andrew Hindle 173 2 175Worcestershire Health and Care NHS Trust Community/Mental Health Andrew Hindle 82 1 83Nuffield Health Acute Mark Curran 174 38 2 3 216

TOTAL £12,524 £77,064 £46,168 £48,974 £38,078 £11,820 £32,869 £54,280 £3,972 £325,749

Lead CommissionerGeraint

Griffiths

Geraint

GriffithsMark Curran Mark Curran

Trish

Taylor

Geraint

Griffiths

Andrew

HindleMark Curran

Caroline

Brunt

Indicative Value (£'000)

Appendix 10: Better Care Fund Services


AREA Indicative Value (£)

Dudley Group Foundation Trust

District Nursing 10,083,894

Rehab - T&O 1,747,525

Palliative Care Service 1,776,914

Rehab - Stroke 988,584

Locality Wide Continence Pass Through 1,272,608

Physiotherapy MSK 795,201

Community Heart Failure 675,680

Elderly Frail Team 691,260

OT Primary Care 687,537

Primary Care Neurology Team 729,661

Community Stroke Rehabilitation 771,563

Intermediate Care Team - OT 459,983

Specialist Nursing-Diabetes 458,095

Locality Wide Continence Activity 109,815

District Nursing - Oncology Outreach/VIV/OPAT 449,408

Respiratory specialist nurses - Outpatient Follow ups 374,691

Leg Ulcer 472,407

Respiratory specialist nurses - Outpatient Firsts 656,525

Intermediate Care Team - Physio 214,170

Speech Therapy Adults 225,033

Virtual Ward/Assertive Case Managers 177,570

Intermediate Care Team - Nursing 151,041

Tissue Viability 1,271,463

Rehab - Other 540,916

Falls Team 159,688

TOTAL 25,941,232

Other

Baseline Transfer 5,427,673

Previous Section 256 monies (NHSE) 7,299,832

Intermediate Care - BUPA 1,509,765

Intermediate Care - Leyton Healthcare 834,017

Intermediate Packages of Care 584,900

Community Equipment Stores 436,591

Intermediate Care - Shaw 528,783

GP Respite Beds 281,728

Intermediate Care - Prestwood 332,573

Palliative Care Front End 227,789

Intermediate care - Physiotherapists 163,499

GP Locality Leads 178,175

Crossroads 79,160

Intermediate Care Support - Dr Plant 65,865

Intermediate Care - Other Private Care Homes 59,162

Alzeimers Carer Family Support Service 14,087

MH Care Home Practioner 58,542

Stepdown Cover 84,780

TOTAL 18,166,921

GRAND TOTAL 44,108,153

Note :- Indicative, subject to final clarification

Appendix 11: Long Term Financial Model 2018/19 to 2022/23


Commissioning Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total

ACUTE SERVICES

Acute Commissioning 224,234 (595) 223,639 238,369 - 238,369 244,010 - 244,010 249,785 - 249,785 255,696 - 255,696 261,748 - 261,748

Ambulance Services 9,721 153 9,874 11,968 - 11,968 12,598 - 12,598 13,262 - 13,262 13,960 - 13,960 14,695 - 14,695

NCAs 3,207 - 3,207 3,403 - 3,403 3,483 - 3,483 3,566 - 3,566 3,650 - 3,650 3,737 - 3,737

Planned Care 2,602 - 2,602 2,858 - 2,858 2,955 - 2,955 3,056 - 3,056 3,161 - 3,161 3,269 - 3,269

NHS 111 1,028 - 1,028 1,029 - 1,029 1,045 - 1,045 1,060 - 1,060 1,076 - 1,076 1,092 - 1,092

Urgent Care 2,945 - 2,945 2,945 - 2,945 2,975 - 2,975 3,005 - 3,005 3,035 - 3,035 3,065 - 3,065

Winter Resilience 1,465 - 1,465 1,465 - 1,465 1,480 - 1,480 1,494 - 1,494 1,509 - 1,509 1,524 - 1,524

ACUTE SERVICES TOTAL 245,201 (442) 244,759 262,037 - 262,037 268,546 - 268,546 275,228 - 275,228 282,087 - 282,087 289,130 - 289,130

MENTAL HEALTH SERVICES

Mental Health Contracts 25,711 - 25,711 27,339 - 27,339 27,877 - 27,877 28,425 - 28,425 28,984 - 28,984 29,554 - 29,554

Dementia 104 - 104 110 - 110 112 - 112 115 - 115 117 - 117 119 - 119

Learning Difficulties 7,315 5 7,320 8,677 - 8,677 8,847 - 8,847 9,021 - 9,021 9,199 - 9,199 9,380 - 9,380

Other Mental Health 2,939 - 2,939 3,299 - 3,299 3,364 - 3,364 3,430 - 3,430 3,497 - 3,497 3,566 - 3,566

Child and Adolescent Mental Health 5,272 134 5,406 5,606 - 5,606 5,948 - 5,948 6,065 - 6,065 6,185 - 6,185 6,306 - 6,306

MENTAL HEALTH SERVICES TOTAL 41,340 139 41,479 45,031 - 45,031 46,149 - 46,149 47,056 - 47,056 47,982 - 47,982 48,925 - 48,925

PRIMARY CARE DEVELOPMENT

GP Practice Training - - - - - - - - - - - - - - - - - -

Primary Care IT - Programme 1,267 176 1,443 1,465 - 1,465 1,487 - 1,487 1,509 - 1,509 1,532 - 1,532 1,555 - 1,555

GP Forward View 1,923 166 2,089 1,923 - 1,923 1,923 - 1,923 1,923 - 1,923 1,923 - 1,923 1,923 - 1,923

GPwSI & Nurse Mentors 56 55 111 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0

Primary Care Investments 878 - 878 1,014 - 1,014 1,310 - 1,310 1,440 - 1,440 1,492 - 1,492 1,546 - 1,546

PRIMARY CARE DEVELOPMENT TOTAL 4,124 397 4,521 4,402 - 4,402 4,720 - 4,720 4,872 - 4,872 4,947 - 4,947 5,024 - 5,024

DRUGS AND GP PRESCRIBING

Central Drugs 1,852 - 1,852 1,832 - 1,832 1,923 - 1,923 2,018 - 2,018 2,118 - 2,118 2,223 - 2,223

Medicines Management - Clinical 875 - 875 887 - 887 896 - 896 905 - 905 914 - 914 923 - 923

Home Oxygen 671 - 671 682 - 682 716 - 716 752 - 752 789 - 789 828 - 828

Prescribing 51,020 - 51,020 50,155 - 50,155 52,646 - 52,646 55,260 - 55,260 58,005 - 58,005 60,886 - 60,886

POD - - - 0 - 0 0 - 0 0 - 0 0 - 0 (0) - (0)

DRUGS AND GP PRESCRIBING TOTAL 54,417 - 54,417 53,555 - 53,555 56,180 - 56,180 58,935 - 58,935 61,826 - 61,826 64,860 - 64,860

INTERMEDIATE & CONTINUING HEALTHCARE

CHC Adult Fully Funded 12,139 - 12,139 13,140 - 13,140 13,924 - 13,924 14,615 - 14,615 15,341 - 15,341 16,103 - 16,103

CHC Adult Fully Funded Personal Health Budgets 1,701 - 1,701 1,802 - 1,802 1,910 - 1,910 2,005 - 2,005 2,104 - 2,104 2,209 - 2,209

Continuing Healthcare Assessment & Support 930 - 930 1,042 - 1,042 1,052 - 1,052 1,062 - 1,062 1,073 - 1,073 1,084 - 1,084

Funded Nursing Care 4,479 - 4,479 4,224 - 4,224 4,476 - 4,476 4,699 - 4,699 4,932 - 4,932 5,177 - 5,177

Intermediate Care 4,247 - 4,247 4,445 - 4,445 4,596 - 4,596 4,753 - 4,753 4,915 - 4,915 5,082 - 5,082

INTERMEDIATE & CONTINUING HEALTHCARE TOTAL 23,496 - 23,496 24,653 - 24,653 25,958 - 25,958 27,134 - 27,134 28,366 - 28,366 29,655 - 29,655

COMMUNITY SERVICES

Community Services 24,971 - 24,971 27,588 - 27,588 28,528 - 28,528 29,500 - 29,500 30,505 - 30,505 31,544 - 31,544

Acute Childrens Services 147 - 147 115 - 115 119 - 119 123 - 123 127 - 127 131 - 131

CHC Children 787 - 787 613 - 613 649 - 649 682 - 682 716 - 716 751 - 751

CHC Children Personal Health Budgets 261 - 261 316 - 316 335 - 335 352 - 352 369 - 369 387 - 387

Children Services 6,148 - 6,148 6,559 - 6,559 6,783 - 6,783 7,014 - 7,014 7,253 - 7,253 7,500 - 7,500

COMMUNITY SERVICES TOTAL 32,313 - 32,313 35,191 - 35,191 36,413 - 36,413 37,669 - 37,669 38,969 - 38,969 40,313 - 40,313

2018/19 2020/21 2021/22 2022/23 2023/242019/20

Appendix 11: Long Term Financial Model 2018/19 to 2022/23


Commissioning Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total

2018/19 2020/21 2021/22 2022/23 2023/242019/20

OTHER COMMISSIONING

Better Care Fund 12,505 - 12,505 12,707 - 12,707 13,240 - 13,240 13,755 - 13,755 14,261 - 14,261 14,753 - 14,753

Local Enhanced Services 1,403 476 1,879 1,850 - 1,850 1,876 - 1,876 1,901 - 1,901 1,927 - 1,927 1,954 - 1,954

Statutory Reserves 5,588 553 6,141 5,029 1,920 6,949 5,105 - 5,105 5,181 - 5,181 5,259 - 5,259 5,338 - 5,338

Non Recurrent Reserve - - - - - - - - - - - - - - - - - -

Patient Transport 1,545 - 1,545 1,592 - 1,592 1,616 - 1,616 1,640 - 1,640 1,665 - 1,665 1,690 - 1,690

NHS PS & CHP Property Charges 3,342 - 3,342 3,010 - 3,010 3,116 - 3,116 3,225 - 3,225 3,337 - 3,337 3,454 - 3,454

Safeguarding 315 26 341 532 - 532 537 - 537 543 - 543 548 - 548 554 - 554

Integrated Clinical Leads 368 - 368 520 - 520 525 - 525 530 - 530 536 - 536 541 - 541

Other 2,820 399 3,219 3,193 - 3,193 6,192 - 6,192 10,754 - 10,754 14,642 - 14,642 17,591 - 17,591

OTHER COMMISSIONING TOTAL 27,886 1,454 29,340 28,434 1,920 30,354 32,205 - 32,205 37,529 - 37,529 42,175 - 42,175 45,875 - 45,875

SURPLUS

Surplus - 13,611 13,611 - 11,691 11,691 - 11,691 11,691 - 11,691 11,691 - 11,691 11,691 - 11,691 11,691

SURPLUS TARGET TOTAL - 13,611 13,611 - 11,691 11,691 - 11,691 11,691 - 11,691 11,691 - 11,691 11,691 - 11,691 11,691

TOTAL COMMISSIONING 428,778 15,159 443,937 453,303 13,611 466,914 470,172 11,691 481,863 488,424 11,691 500,115 506,351 11,691 518,042 523,782 11,691 535,473

Running Costs Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total

CORPORATE SERVICES

Clinical Management 432 - 432 437 - 437 441 - 441 445 - 445 450 - 450 454 - 454

Other Board 126 - 126 134 - 134 135 - 135 137 - 137 138 - 138 139 - 139

Organisational Development 130 - 130 137 - 137 138 - 138 140 - 140 141 - 141 142 - 142

CCG Management Team 932 - 932 818 - 818 826 - 826 834 - 834 842 - 842 851 - 851

Communications & Engagement 315 - 315 334 - 334 337 - 337 341 - 341 344 - 344 348 - 348

Finance & Performance 1,143 - 1,143 1,199 - 1,199 1,211 - 1,211 1,223 - 1,223 1,235 - 1,235 1,247 - 1,247

Administration & Business Support 412 - 412 441 - 441 445 - 445 449 - 449 454 - 454 458 - 458

Commissioning 655 - 655 683 - 683 690 - 690 696 - 696 703 - 703 710 - 710

Membership Development & Primary Care 253 - 253 315 - 315 318 - 318 321 - 321 324 - 324 328 - 328

IM&T Support 352 5 357 371 - 371 375 - 375 379 - 379 382 - 382 386 - 386

Quality 318 - 318 441 - 441 445 - 445 450 - 450 454 - 454 459 - 459

Contracting 340 - 340 390 - 390 394 - 394 398 - 398 402 - 402 406 - 406

Governance 240 - 240 240 - 240 242 - 242 245 - 245 247 - 247 250 - 250

Estates and Facilities 202 5 207 207 - 207 209 - 209 211 - 211 213 - 213 215 - 215

Other Corporate Support Services 942 - 942 (3) - (3) (867) - (867) (959) - (959) (1,052) - (1,052) (1,145) - (1,145)

RUNNING COST TOTAL 6,792 10 6,802 6,142 - 6,142 5,340 - 5,340 5,310 - 5,310 5,280 - 5,280 5,250 - 5,250

Primary Care Co-Commissioning Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total Rec Non Rec Total

GP COMMISSIONED SERVICES

General Practice - GMS 26,855 - 26,855 26,255 - 26,255 26,877 - 26,877 28,186 - 28,186 29,203 - 29,203 30,263 - 30,263

General Practice - APMS 511 - 511 520 - 520 532 - 532 558 - 558 578 - 578 599 - 599

General Practice - PMS - - - - - - - - - - - - - - - - - -

QOF 149 - 149 136 - 136 140 - 140 146 - 146 152 - 152 157 - 157

Local Enhanced Services 6,877 - 6,877 7,980 - 7,980 8,169 - 8,169 8,567 - 8,567 8,876 - 8,876 9,198 - 9,198

Premises Cost Reimbursement 4,464 - 4,464 4,315 - 4,315 4,417 - 4,417 4,632 - 4,632 4,799 - 4,799 4,973 - 4,973

Other Premises Costs 353 - 353 306 - 306 313 - 313 329 - 329 340 - 340 353 - 353

Collaborative Payments - - - - - - - - - - - - - - - - - -

Dispensing/Prescribing Drs 250 - 250 235 - 235 241 - 241 253 - 253 262 - 262 271 - 271

Other GP Services 2,383 165 2,548 3,219 - 3,219 3,893 - 3,893 4,082 - 4,082 4,229 - 4,229 4,383 - 4,383

PRIMARY CARE CO-COMMISSIONING TOTAL 41,842 165 42,007 42,967 - 42,967 44,581 - 44,581 46,752 - 46,752 48,440 - 48,440 50,198 - 50,198

TOTAL 477,412 15,334 492,746 502,412 13,611 516,023 520,093 11,691 531,784 540,486 11,691 552,177 560,071 11,691 571,762 579,230 11,691 590,921

* Note at this point the figures presented do not include MCP due to the on going procurement

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Report: NHS Long Term Plan – Proposed Legislative Changes Agenda item No: 4.0

TITLE OF REPORT: NHS Long Term Plan – Proposed Legislative Changes

PURPOSE OF REPORT: To approve the CCG’s responses to proposed legislative changes from NHS England and NHS Improvement.

AUTHOR OF REPORT: Mr H Bucktin – Graduate Assistant

MANAGEMENT LEAD: Mr N Bucktin – Director of Commissioning

CLINICAL LEAD: N/A

KEY POINTS:

1. NHS England and NHS Improvement have published proposed legislative changes which they believe will make implementation of the Long Term Plan faster and easier.

2. Engagement is taking place on these proposals with NHS organisations.

3. Proposed comments in response to the proposed changes are attached as Appendix 1.

RECOMMENDATION: That the CCG’s comments in response to the proposed legislative changes be approved.

FINANCIAL IMPLICATIONS: None

WHAT ENGAGEMENT HAS TAKEN PLACE:

None

ANY CONFLICTS OF INTEREST IDENTIFIED IN ADVANCE:

None

ACTION REQUIRED: Approval

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DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 28 MARCH 2019 REPORT ON PROPOSED LEGISLATIVE CHANGES 1.0 PURPOSE OF REPORT 1.1 To approve the CCG’s responses to proposed legislative changes from NHS England and NHS

Improvement. 2.0 BACKGROUND 2.1 NHS England and NHS Improvement are consulting on proposed changes to health and social care

primary legislation, to facilitate faster and easier implementation of the NHS Long Term Plan. 2.2 NHS England’s Strategy and Innovation Directorate and NHS Improvement’s Strategy Directorate have

produced a document – Implementing the NHS Long Term Plan: Proposals for Possible Changes to Legislation.

2.3 The CCG has participated in the development of proposals, including the Chief Accountable Officer

appearing before the House of Commons’ Health and Social Care Select Committee in March 2018. 3.0 PROPOSED LEGISLATIVE CHANGES 3.1 Implementing the NHS Long Term Plan sets out nine groups of proposed changes to current legislation,

which NHS England and NHS Improvement believe would facilitate a faster and easier implementation of the Long Term Plan.

3.2 The main groups of proposed changes are:

1. Promoting collaboration 2. Getting better value for the NHS 3. Increasing the flexibility of national NHS payment systems 4. Integrating care provision 5. Managing the NHS’s resources better 6. Every part of the NHS working together 7. Shared responsibility for the NHS 8. Planning our services together 9. Joined-up national leadership

3.3 The proposed legislative changes are positive and, subject to certain clarifications, are supported.

Proposed comments in response are included as Appendix 1. 4.0 CONSULTATION 4.1 Implementing the NHS Long Term Plan includes a short survey at the end and a link to a more detailed

online consultation tool. Ongoing discussions will ‘actively reach out to the NHS’ and ‘seek views at targeted events with partner organisations and interested bodies’, running until 25th April 2019.

4.2 A report setting out the views received and making firm recommendations to the Secretary of State will

be published by NHS England and NHS Improvement after all responses have been received and considered.

5.0 RECOMMENDATION 5.1 That the CCG’s comments in response to the proposed legislative changes in Appendix 1 be approved.

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APPENDICES Appendix 1 – Long Term Plan: Dudley CCG responses to proposed legislative changes. Mr N Bucktin Director of Commissioning March 2019

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APPENDIX 1 – Long Term Plan: Dudley CCG responses to proposed legislative changes

Proposed change Reason CCG response

1. Promoting collaboration

Removal of the CMA’s function

to review mergers involving

NHS foundation trusts.

Considerations of proposed

mergers have been costly and

time-consuming for the

organisations involved.

Agreed.

Removal of NHS

Improvement’s competition

powers and duties.

NHS Improvement’s primary

role is to support improvement

in quality of care/use of

resources.

Agreed.

Removal of need for NHS

Improvement to refer contested

licence/National Tariff

provisions to the CMA.

NHS Improvement/England,

provided they have consulted

on the proposals/given proper

consideration to any concerns

raised, should be able to reach

final decisions on these matters

without referral to a competition

authority.

Agreed.

2. Getting better value for the NHS

Revoking of regulations made

under 2012 Health and Social

Care Act Section 75.

Current procurement legislation

can lead to protracted

procurement processes and

wasteful legal/administrative

costs in cases where there is

strong rationale for NHS

organisation to provide

services.

Current legislation makes it

more difficult for organisations

to ensure they are using

collective financial resources in

the most effective way for local

populations.

Current legislation can

discourage NHS organisations

from collaborating to develop

new models of care in case this

is challenged on the grounds of

not treating all providers

equally.

This is to be welcomed. The

requirement to conduct a

procurement exercise has

hindered the development of

the MCP and created

unnecessary tensions in the

system.

Repealing of the powers in

primary legislation under which

the above are made.

Replacement of the above by a

best value test.

Effective removal of

arrangements between

commissioners and providers

from the scope of the Public

Contracts Regulations.

Subjection of NHS

commissioners to a new best

value test when making the

above arrangements with

supporting statutory guidance.

Clarity is required in relation to

what the best value test will

consist of. It would be helpful if

NHS England could describe

the ‘route map’ and

requirements for the creation of

ICPs using ‘best value’. This

should recognise the

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requirements of the ISAP to

provide appropriate

safeguards.

3. Increasing the flexibility of national NHS payment systems

Legislation should:

Allow national prices to be set

as a formula rather than a fixed

value.

Providing more flexibility in

supporting new ways of

delivering care.

Price payable can reflect local

factors.

Agreed.

Provide a power for national

prices to be applied only in

specified circumstances e.g.

allowing national prices for

acute care to cover out-of-area

treatments but enabling local

commissioners and providers

to agree appropriate payment

arrangements for services

patients receive from their main

local hospital in accordance

with tariff rules.

Agreed.

Allow adjustments to provisions

within the tariff to be made

(subject to consultation) within

a tariff period, e.g. to reflect a

new treatment, rather than

having to consult on a new

tariff in its entirety for even a

minor proposed change.

Agreed.

Removal of power to apply to

NHS Improvement to make

local modifications to tariff

prices, once ICSs are fully

developed.

Providers’ ability to apply to

NHS Improvement in certain

circumstances to make local

modifications to national prices

is arguably out of keeping with

the move to ICSs.

Agreed.

Changing of primary legislation

so the national tariff can

include prices for ‘section 7A’

public health services.

Current impossibility of setting

national tariff prices for ‘section

7A’ public health services

commissioned by NHS England

or CCGs on behalf of the

Secretary of State has created

difficulties where these services

are part of a patient pathway for

a particular service.

Agreed.

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4. Integrating care provision

Clarification of the law so the

Secretary of State can set up

new NHS trusts to deliver

integrated care across a given

area.

Single provider organisations

can make faster progress in

developing integrated care and

provide stronger incentivises for

providers to prioritise

preventative action and improve

population health.

Powers to the minister could

overcome the difficulties

commissioners can face in

identifying an existing

organisation that could take on

responsibility for an ICP

contract.

Agreed, subject to comments

above in relation to a ‘route

map’. Proposal refers to ‘run in

a way that involves the local

community’. This is to be

welcomed and is consistent

with the MCP Prospectus.

Further consultation is required

as to how an appropriate

governance model can be

developed.

5. Managing the NHS’s resources better

Giving of targeted powers to

NHS Improvement to direct

mergers/acquisitions involving

NHS foundation trusts in

specific circumstances where

there are clear patient benefits.

Provider organisations and their

system partners agreeing on

these kinds of improvements

can be frustrated by the

reluctance of one local trust to

consider such arrangements.

Current primary legislation only

allows this NHS Improvement

direction in extreme

circumstances for foundation

trusts.

Agreed.

Giving of powers to NHS

Improvement to set annual

capital spending limits for NHS

foundation trusts in same way

as it can for NHS trusts.

Limits would mean that

foundation trusts would agree

with NHS Improvement and

local health systems when to

make large capital investments

that might otherwise force other

organisations to constrain high-

priority investments or increase

the risk of breaching the NHS’s

overall capital expenditure

limits.

Agreed.

6. Every part of the NHS working together

Giving organisations the ability

to create joint committees of

CCGs and NHS providers.

Currently no powers in place for

this.

Agreed.

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Would allow joint decisions in

the interests of local

populations and support more

efficient/effective functioning of

ICSs.

Seeking new provisions

relating to the formation and

governance of these joint

committees and the decisions

that could appropriately be

delegated to them.

Ensure the new joint

committees act openly and

transparently, avoiding conflicts

of interest, e.g. commissioners

would be unable to delegate to

them decisions on purchasing

services.

Regulations in relation to

Section 75 of the NHS Act

2006 should be reviewed to

permit an ICP to enter into

arrangements with a local

authority to facilitate

commissioning activities.

Removal of the restriction that

prevents the designated nurse

and secondary care doctor

appointed to CCG governing

bodies from being clinicians

who work for local providers.

Current legislation specifies

inclusion of a registered nurse

and a non-GP doctor who

cannot work for a provider with

which the CCG has

commissioning arrangements.

Present rules inconsistent and

too limiting for CCGs to plan

services effectively.

Would bring knowledge and

insights from their provision of

local hospital/community/mental

health services.

Agreed.

Express provision in legislation

to enable CCGs and NHS

providers to make joint

appointments.

Enables joint decision-making,

enhancing local leadership,

improving delivery of integrated

care.

Can reduce management costs

and engender culture of

collective inter-organisation

responsibility.

Current ambiguous legislation =

legal costs in seeking advice

and vulnerability to challenge in

the future for appointments

made.

Agreed.

7. Shared responsibility for the NHS

Introduction of a new shared

duty that requires CCGs and

providers to promote the Triple

Stronger duty of co-operation

than exists already for

organisations to work together

Agreed. This is consistent with

the role of the ICP in reducing

health inequalities.

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Aim for both their local system

and the wider NHS

to consider the potential wider

impact of organisational

decisions on services/financial

sustainability both in their local

community and with

neighbouring health systems

Consideration should be given

to extend this to local

authorities and other public

bodies.

8. Planning our services together

NHS England should be given

the ability to allow groups of

CCGs to collaborate to arrange

services for their combined

populations

Several legal barriers in the

way of more integrated NHS

commissioning.

To avoid ‘double delegation’.

This would further empower

CCGs to make joint decisions

about planning and delivering

care.

Agreed.

CCGs should be able to carry

out delegated functions as if

they were their own.

Agreed. This should be

designed to allow the

channelling of resources

related to the commissioning of

primary care through ICPs to

facilitate greater integration.

Groups of CCGs should be

able to use joint and lead

commissioner arrangements to

make decisions/pool funds

across all their functions.

Agreed. Any changes should

recognise the role of an ICP in

conducting commissioning-

related activities.

Enable NHS England to jointly

commission with CCGs the

specific services currently

commissioned under the

section 7A agreement or to

delegate the commissioning of

these services to groups of

CCGs.

As above.

Changing legislation to enable

NHS England to enter into

formal joint commissioning

arrangements with CCGs,

including providing the ability to

pool budgets.

Overcome split in

commissioning responsibilities

within the same pathways that

can hinder efforts to organise

care around patients’ needs

and make it difficult to make

decisions in the round based on

the balance of investment

between preventing ill-health,

care and support for people

with stable long-term health

problems and specialist

treatment for people with

serious health complications.

Agreed. Consideration should

be given to extending to local

authorities as well.

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Only formal mechanism

currently available is re-

designation by the Secretary of

State but this is not appropriate

for many services which need

to be planned on a larger

population footprint.

9. Joined-up national leadership

Bringing together NHS England

and NHS Improvement closer,

beyond limits of current

legislation, whilst clarifying the

accountability to Secretary of

State and Parliament:

Either by creating a single

organisation which combines

all the relevant NHSE/NHSI

functions (including Monitor

and the TDA)

Or by leaving existing bodies

as they are but with more

flexibility to work together

including power to carry out

functions jointly or to

delegate/transfer functions to

each other, and the flexibility to

have non-executive Board

members in common.

Enabling NHS England and

NHS Improvement to go further

in speaking with one voice,

developing a single oversight

and support framework for the

NHS that supports

integration/best use of

resources, bringing together

national programmes of work

and key activities and using

their collective resources more

efficiently to support local

health systems.

Agreed.

Enable wider collaboration

between ALBs by establishing

new powers for the Secretary

of State to transfer or require

delegation of ALB functions to

other ALBs and create new

functions of ALBs (with

appropriate safeguards).

ALBs play a vital role in

supporting the health system.

Health and Social Care Select

Committee has recommended

all national ALBs act in a more

joined-up way, particularly on

priority areas such as

prevention of ill-health and

workforce education/training.

Responsibility for these

currently sits in different

organisations, specifically

Public Health England and

Health Education England.

Agreed.



Report: CCG Operational Plan 2019/20 Agenda item No: 5.0

TITLE OF REPORT: NHS Long Term Plan and CCG Operational Plan 2019/20

PURPOSE OF REPORT: To approve the CCG’s Operational Plan for the period 2019/20

AUTHOR OF REPORT: Mr H Bucktin – Graduate Assistant

MANAGEMENT LEAD: Mr N Bucktin – Director of Commissioning

CLINICAL LEAD: Dr D Hegarty – Chair

KEY POINTS:

1. The NHS Long Term Plan and 2019/20 Planning Guidance have been published.

2. The CCG’s Operational Plan for 2019/20 has been drafted to reflect this.

3. A key task for 2019/20 will be the mobilisation of the MCP, which will meet many of the requirements outlined in the Long Term Plan.

RECOMMENDATION: That the Operational Plan 2019/20 be approved

FINANCIAL IMPLICATIONS: None arising directly from this report. The CCG’s Financial Plan for 2019/20 is the subject of a separate report on this agenda.


None


None identified

ACTION REQUIRED: Approval

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DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 28 MARCH 2019 NHS LONG TERM PLAN AND CCG OPERATIONAL PLAN 2019/20

1.0 PURPOSE OF REPORT

1.1 To consider the NHS Long Term Plan and approve the CCG’s Operational Plan for 2019/20.

2.0 BACKGROUND

2.1 The Long Term Plan for the NHS, published in January 2019, sets out the health service’s vision and strategy for the next decade.

2.2 Alongside the Long Term Plan, NHS England also published operational planning and contracting guidance for 2019/20, representing the first year of the Long Term Plan.

2.3 This report sets out the key elements of the NHS Long Term Plan, the planning guidance and the CCG’s Operational Plan for 2019/20.

3.0 THE LONG TERM PLAN

3.1 The main features of the Long Term Plan are:-

A new service model for the 21st Century:-

o Boosting ‘out-of-hospital’ care and dissolving the historic primary-community health services divide

o Reducing pressure on emergency hospital services o Giving people more control over their own health and more personalised care when

they need it o Making digitally-enabled primary and outpatient care mainstream across the NHS o Focusing increasingly in local NHS organisations on population health

More NHS action on prevention and health inequalities

Further progress on care quality and outcomes

NHS staff receiving the backing they need

Digitally-enabled care going mainstream across the NHS

Taxpayers’ investment being used to maximum effect

3.2 The Plan also requires a focus on population health and the development of Integrated Care Systems (ICSs) with typically a single CCG for each ICS by April 2021.

3.3 In order to implement the Plan, a number of legislative changes have been proposed. These are the subject of a separate report on this agenda.

4.0 PLANNING GUIDANCE 2019/20 4.1 The national deliverables in the planning guidance include:

Emergency care

RTT

Cancer treatment

Mental health

Learning disabilities and autism

Primary care and community health services

Workforce

Data and technology

Personal health budgets

System architecture

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5.0 CCG OPERATIONAL PLAN 2019/20 5.1 The CCG’s Operational Plan for 2019/20 has been drafted to reflect this guidance, the Long

Term Plan and the Joint Health and Wellbeing Strategy. In terms of the latter, the CCG is required to share the plan with the Health and Wellbeing Board to demonstrate that it has taken account of the Joint Health and Wellbeing Strategy. A draft was considered by the Board on 21 March 2019 and the Board was satisfied that it had taken appropriate account of the Joint Health and Wellbeing Strategy.

5.2 The main feature of our activity for the next year is the mobilisation of the new service model to

be delivered by the MCP and changing our existing governance arrangements to reflect the new landscape. Once mobilised, the MCP will meet most of the Long Term Plan’s requirements on primary care and community services, a number of which are already in place. This is demonstrated in Appendix 2.

6.0 RECOMMENDATION 6.1 That the draft Operational Plan for 2019/20 be approved. Mr N Bucktin Director of Commissioning March 2019

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Operational Plan 2019/20

Version VII: 22/03/2019

APPENDIX 1

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Contents……………………………………………………………………………..2-5

Chapter 1: National and Local Context…………………………………….……..…6-9

a) Background……………………………………………………………………....6-7

b) Strategic Vision…………………………………………………………………….7

c) Challenges………………………………………………………………………..…7

i. System Challenges……………………………………………….……..7-8

ii. Financial Challenges………………………………………………….…..8

iii. Performance Challenges………………………………………………....8

iv. Health Challenges………………………………………………………....8

v. Care and Quality Challenges……………………………..……………8-9

Chapter 2: Health Needs and Health Inequalities……………………………....10-17

a) Prevention………………………………………………………………………....10

b) Healthy Living Practices……………………………………………….……10-11

c) Early Years…………………………………………………………………….…..11

i. Pregnancy……………………………………………………………..11-12

ii. Breastfeeding……………………………………………………………..12

iii. School Readiness………………………………………………….…….12

iv. Health Checks…………………………………………………….......12-13

d) Being in Work, Reducing Poverty and Tackling Deprivation………...…..13

i. Employment…………………………………………………………...…..13

ii. Vulnerable Groups……………………………………………………….14

iii. Accessing Services………………………………………………………14

iv. Fuel Poverty……………………………………………………………….14

v. Community Resilience……………………………………………….14-15

vi. Obesity………………………………………………………………….15-16

e) Elderly………………………………………………………………………………16

i. Isolation…………………………………………………………………….16

ii. End-of-Life……………………………………………………………..16-17

f) Other Vulnerable Groups…………………………………………………….…17

g) Dudley’s Joint Health and Wellbeing Strategy……………………………...17

Chapter 3: Public Feedback………………………………………………….……..18-21

a) Developing Dudley MCP………………………………………………………...18

b) Supporting the Dudley Vision for Community Resilience……………......18

c) Listening to Learning Disability Service Users……………………………..19

d) Measuring Value in Acute Care………………………………………………..19

e) Driving Improvements in Primary Care…………………………………..19-21

f) End-of-Life Care…………………………………………………………………..21

g) Co-production……………………………………………………………………..21

h) Championing the Voice of Young People……………………………………21

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Chapter 4: Key Objectives and Priorities for 2019/20……..……………….…....22-5

a) Corporate Objectives……………………………………………………...…..22-4

b) Priorities……………………………………………………...……………….…24-5

Chapter 5: Black Country System – STP/JCC…………………………….………26-9

a) Developing the Black Country Integrated Care System………………...26-7

b) Developing our Local Integrated Care Partnerships/Providers………….27

c) Strategic Commissioning in the Black Country…………………………….27

i. Mental Health Services…………………………………………………..28

ii. Cancer………………………………………………………………………28

iii. Maternity……………………………………………………………………28

iv. Transforming Care……………………………………………………….28

v. Care Homes………………………………………………………………..29

vi. Empowering People and Communities through Personalisation……...29

d) Our Clinical Strategy……………………………………………………………..29

e) Joint Development of Emergency and Urgent Care…………………..……29

Chapter 6: Future Dudley System…………………………..……………….…….30-31

Chapter 7: Activity/Finance…………………………………......................…….....32-9

a) Key Planning Assumptions and Business Rules……………………...…...32

b) Key Features of the Plan……………………………………………………...33-4

c) QIPP and RightCare……………………………………………………………...34

i. QIPP Plans 2019/20…………………………………………………....34-5

ii. Schemes for 2019/20…………………………………………………..35-6

iii. 2019/20 Programme………………………………………………..…..36-9

Chapter 8: National and Local Deliverables…………………………….............40-74

a) Emergency Care…………………………………………………………………..40

i. Background…………………………………………………………....40-41

ii. Pre-Hospital Urgent Care………………………………………………..41

iii. Same-Day Emergency Care…………………………………………..41-2

iv. Cutting Delays in Patients Being Able to Go Home………………..42

b) Referral to Treatment Times (RTT)…………………………………………….43

i. Background………………………………………………………………..43

ii. Pain Management………………………………………………………43-4

iii. Guided Joint Injections……………………………………………...…..44

iv. Back Pain…………………………………………………………………..44

v. Outpatients………………………………………………………………44-5

vi. Procedures of Limited Clinical Priority……………………………….45

vii. Diagnostics………………………………………………………………..45

viii. Direct Referrals……………………………………………………………45

ix. Gynaecology………………………………………………………………45

x. Urology………………………………………………………………..…45-6

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c) Cancer Treatment…………………………………………………….…………..46

d) Mental Health……………………………………………………………………46-7

e) Learning Disabilities and Autism……………………………………..…….47-8

f) Children, Young People and Families………………………………………...48

i. Background……………………………………………………………..48-9

ii. Primary Care………………………………………………………..……..49

iii. Community Care………………………………………………………….50

iv. Reducing Pressure on Emergency Hospital Services…………50-51

v. Emotional Health and Wellbeing………………………………………51

vi. Learning Disability and Autism………………………………………..52

vii. Integrated Young People’s Wellness Service…………………….52-3

viii. Early Help Support……………………………………………………….53

g) Maternity…………………………………………………………………………53-4

h) Primary Care and Community Health Services……………………………..54

i. ‘Investment and Evolution: A Five-Year Framework for GP

Contract Reform to Implement the NHS Long Term Plan’………..54

ii. Investing in Primary Care…………………………………………….54-5

iii. Primary Care Networks – Future Development…..……………...….55

iv. Primary Care Networks and Multi-Disciplinary Teams…………….56

v. Primary Care Networks and Integrated Community Teams………56

vi. Primary Care Development – General Practice Forward View

(GPFV)………………………………………………………………………57

vii. Primary Care Commissioning – Outcomes Framework………...57-8

viii. Primary Care Contracting……………………………………………….58

ix. Estates……………………………………………………………….…..58-9

x. Primary Care Engagement…………………………………………..….59

xi. Engagement with Patients………………………………………………59

xii. Primary Care and the STP………………………………………………60

xiii. Community Health Services and the Long Term Plan………....60-61

xiv. Dudley CCG Progress on MCP Implementation……………….…61-2

xv. Long Term Plan – Alignment Plans for 2019/20…………………..62-4

i) Better Care Fund (BCF)………………………………………………………….64

i. Background……………………………………………………………..64-5

ii. The Emergency Response Team (Front of House)…………………65

iii. Discharge to Access, Pathways 1-3…………………………………..65

iv. Improved Discharge Flow……………………………………………….65

v. Single Handed Care………………………………………………………65

vi. Palliative Care……………………………………………………………..66

vii. Community Response Team (CRT)……………………………………66

viii. Reablement……………………………………………………………..…66

ix. Performance……………………………………………………..……...66-9

j) Medicines Optimization………………………………………………………….69

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k) Workforce………………………………………………………………………….70

i. Primary Care Workforce………………………………..…………….…70

ii. New Forms of Workforce……………………………………......….70-71

iii. Being the Employer of Choice…………………………………………71

iv. The Future of Commissioning………………………………………….71

l) Data and Technology……………………………………………………........71-2

i. Business Intelligence (BI)…………………………………………….72-3

m) Personal Health Budgets (PHBs) and Personalization………………….…73

Chapter 9: Commissioning for Quality and Safety………………………….…...74-6

a) Holding Providers to Account………………………………………………….74

b) Patient Safety…………………………………………………………………...74-5

c) Staff Satisfaction………………………………………………………………….75

d) Safeguarding Children, Young People, Adults and Children Looked-

After………………………………………………………………………………75-6

Chapter 10: Future Commissioning Organisation………………………………....77

Chapter 11: Governance and Delivery……………………………………….……….78

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1) National and Local Context

a) Background

In February 2017, the CCG approved its Operational Plan for 2017/18 – 2018/19. This plan now represents our local Operational Plan for 2019/20. It is designed in the context of the NHS Long Term Plan, the Black Country Sustainability and Transformation Partnership (STP) and Clinical Strategy, and the move towards a Black Country Integrated Care System (ICS).

This plan is designed to:

Build on our achievements in implementing our plan for 2018/19

Implement our plans heralded in our commissioning intentions for 2019/20 and 2020/21

Fully implement our new Dudley model of care, establishing place-based integrated health and care services, through the mobilisation of an Integrated Care Provider contract for our Multispecialty Community Provider (MCP)

Redefine our role as a clinically-led commissioning organisation, given the changes that will result from the commissioning of our new care model

Reflect the work we are doing as the local leader of the NHS, in conjunction with our NHS providers, our local government partners and the voluntary/community sector

Meet the expectations placed upon us through the national planning system

Respond to the significant clinical, service and financial challenges of the coming years

In the sections later in this document we have:

Identified the financial, performance, and health challenges we face

Reaffirmed and developed our objectives

Explained how our commissioning priorities will position us to have a sustainable local health and care system, centred upon the delivery of a new model of care and meeting our vision for population health and wellbeing

Demonstrated how we will ensure we meet the highest standards of quality and patient safety

We have shown how we will be:

More joined-up and coordinated in our care, so as to support the increasing number of people with long-term health conditions and complex care needs

More proactive in the services we provide with a strategic shift to ‘population health management’ and predictive prevention

More differentiated and personalised in our support offer to individuals, through engaging with and tailoring prevention to people most in need

The main focus of our plan is to mobilise the MCP contract by the end of the plan period. This will include the MCP becoming responsible for the delivery of a number of commissioning activities that are currently the responsibility of the CCG.

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This will be executed in a manner that is consistent with the “five major, practical, changes” to the NHS service model set out in chapter one of the Long Term Plan for the NHS. Our MCP will:

Boost out-of-hospital care

Redesign and reduce pressure on emergency hospital services

Provide more personalised care

Digitally-enable primary and outpatient care

Focus on population health

This is addressed further at in chapter 8, part h, later in this document.

b) Strategic Vision

Our original 5-year strategic plan established a new vision for healthcare characterised by:

A Mutualist Culture – recognising the mutual relationship between GP and patient and the associated rights and responsibilities in an organisation of member practices and registered patients.

The Structure of the System – moving away from traditional organisational boundaries and service categorisations to recognise the needs of individual patients in a modern world.

Population Health and Wellbeing Services – commissioning proactive population-based healthcare.

Health and Wellbeing Centres for the 21st Century – providing the capacity needed to deliver our vision of population health and wellbeing services.

Innovation and Learning – investing in research, technology and information systems as a basis for improving our organisational performance and the effectiveness of the system.

These principles are reflected in this plan, in our contribution to the Black Country STP and, most of all, in how we will commission a MCP.

c) Challenges

Challenges exist in terms of the system, finance, performance, health and quality.

i) System challenges

The key challenges facing the Dudley health and social care economy are:

A growing demand for healthcare from a population where, over the next two decades, the number of people over 65 will grow by 25,100 and the number over 85 by 9,900

The financial sustainability of our NHS partners

Budgetary challenges facing Dudley Metropolitan Borough Council, in relation to public health, adult social care and children’s services which may impact upon the development of the MCP

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The need to secure effective transformation in leadership and cultural terms at a local level to ensure our new model of care is capable of delivery

The need to secure full clinical engagement from clinicians across primary, community and secondary care

A primary care system that is under strain and requires radical change to becomes sustainable

An acute services provider facing challenges from the Care Quality Commission (CQC)

ii) Financial challenges

The CCG’s financial plan has been constructed to deliver a sustainable NHS in Dudley. The delivery of a financially sound health economy is, however, not without its challenges.

We set out in chapter 7 how we intend to implement a financial plan that meets all our duties and the business rules set out in the planning guidance, as well as the associated risks and mitigations.

iii) Performance challenges

Our contracts with providers have been constructed to ensure that all NHS Constitution standards are met.

There are specific performance challenges in relation to waiting times for cancer treatment and for diagnostics.

iv) Health challenges

The Dudley population is characterised by:

A higher proportion of people reporting a limiting life long illness or disability

A female life expectancy rate similar to the national average, whilst the male equivalent is 78.5 years, lower than the England average of 78.9

A gap in life expectancy between the least and most deprived areas of 8.2 years

25% of deaths in the 40–59 age band being due to cardiovascular disease, smoking, obesity and lack of physical activity

The percentage of people with a high BMI being significantly worse than the England average

A rate of depression (11.7% of GP-registered patients) that is higher than the England average of 9.9%

Our approach to tackling health inequalities is described in chapter 2.

v) Care and quality challenges

In terms of provider performance:

Dudley’s main provider, Dudley Group Foundation NHS Trust, is currently under scrutiny by NHS regulators and has been rated as ‘requires improvement’ by the CQC. This has had a significant impact on both providers and commissioners to ensure the necessary action is taken to improve its services

There is a failure to report serious incidents and the opportunity to learn is being lost

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Independent sector providers do not have a sufficient overview of quality metrics

We need to ensure proper triangulation of complaints and engaging NHS England appropriately where they are the commissioner

We need to gain sufficient assurance about the quality of care within care homes and work in partnership with Council colleagues to ensure patients are safe

At a population level:

Uptake rates for breast and cervical screening are below the national target of 80%

The CCG is in the worst performing fifth for the percentage of ED admissions that result in emergency admissions

A higher percentage of emergency admissions are terminal than the England average

A growing frail elderly population displaying multiple co-morbidities is a major factor behind our rationale for the commissioning of a MCP. This itself is designed to provide an effective response to issues with provider performance. The MCP presents an opportunity to have a more community-based response to emergencies that avoids unnecessary ambulance conveyance and admission to hospital, particularly in relation to the frail elderly and those in care homes. The MCP will provide the primary care out-of-hours service through the Urgent Treatment Centre and will offer an opportunity for continuity of care with integrated practices.

In addition, we are looking to address a number of the issues identified through our proposed outcomes framework at both a population and individual patient level.

The framework has already been developed and implemented in primary care and this will now be extended with the MCP. This will move us to a position where the system as a whole works to the same set of outcome measures.

2) Health Needs and Health Inequalities

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Our approach to health inequalities is informed by the Dudley Director of Public Health’s annual report, which considers health needs and inequalities across a person’s life course, from pregnancy and the years before starting school, through to the years after retirement.

In addition, the CCG contributes to the Joint Strategic Needs Assessment, which informs the Joint Health and Wellbeing Strategy (see part g).

Following further review with our Office of Public Health and the Health and Wellbeing

Board, We will set out how we will reduce health inequalities by 2023/24 and 2028/29,

focusing specifically on screening and vaccination programmes.

The outcomes-based MCP contract and a move towards a similar contract for acute

services will be key vehicles for improvement.

a) Prevention

Prevention and early intervention is fundamental to reducing health inequalities.

The MCP is being commissioned to deliver a set of health outcomes based on population health management and prevention. Upstream prevention of health conditions is the fundamental approach of our MCP. By helping our local population to remain in good health by providing services that work to prevent or reduce the chance of illness, or by managing people in poor health to remain in as stable a condition as possible, we can potentially avoid highly expensive hospital admissions and other service referrals. This will allow a more efficient use of scarce resources on unavoidable admissions.

By risk stratification we can identify groups at the highest risk and target appropriate treatment to reduce the likelihood of an emergency admission for a worsened condition later on. The MCP is responsible for four key aspects of population health management because it will:

Improve health status

Provide accessible urgent care

Provide joined up care for people with continuing needs

Provide intensive care for patients with the highest needs

b) Healthy Living Practices

The Healthy Living Practices model supports the move from services treating those who become ill, to a proactive- and prevention-focused MCP that takes collective responsibility for whole population health.

A non-clinical member of staff in each GP practice will be trained to take on the role of a Healthy Living Practice Practitioner, who will reduce the workload on GPs by:

Signposting patients appropriately, where there is no requirement to be seen by a member of the clinical staff

o e.g. directing patients to community services using the Community Information Directory, offering brief advice on lifestyle behaviours using MECC principles

Promoting awareness of the use of the Community Information Directory and other resources patients may access to self-manage their long-term conditions

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and minor ailments or illnesses, thus reducing the need for contacting their GP practice

o e.g. using the community pharmacy service for analgesia/cold remedies

Seeing patients referred to them by the clinical staff, where they may benefit from accessing lifestyle or other community advice

Provide 6 health awareness/literacy campaigns in the practice each year. This will be supported by the Healthcare Public Health team and PH other teams

Feedback from practice receptionists to the Office of Public Health suggests that they are largely feeling positive about taking on these roles as an enrichment of their own experience of work.

c) Early Years

During pregnancy and a child’s pre-school years, factors start to affect them which promote health inequalities in later life. Vulnerable women and women from more deprived areas and backgrounds are more likely to not take advantage of all the services and help that they are entitled to, and are more likely to engage in risky behaviours – such as smoking during pregnancy – and experience structural conditions that adversely affect children’s health and can cause inherent health inequalities throughout a child’s lifetime.

Meanwhile, behaviours and wider structural conditions that can engender attachment, resilience and readiness for school – such as breastfeeding and vocabulary enlargement – are less likely to occur among parents and children from more deprived backgrounds.

As such, health inequalities affecting the most disadvantaged children in the years before they start primary school set them up to suffer from continuing socio-economic inequality, and as a result suffer from continuing and further health inequalities, throughout their lives.

Outcome indicators related to smoking during pregnancy, breastfeeding and immunisation will be embedded within the outcomes framework of the MCP.

i) Pregnancy

Readiness for school, which is cultivated in these years and influenced by pregnancy, is the most crucial factor influencing potential health inequalities throughout an individual’s life. From conception, factors that can cause inequalities in health start to have influence. The environment surrounding the developing baby can influence the rest of the child’s life.

Unhealthy pregnancies are a significant causal input into these health inequalities. It is important that we work with the Office of Public Health to commission maternity services appropriately. We will ensure we have an appropriate jointly-developed service specification to support this and encourage women in vulnerable groups to book early for maternity services, so that they can benefit from healthy pregnancy services and support.

BAME women and those living in deprived areas are more likely to experience pre-term births, hospital admissions and interventions in labour. Women who receive care from the same midwife throughout their pregnancy, during birth and postnatally are 16% less likely to miscarry and 24% less likely to experience pre-term birth. We will

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therefore offer continuity of carer for pregnant women, targeted towards BAME women and those living in deprived areas, for whom midwifery-led continuity of care has been linked to significant improvements in clinical outcomes.

Smoking during pregnancy is up to 12 times higher among women in more deprived groups than more privileged sections of society. In Dudley, 14.4% of mothers are still smoking by the time of delivery, which is nearly 4% higher than the England average. Maternal smoking leads to babies being on average 250g lighter at birth and 50% more likely to suffer from heart defects. We will therefore offer specialist smoking cessation services to all pregnant women.

ii) Breastfeeding

Breastfeeding creates attachment between mothers and babies, helping to cultivate more resilient children. The 2016/17 breastfeeding rate in Dudley was only 55.3%, significantly lower than the England average (74.5%), and in some communities in the borough it is the exception, not the rule. By 6 weeks of age, less than 32% of mothers are still breastfeeding when in some areas of the country more than 80% of mothers are still doing so. The active promotion of breast feeding by primary care and the wider MCP will be essential.

We will include outcomes targets for breastfeeding initiation and continuation in maternity services and MCP contracts and engage with communities in Dudley to gain insight into what can be done to increase the proportion of women who intend to breastfeed.

iii) School readiness

Lack of conversation between children and their most trusted adults in the early years can introduce them to fewer new words, which can in turn limit their language development, impact on their school readiness and impact on their eventual educational attainment. Some children from the most deprived backgrounds are starting primary school without some basic premises that are necessary for an effective primary education, such as being untrained to use flushing toilets, insufficiently fed, unable to count to ten and barely able to communicate verbally with teachers.

During 2019/20 we will develop outcome measures that support school readiness within the Outcomes Framework for the MCP. We will also work with our partners to narrow the gap in learning outcomes between children looked-after and all children, and between children on a low income and all children.

iv) Health checks

The Office of Public Health sends health visitors to regularly review children in Dudley between birth and 5 years old, who can pick up on potentially unhealthy behaviours and delayed development. This enables parents to be supported to improve the child’s lifestyle and readiness for school. These are bringing positive results.

Council-commissioned health visitors and family centres also play a vital role in helping mothers and their families give their baby the best possible start by identifying health problems and risks such as post-natal depression, an unsafe environment and developmental problems, which are most effectively addressed early with support. Because the service has a limit on how many new mums it can support it regularly

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reviews its criteria (with a wide range of partners), to ensure that it reaches the most vulnerable, for example the service now supports teenagers with concealed pregnancies – which has been increasing in Dudley.

Health checks can also identify learning disabilities early, because these conditions

are usually present throughout a person’s lifetime. This is significant because people

who have learning disabilities often experience poorer access to healthcare and die

on average 16 years earlier than people without.

We will transform and integrate physical and mental health services for Children and

Young People through the MCP.

We will develop and deliver services to ensure that children in vulnerable groups can

access vaccinations. Through the MCP, NHS providers will be incentivised to narrow

the gap in uptake of preventative interventions such as NHS health checks, screening

and immunisation.

d) Being in Work, Reducing Poverty and Tackling Deprivation

We will work with our partners to develop and deliver an anti-poverty strategy for the

borough to reduce the impact that poverty has on the lives of children and young

people, adults and older people.

As an ‘anchor’ organisation in the borough, we will contribute to the Community Wealth Building Commission, which will explore how our collective resources can be spent to support the local economy, local communities and the local environment through social value.

i) Employment

Being economically active is a major contributor to reducing health inequality. The CCG has a role to play as an employer, an advocate for disadvantaged groups and as an agent of economic regeneration. We will work with our partners to provide multi-agency support to adults at risk of losing work, or out of work for health reasons, to manage their health, stay in work, or return to work.

The MCP will be a major local employer. Its employment practices will make it the employer of choice for staff. It is anticipated that it will seek to recruit, train and develop staff from amongst the local population. We will implement, encourage and support employers in the borough to implement healthy working practices.

We will work with our partners to develop and deliver an inclusive growth approach to the Metro extension corridor so that the benefits of investment reach disadvantaged communities along the corridor, and to ensure that communities living in the inclusive growth corridor have the opportunity to be involved and engaged in developments that will impact on them, for example, by exploring opportunities for participatory budgeting in improvements to the public realm.

ii) Vulnerable Groups

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People with severe mental health illnesses and learning disabilities often suffer earlier deaths and a higher risk of obesity, asthma, diabetes, COPD, cardiovascular disease and hospital admission. Employment is of significant importance to these groups.

The MCP Outcomes Framework sets outcomes of improved employment level for those with a learning disability and mental health need. These will support the reduction of inequalities.

Dudley practices are participating in the West Midlands Combined Authority’s “Thrive” Programme, referring patients for Individual Placement Support. We will maintain participation in this beyond 2019. This will assist people with severe mental illnesses and learning disabilities to find and retain employment, where this is a personal goal.

iii) Accessing services

There is evidence that health services can be harder to access and work less well for people living in disadvantaged areas. The reasons that people in disadvantaged areas are unwell can be complex and thus more difficult for health services to treat. They may also be more difficult to access from lack of transport or because service information is written in technical language that is hard to understand.

Appointments for preventative services such as screening or NHS health checks are given in working hours and can be difficult for people in routine/manual (i.e. lower-paying on average) occupations to attend without taking time off or losing pay. This is reflected in the lower uptake of NHS screening programs for conditions such as bowel cancer, where people who live in more disadvantaged areas are generally less likely to take up the offer of screening and so lose the benefits from an earlier diagnosis and a more treatable condition.

New surgery developments need to consider how they will improve access to primary care for people in more deprived areas. Improving accessibility is a key objective of the MCP.

iv) Fuel poverty

We will work with partners to develop a multi-agency healthy homes programme to reduce fuel poverty and accidents, which should target those that can benefit most from a healthy living environment, including people of all ages with long-term conditions, disabilities and those living in poverty. This should link with the MCP’s Integrated Care Teams.

v) Community resilience

More resilient communities where people receive support to retain their independence contribute to a stable socio-economic system. We will work with our partners to develop and deliver a comprehensive programme of work to develop resilience in early years and school readiness, involving health visitors, family centres, the voluntary sector, primary care and early years settings. We will also work with partners to roll out restorative and trauma-informed practice across schools, children’s services, the voluntary sector and NHS services to increase resilience to adversity in childhood.

We will continue work to empower people and communities with our partners in the voluntary sector. We will identify how we can contribute to increasing community resilience and delivering the community resilience outcomes that have been provided by local people, and participate in the ‘connecting conversations’ campaign,

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encouraging us all to connect people to the assets in their local community. This will be implemented following the launch of the new community information directory, which will include information about community assets in a single place.

The MCP presents an opportunity to have a more community-based response to emergencies that avoids unnecessary ambulance conveyance and admission to hospital, particularly in relation to the frail elderly and those in care homes. The MCP will provide the primary care out-of-hours service through the Urgent Treatment Centre and will offer an opportunity for continuity of care with integrated practices. The CCG and its partners will be involved in services to improve the emotional health and wellbeing of children and young people.

We are going to develop a communication centre and associated response, recommission the reablement service and commission a GP with special interest (GPWSI) in frailty, all by July 2019.

Around a tenth of the Dudley population are carers. Carers are twice as likely to suffer from poor health, primarily due to a lack of information and support, finance concerns, stress and social isolation. They often feel invisible and in distress, and up to 40% report mental health problems arising from their experience. Nationally, 600 people a day are quitting their day jobs because of the pressure of being carers.

Dudley’s MCP will empower and mobilise patients, their families, carers, communities, local employers and the voluntary sector. The MCP will operate in a manner consistent with the “5 principles” that support the delivery of the Five Year Forward View, including ensuring that carers are identified, supported and involved. Our Carers Strategy seeks to identify, support and involve carers by raising the profile of carers (where there is an increasing number of older people who are carers of older people, or who are carers of adult children with learning or physical disabilities). Carers Personal Budgets (CPBs) are offered to carers with eligible needs.

The Carer Support scheme has focused on the development and implementation of a new Carer Strategy. The Carer Strategy is a long-term plan with many of its elements being in the early stages of implementation. The carer performance framework is under development, with measures of residential and nursing home admissions due to carer breakdown being added in 2017/18, and we are going to commission a Carers Health and Wellbeing Service by September 2019.

vi) Obesity

Children in more disadvantaged communities are more likely to be overweight or obese, because unhealthy food is often easier to find in shops in more deprived areas than fresh fruit and vegetables, and unhealthy food also often has a longer shelf-life. 27% of children in Dudley are overweight by the time they start primary school, compared to 15% in the healthiest areas of the country. In 2017/18 more than 25% of children aged 10-11 in Dudley were obese – worse than the England average of 20.1%.

Primary care will work with the Office of Public Health in promoting the ‘Daily Mile’ walk at all primary schools in Dudley, including exploring incentives for schools with pupils from deprived areas or those with higher rates of overweight children. We will deliver

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a programme of deliberative enquiry with families from across the borough to co-design and deliver action to promote healthy weight, within the context of a whole system approach to obesity.

e) The Elderly

i) Isolation

Over 1 in 8 households in Dudley have a person aged over 65 living alone – and loneliness is as harmful to our health as smoking a pack of cigarettes every day. When people become socially isolated they become more vulnerable and are less able to participate in voluntary activities and become part of a virtuous circle that improves community resilience. Isolation and loneliness put additional pressure on health and social services as people find themselves unable to cope. Reducing loneliness is one of Dudley Health and Wellbeing Board’s top three priorities.

We will continue to commission services from the voluntary sector, such as support for the elderly and carers.

Our “Integrated Plus” service builds the bridge between primary care and the voluntary sector, through a social prescribing approach. The locality link officers and their support officers are free of professional boundaries and can therefore enable teams to look holistically at individual needs. Those who were previously socially isolated are now connected back into their local communities; small non-health related problems are resolved which then gives confidence to individuals and reduces their utilisation of healthcare; patients report how their quality of life has improved; and many now contribute more by being part of social groups and thus adding social value back into their community. The MCP will build on this way of working with the voluntary sector to recognise the value of supporting community, carer and social networks to help maintain the resilience and quality of life for individuals.

We will maintain the Integrated Plus service beyond April 2019. We will scale up health

coaches and self-management for people with long term conditions, so that more

people can be empowered to care for their own health and wellbeing.

ii) End-of-Life

When the end of life approaches most people say they want to die at home rather than hospital, but people who live in more disadvantaged areas tend to be more likely to die in hospital than those who do not.

Shared care plans will be developed with a range of personalised services wrapped around the patient to meet their needs, supported by a named case manager and proactive monitoring of progress against the agreed plan. We have commissioned a 7-day palliative care team, increased the number of advanced care plans, and are commissioning additional support for end-of-life patients in residential care.

During 2019 we will review the end-of-life pathway to avoid admissions to hospital and amend the care home contract, such that care home staff initiate preferred place of care discussion. Further analysis will be undertaken to understand the causes of inequalities at the end of life, indicated by the deprivation gap in those who die at home.

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f) Other vulnerable groups

The NHS Long Term Plan identifies other vulnerable groups affected by health inequalities. These include:

People in the most deprived decile

People in the most deprived geographical areas

People with autism

Homeless people

Carers

People with gambling problems

We will assess the significance of these inequalities for Dudley and identify appropriate actions.

g) Dudley’s Joint Health and Wellbeing Strategy

The CCG is a partner in the Dudley Health and Wellbeing Board and contributed to

the development of the 2017/22 Joint Health and Wellbeing Strategy, informed by the

Joint Strategic Needs Assessment. This is based upon four principles and three goals.

4 principles:

A new relationship with communities

A shift to prevention

A stronger focus on joining up health and care services

A stronger focus on what the strategy has achieved

3 goals:

Promoting healthy weight

Reducing the impact of poverty

Reducing loneliness and isolation

This plan has been informed by and is consistent with this strategy. Our development

of a new care model based around integrated care, preventative action, the

empowerment of people and communities, and the delivery of health and care

outcomes, meets the 4 principles.

The MCP Outcomes Framework itself addresses the 3 goals as well as other specific

actions identified in the plan.

3) Public Feedback

Our annual ‘Duty to Report’ details our public engagement activity throughout the year. From this and the insight from engagement exercises led by our partners, we can build an understanding of the views of local people on how services can meet their needs.

Detailed in this chapter are some key views we have already heard which have helped to shape this plan.

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a) Developing Dudley MCP

Extensive public, clinical and stakeholder engagement has taken place to develop the proposals. Engagement has taken place in relation to the prospectus, clinical model, service scope and outcomes framework. There is strong clinical support in primary, community and secondary care, and a concern to see its implementation accelerated. Extensive engagement with patients, professionals and the public has shown us that different constituents of our population require different responses:

The majority of our population want enhanced access to care. They want more flexibility in the time and mode of access

Many, especially those with long term conditions, want improved continuity of care. They want more consistent and proactive services that support them to manage their conditions and achieve their goals. They have needs (mental and physical) that are independent and that change. They expect services to do the same

Some, notably those with multiple co-morbidities, those with frailty and those nearing the end of life, want better coordinated care. They want the services that are supporting them to work closely together, integrating (rather than duplicating) care closer to home and improving their experience of it

From formal public consultation in 2016 we learnt the following:

b) Supporting the Dudley vision for community resilience

The community-led vision for Dudley was launched in September 2018 by Dudley Metropolitan Borough Council. The ambitious plan, developed after engagement with local people, outlines plans for the next 12 years in creating a thriving borough where people want to live, work and visit. The CCG is a key partner in the delivery of the Dudley Vision, in particular the ambition to create a place of healthy, resilient, safe communities with high aspirations and the ability to shape their own future.

c) Listening to learning disability service users

The Transforming Care Partnership has prioritised engagement with service users, their families and carers to ensure meaningful service users’ voices are heard and used. This demonstrates that service users are largely in favour of the new community-based services and identifies the following key themes from service user feedback:

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Service users had a negative experience of hospital care and were much happier in their community placements, where they generally felt safe and experienced improved health outcomes

Service users have a variety of aspirations and ambitions and should be helped to pursue them to promote independence and self-confidence

Increased focus on early intervention is vital to avoid hospital admissions

Service users and their families should be seen as partners in planning their care

Service users require consistent and ongoing support from a multi-specialist team to avoid and alleviate crisis situations and prevent future hospital admissions

In terms of access to other health services, local learning disability service users expressed their views at a ‘Big Health Day’ in November 2018. We heard about the best environment to improve hospital care, concerns about continuity and access to general practice and the wish for more time to hear their views during consultations.

d) Measuring value in acute care

In December 2018 we explored the expectations of local people when using hospital services. There were many experiences shared. The comments, concerns and questions raised throughout the event were diverse and wide ranging but mainly fell into the following six expectations of high quality care:

Effective communication between healthcare professionals and also between the clinician and patient/family

Good quality treatment and post-treatment care

Accessible hospital services, supported by good facilities

Patients are cared for by competent healthcare professionals

Demand and capacity are managed effectively

Outcome measures focus on improving the patient experience

e) Driving improvements in primary care

Throughout 2018/19 we have heard the views of many people on recent practice and branch surgery closures. This feedback, whilst negative in relation to the closures themselves, has indicated a general acceptance that we need to act to make our primary care services more stable.

More widely, we have analysed the response to the GP Patient Survey and identified areas for action. The highlights from the survey follow.

Overall, how would you describe your experience of your GP practice?

Dudley CCG is in line with national average for those who responded “good” or “poor”:

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Generally, how easy is it to get through to someone at your GP practice on the phone?

Dudley CCG performed 6% worse than the national average for patients who responded that it was “easy” to get through on the phone:

Online services:

Dudley CCG as a whole had a significantly higher percentage of patients who responded that they were aware of and used online services than the national average. However, there was a wide variance in individual practice scores:

Overall experience of making an appointment:

Dudley CCG performed 5% lower than the national average for patients who responded that their overall experience of making an appointment was “good”:

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In 2019/20 we will involve local Patient Participation Groups (PPGs) in developing solutions to the issues raised at each practice.

We will continue to seek views on any specific service developments and plans. We will hold a public consultation on proposed changes to Learning Disability services and ensure that any other service changes are informed by local views.

f) End-of-life care

In 2019/20 we have help workshops to explore views on the end of life. These informed the

We will work with partners to raise awareness of ‘Dying Matters’ and support local people to talk openly about their experiences and wishes for the ends of their lives.

g) Co-production

We are reaffirming our commitment to empowering people to have a voice in the decisions we take and are developing a strategic co-production group with the aim of building the capacity, skills and confidence of local patients and carers to have a voice and influence locally in the development of health services. This group is in addition to our existing involvement mechanisms:

Quarterly public Healthcare Forum

PPGs in every practice (46 in total)

Patient Opportunity Panel (made up of PPG members)

Annual #mefestival aimed at younger people

h) Championing the voice of young people

The CCG funds a Young Health Champions (YHC) Project Coordinator, in partnership with Dudley Public Health. This post is managed by Healthwatch Dudley and the Dudley Council for Voluntary Service (DCVS). This creates an independent and flexible approach, to encourage young people to share their issues around health services and help develop solutions. We are committed to the scheme and will reinvest in 2019/20 to ensure its continuation.

4) Key Objectives and Priorities for 2019/20

The CCG Board has set its corporate objectives for 2019/20.

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a) Corporate Objectives

Objective 1: Develop the MCP place-based care model – create a local health and

care service with our partners.

Deliver on:

1. OD for MDT/ICT working

2. Development of the SPA/ urgent community response and recovery support

3. Integrated governance between primary and community services

4. CCG activities in the MCP

5. Development of effective PCNs of local GP practices and community teams

6. Supporting people living in care homes by implementing the EHCH care model

7. Supporting people to live well

8. Reducing pressure on emergency hospital services

9. Personalisation – giving people choice and control

10. Digital-first primary care

11. Management of long term conditions pathways

12. Local place-based assurance

Objective 2: Develop the quality improvement assurance framework – ensure that the

services we buy are of good quality, delivered safely and perform well.

We will bring together our assurance processes and report to a single committee. We

will make positive improvements in primary care as a basis for the local care model.

We will improve the assurance to the governing body on the delivery of quality and

safety.

Focus on key areas for improvement:

1. The urgent care system

2. EOL/mortality in the ED

3. Maternity services

4. Learning disabilities and the Transforming Care Programme, including

individual case management, community care and the wider scope of access

to services for people with learning disabilities

5. Children and young people’s services

Deliver on:

1. The Improvement and Assurance Framework measures where we need to see

significant improvement

2. The nine ‘must do’s’

3. Health inequalities

Objective 3: Manage the money well.

1. Deliver the QIPP plan.

2. Financial performance

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3. Demonstrate effective financial risk management

Objective 4: Maintaining compliance with our statutory duties – work within the law.

Deliver on the duties which we directly manage now and understand how we will

quantify the delivery of these by the MCP, including:

1. NHS Continuing Healthcare

2. Medicines management

3. Safeguarding

4. Individual case management

5. The functions evaluated by A&G or REM & HR, i.e. GDPR, H&S, ERPP, E&D

Objective 5: Develop the plans for the CCG for both the here and now and the future

– make sure the CCG is the best we can be.

Deliver on:

1. Developing our vision for the Long Term Plan

2. Improving collaboration with Walsall CCG

3. Collaboration with partner CCGs

4. Moving towards a single CCG team

5. Achieving the 20% management cost reduction

6. Establishing a single management of change process

7. Building CCG resilience and maintaining business continuity

8. Reviewing CSU support requirements

9. Staff engagement process

10. Develop and deliver OD plan

11. Improving our relationships with primary care practices

12. Our resilience, effectiveness and preparations for change

Objective 6: Develop place-based partnership arrangements – work well with the

Local Authority.

To understand the role of the CCG in:

1. The local system for placed-based care

2. Economic regeneration and the creation of community wealth

3. Joint statutory arrangements with the Council and other partners

Ensure effective governance and delivery of statutory responsibilities, particularly with

the Council in the context of moving to a future single CCG team arrangement.

Objective 7: Lead and design the development of the Black Country STP – work with

the other Black Country CCGs and providers to provide joined up health and care

services where it is best for the public.

To ensure the CCG makes a fair and appropriate contribution to:

1. The system in readiness for moving towards an ICS

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2. Service review programmes and the clinical leadership group agenda

3. Evaluating risks and opportunities for acute, mental health and learning

disability provider collaboration

4. Ensuring alignment between CCG commissioning of services which form part

of the horizontal integration plan

5. Increase our contribution to the Clinical Leadership Group for effective

influence on clinical priorities across the Black Country

Objective 8: Develop the IT systems to make a real difference to patient care.

1. Ensure appropriate digital considerations are made when making

commissioning decisions

2. Ensure the requirements of the Long Term Plan are included in CCG digital

strategies/BC LDR

3. Ensure compliance with GP IT operating model

4. Manage performance of IT providers

b) Priorities

Our plan is developed in the context of the NHS Long Term Plan and addresses the 2019/20 national planning guidance deliverables:

Emergency Care

Referral to Treatment Times (RTT)

Cancer Treatment

Mental Health

Learning Disabilities and Autism

Primary Care and Community Health Services

Workforce

Data and Technology

Personal Health Budgets and Personalisation

In addition, we have set out our key priorities in relation to:

Children, Young People and Families

Maternity Services

Better Care Fund (BCF)

Medicines Optimisation

Commissioning for Quality and Safety

Future Commissioning Arrangements

Governance and Delivery

The Long Term Plan clearly describes the requirement to implement Integrated Care Systems (ICSs). This and the development of our local system are addressed in the next chapter.

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5) Black Country System – STP/JCC

a) Developing the Black Country Integrated Care System

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The Black Country STP is made up of four ‘places’. Each of the four ‘places’ are developing an Integrated Care Partnership and/or Integrated Care Provider (ICP), which incorporates local primary and community care and local mental health and acute services, and works together with local council care and public health services, and the local CCGs. A three-phased approach towards a single ICS and local place-based provider arrangements are being developed, with 2019/20 as our transition year. During 2020/21, a single executive team will be established to serve the four CCGs. The four ICPs will then come together, with the collaboration of acute, mental health and ambulance services, at scale, to form our Black Country ICS by April 2021.

CCGs will become leaner, more strategic organisations, which support providers to partner with local government and other community organisations on population health, service redesign, and Long Term Plan implementation. This will prevent avoidable hospitalisation and tackle the wider determinants of mental and physical ill-health. The ICS will agree system-wide objectives with the relevant NHS England/NHS Improvement regional director and be accountable for their performance against these objectives.

It is a pragmatic and practical way to deliver the “triple integration” of primary and specialist care, physical and mental health services, and health with social care. Our combined CCG operational plans are designed to support the ongoing development of our ICS and are based upon four main themes from our wider system strategy:

WalsallWolverhampton

Dudley

Sandwell and WestBirmingham

Black Country Integrated Care System

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Each CCG has set out their own operational plan to progress the development of their local ICP

The CCGs have agreed a suite of services which we are seeking to commission strategically, at scale

We are collaborating on key system-wide service review and development initiatives which are set out in our shared Black Country Clinical strategy as developed by the Black Country and West Birmingham STP

We are seeking to make a stepped-change in the way we commission emergency and urgent care services, with a focus on ambulance services as the key shared connecting service that operates across the system and its interface with all other providers

b) Developing our Local Integrated Care Partnerships/Providers

Whilst there are differences in design and pace of development with each local ICP, there are also many common themes which we will be collaborating on increasingly as four CCGs. These themes include:

Health and care services being brought together as a means of responding to the needs of a growing frail elderly population displaying multiple co-morbidities

Creating a more resilient primary care system and placing the patient registered with general practice at the centre of the care model

A population health approach to the management of demand

A move away from activity-based contract models to our Integrated Care Partnerships/Providers being responsible for the delivery of a set of health and wellbeing outcomes

Each CCG has begun work on developing an Outcomes Framework to look at improvement in patient health over time. We are committed to working together to align these frameworks, which predominantly focus on the health management of our local populations, with a view to agreeing an overall common outcomes framework for the Black Country ICS.

c) Strategic Commissioning in the Black Country

There are a number of priority services on which our CCGs have been collaborating to develop strategic commissioning plans. We plan to collectively agree with our providers both the specification and performance requirements for these services and their expected pace of development.

i) Mental Health Services

Following a joint workshop with providers in May 2018, the services which have been collectively identified - from an STP perspective - are those which:

Are specialist in nature

Can be provided with greater economies of scale and scope across a larger footprint

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Demonstrate there is variation and/or service deficits in quality and provision, respectively

Are (in some instances) imperatives as part of the Five Year Forward View for Mental Health delivery programme

Can be addressed in the relatively short term

ii) Cancer

We are working as part of the West Midlands Cancer Alliance to deliver the national Cancer Priorities, including:

Working with providers to ensure the implementation of nationally-agreed rapid assessment and diagnostic pathways for lung, prostate and colorectal cancers

Working with partners to achieve improvements in cancer screening uptake and early diagnosis

Commissioning cancer services that offer consistent and high quality services, including meeting national waiting time standards for diagnosis and treatment

Improving patient experience, including through implementation of the national Recovery Package

We will work with partners across the STP to create a cancer plan for the Black Country, looking in particular to explore opportunities to develop local services to enable more people to be treated in the STP.

iii) Maternity

All four CCGs are adopting the same maternity specification, with local changes to reflect demographics and population needs.

This approach is supported by the Local Maternity System (LMS), which will reflect the summarised specification. The LMS plan for our STP is assured by regulators as a comprehensive, honest and robust system approach to improving maternity services across the system.

iv) Transforming care

The Learning Disability service (as part of the Transforming Care Programme) will be a single delivery model across the Black Country. It will support the discharge of patients from hospital with intensive community, case support and forensic staff as well as acting in a preventative manner to minimise future hospitalisation of this cohort of patients.

v) Care homes

We want to build on the excellent example from Walsall CCG on their working with the Care Home Sector to improve their capabilities and reduce conveyances to A&E and develop this work with Local Authority Partners.

vi) Empowering people and communities through personalisation

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Each ICP places more importance on harnessing the renewable energy of people and communities and the need to engage with communities and citizens in new ways, involving them directly in decisions about the future of health and care services.

d) Our Clinical Strategy

Our joint clinical strategy, developed by our STP, sets out a number of service issues which we plan to progress collectively, including:

Primary care

Children and Young People (CYP)

Cardiovascular disease

Musculoskeletal (MSK) conditions

Respiratory disease

Frailty - specifically the Care Homes Agenda

Histopathology

Interventional radiology

We expect to establish a set of shared priorities arising from the clinical strategy, in partnership with the rest of our STP.

e) Joint Development of Emergency and Urgent Care

We are seeking to make a stepped change in the way we commission emergency and urgent care services, with a focus on ambulance services as the key shared connecting service that operates across the system and its interface with all other providers. We commission ambulance services jointly with all other CCGs across the West Midlands and in partnership with them we plan to change the way we commission this service. However, as part of this we also plan to develop the Black Country model for emergency and urgent care, which sets out how the ambulance service will be able to interface with each local hospital and each local ICP as these develop, in order to improve the experience of patients, reduce avoidable conveyances and provide enhanced care to people in the community.

6) Future Dudley System

Multispecialty Community Provider (MCP) At the heart of this operational plan is the procurement of a MCP. The MCP Care Model, with ten Integrated Community Teams (ICTs) serving populations of c. 30,000 patients across the five Dudley localities, aims to operate as a ‘team without walls’,

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integrating primary care with a range of other services (including mental health and social care), to coordinate care and improve outcomes for patients most at risk.

This includes a different approach to outcomes. The Dudley MCP will introduce a truly outcomes-focused framework which is much broader in scope and more ambitious in aspiration than traditional targets and quality requirements.

To support the development of the MCP, the CCG will commission a range of services to increase support and provision of care in the community, together with the capability to manage capacity and access to care in a more streamlined way. This is likely to impact on existing services commissioned by the CCG, as well as additional capacity.

Early changes are expected to be made in the shape of community services to integrate around the ten ICTs, and to the provision of Single Points of Access to coordinate into a single MCP Communications Centre. The CCG will work with the MCP partner organisations to enable changes to be made in advance of the MCP organisation being formed. This may require resources to be moved between organisations where a coordinating body is agreed prior to transfer to the MCP.

It is expected that more detailed plans will be developed by the MCP Transition Board. As this is a partnership body, it is proposed that changes agreed by this body will be accepted by all organisations as a variation to the commissioning plans, without contractual notice periods being sought.

We will develop similar arrangements covering the rest of the planned and urgent care system (with the exception of the ambulance service). This will reflect the features of the MCP contract:

A Whole Population Budget

A set of contracted outcomes

A longer contractual length These contracts will be linked by a gain/loss share agreement.

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In our fully developed system, the CCG will hold three main outcomes-based contracts: the MCP, the Dudley Group NHS Foundation Trust (planned and urgent care), and the West Midlands Ambulance Service (WMAS).

We plan to establish "shadow" contract arrangements for the two elements of the system by 1 April 2019. This will necessitate a different approach to commissioning and a different style of commissioning organisation which this plan addresses.

7) Activity/Finance

a) Key Planning Assumptions and Business Rules

The financial plan has been prepared taking NHS England specific assumptions around growth and inflation into account, and these are summarised in the following table:

CCG PLAN AS SUBMITTED

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NHS ENGLAND PLANNING ASSUMPTIONS & BUSINESS RULES

2017-18 2018-19 2019-20

Business Rules

Minimum 0.5% Contingency Fund Held

0.5% 0.5% 0.5%

Minimum 1% Cumulative / Historic Underspend

1.2% 3.1% 2.5%

Plan triangulation

Commissioner financial plans must triangulate with efficiency plans,

activity plans and agreed contracts; finance, efficiency and activity

assumptions must be consistent between commissioners and

providers

Quality Premium Funding must be applied to

programme spend

Minimum in-year financial position

All Commissioners are required as a minimum to break-even, subject to

prior agreement of drawdown of historic underspends

Minimum contribution for Better Care Fund must be complied with

1.7% 1.98% 1.79%

NHS ENGLAND PLANNING ASSUMPTIONS & BUSINESS RULES

CCG PLAN AS SUBMITTED

2017-18 2018-19 2019-20

Growth & Inflation Assumptions

Demographic Growth-local determination based on ONS age profiled weighted population projections

0.3% 0.29% 0.27%

Prescribing Inflation expected range 4%-7%

6.5% 6.5% 6.5%

Mental Health Investment Standard in line with allocation growth plus 0.7% for 19/20

2.0% 1.99% 6.0%

Net QIPP Savings – not less than 3%

3.1% 3.5% 3.3%

Running Costs Not to exceed management costs allowance in each financial year (per head of population)

Achieved £21.91

Achieved £21.29

Allowance £21.05 Planned £19.17

b) Key Features of the Plan

i. Overall Surplus - the CCG is planning for an overall surplus of £11.69m in 2019/20. This has been developed in line with the business rules set in the planning guidance and adheres to the control totals set over the two financial years by NHS England. For 2018/19 this consists of £12.65m as the CCG’s initial planned surplus for 2018/19, plus £0.96m in year surplus agreed with NHS England. For 2019/20 this consists of the planned £13.61m surplus to be

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carried forward from 2018/19 less the £1.92m planned draw down to achieve the revised control set.

ii. Resource Limit – the CCG’s total notified allocation increases from £477.4m to £504.3m. The increases are due to demographic growth of £23.7m, the non-recurrent inclusion of the in-year drawdown of historic surpluses achieved of £1.9m, and the £1m included for the transfer from specialized services. The CCG remains below target allocation by 1.26% in 2018/19 and 1.32% in 2019/20.

iii. Running Costs – such budgets are increased slightly due to population changes and in line with NHSE guidance, a further 20% reduction to CCG running costs allowances in 2020/21 has meant savings plans are to be developed and implemented in 2019/20 to address the reduction. This results in a budget of £21.29 per head of population in 2018/19 and £19.17 per head of population in 2019/20.

iv. Underlying Surplus as percentage of recurrent allocation – this has reduced from 1.2% in 2018/19 to 1% in 2019/20. Implementation of latest planning guidance has resulted in an increase in recurrent commitments required to ensure delivery of the long term plan, in the main Acute tariff impact changes and growth of investments in community, mental health and primary care to meet the required investment standards. This further demonstrates the requirement for a more robust financial framework, responsibility and accountability for the remainder of 2018/19 and in 2019/20.

v. QIPP – the QIPP target for 2019/20 is £16.8m, equating to 3.3% of resource. The main initiatives are set out at part c. It is imperative that these schemes deliver the operational and financial impact expected to maintain the financial position of the CCG.

vi. Risks and Mitigations – risks identified in the plan are:

The contract with DGFT is yet to be agreed and includes risk around any potential increases in contract value to be negotiated.

QIPP delivery – The cash releasing target for 2018/19 (£16.99m) and 2019/20 (£16.8m) is extremely challenging and the extent of slippage against non-delivery of cash releasing savings is a significant risk to the CCG. QIPP PIDs have been developed however a risk of £2.3m slippage of efficiency savings has been identified following the risk profiling of the QIPP programme for 2019/20.

Prescribing - Volatility of prescribing spend remains a key risk in 2018/19 and 2019/20. QIPP schemes in prescribing have been developed and amount to a net saving of £4.2m, whilst the schemes are good and the rationale is clear there is a risk they may be too ambitious.

NHS Continuing Healthcare – Further increase in demand for packages of care remains a risk. Notification of the Funded Nursing Care rates for 2019/20 are yet to be received.

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Acute over-performance – A risk that demand for acute services, such as emergency care and elective care exceeds the level of growth assumed within the plan. Over-performance could also occur as a result of non-delivery of the QIPP programme.

If such risks occur, they will be mitigated by the use of contingency, risk reserves and delaying investment plans initially, although there will be the need to implement additional actions, such as extra QIPP schemes, disinvestment and decommissioning if required.

c) QIPP and RightCare

i) QIPP Plans 2019/20

The QIPP programme is being developed with a focus on ensuring that the identified schemes are deliverable and meet the quality impact assessment tests. Further testing is underway to ensure the affordability of any investments required to deliver the programme against the savings being made. Regardless of required changes to the programme, the CCG is confident of delivering the recurrent value of the programme in 2019/20, whilst identifying non-recurrent slippage in order to cover any part year effects.

As part of the QIPP development process, the GP Clinical Forum has considered a number of potential opportunities for new schemes and opportunities under the RightCare programme. A number of the new proposals have been tested through GP locality meetings.

Based on the likely requirements for the financial plan, QIPP plans are being developed to deliver a programme of £16.78m cash-releasing savings (3.5% of CCG allocation) in 2019/20, with a full year effect of all schemes being delivered for 2020/21. Wherever possible, schemes will be aligned to the emerging MCP model to ensure a smooth transition and to enable the QIPP programme to transfer as a legacy in the areas for which the MCP will have responsibility.

For each of the areas identified, an executive, clinician, finance and commissioning manager lead, have been identified to develop the scoping template for each scheme and determine initial project requirements, likely delivery milestones and value. For areas requiring business cases, these have been overseen by a group consisting of representatives from quality improvement, governance, finance, information and public engagement. Business cases have been approved by the Commissioning Development Committee (CDC) where required. Project Initiation Documents (PIDs) are in place for each scheme with a 2019/20 delivery component, some being agreed as part of the sign off process for 2018/19, when the implementation phase required a longer-term development.

The current plans give a saving of £16.78m for 2019/20. Additionally, the Prescription Ordering Direct (POD) and Musculoskeletal conditions (MSK) schemes deliver savings in primary care that are not cash-releasing.

As part of the programme development, the CDC has agreed business cases for:

MSK – First Contact Practitioners

MSK – Joint Injections

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Minor Eye Conditions

Community Respiratory Service

Urgent Treatment Centre (UTC)

Improving Access to Psychological Therapies (IAPT)

POD

High Intensity User Service

Care Home Team

End of Life support to Care Homes

Paediatric Triage

Further cases are being developed to deliver:

Back Pain Management

Diagnostic pathway support (i-refer)

Extension to community rehabilitation

Dermatology

Continence provision

The current QIPP programme is a bottom-up delivery of identified schemes. A further level of scheme will be developed to deliver a top-down saving for all areas of CCG spend and achieve headroom in the process. This process will start in January and should add additional schemes during the second half of 2019/20, to backfill start dates of current schemes and begin to deliver the 2020/21 programme. A similar review in 2018/19 generated additional savings of £3m.

The QIPP programme has also been assessed twice by the Internal Audit programme during 2018/19, with the latest rating giving significant assurance.

ii) Schemes for 2019/20

PIDs will be produced for all schemes with a 2019/20 financial delivery, where they are not already in place. The PIDs broadly follow the national best practice format in the Menu of Opportunities (MoO) and all have executive, project, financial and clinical leads. Each will be assessed against the NHS England framework (once the 2019/20 version is published) and risk-scored centrally in the CCG. The risk outcome will be shared with the project lead.

There are twelve RightCare schemes, which build on the redesigns developed during 2018/19. All have been discussed and agreed with the RightCare lead. In the updated RightCare summary, most of the opportunities identified in 2018/19 have reduced to statistically insignificant levels, with the exception of MSK, where the CCG is a huge outlier nationally and against the peer group comparators. There are smaller areas requiring investigation and these will be built into the stretch target schemes to start a programme for 2020/21. The largest unexplored opportunity is Genito-Urinary medicine (GUM).

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iii) 2019/20 Programme

Scheme Description Value

2018/19 2019/20

Diagnostics

advice and

guidance

Our clinical teams recognise that there are too many inappropriate

referrals for procedures such as non-obstetric ultrasound. We will be

working more closely with the hospital specialists to ensure

appropriate advice and guidance is sought to screen out those

inappropriate referrals. This will reduce the need for patients to

undergo inappropriate tests and save the system money.

£13,000 Full year

effect

£296,000

Paediatric

triage

To ensure that children who require further advice from hospital

colleagues are seen in the right place, by the right person the first

time, each of the referrals made to hospital by our GPs are reviewed

beforehand by a specialist doctor/nurse to ensure they are directed in

the right way. This prevents children being seen by the wrong

person/department in the first instance, improving the experience of

care and ensuring timely appointments with the right person first time

and saving money for the system.

£121,000 Full year

effect

£119,000

Pain

management

Clinical evidence suggests that if people see no benefit from two joint

injections, they should receive no further injections. There is a policy

in place for this in Dudley and we want our hospital to adhere to this

policy to reduce wastage of injections which are providing no clinical

benefit.

£400,000 Full year

effect

£153,000

Urgent

Treatment

Centre

We will be working with the provider of our Urgent Treatment Centre

to ensure that they are maximising the benefits from their front door

streaming. We want to ensure that only those people who really need

to be seen in the Emergency Department (ED) are seen there.

Streaming people who can be seen by a GP in the Urgent Treatment

Centre instead will ensure the ED is there for those who really need

it. It will also ensure that care is provided in the most cost effective

way and encourage the right behaviours in our patients.

Not

delivered

£603,000

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Hospital

Admission

units

We recognise that we need to work with partners to ensure the most

efficient flow through our ED. We believe that there are some changes

that can be made internally to this department to improve the way that

people who need a hospital stay are admitted in a timely way. This is

particularly true for those who are most frail. To ease the flow we are

proposing support the hospital to implement a frailty unit and a

number of other recommendations to improve the experience, quality

of care and the use of resources.

Not

delivered

£750,000

Ambulance

triage

When an ambulance arrives at the hospital we want the crew to be

able to hand the patient over to the teams within the ED as soon as

possible. Any delays in this handover result in essential ambulance

resources being removed from attending to other patients, disrupt the

patient’s care and result in fines to the CCG. We want to work with

the ED to become more efficient at receiving patients and work with

the ambulance service to ensure that they don’t send patients to

hospitals who can receive care in the community. We believe this

work will improve quality of care and save the Dudley system money.

Not

delivered

£200,000

Reduction in

excess bed

days

When people are ready to leave hospital we want to ensure they can

be discharged as soon as possible. Any delay in discharge results in

the bed not being available for other patients (impacting on the flow

through the hospital), the person in the bed not being able to

rehabilitate as quickly as they should be, and in more cost to the

system. We have made a great reduction in what we call excess bed

days over the last 12 months by working with partners and we want

to ensure this continues.

£754,000 £200,000

full year

effect

Improves

Access to

Psychological

Therapy (IAPT)

We know that people with long term conditions sometimes experience

episodes of poor mental health. These can affect someone’s ability to

manage their condition and result in more attendances to the hospital

for outpatient appointments and emergencies. By increasing the

access to talking therapies for people with Long Term Conditions we

hope to reduce the number of these appointments as people will feel

more able to manage their conditions.

Not

delivered

£300,000

Prescription

Ordering Direct

(POD)

Our Prescription Ordering Direct service gives patients the

opportunity to complete repeat prescription ordering over the phone,

with access to specialist medicines advisors who ensure that they are

getting the right medication in the right quantities. This scheme

currently runs in a handful of practices in Dudley and has shown

improved experience for patients, reduced workload for our practices

and savings in medicines wastage. In 2019/20 we will roll this service

out to all practices.

£50,000 £790,000

End-of-life

support to care

homes

We want people who are at the end of their life to die in their place of

choice. During 2019/20 we will invest in the hospice sector to support

care plans and allow residents to die in their normal place of care

rather than going into hospital. This will enable more patients’ end of

life preferences to be achieved, support families and carers to make

this happen and save money by reducing the number of hospital

admissions at the end of people’s lives.

£50,000 Full year

effect of

£70,000

Colonoscopy

reduction

There is a test called faecal calprotectin which can be done to

differentiate between irritable bowel syndrome and bowel cancers.

We plan to introduce this test to avoid the number of colonoscopies

that are performed. This is a less invasive procedure, provides an

accurate result at a lower cost and should result in savings to the

system.

£50,000 Full year

effect of

£20,000

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High intensity

users

There are a small number of people in Dudley who use our

emergency services very frequently. By working with these people to

address the wider issues which may be affecting their lives causing a

reliance on emergency services, we hope to reduce attendances,

improve lives and save money.

£130,000 Full year

effect of

£170,000

Day case to

outpatient with

procedures

At present there are some procedures that are delivered as day cases

and are paid for as day cases. We will work with the provider to

ensure, where appropriate, that more of these procedures are

delivered as outpatient appointments and are costed at that lower

rate.

£195,000 Full year

effect of

£584,000

Biosimilars There are currently drugs prescribed that cost a higher sum as they

are branded medications. We have been working hard to reduce the

number of these drugs prescribed, replacing them with identical

products that are at a lower cost for the NHS. This programme will

continue into 2019/20.

£400,000 £400,000

Practice-based

pharmacists

(PBP)

Each of our practices has a practice-based pharmacist to ensure that

only medicines of clinical value are prescribed in Dudley. Their

continued work into 2019/20 will ensure consistent application of our

policies in this area and reduce costs to the public purse.

£2,177,000

(after

funding

PHBs)

£3,423,000

Support to care

homes

We have been working with the 18 care homes in Dudley that had the

highest history of hospital admissions. Our work to train staff and

provide advice on appropriate care has resulted in savings and a

reduction in people being taken to hospital unnecessarily. During

2019/20 we will roll this scheme out to all care homes.

£655,000 £1,345,000

MSK – first

contact

practitioners

We are increasing access to physiotherapy services at a practice level

to reduce the need for hospital referrals and surgery. No savings

assumed

£500,000

MSK – routine

joint injections

We are increasing the skills within primary care to deliver joint

injections that would previously have only been available in hospital.

This increases the access options to the service, removes the need

for people to attend the hospital and provides a more cost-effective

service. We will also ensure that the policy for joint injections is

applied consistently so that only those who will see a clinical benefit

from joint injections receive them.

No savings

assumed

£562,000

MSK – back

pain

There are many lessons which Dudley can take from other areas to

ensure that the pathway of care for back pain is as effective and

efficient as possible. We are hopeful that this will mean a smoother

process for patients, meaning they access care in the right place the

first time. This should also result in savings to the system.

No savings

assumed

£203,000

Reduction in

inpatient

rehabilitation

We are developing a framework to ensure that those people who need

rehabilitation get access to the service in a timely way. We are

introducing an assessment process to establish where people might

benefit from rehabilitation in the community rather than hospital

setting. This should mean less time spent in hospital and improved

outcomes for patients along with a more cost effective service and

savings to the system.

£500,000 £1,200,000

(net of

investment

required)

Dermatology There are currently many outpatient appointments for dermatology

which result in no treatment or follow-up. We think that there may be

some other ways in which this specialist advice can be sought from

hospital colleagues via photographs. This would mean a more timely

response, reduce the need for patients to attend the hospital and

ensure that those requiring treatment are seen quickly. After

investment in the required equipment this would still result in savings

to the system.

Not

delivered

£50,000

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Continence There are still some patients being delivered a large quantity of

continence pads which may not always be used. We will be working

with patients to ensure that the number of pads they receive is

appropriate to their needs, to reduce wastage.

£250,000

High cost

drugs

These savings are anticipated through work to reduce the cost of

some of our most expensive medication by negotiating better prices

with pharmaceutical companies.

£1,136,000 £1,000,000

Emergency

activity

We are committed to continued investment in community and primary

care to reduce the number of people needing hospital treatment. We

aim to keep the demand for emergency activity as low as possible and

make savings for the Dudley system.

£1,989,000 £750,000

Advice and

guidance

There are times when our GPs simply need advice from hospital

specialists on the most appropriate pathways for patients. By

increasing the access to advice and guidance we are both supporting

GPs to manage patients in the community and reducing the numbers

of appointments to specialists. Improvements in this area will reduce

wastage, improve the patient experience and reduce waiting times, to

ensure access to the right care and save money.

£1,989,000 £750,000

Running costs As a CCG we are always conscious that we need to be as efficient as

we can in our running costs. We are committed to becoming more

efficient each year and these savings will come from a reduction in

spend on management each year.

£266,000 £600,000

Contract

reviews

We anticipate that we can renegotiate contracts with our providers to

get more value for money. We think we can agree these savings

through demand management and joint working.

£4,000,000 £1,292,000

8) National and Local Deliverables

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a) Emergency Care

i) Background

As part of the development of the MCP, the Dudley health and social care economy has promoted a community-focused alternative to hospital care for unplanned care. There has been a planned diversion of resources into pathways designed to prevent hospital attendance, in addition to increasing acute capacity for those requiring acute care, including:

Development of MDT reviews in primary care of patients with long term conditions

Extended hours access to primary care in all practices

Additional primary care sessions during bank holidays

Development of an Urgent Treatment Centre (UTC) to more appropriately manage primary care patients who attend the acute site

Integration of NHS 111 with the UTC, to allow direct booking of primary care appointments as an alternative to Emergency Department (ED) attendance

Development of a Single Point of Access for community services, to allow ambulance crews to access support as an alternative to hospital conveyance

Establishment of a MDT to support care and nursing homes through enhanced training and rapid support at times of exacerbation

Creation of a High Intensity User service to support patients who frequently access the urgent care system, to identify services to meet their long term needs

Commissioning community capacity for those requiring social care assessment for long term needs, either to avoid admission to hospital or allow more rapid discharge

New community-based beds for patients who are unable to weight-bear but do not need to be in an acute bed

Creation of specialist diagnostic and assessment areas for those requiring acute diagnostics:

o Ambulatory Emergency Care centre o Cardiac Assessment Unit o Frailty Unit o Rapid Access hot clinics

Increase in the number of A&E consultants

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These developments have contributed to both a reduction in emergency admissions and a significant reduction in delayed discharges from hospital. However, despite these improvements, the urgent care system remains under significant pressure, with the percentage of patients being treated in ED within 4 hours currently at 84.94%. Whilst this is a direct measurement of the ED’s performance, it is representative of pressure across the whole system and recognises that improvements are still required in all areas. It is important that the improvements are sustainable and able to meet demand at times of peak pressure, such as winter.

Our activity plans are designed to meet all national deliverables and NHS Constitution standards.

ii) Pre-hospital urgent care

In order to support patients navigate the urgent care system, the CCG has integrated key services to ensure healthcare professionals are joined up outside the hospital sector. NHS 111 have a direct link to the UTC, which also provides the GP Out of Hours service to ensure that patients have 24/7 access to primary care when they cannot access their own GP. The doctors at the UTC can offer clinical advice to 111 as well as being able to see patients face to face at the UTC, or through home visits. They also have access to a Single Point of Access to community teams, to be able to access rapid community support when required. The UTC has access to all GP clinical systems so that the patient’s record is available at all times, to avoid duplication and allow better continuity of care.

The UTC has been relocated next to the ED to allow primary care doctors access to a

specialist opinion if required. The UTC also forms part of the ambulance reception

area to ensure patients who arrive at the hospital site by ambulance can also be

directed to primary care when clinically appropriate.

In conjunction with our partner CCGs, we will implement the Clinical Assessment

Service (CAS) and develop this as part of our local urgent care system. We will ensure

the Directory of Service is maintained and supports the appropriate delivery of local

responsive services. The development of ambulance triage will be reviewed in our

UTC, as a means of reducing ambulance delays. The ambulance service will be

expected to use the existing Single Point of Access to community services where

appropriate. Our care home support service will be designed to avoid unnecessary

ambulance journeys.

iii) Same-day emergency care

The acute hospital has developed a series of rapid assessment areas, allowing patients to receive a diagnosis of their condition rather than being admitted to a ward. Currently 23% of patients treated at the hospital do not require an overnight stay, and this will increase to 33% as the community support teams are expanded.

Social care support is now available for seven days a week at the ED to ensure that patients whose medical needs can be addressed without the need for admission can be safely discharged, with community support provided immediately.

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The development of a frailty unit will enable rapid assessment of patients by a dedicated MDT. This will provide assessment and treatment by a specialist geriatric team with support from social care as required. This will reduce the need for an inpatient stay for those without an immediate medical need.

Over the past twelve months, the acute hospital has undertaken significant improvements within the ED to treat patients who arrive with cardiac and sepsis conditions. These improvements are evidenced to reduce the risk of death and disability and increase the long term independence of the patient.

The CCG will continue to commission specialist care from major tertiary hospitals to enable rapid access to specialist care when required.

iv) Cutting delays in patients being able to go home

The Dudley health and social care economy has made considerable investment in reducing delayed discharges. Two years ago Dudley Council ranked 132nd out of 152 Local Authorities – 152nd being the worst – for Delayed Transfers of Care. Over 9% of beds in the local hospital were occupied by people who were ready to be discharged. There has been a sustained improvement through implementation of the high impact changes. These improvements equate to an additional 26 beds being available for urgent care needs and to enable planned care admissions. Dudley is now ranked 44th nationally and is continuing to improve.

Through our Urgent Care Operational Group we will monitor and sustain our performance in reducing the number of long stay patients, setting targets for 7-day or more and 14-day or more lengths of stay.

b) Referral to Treatment Times (RTT)

i) Background

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Our main acute services provider – the Dudley Group Foundation NHS Trust (DGFT) – is currently delivering the RTT standard and it is anticipated that this will be maintained into 2019/20. The main concern remains ophthalmology, which has not delivered its RTT standard since 2016. A Remedial Action Plan (RAP) is in place to achieve the standard and monitoring will continue.

Ramsay Health Care’s overall RTT position has deteriorated since August 2018. Activity delivered is significantly below contract. Sanctions are now being applied to this contract.

Contracted levels of activity for 2019/20 have been modelled and agreed as the basis

for meeting RTT standards in 2019/20.

We are fully compliant with the national choice standards and will monitor these

through our engagement with local GPs, practice managers, our Healthcare Forum

and patient participation groups. The use of Capacity Alerts and actions to deal with

six-month waiters will be developed with our providers. There are currently no 52-week

waiters. Our activity plans are designed to meet all national deliverables and NHS

Constitution standards.

ii) Pain management

Many joint injections which should be delivered in primary care (where needed at all) are currently being delivered in secondary care.

In reviewing the MSK pathway the CCG has reviewed the increase in joint injections and the place of treatment. Following clinical review, the CCG will only commission joint injections from the following clinicians:

Site By Whom Includes Exceptions / Considerations

Primary Care Only Shoulder GP a) Sub-acromial

b) Gleno-humeral N/A

Elbow GP a) ‘Tennis’ elbow Conditions related to rheumatoid arthritis

Wrist GP a) Carpal tunnel Possible opportunity to develop a service

Nerve conduction studies to be considered

Numbers are relatively low

Procedures of Limited Clinical Priority (PLCP)

Knee GP N/A GP & Consultant /Specialist Hand/Fingers GP

Consultant / Specialist

a) Trigger finger / thumb Rheumatology / Orthopaedics

Could be done in a community setting

Hip GP

a) Trochanteric bursitis b) Hip injection (guided)

X-ray required only as a diagnostic test

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Consultant / Specialist

Foot GP Consultant / Specialist

a) Plantar fasciitis N/A

Consultant /Specialist Only Back Consultant /

Specialist X-ray required

Prior Approval only Neck Consultant /

Specialist X-ray required

Ankle Consultant / Specialist

N/A

Our roll-out plan for MSK First Contact Practitioners (see QIPP in chapter 7) will continue.

Any patient who is assessed in secondary care (including triage/first contact practitioner services) must be referred back to primary care where the GP is the identified clinician. Any patient not referred back to primary care who receives their injection in secondary care will only be paid for at the primary care rate.

It is very likely that the CCG and DGFT will ‘decommission’ primary care-level joint injections. In so doing, such injections will only be done by GPs or other appropriately qualified staff. Payments will be made under the Minor Surgery tariff. All future clinically appropriate joint injections for this service will only be paid at the primary care rate.

iii) Guided joint injections

We will develop a guided joint injection service through the introduction of a GP with specialist interest.

iv) Back pain

The CCG will implement the national back pain pathway from April 2019, harmonising its policy with all Black Country CCGs.

Additionally, we will implement the National Lower Back Pain and Radicular Pain Pathways by March 2019.

v) Outpatients

We will extend the use of peer review in primary care and advice and guidance. This is expected to extend the range of conditions treated in primary care, reducing waiting times for patients who need to see a specialist in secondary care.

The peer review service has been in place since October 2017. Uptake and usage remains lower than required and therefore its impact has been minimal when reviewed as a whole service. DGFT are in their second year of delivering a national CQUIN to ensure that over 75% of activity is supported by the option for Advice and Guidance.

DGFT is on target to meet the requirement for 75% of specialties to be covered by

Advice and Guidance. This will be achieved in 2019/20. It may be subject to a local

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tariff in 2019/20 – to be agreed – and a rollout plan of specialties offering Advice and

Guidance will be developed.

vi) Procedures of Limited Clinical Priority

The list of Procedures of Limited Clinical Priority will be reviewed in the light of the national consultation led by NHS England. The opportunity will also be taken to harmonise policies, where required, with the rest of the STP.

vii) Diagnostics

We will review the current use of direct access diagnostics and pre-referral diagnostics and develop a diagnostics formulary. Evidence from both primary and secondary care suggests that inappropriate diagnostics are being requested and performed.

We will review the iRefer system as a basis for managing activity.

viii) Direct referrals

We will work with providers to introduce direct access to surgery for GPs with a specialist interest. This will build on the successful model in Ear, Nose and Throat (ENT).

ix) Gynaecology

We will review the community Gynaecology service supported by specialist input. This will be developed as an integrated pathway with the sexual health service.

x) Urology

We will seek to develop a community urology service, focussed on lower urinary tract symptoms and over-active bladder conditions.

We participated in the NHS England Specialty-Based Transformation Programme for urology during 2018. There are a number of initiatives that will come out of the programme such as:

Rethinking referrals

Transforming outpatients

Shared decision making and self-care

We contributed to the Wave 3 Handbook good practice guide. It will be published in February 2019. Local initiatives will require further development.

We have examined “Right Care”, in conjunction with our secondary care and public health colleagues. We will be placing a particular focus on addressing issues in relation to MSK- (see earlier) and respiratory-related admissions.

The roll out of NHS E-Referral is now complete and Advice and Guidance will be completed by March 2019

Triage for MSK and Paediatrics is in place

A programme for reducing follow-up attendances for ENT, MSK, ophthalmology and urology will be linked to specialty based transformation

A “Consultant to Consultant Protocol” has been drafted but requires further input in light of further national guidance

Peer review is already in place

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The CCG is an active user of RightCare information and analysis

c) Cancer Treatment

This standard is currently not being delivered on a consistent basis – there is a 62-day standard, 104-day-long waits and tertiary referrals to the Royal Wolverhampton NHS Trust (RWHT). A RAP is in place to achieve the standards identified. Oversight is provided by the Cancer Local Improvement Team (LIT).

Requirements and current positions on Dudley CCG’s Commissioning Intentions 2019-20

We will work as part of the West Midlands Cancer Alliance to deliver the national Cancer Priorities. We are currently working with providers to ensure the implementation of nationally-agreed rapid assessment and diagnostic pathways for lung, prostate and colorectal cancers. We are working with partners to achieve improvements in cancer screening uptake and early diagnosis, and commissioning cancer services that offer consistent and high quality services, including meeting national waiting time standards for diagnosis and treatment, whilst also improving patient experience, including the implementation of the national Recovery Package.

The West Midlands Cancer Alliance are now part of the Cancer LIT and are playing an active role in supporting the local, regional and national cancer agenda.

We will work with partners across the STP to create a cancer plan for the Black Country, through the Black Country Cancer Group, looking in particular to explore opportunities to develop local services to enable more people to be treated in the Black Country.

Dudley CCG is now represented at this meeting and feedback is provided back into the Cancer LIT.

d) Mental Health

We have developed a mental health and wellbeing strategy in conjunction with our partners overseen by the Health and Wellbeing Board. This has six priorities:

Developing services that focus on mental and physical health, prevention and self-help and digital solutions

Supporting people to find and stay in work

Developing strong and resilient communities who can do more for themselves

An ambition of zero suicides

Developing wellbeing-friendly environments in communities and workplaces

Consistent and accessible services with a focus on out of hours and crisis support, maternal mental health and transition from child and adolescent to adult services

The implementation of this strategy will continue during the period of this plan.

In conjunction with our Black Country CCG colleagues, we have developed a number of common service specifications including crisis care, dementia, eating disorder and

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personality disorder services. We will seek to implement these working with a single provider for the Black Country.

We have invested in CAMHS, IAPT and dementia services in a manner designed to deliver the required national targets. Providers will be held to account for their delivery in relation to this investment and the associated targets.

Our joint mental health and wellbeing strategy has a clear focus on suicide reduction, with an ambition of zero suicides. This will be pursued on a multi-agency basis in conjunction with our partners.

Our performance in the management of out-of-area placements has historically been good. We will work with our providers to ensure that patients are cared for locally and that risk is appropriately managed.

The implementation of ICTs will be conducted in a manner that reflects the role of mental health and supports the continued integration of mental and physical health services. Our specific mental health MDTs will be rolled out across all practices.

Our outcomes framework recognises the importance of physical health checks for people with mental health needs and performance in relation to this will be actively monitored.

The impact of social isolation has been identified as a particular health need and a contributor to health inequalities. The role of Integrated Plus and our frequent service user service in relation to this will continue.

The role of schools and colleges in supporting children and young people is recognised in our CAMHS Transformation Plan. We have already developed some services and we will work with local schools and colleges to examine how this can be expanded.

We will develop plans to meet the Mental Health Forward View requirements, working

in conjunction with our STP partners in relation to perinatal mental health, crisis care

and support for the severely mentally ill. This will be supported by appropriate plans

for workforce, data and technology.

We will work with our voluntary sector partners to enhance post-diagnosis support for

people with dementia.

e) Learning Disabilities and Autism

The implementation of the Transforming Care Partnership (TCP) will continue in 2019/20. A single delivery model will operate across the Black Country. It will support the discharge of patients from hospital with intensive community, case support and forensic staff, as well as act in a preventative manner to minimise future hospitalisation of patients. This personalisation of care will reduce avoidable admissions to inpatient services, enable shorter lengths of stay and end out-of-area placements.

The new community service model will embed the principles of Building the Right Support and ensuring that people receive timely support in the community. Work on outcomes-based new models of community care will be undertaken, in partnership

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with the local authority, as part of local and regional pilots. This will improve awareness of, and support for, people with learning disabilities, autism or both.

A Black Country approach will be applied to models supporting people with autism where there is no learning disability, or where there is a dual diagnosis of autism and mental health. The Transforming Care Programme is applicable to people with learning disabilities and/or autism of all ages. We will work with the Black Country STP to make sure all local healthcare providers are receiving information and training on supporting people with a learning disability and/or autism and are making reasonable adjustments to support these individuals.

Focused work on health inequalities of the wider population of people with learning

disabilities continues, so we may better understand why they experience poorer

physical and mental health when compared to the general population. The mortality

review (LeDeR) is the specific programme that helps us understand why people die.

We will report to our Learning Disability Partnership Board and our Safeguarding

Board on the action and outcome of LeDeR reviews and working with our Council

partners, we will enhance our capacity to deliver timely and effective Care and

Treatment Reviews.

Work to improve the health of people with learning disabilities is supported by annual health checks, ensuring reasonable adjustments are made and enabling access to Personal Health Budgets as may be appropriate.

People with autism experience the same health inequality issues as those with learning disabilities. Pilots for a specific health check for people with autism will be established.

Following the 2018 autism Self-Assessment Framework (SAF) and the revision of the Dudley Autism Strategy, the autism diagnostic pathway will be reviewed with partners to address the gaps identified. This will be done with the aim of reducing waiting times for specialist services and to achieve timely diagnostic assessments, in line with best practice guidelines.

In order to ensure that people with learning disabilities, autism or both are receiving the correct medicine, we will ensure that people with learning disabilities and/or autism have regular medication reviews as part of the commitment to STOMP (STop Over-Medication of People with a learning disability and/or autism), including children and young people as part of the STAMP (Supporting Treatment and Appropriate Medication in Paediatrics) programme.

f) Children, Young People and Families (CYP)

i) Background

Child health has changed. Over the last 45 years mortality data show an epidemiological transition away from acute infectious illness towards chronic long-term conditions and away from biomedical and biopsychological problems. However, the way health and care services are provided is still heavily hospital-focused, reactive and fragmented across physical health, mental health and social care.

An ‘ideal’ child health model is one:

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That understands CYP and their families’ specific needs (including the broader determinants of health) and is designed to address them

Where there is access to high-quality paediatric and child health expertise and multidisciplinary teams in the community

That has linked-up timely information, communication, data and care (different forms of integration) to allow for continuous quality improvement

Where health literacy and education for CYP and their families, as well as professionals, is prioritised

Which integrates physical and mental health

In developing a new model of care it is also important to understand that children differ from adults in at least four important ways:

Developmental changes as they grow older

Dependency on parents and other carers

Differential epidemiology (e.g. different health, illness and disabilities)

Demographic patterns within an economy (e.g. socio-economic determinants)

Furthermore:

Children’s use of health services is also different to other age groups, for example the rate of acute, short-stay hospital admissions in children is higher, and rising

Children may need to be transitioned from paediatric to adult services, and have constantly changing needs in relation to their age/developmental stage

Education is especially important, in addition to social care, and there is a greater dependence on the family than social care, compared to adults

ii) Primary Care

The CCG plans to apply to engage in the PACE Setter Programme, which is a new improvement programme for practices providing primary care services to CYP, their families and carers. This is a quality mark awarded to practices following their young people and families in relation to four areas:

Patient and care engagement

Accessing services

Clinical pathway development

Education

We plan to invest in a training programme for all our GPs and practice nurses to expand their knowledge and skills to support children in the community that present at urgent care with the ‘big six’ conditions:

Bronchiolitis/croup

Fever

Gastroenteritis

Head injury

Asthma

Abdominal pain

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iii) Community care

We are working with our consultant paediatricians to develop a service whereby they will provide out of hospital care for CYP. The community paediatricians need to work within the wider health network of therapists and nurses, with the local authority’s services and the voluntary sector. The role of the paediatrician involves prevention, identification, assessment, diagnosis, treatment and support. Many will also have specialist skills/interests in addition to their general work. They must be closely networked with acute general paediatricians and other Specialist Community Clinicians, such as CAMHS, physiotherapists, occupational therapists and speech and language therapists.

It is expected that CYP with the following conditions will be seen by consultant paediatricians in community clinics:

Children with long term conditions

Concerns regarding a child’s development such as developmental delay or disordered development

Neurological disability

Children with coordination or fine motor difficulties

Behavioural problems

Autistic Spectrum Disorder

ADHD

Significant learning difficulties/disabilities

Sensory impairment

Visual impairment

Hearing impairment

Symptom management in palliative and end of life care

In parallel, we will expand the paediatric triage service to reduce out-patient attendances.

Most of these would need a MDT approach with CAMHS and children’s community services and will be provided in our ICTs, which will be based within our Primary Care Networks.

We will invest in GP with a Special Interest (GPWSI) to work in the ICTs to provide a link between the community paediatricians and individual practice GPs. The GPWSI will also link in with the Integrated Young People's Wellness service.

iv) Reducing pressure on emergency hospital services

As CYP account for 25% of ED attendances and are the most likely age group to attend ED unnecessarily, we are reviewing our pathways between the ED, the Urgent Treatment Centre and the Paediatric Assessment Unit.

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Over the next five years, paediatric critical care and surgical services will evolve to meet the changing needs of patients, ensuring that CYP are able to access high quality services as close to home as possible. Specifically, we will:

Incorporate the Paediatric Assessment Unit into the relocated and expanded dedicated paediatric ED facility

Redesign our community and acute children’s out-reach nurse services

Review children’s ambulatory emergency care admissions and improve pathways and treatments in primary and community care

v) Emotional Health and Wellbeing

We have invested in and developed an Emotional Health and Wellbeing Support Team (EHWT) to support CYP. The team was initially commissioned to support schools and School Health Advisors (SHAs) in meeting their universal role of addressing emotional health and wellbeing needs, but also with a strong emphasis on providing a more ‘hands on’ non-stigmatising service. We have expanded emotional health and wellbeing services to include a team of skilled workers (primary mental health workers) to deliver evidence-based models, which are based on the national recommended Children and Young People’s Improving Access to Psychological Therapies (CYP-IAPT) approach so that staff have access to training required to improve skills and knowledge in evidence-based interventions, introduce new ways to involve CYP in decisions about their care and meet the CYP-IAPT outcomes.

Our integrated “Tier 2” service has been fully operational since September 2017 and is provided by our CAMHS service. It consists of several multi-skilled staff, trained to deliver therapeutic interventions that will also have a specialist role in supporting both universal staff and school nurses in meeting the emotional health and wellbeing needs of CYP in educational/universal settings. The service model is based on the national recommended IAPT approach so that staff have access to training to improve their skills and knowledge in evidence-based interventions. It introduces new ways to involve CYP in decisions about their care, recording outcomes session by session, that will support the outcomes-based commissioning approach used to develop this service.

We also have a GP Liaison Specialist Team to support GPs in Dudley. The team consists of a Clinical Specialist GP Liaison Lead and a GP Nurse Liaison. The team goes out to GP practices once a month and offers a triage service. They meet with young people and their families at the GP practice, as requested by the GP, and discuss the needs of the young person. Together with the young person and family, they then offer advice and decide on the best support for the young person, whether this is CAMHS or other services available such as counselling or educational psychology, etc. GP Liaison is also available for GPs to call or email should they want any advice regarding a young person.

The CCG has commissioned a Children and Young People’s Eating Disorder Service, which has been operational since January 2017 and meets the NICE guidelines. The service has been, and is currently meeting, the access and waiting time standard.

vi) Learning disability and autism

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The Black Country Transforming Care Partnership (TCP) aims to reduce the number of people with learning disabilities and/or autism residing in hospital so that more people can live in the community, with the right support, close to their home. To achieve this, we will be engaging on the future of inpatient services.

The pathways for CYP with learning disabilities and/or autism are evident in the use of the pre-admission CETR (Care, Education and Treatment Review) process, which involves all relevant agencies in the local area. For those under 18 years, by integrating the provisions of both the CETR process and the Access Assessment for an inpatient bed, it ensures that consideration is given to the whole care pathway and will help to strengthen the range of treatment modalities available and wider support for the adult or child, young person and their family. It will also ensure that all other alternatives have been considered before secure provision is agreed as the appropriate placement option. Specialist commissioning from NHS England are also part of this process as well as commissioners from the CCG, specialist CAMHS, CYP and/or parents/carers, social care and education from the local authority as well as a service user and independent clinician. It is hoped that in the future the funding from specialist commissioning for NHS England will return to the CCG to support this reduction in admissions and allow more individual personalised commissioning to take place to meet the child or young person’s needs and continue allowing them to remain at home. Dudley has a specialist CAMHS learning disability service, which supports the difficulties which sometimes exist when there are separate mental health and learning disabilities services.

We have invested in our CYP’s autism service, to reduce the current waiting times from 22 weeks for a diagnostic assessment. Further assessment is planned in 2019-20 to develop a community-based post-diagnostic service. CYP with a learning disability, autism or both, with the most complex needs, will have a designated keyworker. Initially, keyworker support will be provided to CYP who are inpatients or at risk of being admitted to hospital. Keyworker support will also be extended to the most vulnerable children with a learning disability and/or autism, including those who face multiple vulnerabilities such as looked after and adopted children, and CYP in transition between services.

The CCG is a key player in ensuring that the health needs of children who have a Special Educational Need and disability are met and that their outcomes are improved. Our community paediatric therapy services input into the Educational Health and Care Plans.

vii) Integrated young people's wellness service

The young person wellbeing promotion and treatment service is being developed to include both generic and targeted support interventions to meet the varying needs of CYP in Dudley. The service will assess each young person’s needs (taking a ‘no wrong door’ approach) to tailor the most relevant and timely range of advice and support, complementing any existing models of support for young people, including synergies with the Healthy Child Programme.

Interventions will include a range of self-help strategies and specialist services, within a strong governance framework to identify and address safeguarding risks, promote wellbeing and enable young people to flourish and thrive.

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The service delivery model will include:

A welcoming front door, offering advice and support for a range of issues

A ‘Making Every Contact Count’ approach should be embedded into staff training to ensure the provision of healthy lifestyle advice and wellbeing promotion using the five ways to wellbeing. All services should be fully integrated with seamless pathways to deliver a coherent package of advice and support for any issue

Open access to integrated sexual health services, treatments, advice and prevention

A substance misuse service including targeted, early interventions

Availability of smoking cessation services across a range of domains

Pathways into CAMHS Tier 2 services

Other services for young people are being considered for future integration into this model of support, including primary care services for young people and school nursing services.

Links and referral pathways should be available to ensure young people are able to access support from a range of agencies, including local authority services and community-based providers, depending upon need. The service will be developed in partnership with existing third sector providers.

viii) Early Help Support

The CCG has been working closely with Dudley Metropolitan Borough Council to develop the Early Help Service delivery model. A key part of the early help operating model requires “MDT Allocation Meetings” taking place in five locality Family Centres across the borough. Representatives from universal and targeted health, early help social services, schools and services provided by the voluntary and community sector, along with the emotional health and wellbeing practitioner, are involved.

The MDT must ensure that practices then arrange for the patient cohort to be discussed in existing practice MDTs as above, with relevant professionals involved in the child’s health, educational and/or social care.

The Early Help Support model will be integrated into our ICTs.

g) Maternity

The Black Country CCGs are adopting a single maternity service specification with local variations to reflect demographics and population needs.

Dudley CCG agreed its service specification with DGFT in 2017. This is now being adopted across the Black Country. Delivery of the services is monitored through the Maternity Performance Assurance Group, which meets on a monthly basis.

This approach is supported by the Local Maternity System (LMS), which will reflect the summarised specification. The LMS plan for our STP is assured by regulators as a comprehensive, honest and robust system approach to improving maternity services across the system.

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We will include the Saving Babies Lives Care Bundle in our service specification,

alongside the opportunity to be cared for by the same midwife and the delivery of an

evidence-based baby feeding programme.

Continuous glucose monitoring will be available for pregnant women with Type 1

diabetes.

h) Primary Care and Community Health Services

The commissioning of our model of care rests upon the unique position of primary care, starting with the person, registered with the practice. The role of the GP is therefore fundamental. They take overall responsibility for the care provided by other services.

In our model, these services include Multi-Disciplinary Teams (MDTs), a wider network of community-based and voluntary sector services organised around Dudley’s five Primary Care Networks (PCNs – see later in this chapter).

Our commissioning of primary care is therefore aligned to our commissioning of the MCP – to deliver improved health outcomes for our registered practice population through a range of integrated, responsive and innovative primary and community health and care services.

i) ‘Investment and Evolution: A five-year framework for GP contract reform to implement the NHS Long Term Plan’

This document, published on 31st January 2019 by NHS England and the British Medical Association translates the commitments in the NHS Long Term Plan into a five-year framework for the GP services contract.

The Primary Care Commissioning Committee will be reviewing the detail, however, our initial assessment of the requirements set out in the document are to a large extent already being achieved in Dudley as part of our commissioning of the MCP model of care, our Outcomes Framework, and development of our MDTs and PCNs that are already well established.

ii) Investing in Primary Care

The CCG has, for a number of years, prioritised and invested in the development of primary care and implementation of our new care model within the MCP. In addition to the £3 per head invested during 2017/18 and 2018/19, the CCG has committed over £650,000 each year into the support, mentoring and training of practices, as well as engagement and development of our PCNs.

In addition to these funds, the CCG has invested further in schemes to reduce the burden of prescribing administration by funding additional pharmacist support into general practices, launching a centralised repeat prescribing function, and commissioning link workers to assist practices in social prescribing.

We will continue to invest in our new model of care and meet the commitments within the long-term plan, retaining the schemes outlined above, committing to continue investing a recurrent £1.50 per head into PCN development and investing a further £300,000 in the expansion of our centralised repeat prescribing team to cover additional practices.

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We will be producing a financial plan that sets out our investment in primary care development for approval of the Primary Care Commissioning Committee by March 2019.

iii) Primary Care Networks – Future Development

The MCP model is enabled by the integration of primary care services, whereby GPs have more influence and co-ordination for the care provided to their patients by other community services, including MDTs. These teams will become part of the wider primary health care team.

In order to assume this responsibility, GP practices in Dudley have already begun the process of organising themselves into PCNs.

Initially, we have five PCNs that we refer to as our ‘localities’. This map sets out the configuration of each. They are organised geographically, and serve populations of between 50,000 and 70,000 patients.

Dudley surgeries by Localities/Primary Care Network

Our PCNs are already provided with primary care data analytics for population segmentation and risk stratification in support of MDT working in line with the Long Term Plan requirements in respect of data analytics and the operation of PCNs.

iv) Primary Care Networks and Multi-Disciplinary Teams

All practices in Dudley have a MDT. The teams are designed to work to the principles of shared responsibility for shared outcomes for a shared population, using a population health management approach. These teams bring together:

GPs

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Community nurses

Mental health workers

Social workers

Practice-based pharmacists

Voluntary sector services

Other specialist health services including heart failure, respiratory, end-of-life

Specialist care consultants

v) Primary Care Networks and Integrated Community Teams (ICTs)

PCNs will have ICTs within them, serving a group of practices with a combined population of approximately 35,000 patients. They will be led by an appointed GP integration lead from one of the practices within the PCN, who will co-ordinate the delivery of the MDT services for their population.

All PCNs provide extended access to GP appointments at evenings and weekends. This is co-ordinated and led by a lead practice within each PCN.

The ICTs bring together a group of staff to deal with population health management issues around a geographical area. Services are then operationalised to the same geography, operating under the direction of each PCN (with a dedicated GP lead). There will be ten teams (two in each PCN) providing:

Community-based physical health services for adults and children

All mental health and learning disability services

Intermediate care services and NHS Continuing Health Care

End-of-life services

Voluntary and community sector services

Practice-based pharmacists

In addition, each PCN will have a range of additional services available to their population which will be operationalised following a transitional process within the MCP. These will include:

Outpatient services for adults and children

Urgent care centre and primary care out of hours service

Primary medical services provided under existing GMS/PMS/APMS contracts

Services commissioned by Dudley Metropolitan Borough Council’s Office of Public Health, including health visiting, family nurse partnership, substance misuse and sexual health services

Adult social care services (to be phased in)

Further work will take place with our GP membership to establish the final PCN and ICT configuration.

vi) Primary Care Development – General Practice Forward View (GPFV)

Our GPFV implementation plan describes how we will support and enable the continued development of our model of care. This will be updated and refreshed for 2019/20 to ensure that we:

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Continue our clinically-led programme of investment in primary care transformation, to ensure that family doctor services are safe, sustainable and able to play a leading role in the successful delivery of the MCP

Offer expanded choice and enhanced access to primary care services for our population by expanding roles such as practice based pharmacists

Provide training and development to improve the working of MDTs and ICTs and widen the range of clinical and non-clinical input to those teams

Ensure that we take full advantage of the opportunities offered by new technology to drive innovation, underpin integration of services, improve efficiency and empower patients

Support and encourage practices in their ongoing efforts to work collaboratively, build effective support and development networks and manage growing demand safely and sustainably

Invest in the infrastructure and estate needed to support and promote our ambitions

Maximise the benefits and opportunities offered by the adoption of borough-wide frameworks (such as our Outcomes Framework)

Evaluate what we do through constant monitoring, challenge and peer review

vii) Primary Care Commissioning – Outcomes Framework

In commissioning primary care, we have replaced the GP Quality and Outcomes Framework (QOF), Local Incentive Schemes and Directed Enhanced Services with our Outcomes Framework.

This provides a rationalised set of performance indicators, with the aim of increasing efficiency and effectiveness, alongside an increased focus on care planning and shared decision-making for people with long-term conditions.

Aims of the Dudley Quality Outcomes for Health Framework

The Primary Care Commissioning Committee will continue to review and refresh the outcomes measures commissioned from primary care – this will include refreshing and producing:

Commissioning framework and outcomes

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Participation agreement to enable practices to participate voluntarily

Business rules

Performance monitoring framework

Performance monitoring process

viii) Primary Care Contracting

We will maintain compliance in discharging our delegated commissioning and contracting activities for primary care, assured by our Primary Care Commissioning Committee and external audit. The Committee will receive and approve a work plan that will include our approach to:

Primary care commissioning and contracting

Primary care contract and performance management

Primary care financial management

Governance of all primary medical care delivery

We will participate in external assurance and audit and produce an annual review of our delegated commissioning and contracting functions.

ix) Estates

Ensuring strategic fit

A fit for purpose healthcare estate will be a key enabler in the delivery of the MCP model, the implementation of PCNs and the wider rebalancing of healthcare services towards out-of-hospital care. Dudley CCG’s estates programme is therefore geared towards ensuring the provision of sufficient high quality estate in the community to enable the delivery of a wide range of community and outpatient services, co-located where possible with at-scale primary care, voluntary sector and other services.

Changing patterns of healthcare and the historic mix of premises mean that the current estate is not always fit for the future or located in the right place and some high quality estate is currently underutilised. The CCG will seek to address these issues over the next twelve months, leading the whole health economy in a full review of future requirements and proposing an appropriate future estates configuration within each local area in the coming year, including the mix of premises required to meet the needs of the MCP and wider health economy.

This review will identify areas where new or improved premises are required, as well as areas of overcapacity where surplus sites could potentially be disposed of, allowing the reinvestment of resources back into frontline services.

Premises development and rationalisation

In the coming year the CCG will continue to work with practices to develop business cases for premises developments in a number of areas. Where these provide demonstrable improvements for patients and represent value for money, they will be supported by the CCG, subject to consultation with patients.

The health economy has made good progress in the consolidation and rationalisation of the estate across a number of schemes during the previous planning period. We will continue to seek and exploit opportunities to do so, both as part of the review

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outlined above and in collaboration with partners across the healthcare sector and wider One Public Estate.

Regularising occupation

In common with much of the NHS, most GP and NHS tenants occupying premises operated by the two NHS property companies, NHS Property Services (NHSPS) and Community Health Partnerships (CHP), are undocumented and operating from the buildings without a formal lease in place. Dudley CCG recognises that this position is undesirable and is coordinating a pan-health economy approach to the agreement of formal leases for these premises, and which will result in these leases being signed within 2019/20.

Improving use of sessional space

In addition to the formal occupation outlined above, a number of services operate on a sessional basis from rooms within health centres. Working with partners at NHSPS and CHP, Dudley CCG will improve the systems and processes for accessing this space, making it easier for frontline services to identify and book space for their clinics, increasing their ability to respond flexibly to changes in demand. This will begin in the first quarter of 2019/20 with the pilot of a new online booking system for NHSPS premises.

x) Primary Care Engagement

We will continue our annual programme of GP visits, engaging practices in their commissioning performance and delivery of QIPP. We will continue to meet with every practice and seek their views on the development of the Integration Agreement – the agreement that determines the relationship between the practice and MCP.

We will continue to meet with the GP membership on a monthly basis through our PCN meetings, and bi-monthly with the wider membership events. We will continue to engage with practice managers on a regular basis at the Dudley Practice Management Alliance to discuss practice management development and the implementation of our GPFV.

xi) Engagement with Patients

We will continue to engage directly with the public on the matters which are most important to them. This will include holding public meetings in those areas affected by potential service changes.

Healthwatch continues to work in collaboration with the Primary Care Commissioning Committee to ensure that we consider the patient voice in any decisions we make. We will continue to have engagement with our Patient Participation Groups through our Patient Opportunity Panel.

xii) Primary Care and the STP

We are already working collaboratively with other CCGs within the STP, taking consistent approaches to the way in which we commission and develop primary care:

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Collaborative workforce planning

Participating in the STP Intensive Support Site (ISS) on projects to increase the number of GPs retained in the Black Country

Bidding and securing additional resource to support the training and development of primary care staff

Joint working with the Black Country training hub to implement our GPFV plans

In 2019/20 we will:

Contribute to the development of the STP primary care strategy

Contribute and lead on specific projects on behalf of the STP

Identify areas for a common approach to the commissioning or contracting of services across the STP

Identify and develop common approaches for the governance of delegated commissioning functions across the STP

xiii) Community Health Services and the Long Term Plan

The Long Term Plan for the NHS describes the need for new service models. Its first chapter outlines how the NHS, in following the plan’s provisions, will become more integrated and coordinated in its care, more proactive in the services it provides and more differentiated in its support offer to individuals, all through five major practical changes, many of which are consistent with our MCP development.

1 – Boosting ‘out-of-hospital’ care and dissolving the historic primary-community health services divide

The NHS is to commit to a series of community service redesigns, such as MCPs, and to increasing primary medical and community health service investment as a share of its total spend to 2023/24. New urgent community response and recovery support is to be offered, with all areas increasing the capacity and responsiveness of community and intermediate care services to those judged clinically to benefit most. Expanded community MDTs, aligned with new PCNs based on neighbouring GP practices, will result in fully-integrated community-based healthcare. People living in care homes will receive guaranteed NHS support and people will be supported to age well.

2 – Reducing pressure on emergency hospital services

Proliferation of pre-hospital urgent care, same day emergency care, and cuts in delays in patients being able to go home will all reduce the pressure on A&E departments.

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The MCP development is consistent with the requirements described above. In 2019/20 we will further develop our MCP care model to be fully compliant with the Long Term Plan requirements and ready for contract commencement.

xiv) Dudley CCG progress on MCP implementation

The first MDTs were established in August 2014. They now cover all practices, encompassing health, social care, physical health and mental health, all aligned to a common population, with further alignment of other services to the same population including respiratory services and diabetes. Practice-based pharmacists and a social prescribing service – ‘Integrated Plus’, our repeat prescribing POD now serves 11 of our 43 practices, and enhanced end-of-life care for seven days per week, have been implemented.

Care homes are being supported through an education programme community response teams and care home support teams. A community-based team for older adults with mental health problems, health coaching and aligned points of access are in operation, and a local outcomes framework for general practice has been put in place.

3 – Giving people more control over their own health and more personalised care when they need it

Patients are to be offered more personalised therapeutic options thanks to advances in precision medicine. A more fundamental shift will take place to more ‘person-centred’ care, with a wider move to “shared responsibility for health” over the next five years. The NHS Personalised Care Model is to be rolled out nationally and social prescribing, using link workers in PCNs, will help people develop tailored plans and connect them to local groups and support services. Accelerating the roll-out of Personal Health Budgets will give people greater choice and control of their care planning and delivery, and end-of-life care will be personalised too.

4 – Making digitally-enabled primary and outpatient care mainstream across the NHS

Digital technology will provide convenient ways for patients to access advice and care. Digital-first primary care will become a new option for each patient, and outpatient services will be fundamentally redesigned to massively reduce the necessity of outpatient visits.

5 – Focusing increasingly in local NHS organisations on population health

Everywhere will move towards Integrated Care Systems, bringing together local organisations to redesign care and improve population health. They are a pragmatic and practical way of delivering the ‘triple integration’ of primary/specialist care, physical/mental health services and health/social care, in line with what more than 90% of doctors consistently say is the need to integrate primary and secondary care.

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From experience, there is evidence of more extensive primary care access, improved management of long term condition, more effective care coordination and improved staff and patient engagement. However, there are still significant numbers of potentially avoidable A&E attendances and EM admissions, with up to 40% of EM cases coming through A&E. Our progress on new workforce models and primary care at scale is thus far insufficient, and HLE trajectories are going in the wrong direction. Further development will continue during the period of this plan.

xv) Long Term Plan – alignment plans for 2019/20

We will be taking several actions during 2019/20 to fully align with the new care model requirements of the NHS Long Term Plan.

A new NHS offer of urgent community response and recovery support:

We will develop plans for a communication centre and associated response by July 2019

We will re-commission our reablement service by July 2019

We will commission a new frailty pathway that will include a GP with special interest (GPWSI) in Frailty by July 2019. This will improve the responsiveness of teams in the community hub and prevent unnecessary admissions to hospitals

PCNs of local GP practices and community teams:

We will align ICTs and proposed PCNs by April 2020

We will review the MCP Outcomes Framework in light of changes to the Quality and Outcomes Framework by April 2020

Guaranteed NHS support to people living in care homes:

We will evaluate the impact of the existing enhanced care home service by June 2019 and assess the current system against the EHCH model and identify gaps by June 2019

We will develop proposals to be fully compliant with the model by July 2019

We will develop the existing enhanced care home team to provide a ‘hospice at home’ service by July 2019

We will review the primary care Local Improvement Scheme (LIS) for care homes by April 2019

We will initiate the ‘Red Bag’ scheme to facilitate a safer and more effective transfer of patient information when residents are conveyed to hospital and their return to the care home

We will extend the Trusted Assessor role for care homes across 7 days

We will develop the clinical education training programmes to care home staff

We will offer NHS.net emails for care homes to support easier and secure sharing of information between care homes and NHS

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Supporting people to age well:

We will support PCNs to take appropriate action through the use of data analytics by September 2019

We will screen, identify and manage people with mild, moderate and severe frailty

We will commission a Carers Health and Wellbeing Service by September 2019

We will commission the Dementia Assessment and Diagnosis Service by June 2019

We will commission Admiral Nurses to provide post-diagnosis professional support by June 2019

We will support Age UK input for residents in care homes with dementia, for training staff and avoidance of social isolation by April 2019

We will review existing services commissioned from Alzheimer’s Society, with a view to developing a revised service offer, by September 2019

Pre-hospital urgent care:

We will establish a Communications Centre

We will review the existing system in the context of proposed national requirements by July 2019

Cutting delays in patients being able to go home:

We will commission appropriate schemes through the ICBF to maintain existing performance by September 2019

People will get more control over their own health and more personalised care when they need it:

We will maintain Integrated Plus services

We will develop a plan by April 2019 to roll out Personal Health Budgets covering wheelchairs, patients with mental health needs under Section 117, and other appropriate areas

We will review the end of life pathway to avoid admission to hospital by October 2019, in line with the recommendations in the Dudley End of Life and Palliative Care Strategy and delivering the national framework six ambitions for palliative and end of life care

We will amend the care home contract, such that care home staff initiate preferred place of care discussion (ACPs)

Learning disability and autism:

Providers will hold budgets for external placements in ‘shadow form’ from April 2019 and budgets are to be included in the MCP whole population budgets from April 2020

Cardiovascular disease:

Practice Based Pharmacists are to operate within PCNs once they are established, by April 2020

Respiratory disease:

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We will incorporate this within Practice Based Pharmacists’ work plans by April 2019

The RightCare action plan includes continuing with the respiratory consultant outreach supporting MDTs, continuing with the respiratory direct access clinics and continuing with the respiratory advice and guidance

From April 2019 the respiratory service will be commencing a new education and training programme for newly-diagnosed people with COPD

Working with the respiratory nurses will be integrated with the community hub and provide reactive responses for complex patients as well as proactive work

Common adult mental health disorders:

Our IAPT long term conditions service will be fully operational by April 2020

Short waits for planned care:

First Contract Practitioners will be fully rolled-out by April 2020

Supporting wider social goals:

Through our GPs continuing to refer patients requiring employment support, we will maintain our participation in the Thrive Programme and contribute to Dudley’s approach to ‘inclusive growth’

I) Better Care Fund (BCF)

i) Background

The CCG and Council have worked together closely for the last three years to jointly develop services in the community to promote alternatives to acute hospital care, and to facilitate discharge for those who are unavoidably hospitalised. The key to the strategy has been to promote independence and avoid the need for long term supported care wherever possible. As part of the joint working, the two organisations have pooled £77.6m of services, including protecting the improved BCF (iBCF) allocation to develop evidence-based community services.

Two years ago Dudley Metropolitan Borough Council ranked 132nd out of 152 Local Authorities (152nd being worst) for Delayed Transfers of Care (DTOC). Over 9% of beds in Russells Hall Hospital were occupied by people who were ready to be discharged. The Council had a high proportion of older people entering permanent residential and nursing care. The pace and effectiveness of reducing dependence or returning home via reablement services was variable. The CCG had rising emergency admissions and was incurring significant expenditure in excess bed day costs. The challenge, therefore, was to reduce DTOCs, improve levels of independence for older people and enable people to be able to access the hospital for planned surgery in a timely fashion. The overall objective was to offer people a good quality and timely discharge.

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The joint working was kick-started by the iBCF. The Integrated Commissioning Executive decided to ring-fence the entirety of the monies provided to improve the urgent care system. The objectives of the BCF were mirrored in both the Operational Plan and the Council strategy. Dudley Borough Council has experienced more than a 30% reduction in the Revenue Support Grant since 2010 and, like many local authorities, has had to deliver significant savings across all services to balance the books, including the closure or transfer of all council-run residential care homes. The iBCF funding was non-recurrent and therefore the project had to be designed in a way that capacity could be maintained in the long term by reducing system costs.

The following schemes follow national best practice and the eight high-impact changes proposed by NHS England (such as Discharge to Assess or D2A). Some of the schemes were created as a response to local demand.

ii) The Emergency Response Team (front of house)

Adult social care staff moved into the Emergency Department of Russell’s Hall Hospital to provide a social care response to Dudley residents who may need immediate support and assistance at home, alongside clinical intervention.

The team will also divert the person away from hospital (if achievable and appropriate) to enable appropriate support in the most appropriate non-acute care setting.

iii) Discharge to Assess, Pathways 1-3

We have fully implemented Discharge to Assess (D2A), Pathway 1 (straight home with domiciliary care), Pathway 2 (intermediate care/reablement) and Pathway 3 (complex discharges) at DGFT.

Pathway 3 provides a period of non-acute bed-based assessment for the stabilisation of needs and a period of recuperation. The assessment period will gather clear evidence of support needs, to enable an accurate assessment of the long-term care support required. This enables people with complex needs to be discharged from hospital. Often this cohort of people would otherwise experience the lengthiest delays.

iv) Improved Discharge Flow

We have increased the number of supported discharges for people who require non-bed-based social care input, in a more timely and effective manner, with a target of 24-hour Length of Stay for each discharge.

v) Single Handed Care

This enables care for a greater number of people by maximising the use of carer and financial resources. The technology improves dignity, care and wellbeing by having more meaningful and satisfactory engagement in the care provided (one-to-one relationship). The service has supported individuals in the setting of their choice for longer and increased the amount of available care capacity in Dudley, reducing delays and allowing earlier intervention.

vi) Palliative Care

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We have fully integrated palliative care services. People at the end of life get multi-agency support to remain at home or in a residential/nursing placement, to enable a dignified death.

vii) Community Response Team (CRT)

CRTs work alongside residential and nursing home providers to improve long term care planning and support people in the homes at a point of crisis.

viii) Reablement

We created a bespoke reablement service (home care) with the external provider market. This has increased capacity for reablement and incentives for providers to maximise independence through gain share payments. Three care providers deliver this work with a guaranteed number of hours (block) for providers and greater levels of autonomy for them to deliver the service around the needs of the individual.

xi) Performance

The iBCF saw the following monies invested on a decreasing basis across three financial years:

Financial Year

Approved Budget (£m)

2017/18 7.2

2018/19 4.4

2019/20 2.2

Total 13.8

Avoidance of hospital admission and reduction in excess bed day costs has generated a significant level of financial efficiency. Expenditure is currently £2m below the baseline position for the BCF.

There has also been a positive impact on reducing long-term spending of Council resources on residential care for older people – currently c. £1.3m lower than this time last year, as more people are cared for in their own homes.

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The shared aspiration of the Council and CCG is to mainstream the c. £4m per annum investment needed to maintain the schemes. This will be achieved through the efficiencies realised to date and the CCG has already set future Commissioning Intentions accordingly.

The most important measure is the view of local people. We set out to improve the quality of discharges and speed up the process. We have conducted a full survey of over 730 people who have experienced the discharge process.

We have reduced social care DTOC in Russells Hall Hospital by 92.4% from August 2017 to August 2018.

Our improvement trajectory is the best of any Council in the West Midlands and we have risen to the top quartile of the national performance tables. In September 2018 the combined health and social care delays were in the top quartile of performance nationally (i.e. from the bottom 15% to the top 25% in little over twelve months).

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From December 2017 to September 2018, we achieved the performance target set by NHS England. Less than 3.5% of all beds in the hospital were being occupied by a person due to a delayed discharge. This performance has been sustained for a long enough period to conclude that less than 3.5% delays are now business as usual.

Over 1000 people have had their needs identified and met at the front door of the hospital without the need for an admission at all.

Our use of Assistive Technology has been acknowledged by the Telecare Services Association as excellent – we were the first system to achieve platinum accreditation status. We are also rolling out single-handed care technology that has already reduced the need for double-handed (two person) packages of care by 15%.

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There is commitment from all partners to build on the success of the Better Care Fund achievements and to continue to meet the outcomes in the local and national priorities.

j) Medicines Optimisation

The CCG has a strong record, in conjunction with Public Health colleagues, of leading innovative medicines optimisation initiatives, a number of which have received national accolades.

The CCG will be implementing a medicines optimisation plan, which will include:

Continued development and roll out across all practices of our Prescription Ordering Direct (POD), designed to optimise repeat prescribing processes

Continued implementation of a policy on medicines of limited clinical value and self-care

Polypharmacy reviews, focussing on a risk-stratified cohort of patients

Contribution to STP-level programmes, including a focus on medicines issues in patients with learning disabilities (the STOMP LD programme), development of the pharmacy cross-system workforce, and improvement in prevention, detection and management of cardiovascular risks

Continuing to address issues in relation to antimicrobial resistance

Developing the pharmacy workforce in Primary Care Networks to case find and treat

Ensuring patients have access to flash glucose monitors

The team are preparing for transition into the Dudley MCP, which includes a review of governance arrangements around prescribing, the further development of a population approach to medicines safety and effectiveness, and targeting clinical interventions according to need and potential benefit.

k) Workforce

Metric Definition Assessment of progress

against the planned

target for the quarter

NEAReduction in non-elective

admissionsOn track to meet target

Res Admissions

Rate of permanent admissions to

residential care per 100,000

population (65+)

On track to meet target

Reablement

Proportion of older people (65 and

over) who were still at home 91

days after discharge from hospital

into reablement / rehabilitation

services

On track to meet target

Delayed Transfers

of Care

Delayed Transfers of Care (delayed

days)On track to meet target

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The MCP will be the main vehicle for developing the workforce required for meeting the challenges associated with a growing frail elderly population.

i) Primary care workforce

Primary care professionals will increasingly work at different organisational levels and at scale (their own practice, a neighbourhood of practices and across the local health economy). The MCP will open up opportunities in pathway design, service leadership, education, training and research, or developing areas of specialist clinical interest supported by colleagues from secondary care. These changes will develop a more unified team approach, creating portfolio opportunities to offer more satisfying and rewarding career choices in primary care.

In preparation for the MCP, working with our PCNs, we will:

Undertake workforce mapping across primary care (and the wider MCP)

Facilitate the development of a workforce development plan for PCNs, the MCP and the Black Country and West Birmingham STP

Ensure that our GPFV implementation plan supports the development of new roles and competency frameworks for use in the MCP

The CCG will contribute to the STP activities by:

Regular promotion of the Black Country STP as a great place to work, including marketing material such as the promotion of portfolio careers across the STP

Encouraging practices to participate in a range of other projects associated with GPFV recruitment and the introduction of new roles, in addition to flexible career options for early, mid to late career GPs

A recruitment programme (including advertising practice vacancies across the STP, working with universities, recruitment events, providing relocation support etc.)

Expanding engagement activities across the system within primary and secondary care, e.g. learning events, progress updates, sharing learning and best practice, via the primary care-secondary care interface toolkit

Sharing our learning on the development of the MCP as the STP continues its transition to an ICS

ii) New forms of workforce

We have identified particular new roles and invested in these and this process will continue. This will include:

Pharmacists – both supporting primary care and actively leading the population health management process

Social prescribing – we have already developed the link worker role described in the Long Term Plan, this will be developed

Supporting frequent service users – ensuring we have a workforce trained to manage this population cohort

Care co-ordinators – a key role within our ICTs

IAPT – ensuring we have the most appropriate workforce to integrate physical and mental health services, as well as supporting children and young people

Community-based urgent care response – ensuring we have the capacity to meet the 2-hour response target.

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iii) Being the employer of choice

The MCP will be a significant local employer in its own right. As such it has a key role to play in Dudley’s ‘inclusive growth’ agenda. Its employment practices and the role of its supply chain will be important factors in this.

Strong evidence shows that a motivated workforce delivers better outcomes for patients. The MCP procurement process has taken account of this in the evaluation of the bid. Staff engagement is crucial to this and we will continue to promote appropriate mechanisms during the contract mobilisation process and beyond.

iv) The future of commissioning

The creation of an intelligence-led and data-driven commissioning organisation will require a focus on the skills that are required for the future. A suitable workforce plan will be developed for this.

l) Data and Technology

Dudley continues to make progress in line with our Local Digital Roadmap, published in 2017. Central to the roadmap is provider Patient Administration System/Electronic Patient Record system upgrades and the introduction of a system-wide interoperability platform aimed at data sharing across providers.

The CCG will continue to support providers who wish to be part of the Global Digital Exemplar and/or Local Health and Care Record Exemplar programmes. To date, only the West Midlands Ambulance Service has expressed interest in being part of these programmes.

Where new standards are introduced, we will adopt as appropriate and this will be particularly relevant as we develop our interoperability capability, STP-wide. Cyber Security remains high on the agenda, with both the CCG and providers paying particular attention to this area. All new systems within Dudley should already be tested against Cyber Essentials/Cyber Essentials Plus as part of the procurement process.

In the area of apps, Dudley CCG has been active for a number of years with Sense.ly and has been at the heart of the development of their app for use within the NHS, in particular patient triage and NHS 111 integration. We have continued to develop the relationship and will be implementing the latest iteration of the app as part of our online consultation solution during 2019. This will include a Long Term Conditions (LTC) template to capture information more frequently and more easily from patients suffering from LTCs. We are keen, however, to continue to explore alternative and complementary solutions and will be investigating the use of the NHS app alongside existing deployments.

There is a major project already in train at the STP level to create a single view of maternity records across the Black Country STP. We will explore how both the

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Sense.ly and NHS apps can provide additional functionality to support this initiative, as well as other remote access programmes such as Diabetes Prevention, COPD and other LTCs.

i) Business Intelligence (BI)

The MCP is a sea-change in health and social care provision. For the first time

Primary Care, Community Care, Mental Health and some Local Authority services will

be bound contractually to the same strategic objectives under a single incentivised

MCP Outcomes Framework.

Therefore, the Business Intelligence (BI) required to support this fundamentally

different service provision will need to progress from the current position, of chiefly

reconciling activity and finance, to dynamic population health analytics delivering

actionable insights to front line staff.

In order to achieve this, Dudley CCG and Dudley MCP will:

Progress integration of data across and within organisations

Improve accessibility of data

Locate the required skills and knowledge in the right places

Reduce data and analytical lag

Improve the technological infrastructure in order to support the delivery of

actionable insights

Align BI effectively with strategic objectives

Establish optimal collaboration between teams both within and across

organisations

Improve confidence in data and insights through a rigorous ‘Kite Mark’

mechanism, assessing the validity and reliability of conclusions and

recommendations

Dudley CCG will test the current BI maturity across the Dudley health and social care

environment and produce a roadmap towards the end-point of a BI function, fully

aligned with outcome goals. The MCP will refocus health and social care

commissioning and provision upon improving health and wellbeing at the population

level. Therefore, BI delivery across commissioners and providers will be geared to

facilitate these new population-centred strategic objectives.

A strong analytics education and development programme will facilitate growing talent

from within, standardising analytical approaches around validity and reliability, but also

embedding a wider set of skills relating to cross-team working, communicating and

project management.

Much of the success of BI rests upon the IT infrastructure support. Data storage and processing will need to accommodate big data, machine learning and potentially artificial intelligence. Dudley CCG and Dudley MCP will actively engage in this space for example, combining apps with interactive digital health coaching. Therefore, developments in BI will have strong links and interdependencies with the local and national technology strategies.

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m) Personal Health Budgets (PHBs) and Personalisation

The Black Country is a “Wave 1 Demonstrator Site” for personalisation, and we will continue to build on our work in relation to personalised care. We will increase the amount of people in Dudley benefiting from personalised care approaches. Our work will focus on:

Growing a network of health coaches to support those people with the lowest activation to better manage their health

Increasing the number of Patient Activation Measures being used to understand the activation levels of people we are supporting

Supporting our network of peer support groups using the DCVS

Using social prescribing to help reduce social isolation and empower individuals

Increasing the number of people with a personalised care and support plan

As commissioners we will also see PHBs – particularly for those with long term conditions, heart failure and cancer – as our default position for NHS Continuing Health Care and wheelchair provision from 1st April 2019. During 2019/20 we will increase the spread of Personal Health Budgets (PHBs) to include patients in receipt of aftercare under Section 117 of the Mental Health Act, people using our Frequent Service User scheme, people with learning disabilities and people at the end of life. Our target is to have 340 PHBs in place by the end of 2019/20. We have demonstrated our full compliance with all nine of the Choice Standards. We will maintain our delivery of these in 2019/20.

9) Commissioning for Quality and Safety

a) Holding Providers to Account

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The CCG will continue to work with our providers across primary, community and secondary care to develop clear clinical quality standards for their services, focusing on improving patient outcomes, for inclusion in contracts which are monitored and mapped to the NHS outcomes framework. We will also work with our providers to further develop dashboards to illustrate their performance and to inform patient choice through 2019/20.

Performance data, including mortality information, continues to be used to triangulate an overall view of the services provided across the borough. The quality and safety of care is monitored through the Clinical Quality Review Meeting (CQRM) process and mortality and morbidity meetings, including the use of national metrics alongside other qualitative intelligence such as complaints and incidents. The CCG encourages a collaborative quality improvement approach, and where emergent patterns or themes are identified these are explored and shared across providers and the wider system to ensure lessons can be learnt, for example, the development of the Dudley Suicide Prevention Strategy.

The CCG governing body will continue to take every opportunity to hear the experiences and views of Dudley citizens and build their feedback into the service design process.

b) Patient Safety

The processes described in place to oversee this work and other contract review processes held between the CCG and providers report through to the CCG Quality and Safety Committee, which in turn provides the governing body with a comprehensive summary at each meeting.

The Quality and Safety Committee have an extensive patient safety agenda with a responsibility for oversight of:

Development of locally sensitive quality indicators and metrics to continually improve the quality outcomes of services

The review of all children and adult safeguarding issues

Monitoring of the performance of service providers quality improvement plans, including those to address shortfalls in the standards of quality and safety to ensure remedial actions are taken to comply with the expected standards. These reviews include monitoring of a suite of key indicators including Health Care Associated Infections (HCAI) data, patient complaints and compliments, and patient experience information i.e. family and friends test data, safety thermometer data and quality visit feedback

The review of any notification, advice or instruction issued by the National bodies and Regulators

The review of any notification, advice or whistleblowing issued by other agencies or individuals

The monitoring of incident data (Serious Incidents, Never Events, unexpected deaths) and actions associated with taking remedial actions

The oversight of quality exceptions reported (such as whistleblowing, serious case review, adverse media reports)

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c) Staff Satisfaction

We will use nationally reported staff surveys to focus on the views of staff and to encourage their engagement.

d) Safeguarding Children, Young People, Adults and Children Looked-After

Dudley CCG is committed to safeguarding the most vulnerable people in the borough. The CCG has a statutory duty under legislation and statutory guidance to ensure that adults, children, young people, families and children looked after are safeguarded and that all NHS bodies make arrangements to safeguard and promote the welfare of all children and adults. These duties must be discharged in cooperation with the Council and the Police.

New measures include three fundamental changes to safeguarding children arrangements. Local Safeguarding Children Boards (LSCBs) will be replaced by Multi Agency Safeguarding Arrangements (MASA). The current system of serious case reviews will be replaced with a two-tier system comprising of a National Panel responsible for commissioning and publishing reviews into the most serious and complex cases, which will lead to a national learning and local Child Safeguarding Practice Reviews (CSPRs) managed by the MASA. The responsibility for child deaths will transfer from LSCBs to the CCG and Local Authority and will be reviewed over a population size that gives a sufficient number of deaths to be analysed for patterns, themes and trends.

The CCG will review the link between the Children and Adult Safeguarding Boards, whilst also implementing the statutory changes to the children’s safeguarding agenda. The Strategic Director – People (Local Authority), Borough Commander (Police) and Chief Nurse (CCG), along with the Head of Community Safety and the statutory partner’s respective Safeguarding Leads, will be instigative in driving the change in order to progress the ‘think family’ agenda, avoid duplication and to consider a leaner and more efficient way of working.

Adult and Children Safeguarding Boards (or any future MASA) and Corporate Parenting Board are statutory functions, and the CCG must be a member of these boards. It is also a statutory requirement for CCGs to employ, or have in place, a contractual agreement to secure the expertise of designated professionals (Designated Nurses for Safeguarding Adults, Children and Children Looked After and Designated Doctors for Safeguarding and Children Looked After).

It remains the responsibility of every NHS-funded organisation and each individual healthcare professional working in the NHS to ensure that the principles and duties of safeguarding adults and children are holistically, consistently and conscientiously applied, with the wellbeing of those adults and children at the heart of what we do. For adult safeguarding this also needs to respect the autonomy of adults and the need for empowerment of individual decision-making, in keeping with the Mental Capacity Act and its Code of Practice.

As a member of Local Safeguarding Boards, the CCG must ensure that their duty to safeguard and promote the welfare of children and adults is carried out in such a way

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as to improve outcomes people in the borough. Wherever possible, evidence of impact on improving outcomes for children should be identified.

For the Local Safeguarding Boards or MASA to maintain oversight of the effectiveness of safeguarding practice across the borough, and of the extent to which it is continuously improving, the key Section 11 agencies are expected to provide information on the arrangements they have in place to protect and promote the welfare of children and young people. This includes Dudley CCG as a statutory member of the Safeguarding Children Board. The Section 11 audit has been completed on behalf of the CCG for 2018 and going forward it will be monitored and maintained.

NHS England have developed a Self-Assessment Tool (SAT) which has been completed and regularly updated by the Dudley CCG Safeguarding Team to provide assurances to NHS England that the responsibilities for Safeguarding Children, Adults and Children Looked After are being met.

The CCG, as the commissioner of local health services, needs to assure itself that the organisations from which they commission have effective safeguarding arrangements in place (Safeguarding Vulnerable People in the NHS – Accountability and Assurance Framework 2015). Safeguarding forms part of the NHS standard contract (service condition 32) and commissioners need to agree with their providers, through local negotiation, what contracting monitoring processes are used to demonstrate compliance with safeguarding duties. The CCG must gain assurance from all its commissioned services throughout the year to ensure continuous improvement. Assurance may consist of assurance visits, section 11 audits (children), formal reports, dashboards and attendance at provider safeguarding committees. Contracts specify compliance with CQC Essential Standards and related legislation, including the Mental Health Act, Mental Capacity Act (Deprivation of Liberty Safeguards) and the Care Act.

The CCG Safeguarding Quality Review Meeting (SQRM) aims to safeguard Dudley residents by effective high quality formal communication and partnership working, applying the Local Safeguarding Board’s priorities (children and adults) in order to achieve the best local outcomes. Dudley CCG seeks assurance from all providers regarding safeguarding arrangements. The SQRM is established within the Quality and Safety Committee structure in accordance with Dudley CCG statutory safeguarding responsibilities and aims to provide assurance regarding the health economy actions for the Dudley Safeguarding Boards as necessary.

Other mechanisms to ensure accountability and assurance, built into the health system, include contract monitoring and commissioner assurance mechanisms and local health overview and scrutiny committees. These can call local health organisations to account for their safeguarding arrangements. In order to ensure that service developments and redesigns consider the statutory safeguarding element, the CCG Safeguarding Team have developed a safeguarding Commissioning and Procurement framework, aligned to a set of standards which going forward will be included in all future contracts.

10) Future Commissioning Organisation

The move towards an ICS for the Black Country requires a change to the existing commissioning system, with the creation of a single commissioning function across the Black Country serving the four CCGs.

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During 2019/20, the four CCGs will develop and seek to implement their place-based care models, with the development of a single commissioning function during 2020/21.

The establishment of the MCP requires a redefinition of the CCG’s commission role and capacity. The MCP, in holding a long term outcomes-based contract and managing a Whole Population Budget, will require the capacity to manage risk, redesign services and align its activities to the delivery of a set of outcomes. Clinical and managerial leadership capacity will transfer from the CCG to the MCP in order to carry out a series of tasks that are traditionally the direct responsibility of the CCG. This will include capacity in relation to:

GP clinical leadership

Commissioning management – community, mental health, children’s, individual placements and other services within the scope of the MCP’s Whole Population Budget

NHS Continuing Healthcare and Intermediate Care assessment

Pharmaceutical Public Health

GP IT management

Finance

Contracting

Whilst the CCG retains its statutory duty to arrange for the provision of healthcare for its population, this transfer will recognise that other parts of the system can ‘arrange’ without having the same statutory duty. In this sense the MCP will operate in a manner not dissimilar to the CCG by following a commissioning cycle: assessing need, arranging services to meet that need, monitoring performance and reviewing future provision.

The future relationship between commissioner and provider will move from being transactional to transformational. Both parties will share a common interest in the MCP managing within its Whole Population Budget and will need to deploy their collective resources to do this, taking a quality improvement approach to the contract management process.

The Business Intelligence function will play a unique and distinctive role in these arrangements. A shared function will be required to support the whole system using data analytics to inform the process based on the principle of ‘one version of the truth’.

Consequential changes to the CCG’s governance arrangements are described in the next chapter (11).

11) Governance and Delivery

This Operational Plan will ultimately be overseen by the CCG governing body.

The development of individual initiatives, QIPP schemes and service redesigns will be the responsibility of its Commissioning Development Committee and Primary Care Commissioning Committee.

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The transfer of commissioning capacity to the MCP requires a review of the CCG’s governance arrangements, particularly in the light of the membership of the governing body, where there are currently ten elected GPs. It is planned to transfer 50% of this clinical leadership capacity to the MCP, such that in future the elected GP membership is five – one per Locality/Primary Care Network. The remaining non-GP membership of the governing body will also be reviewed in this context and following consultation with the GP membership, a revised constitution will be submitted to NHS England.

The arrangements for committees will also be revised such that:

A new Integrated Assurance Committee brings together all assurance functions across quality and performance

A new Policy and Commissioning Committee brings together the existing work of the Commissioning Development Committee, the discretionary elements of primary care commissioning not governed by the delegation agreement with NHS England and providing a renewed focus on data analytics to model future scenarios

A new Primary Care Commissioning Committee will be established. It is expected that in future this will operate ‘in common’ with Walsall CCG, dealing with those issues covered by the delegation agreement with NHS England

APPENDIX 2

NHS Long Term Plan – “New Service Model for the 21st Century” – MCP Position

Long Term Plan

Dudley Multispecialty Community Provider (MCP)

Improved responsiveness of community health crisis response services

Reablement care within two days of referral

More community-based response to emergencies, particularly in relation to the frail elderly and those in care homes

Urgent Treatment Centre

Continuity of care with integrated practices

Expanded community MDTs aligned with new PCNs based on neighbouring GP practices

Population-based and founded upon list-based general practice

Primary care-led model incorporating GPs as significant component of the leadership model

Wide range of integrated services brought together around general practice

Community Integrated Teams = timely input to keep people in their own homes and avoid emergency admission or facilitate timely discharge

Clear community identity and presence consistent with 5 localities

Services delivered from accessible community-based locations

Significant changes to the GP Quality and Outcomes Framework (QOF)

GPOF is incorporated within MCP Outcomes and MCP IPS

All GPOF items are allocated an incentive within the MCP IPS to incentivise integrated working between General Practice/rest of the system

Upgraded NHS support to all care home residents who would benefit

EHCH model rolled out across the whole country

Whole Population Budget will include budgets associated with emergency admissions due to falls, ambulatory care sensitive conditions and from care homes, incentivising the MCP to take appropriate preventative measures

Local GP practices/community teams will work together to provide more proactive care that helps patients to remain at home

GP ‘ward rounds’ for care homes

‘Red Bag’ scheme to support residents admitted or discharged from hospital

Community Response and Care Home Support Teams (including out of hours)

Single Point of Access number for support and clinical triage across 7 days

Educational and training support programme for care homes

PCNs will assess local populations by risk of unwarranted outcomes and work with local community services to make support available where it is most needed

Integrated Care Teams will work holistically with GPs using formal risk to coordinate evidence-based case management for these patients

Working in partnership with the Council and other stakeholders to tackle the wider determinants of health/health inequalities and build community capacity and resilience

Greater recognition and support for carers

MCP will ensure that carers are identified, supported and involved

Carers Strategy seeks to identify/support/involve carers by raising their profile

Carer Support scheme has focused on the development and implementation of a new Carer Strategy

Carers Personal Budgets are offered to carers with eligible needs

Improving care to people with dementia/delirium in hospital or at home

Increased emphasis on prevention, self-management, early diagnosis and proactive engagement with people who are at high-risk of developing Long-Term Conditions including Dementia

Voluntary sector support for people diagnosed with dementia

Dementia assessment service, including psychiatric input

Single multidisciplinary CAS within integrated NHS 111, ambulance dispatch and GP out of hours services

Integrated online and phone-based referral and information service for all MCP services

At least one local access centre/hub in all 5 localities for extended access 7 days per week.

Fully implemented UTC model by autumn 2020 with option of appointments booked through a call to NHS 111

Whole Population Budget will include urgent care centres and primary care out-of-hours services

More community-based response to emergencies that avoids unnecessary ambulance conveyance and admission to hospital

Improving performance at getting people home without unnecessary delay when they are ready to leave hospital

Community Integrated Teams will provide intensive support from advanced nurse practitioners working with rehabilitation/social care staff to facilitate timely discharge

Social prescribing for a more wide/diverse/accessible range of support

Link workers in PCNs will work with people to develop tailored plans and connect them to local groups and support services

“Integrated Plus” within ICTs work particularly with the most vulnerable people who are often socially isolated and have an unnecessary dependence on health and social care

Link workers are free of professional boundaries and can enable teams to look holistically at individual needs

Supporting community/carer/social networks to help maintain the resilience and quality of life for individuals

Accelerated roll out of Personal Health Budgets

Integrated Personal Commissioning and Personal Health Budgets for people with ongoing health needs

NHS will personalise care, to improve end-of-life care

Shared care plans will be developed, with a range of personalised services wrapped around the patient to meet their needs, supported by a named case manager and proactive monitoring of progress against the agreed plan

7-day palliative care team, increased number of advanced care plans, and additional support for end-of-life patients in residential care

Redesigned services so that over the next 5 years patients will be able to avoid up to 1/3 of face-to-face outpatient visits

Services will be delivered from accessible community-based locations consistent with the CCG’s estates strategy. These will support the movement of services traditionally delivered in hospital to community settings, whilst recognising the need to deliver some forms of care in settings that do not create stigmatisation

Some outpatient services, traditionally provided by secondary care, will be delivered by the MCP

More effective, integrated working between GPs and consultants will reduce unnecessary outpatient attendances

Supporting local approaches to blending health and social care budgets where councils and CCGs agree this makes sense

Whole Population Budget will include services currently commissioned and/or provided by Dudley Borough Council in relation to adult social care

Single legal entity commissioned by the CCG and Council with a single contract

Appropriate joint commissioning arrangements when services are the responsibility of Dudley Council are within the scope of commissioned services or Council staff are seconded to the MCP

Implementation and delivery of five-year action plan on Antimicrobial Resistance

Anti-Microbial Stewardship work programme in primary care and collaboration with acute providers

Continuing participation in regional forums

Local providers will be able to take control of budgets to reduce avoidable admissions, enable shorter lengths of stay and end out of area placements

Whole Population Budget will include all CCG commissioning budgets for admissions and placements, giving the MCP responsibility to avoid unnecessary admissions and out of area placements

Appropriate preventative treatments for individuals with high risk conditions, offered in a timely way with support for pharmacists and nurses in PCNs to case find and treat

Partnership with the Council and other stakeholders to tackle wider determinants of health and health inequalities and build community capacity/resilience

Increased incentives to invest in preventative measures to improve population outcomes

ICTs will work holistically with GPs using risk stratification to coordinate evidence-based case management

Practice-Based Pharmacists will support effective case finding

Better support from MDTs in PCNs for people with heart failure/valve disease

Community heart failure team commissioned

Practice-Based Pharmacists have improved mortality rate for hypertensive-related disease

More to support those with respiratory disease to receive and use the right medication. 90% of NHS spend on asthma

Medicine reviews by pharmacists in PCNs, including educating patients on the correct use of inhalers and contributing to multidisciplinary working

Whole Population Budget will include some existing out-patient services for adults and children including respiratory medicine

The initial areas where the MCP will align services to achieve continuity of care, working to a set of shared outcome objectives, are with the Long Term Conditions that are most significant to the Dudley population (i.e. diabetology, respiratory medicine, and mental health)

Practice-Based Pharmacists carry out medicine reviews

ICTs will include specialist nursing teams, including for respiratory medicine

Expand access to IAPT services with a focus on those with long-term conditions

Majority of services will continue to be provided by DWMHT and subcontracted to them by the MCP

Primary community mental health services and IAPT services priority for inclusion in the MCP ICTs

Integrated service for people with mental and physical health needs

Workforce trained to deliver talking therapies for CYP

Integrated primary and community mental health care supporting adults with severe mental illnesses

Physical and mental health services will be integrated

Whole Population Budget will include all CCG-commissioned mental health services

Direct access to MSK First Contact Practitioners (FCP)

First Contact Practitioners are operating in 5 practices in 2018/19, will be extended across Dudley in 2019/20

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Date of Board: 28 March 2019

Report: Constitutional Changes – Version 5.3 Agenda item No: 6.0

TITLE OF REPORT: Constitutional Changes – Version 5.3

PURPOSE OF REPORT: To present a summary of proposed changes to the CCG’s Constitution for approval prior to its submission to NHS England in April 2019

AUTHOR OF REPORT: Mrs E Smith, Governance Support Manager

MANAGEMENT LEAD: Mr M Hartland, Chief Operating and Finance Officer

CLINICAL LEAD: Dr D Hegarty, Chair

KEY POINTS:

The CCG are required to have a constitution as set out in the Health and Social Care Act 2012. Any revisions to the Constitution must be submitted to NHS England for agreement.

The CCG is facing a number of local and regional changes and it is appropriate to review the governance arrangements in order to meet future requirements.

The resulting changes have been made to the constitution and are presented to the GB for agreement prior to submission to NHS England for approval. Once approved the changes can be implemented.

The Board should note that this is an interim constitution change until the New Model Constitution is drafted in the new financial year.

It is proposed that following NHS England’s approval the changes will take place at the 1 July 2019.

A summary of all the proposed changes for submission to NHSE are included in Appendix 1

As a number of these changes relate to enhancement and amendment of the Scheme of Reservation & Delegation (SORD), an amended version of this highlighting the proposed changes is included as Appendix 2

RECOMMENDATION: 1) The Board approve the proposed changes to the Constitution as

outlined in the Appendix for submission to NHSE for approval



Engagement with Membership


None

ACTION REQUIRED:

Decision Approval Assurance

2 | P a g e

DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 28 MARCH 2019 CONSITITUTIONAL CHANGES

1.0 INTRODUCTION

1.1 The CCG are required to have a constitution as set out in the Health and Social Care Act 2012. Any revisions to the Constitution must be submitted to NHS England for agreement. A summary of changes is attached in Appendix 1.

2.0 PROPOSED CHANGES 2.1 The organisational landscape in Dudley is changing, and the CCG believes that the creation of Dudley

Multi-speciality Community Provider (MCP) requires increased input and leadership from clinical primary care colleagues. To support, this, and to make the CCG more efficient and organisationally prepared for future system changes, it was agreed that the CCG would revisit the constitution and explore with our membership how the CCG could be different to ensure our clinical leadership is focussed on the future.

2.2 Further to the paper presented to the CCG Board on the 10 January 2019 which outlined the proposed

changes to the governance structure of the CCG further work and consultation has been carried out in articulating the proposed changes.

2.3 There are four areas proposed for change to the Constitution:

1) Membership Governance Structure 2) Committee Structure 3) Scheme of Reservation and Delegation (Appendix 2) 4) Member Practices

3.0 MEMBERSHIP GOVERNANCE STRUCTURE

3.1 Based on the changes proposed in the previous Board paper and the consultation which took place in February with the membership, the changes to members are outlined below:

Current membership Future membership

Chair Chair

Accountable Officer Accountable Officer

Chief Finance Officer Chief Finance Officer

Director of Nursing Director of Nursing

Three Lay members Three lay members

Secondary Care Consultant Secondary Care Consultant

Up to ten elected Locality Representatives Up to five elected Locality Representatives

Up to five appointed Clinical Executives who are GPs

Up to three appointed Clinical Executives who are GPs

Local Authority representative Local Authority representative

3.2 These changes have been reflected in the CCG constitution and are documented in appendix 1.

4.0 COMMITTEE STRUCTURE 4.1 The proposed changes to the committee structure are to change the following Committees names:

Finance, Performance & Business Intelligence Committee to the Finance and Investment Committee

Quality & Safety Committee to the Integrated Assurance Committee

Commissioning and Development Committee to the Policy and Commissioning Committee

4.2 This would include transferring the performance elements form the Finance & Investment Committee to the Integrated Assurance Committee. The Terms of Reference for each Committee are currently under

3 | P a g e

review and are not included today as they do not form part of the Constitution changes, however they will be presented as part of the paper to Board on the 28th March.

4.3 A requirement of NHS England for changing the CCG Constitution is to engage and consult with the

membership of the CCG. A survey including the following questions, was circulated to the CCG membership via Members News for response and comment. The questions and the outcome rate is indicated below:

Question Yes No

Q1 We want Primary Care at the centre of the MCP development and propose to redistribute some of the existing clinical leadership from the CCG to the MCP to enable this to happen. Do you support a proposal to support the MCP development by aligning existing clinical Governing Body Members to the MCP?

33 3

Q2 We currently have 10 elected GPs on our Governing Body, two representatives from each locality. To support the proposal to align GP leadership to the MCP, do you support a reduction of CCG Governing Body representation from 10 to 5, ie 1 per locality? The remaining five members would continue to represent localities supporting the MCP.

29 7

Question Elected Appointed

Q3 Current Governing Body members are elected with each member having a defined term of office, usually three years. There is an option that we can change our constitution so that locality representation is appointed against a set of locally agreed criteria rather than elected. With this in mind, from a locality perspective, do you think your Governing Body representation should be elected or appointed?

20 16

Question Locality Borough

Q4 Do you think that the five Governing Body Members should be elected/appointed from each locality or from across the borough as a whole?

27 9

Question Yes No

Q5 The CCG currently has six Committees, these are: 1) Audit & Governance 2) Commissioning Development 3) Finance, Performance & Business Intelligence 4) Primary Care Commissioning 5) Quality & Safety 6) Remuneration & HR Three of these Committees are chaired by Clinical Executives and three by Lay Members. To streamline the governance of the CCG and make Committee’s more effective it is proposed to realign Committees to reflect the future model of working. The proposal is to amend the Committee structure to: 1) Audit and Governance 2) Policy & Prevention (now commissioning) 3) Finance & Investment 4) Primary Care Commissioning 5) Integrated Assurance 6) Remuneration & HR Do you support the proposal to amend the CCG Committee structure as described above?

31 3

Q6 To reflect the clinical leadership required to Chair the new committee structure and to facilitate the use of resource to support MCP development we are proposing to reduce the Clinical Executive on the Governing Body from five to three. Do you agree with this reduction in Clinical Executives?

30 6

The outcome of the consultation demonstrated that the membership support the proposed changes to the Constitution.

4 | P a g e

There were a number of comments included in the response. In the main they were general comments to support the response provided, but some pertinent comments for consideration by the Governing Body are highlighted below: Elected or Appointed: A number of comments were made supporting that the Board Members be elected rather than appointed, however there was a suggestion that the “locally agreed criteria” for electing members should be agreed with the membership beforehand. There were three comments from members that stated that locality representatives should be appointed rather than elected as this would ensure that the candidates with the right skills were in place. From Locality or Borough: The question regarding whether locality members were elected/appointed from each locality of from across the borough as a whole, resulted in strong support for a locality basis and for the board member to have that local knowledge. However there were some comments in support of a borough wide basis in terms of ability rather than geography.

Committee Structure:

Whilst there were comments of support, there were many comments in relation to the changes of the Committee structure but this was in relation to “requiring more information” regarding what the changes actually mean, there was a request for more detail and a significant concern that the new proposal was losing the quality focus by renaming the Quality & Safety Committee to Integrated Assurance.

5.0 HR PROCESS 5.1 A HR process to address these proposed changes is currently being drafted and is being presented to the

Remuneration and HR Committee on the 27 March 2019. 6.0 SCHEME OF RESERVATION AND DELEGATION (SORD) 6.1 As some duties will be transferring between Committees, the SORD has been updated to reflect the

changes and is included in Appendix 2 for approval. This will be supplemented by an amendment to the Financial Scheme of Delegation if the amendments to the SORD are agreed. This will aim to improve the efficiency of decision making within the CCG whilst ensuring Committee accountability.

7.0 MEMBER PRACTICES 7.1 There is one amendment to practices within the current CCG membership and this is the closure of

Crestfield Surgery as outlined in Appendix 1. The CCG now has 43 practices and this has been reflected in the Constitution.

7.2 In March 2018 the Board approved an application to NHS England for Kinver Surgery to join Dudley CCG

from South East Staffordshire and Peninsula (SESSP) CCG and an updated application will be submitted to NHS England.

8.0 RECOMMENDATIONS

1) The Board to approve the proposed changes to the Constitution as outlined in Appendix 1 for submission to NHSE

9.0 APPENDICES App 1 – Changes to Constitution App 2 – Scheme of Reservation and Delegation M Hartland Chief Operating and Finance Officer March 2019

APPENDIX 1

NHS DUDLEY CCG – CHANGES TO DUDLEY CCG CONSTITUTION

PROPOSED FOR SUBMISSION MARCH 2019

Item

Constitution Reference

Recommended Change to CCG Constitution

5 FUNCTION & GENERAL DUTIES

Pg 15 – 22 Change of Committee names throughout section. Finance, Performance & Business Intelligence to Finance & Investment Committee Quality& Safety Committee to Integrated Assurance Committee Commissioning Development Committee to Policy & Commissioning Committee

6 DECISION MAKING: THE GOVERNANCE STRUCTURE

6.7 Pg 28 Change of Committee names throughout section. Finance, Performance & Business Intelligence to Finance & Investment Committee Quality& Safety Committee to Integrated Assurance Committee Commissioning Development Committee to Policy & Commissioning Committee

6.9 The Governing Body Pg 30-34 Change of Committee names throughout section and revised proposed wording from Paul Capener in relation to Committees delegation. Finance, Performance & Business Intelligence to Finance & Investment Committee Quality& Safety Committee to Integrated Assurance Committee Commissioning Development Committee to Policy & Commissioning Committee

6.9.2 Composition of the Governing Body - the Governing Body shall not have less than 12 members (and all shall have voting rights unless otherwise stated) and comprise of: a) the chair; (appointed by the voting members of the Governing Body from the 10 five elected appointed GP representatives)

b) the lay member vice chair (elected by the voting members of the Governing Body from the nominated lay members)

c) up to 10 five (including the Chair) elected appointed GP representatives of member practices;

d) up to three Clinical Executives; of which there are currently five

7 ROLES AND RESPONSIBILITIES

Pg 33 - 37 Change of Committee names throughout section. Finance, Performance & Business Intelligence to Finance & Investment Committee

Item

Constitution Reference

Recommended Change to CCG Constitution

Quality& Safety Committee to Integrated Assurance Committee Commissioning Development Committee to Policy & Commissioning Committee

Appendix B LIST OF MEMBER PRACTICE BY LOCALITY

This has been updated in line with current membership information Removal of: Crestfield Surgery Now 43 Practices

Appendix D SCHEME OF RESERVATION AND DELEGATION

This has been updated in line with current membership information

Appendix E PRIME FINANCIAL POLICIES

Pg 78 – 85 Finance, Performance & Business Intelligence to Finance & Investment Committee Quality& Safety Committee to Integrated Assurance Committee Commissioning Development Committee to Policy & Commissioning Committee

March 2019 1 | P a g e

APPENDIX 2 DUDLEY CCG - SCHEME OF RESERVATION & DELEGATION FOR THE GROUP

Policy Area Decision Reserved

to the Membership

Reserved/ Delegated to Governing

Body

Delegated to Committee

Officer

REGULATION AND CONTROL

1. Determine the arrangements by which the members of the Group approve those decisions that are reserved for the membership.

2. Consider and approve applications to NHS England on any matter concerning changes to the Group’s constitution, including terms of reference for the Group’s Governing Body, its committees, membership of committees, the overarching scheme of reservation and delegated powers, arrangements for taking urgent decisions, standing orders and prime financial policies.

3. Exercise or delegation of those functions of the clinical commissioning group which have not been retained as reserved by the Group, delegated to the Governing Body, delegated to a committee or Sub-Committee of the Group or to one of its members or employees.

4. Prepare the Group’s overarching scheme of reservation and delegation, which sets out those decisions of the Group reserved to the membership and those delegated to the

group’s Governing Body

committees and Sub-Committees of the Group, or its members or employees

and which sets out those decisions of the Governing Body reserved to the Governing Body and those delegated to

the Governing Body’s committees and Sub-Committees,

members of the Governing Body,

an individual who is member of the Group but not the Governing Body or a specified person

for inclusion in the Group’s constitution.

Chief

Finance Officer

Director with

responsibility for

Governance

5. Approve the Group’s overarching scheme of reservation and delegation.

6. Prepare the Group’s operational scheme of delegation, which sets out those key operational decisions delegated to individual employees of the clinical commissioning group, not for inclusion in the Group’s constitution.

Chief Finance Officer



to the Membership


Body


Officer

Director with

responsibility for

Governance

7. Approve the Group’s operational scheme of delegation that underpins the Group’s ‘overarching scheme of reservation and delegation’ as set out in its constitution.

Audit &

Governance

8. Prepare detailed financial policies that underpin the clinical commissioning group’s prime financial policies.


9. Approve detailed financial policies.

Finance, Performance and Business Intelligence & Investment

10. Approve arrangements for managing exceptional funding requests.

Commissioning Development

Policy & Commissioning

11. Determination of process for making grants and loans to voluntary organisations


12. Ensure the Group's expenditure does not exceed the aggregate of the CCG's allotments for the financial year


13. Ensure the Group's use of resources (both its capital resource use and revenue resource use) does not exceed the amount specified by NHS England for the financial year

Chief

Finance Officer

14. Take account of any directions issued by NHS England, in respect of specified types of resource use in a financial year, to ensure the Group does not exceed an amount specified by NHS England

Chief

Finance Officer



to the Membership


Body


Officer

15. Publish an explanation of how the Group spent any payment in respect of quality made to it by NHS England


PRACTICE MEMBER REPRESENTATIVES AND MEMBERS OF GOVERNING BODY

1. Approve arrangements for

identifying practice members to represent practices in matters concerning the work of the Group; and

appointing clinical leaders to represent the Group’s membership on the Group’s Governing Body, for example through election (if desired).

2. Approve the appointment of Governing Body members, the process for recruiting and removing non-elected members to the Governing Body (subject to any regulatory requirements) and succession planning.

3. Approve arrangements for identifying the Group’s proposed accountable officer.

STRATEGY AND PLANNING

1. Approve the Group’s operating structure.

Chief Accountable

Officer

2. Approve the Group’s commissioning plan.

3. Approve the Group’s corporate budgets that meet the financial duties as set out in section 5.3 of the main body of the constitution.

4. Approve variations to the approved budget where variation would have a significant impact on the overall approved levels of income and expenditure or the Group’s ability to achieve its agreed strategic aims.


ANNUAL REPORTS AND ACCOUNTS

1. Approve the Group’s annual report and annual accounts.

Audit & Governance

2. Approve arrangements for discharging the Group’s statutory financial duties.

Finance, Performance and Business Intelligence



to the Membership


Body


Officer

Audit & Governance

HUMAN RESOURCES

1. Approve terms and conditions, remuneration and travelling or other allowances for Governing Body members, including pensions and gratuities.

Remuneration &

HR

2. Approve terms and conditions of employment for all employees of the Group including, pensions, remuneration, fees and travelling or other allowances payable to employees and to other persons providing services to the Group.

Remuneration & HR

3. Approve any other terms and conditions of services for the Group’s employees.

Remuneration & HR

4. Determine the terms and conditions of employment for all employees of the Group.

Remuneration & HR

5. Determine pensions, remuneration, fees and allowances payable to employees and to other persons providing services to the Group.

Remuneration & HR

6. Recommend pensions, remuneration, fees and allowances payable to employees and to other persons providing services to the Group.

Remuneration & HR

7. Approve disciplinary arrangements for employees, including the Accountable Officer (where he/she is an employee or member of the Clinical Commissioning Group) and for other persons working on behalf of the Group.

Remuneration & HR

8. Review disciplinary arrangements where the Accountable Officer is an employee or member of another Clinical Commissioning Group.

Remuneration & HR

9. Approve arrangements for discharging the Group’s statutory duties as an employer.

Remuneration & HR

10. Approve human resources policies for employees and for other persons working on behalf of the Group.

Remuneration & HR

QUALITY AND SAFETY

1. Approve arrangements, including supporting policies, to minimise clinical risk, maximise patient safety and to secure continuous improvement in quality and patient outcomes.

Quality& Safety

Integrated Assurance



to the Membership


Body


Officer

2. Approve arrangements for supporting NHS England in discharging its responsibilities in relation to securing continuous improvement in the quality of general medical services.

Quality& Safety


OPERATIONAL AND RISK MANAGEMENT

1. Prepare and recommend an operational scheme of delegation that sets out who has responsibility for operational decisions within the Group.


Director with

responsibility for

Governance

2. Approve the Group’s counter fraud and security management arrangements.

Audit & Governance

3. Approve the Group’s risk management arrangements.

Audit & Governance

4. Approve arrangements for risk sharing and or risk pooling with other organisations (for example arrangements for pooled funds with other clinical commissioning groups or pooled budget arrangements under section 75 of the NHS Act 2006).

Finance, Performance &

Business Intelligence

5. Approve a comprehensive system of internal control, including budgetary control, which underpins the effective, efficient and economic operation of the Group.

6. Approve proposals for action on litigation against or on behalf of the clinical commissioning group.

7. Approve the Group’s arrangements for business continuity

Audit & Governance

INFORMATION GOVERNANCE

1. Approve the Group’s arrangements for handling complaints.

Quality& Safety Integrated Assurance

2. Approve arrangements for ensuring appropriate safekeeping and confidentiality of records and for the storage, management and transfer of information and data.

Audit &

Governance



to the Membership


Body


Officer

TENDERING AND CONTRACTING

1. Approve the Group’s contracts for any commissioning support.

2. Approve the Group’s contracts for corporate support (for example finance provision).


PARTNERSHIP WORKING

1. Approve decisions that individual members or employees of the Group participating in joint arrangements on behalf of the Group can make. Such delegated decisions must be disclosed in this scheme of reservation and delegation.

Chief

Accountable Officer

2. Approve decisions delegated to joint committees established under section 75 of the 2006 Act.

Chief Accountable

Officer

COMMISSIONING AND CONTRACTING

FOR CLINICAL SERVICES

1. Determination of arrangements for discharging the Group’s statutory duties associated with its commissioning functions, including but not limited to securing public involvement, ensuring patient choice, securing continuous improvement in the quality of services, innovation, research, education and training and obtaining appropriate advice.


2. Determination of arrangements put in place to promote a comprehensive health service

3. Determination of arrangements to meet the public sector equality duty

4. Promote the involvement of patients, carers and representatives in decision about their healthcare



to the Membership


Body


Officer

5. Determination of the arrangements to secure engagement with the public, patient and their representatives in decisions about their healthcare – Engagement



6. Determination of the arrangements to secure engagement with the public, patient and their representatives in decisions about their healthcare - Patient Experience

Quality& Safety


7. Determination of arrangements for supporting NHS England as regards improving the quality of primary medical services

Quality& Safety Integrated Assurance

8. Determination of arrangements for co-ordinating the commissioning of services with other groups and or with the local authority(ies),where appropriate.



9. Determination of arrangements for securing health services that are provided in a way that promotes awareness of, and has regard to the NHS Constitution

Policy &

Commissioning

Chief Accountable

Officer

10. Determination of arrangements for the review, planning and procurement of primary care medical services (under delegated authority from NHS England). To include

GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action, such as issuing branch/remedial notices, and removing a contract);

Newly designed enhanced services (“Local Enhanced Services (LES)” and “Directed Enhanced Services (DES)”);

Design of local incentive schemes as an alternative to the Quality and Outcomes Framework (QOF);

The ability to establish new GP practices in an area;

Approving practice mergers; and

Making decisions on ‘discretionary’ payments (e.g., returner/retainer schemes).

Primary Care

Commissioning



to the Membership


Body


Officer

11. Overseeing the arrangements for co-ordinating the commissioning of services, other than primary medical services as delegated to the Primary Care Committee in 8 above, with other groups and or with the local authority(ies)



12. Promoting integration of both health services with other health services and health services with health-related and social care services where the Group considers that this would improve the quality of services or reduce inequalities



13. Decisions regarding the Multi-Specialty Community Provider (MCP) procurement except the decision to commence procurement and to award the contract.

MCP Project

Board

14. Decision to commence MCP procurement and to award the contract

COMMUNICATIONS

1. Approve arrangements for handling Freedom of Information requests.

Audit &

Governance

2. Determine arrangements for handling Freedom of Information requests.

Audit &

Governance

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Date of Board: 28 March 2019

Report: Corporate Objectives for 2019/20 Agenda item No: 7.0

TITLE OF REPORT: Corporate Objectives for 2019/20

PURPOSE OF REPORT: To present to the Board the headline Corporate Objectives for 2019/20

AUTHOR OF REPORT: Mr P Maubach, Chief Executive Officer

MANAGEMENT LEAD: Mr P Maubach, Chief Executive Officer

CLINICAL LEAD: Dr D Hegarty, Chair

KEY POINTS:

1. This paper sets out the headline corporate objectives for the coming year, including key lead responsible executives for each objective

2. The detailed schedule is enclosed in Appendix 1

3. The next paper for assurance will be presented at the May 2019 Board.

RECOMMENDATION: 1. The Governing Body is asked to approve these high-level corporate objectives with the expectation that they will be used to form the objectives for all staff in the CCG.



None

ACTION REQUIRED:

Decision Approval Assurance

2 | P a g e

DUDLEY CLINICAL COMMISSIONING GROUP BOARD – 24 MARCH 2019 CORPORATE OBJECTIVES UPDATE 2019/20

1.0 INTRODUCTION

1.1 The Governing Body sets the corporate objectives at the start of each financial year. They are

informed by the national guidance and local and regional ambitions. This gives the organisation a clear understanding on the priorities and key delivery requirements.

1.2 It is accepted that the delivery of the objectives will involve appropriate patient and public,

stakeholder and membership participation as part of the wider communication and engagement activity.

1.4 The objectives for 2019/20 have set out additional detail on the areas of priority which the objective is

intended to cover. This will assist with the personal development review (PDR) objective setting exercise throughout the organisation in quarter 1.

Aim 1: To effectively commission services which will improve the health and wellbeing for our population

Objective 1: Create a local health and care service with our partners

Aim 2: To comply with our statutory duties and responsibilities and keep people safe

Objective 2: Make sure that the services we buy are of good quality, delivered safely and perform well

Objective 3: Ensure effective delivery of our Statutory Duties

Objective 4: Manage the money well

Aim 3: To ensure strong leadership and governance arrangements

Objective 5: Make sure the CCG is the best we can be

Objective 6: Work well with the Local Authority

Objective 7: Work with the other Black Country CCGs and providers to provide joined up health services where it is

best for the public

Objective 8: Develop the IT systems to make a real difference to patient care

Aim 4: To support the development of the MCP

Objective 9: Assist in the transition arrangements required to manage the MCP care model and create the new MCP

(particularly in relation to CCG activities)

1.5 Once the objectives and details are agreed, a set of ‘what good looks like at the end of the year’

measures will be agreed so that progress can be monitored and reported to Governing Body. 1.6 Each corporate objective is led by a director and is managed through a committee. This gives a clear

line of accountability, risk management and reporting arrangements (Appendix 1). 1.7 It is acknowledged that the requirement to make 20% management reduction costs may impact on

the organisational ability to deliver on all of the corporate objectives in the manner described. The corporate objectives will need to be reviewed in Q1 following the agreement of the 20% reduction plans.

2.0 RECOMMENDATION 1) The Governing Body is asked to approve these high-level corporate objectives with the expectation

that they will be used to form the objectives for all staff in the CCG. Mr P Maubach Chief Executive Officer March 2019

3 | P a g e

Dudley CCG Corporate Objectives 2019-2020

The delivery of the objectives will involve appropriate patient and public, stakeholder and membership participation as part of the wider communication and engagement activity

AIM 1 : To effectively commission services which will improve the health and wellbeing for our population

LEAD LED THROUGH

OBJECTIVE 1: CREATE A LOCAL HEALTH AND CARE SERVICE WITH OUR PARTNERS

1. OD for MDT/ICT working arrangements; Director of HR & Remuneration Remuneration & HR

2. Development of the SPA/ urgent community response and recovery support; Director of Commissioning Policy & Commissioning

3. Integrated governance between primary and community services; Chief Nurse Integrated Assurance

4. Defining the CCG activities and their future contracting as part of the placed-based care model

Director of Commissioning Governing Body

5. Overall coordination of the development of CCG activities in preparation for becoming part of an MCP

Director of Commissioning Governing Body

6. Development of effective PCNs of local GP practices and community teams Chief Nurse Primary Care Commissioning

7. Supporting people living in care homes by implementing the EHCH care model Director of Commissioning Policy & Commissioning

8. Supporting people to live well Director of Commissioning Policy & Commissioning

9. Reducing pressure on emergency hospital services Director of Commissioning Policy & Commissioning

10. The choice and control of the personalised care model Director of Commissioning Policy & Commissioning

11. The digital-first primary care delivery Chief Finance Officer Chief Nurse

Primary Care Commissioning

12. Management of long term conditions pathways Director of Commissioning Policy & Commissioning

13. Develop local place based assurance Chief Finance Officer Audit & Governance

14. Overall commissioning oversight of the MCP Director of Commissioning Policy & Commissioning

Appendix 1

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Aim 2: To comply with our statutory duties and responsibilities and keep people safe LEAD LED THROUGH

OBJECTIVE 2: MAKE SURE THAT THE SERVICES WE BUY ARE OF GOOD QUALITY, DELIVERED SAFELY AND PERFORM WELL

1. CCGs bringing together integrated assurance into a single committee Chief Nurse Integrated Assurance

2. Improve the assurance to the GB on the delivery of quality and safety Chief Nurse Integrated Assurance

3. Making positive improvements in primary care as a basis for the local care model Chief Nurse Integrated Assurance

Focus on Key areas for improvement:

1. The urgent care system Director of Commissioning Policy & Commissioning

2. EOL / mortality in ED Chief Nurse Integrated Assurance

3. Maternity services Chief Nurse Integrated Assurance

4. TCP / LD agenda including individual case management, community care and the wider scope of access to services for people with LD

Chief Nurse Integrated Assurance

5. Children and young person’s agenda Case management for the complex cases, CHC CAMHs, children’s MH

Chief Nurse Integrated Assurance

Deliver on:

1. The IAF measures where we need to see significant improvement Chief Finance Officer Integrated Assurance

2. 9 must dos Director of Commissioning Policy & Commissioning

3. Health inequalities Director of Commissioning Policy & Commissioning

OBJECTIVE 3: ENSURE EFFECTIVE DELIVERY OF OUR STATUTORY DUTIES

Deliver on the duties which we directly manage now and understand how we will quantify the delivery of this then they eventually become part of the placed based care model

Chief Finance Officer Audit & Governance

Providing clear reporting and assurance to the Governing Body on how we deliver on:

1. Continuing Healthcare Director of Commissioning Integrated Assurance

2. Medicines Management Director of Commissioning Policy & Commissioning

3. Safeguarding Chief Nurse Integrated Assurance

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4. Individual case management Director of Commissioning Integrated Assurance

5. The functions evaluated by Audit & Governance or Remuneration and HR ie GDPR, H&S, ERPP, E&D

Chief Finance Officer Audit & Governance

OBJECTIVE 4: MANAGE THE MONEY WELL

1. Establish plans to meet statutory financial duties Chief Finance Officer Finance & Investment

2. Establish effective financial risk management protocols Chief Finance Officer Finance & Investment

3. Recurrently deliver the QIPP programme Director of Commissioning Policy & Commissioning

Aim 3: To ensure strong leadership and governance arrangements LEAD LED THROUGH

OBJECTIVE 5: MAKE SURE THE CCG IS THE BEST WE CAN BE

Deliver on:

1. Developing our vision for the Long Term Plan Director of Commissioning Policy & Commissioning

2. Improving collaboration between Dudley and Walsall CCGs Chief Executive Governing Body

3. Collaboration with partner CCGs across the STP Chief Executive Governing Body

4. Moving towards a single CCG team across the STP Chief Executive Governing Body

5. Achieving the 20% management cost reduction Chief Finance Officer Governing Body

6. Establishing a single management of change process Director of HR & OD Rem Com

7. Building CCG resilience and maintaining business continuity Chief Finance Officer Audit & Governance

8. Reviewing CSU support requirements Chief Finance Officer Finance & Investment

9. Staff engagement process Director of HR & OD Rem Com

10. Develop and deliver OD plan (feedback to GB on the challenges to deliver this) Director of HR & OD Rem Com

11. Improving our relationships with primary care practices Director of Communications & Patient Involvement

Primary Care Commissioning

12. Our resilience, effectiveness and preparations for change Director of HR & Remuneration Remuneration & HR

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13. Continued improvement of our governance arrangements Chief Finance Officer Audit & Governance

OBJECTIVE 6: WORK WELL WITH THE LOCAL AUTHORITY

To understand and develop the role of the CCG in:

1. The local system for placed based care Director of Commissioning Policy & Commissioning

2. The economic regeneration with the local authority Director of Commissioning Policy & Commissioning

3. The joint statutory arrangements with the local authority Director of Commissioning Policy & Commissioning

Ensure effective governance and delivery of statutory responsibilities, particularly with the local council, (SEND and LD with the LA in regard to TCP) in the context of moving to a future single CCG team arrangement (Joint commissioning, safeguarding HWBB arrangements)

Chief Nurse Director of Commissioning


Develop our local Estates Strategy Chief Finance Officer Finance & Investment

OBJECTIVE 7: WORK WITH THE OTHER BLACK COUNTRY CCGS AND PROVIDERS TO PROVIDE JOINED UP HEALTH SERVICES WHERE IT IS BEST FOR THE PUBLIC

To ensure the CCG makes a fair and appropriate contribution to

1. The system in readiness for moving towards an ICS Chief Executive Governing Body

2. Service review programmes and the clinical leadership group agenda Director of Commissioning Policy & Commissioning

3. Evaluating risks and opportunities for acute and mental health / LD provider collaboration

Director of Commissioning Integrated Assurance

4. Ensuring alignment between CCG commissioning of services which form part of the horizontal integration agenda

Director of Commissioning Policy & Commissioning

5. Increase our contribution to the Clinical Leadership Group for effective influence for clinical priorities across the Black Country

Chair Governing Body

OBJECTIVE 8: DEVELOP THE IT SYSTEMS TO MAKE A REAL DIFFERENCE TO PATIENT CARE

1. Ensure appropriate digital considerations are made when making commissioning decisions

Director of Commissioning Policy & Commissioning

2. Ensure the requirements of the LTP are included in CCG digital strategies/Black Country Local Digital Roadmap

Chief Finance Officer Finance & Investment

3. Ensure compliance with GP IT operating model Chief Finance Officer Finance & Investment

4. Manage performance of IT providers Chief Finance Officer Finance & Investment

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Aim 4: To support the development of the MCP LEAD LED THROUGH

OBJECTIVE 9: ASSIST IN THE TRANSITION ARRANGEMENTS REQUIRED TO MANAGE THE MCP CARE MODEL AND CREATE THE NEW MCP

1. Assist in the transition arrangements required to manage the MCP care model and create the new MCP (particularly in relation to CCG activities)

Chief Executive Governing Body

Dudley Clinical Commisioning GroupGLOSSARY - NOVEMBER 2018

Abbreviation Meaning

#NOF Fractured Neck of Femur

£K £1,000 equivalent

A&E Accident and Emergency

ACO Accountable Care Organisation

ACS Ambulatory Care Sensitive Conditions

ACS Acute Coronary Syndrome

ACSs Accountable Care Systems

AD Assistant Director

AfC Agenda for Change

AGM Annual General Meeting

AHSN Academic Health Science Networks

ALE Auditors Local Evaluation

ALOS Average Length of Stay (in hospital)

AMI Acute Myocardial Infarction

AMMC Area Medicines Management Committee

AMR Antimicrobial resistance

Anti-D An antibody occurring in pregnancy

Anti-TNF Drugs used in the treatment of rheumatoid arthritis and Crohn’s disease

AQP Any Qualified Provider

ARIF Aggressive Research Intelligence Facility

ASAP As soon as possible

AVE Advertising Value equivalent

BACs Bank Automated Credit

BAF Board Assurance Framework

BCC Black Country Cluster

BCF Better Care Fund

BCPFT Black Country Partnership NHS Foundation Trust

BFT Behavioural Family Therapy

BMA British Medical Association

BME Black Minority Ethnic

BMJ British Medical Journal

BPAS British Pregnancy Advisory Board

BSCCP British Society of Colposcopy and Cervical Pathology

CAB Citizens Advise Bureau

CAMHS Children and Adolescent Mental Health Service

CAO Chief Accountable Officer

CASH Contraception and Sexual Health

CCBT (CBT) Computerised Cognitive Behavioural Therapy

CCG Clinical Commissioning Group

CCRN Comprehensive Clinical Research Networks

CDC Commissioning Development Committee

CDiff Clostridium difficile

CEO Chief Executive Officer

CETV Cash Equivalent Transfer Value

CFO Chief Finance Officer

CHADD The Churches Housing Association of Dudley & District Ltd

CHC Continuing Healthcare

CHD Coronary Heart Disease

CIP Cost Improvement Plan

CLT Collaborative Leadership Team

CMO Chief Medical Officer

CNST Clinical Negligence Scheme for Trusts

CNT Community Nursing Team

COPD Chronic Obstructive Pulmonary Disease

COSHH Control of Substances Hazardous to Health Regulations 2002

CPA Care Programme Approach

CPN Community Psychiatric Nurse

CPR Cardiopulmonary Resuscitation

CQC Care Quality Commission

CQNO Chief Quality and Nursing Officer

CQRM Clinical Quality Review Meeting

CQUIN Commissioning for Quality and Innovation

CRL Capital Resource Limit

CRRT Community Rapid Response Team

CSG Clinical Strategic Group

CSU Commissioning Support Unit

CT scan Computer Topography

CVD Cardio Vascular Disease

D&N Dudley and Netherton (Locality)

DACHS Directorate of Adult Children and Housing Services

DCS Dudley Community Services

DCVS Dudley Community Voluntary Service

DES Directed Enhanced Service

DfES Department for Education and Skills

DGFT Dudley Group Foundation Trust

DHR Domestic Homicide Review

DMO Designated Medical Officer

DNA Did not attend

DoH Department of Health

DoLS Deprivation of Liberty Safeguards

DoS Directory of Service

DPMA Dudley Practice Managers Alliance

DPO Data Protection Officer

DQOFH Dudley Quality Outcomes for Health

DSCB Dudley Safeguarding Children’s Board

DTC Diagnostic and Treatment Centre

DToC Delayed Transfer of Care

DWMHPT Dudley and Walsall Mental Health Partnership Trust

DXA Dual X-ray Absorptiometry (measures bone density)

E&D Equality and Diversity

EAU Emergency Assessment Unit

ECA Extra Care Area

ECM Every Child Matters

ECT Electroconvulsive Therapy

ED Emergency Department

EI Early Implementer

EI Early Intervention

EIP Early intervention in Psychosis

EMI Elderly Mentally Ill

EMIS Education Management Information System

EoL End of Life

EPC Empowering People and Communities

EPIC Enabling Practices to Improve and Change

EPP Expert Patients Programme

EPR Electronic Patient Record

EPRR Emergency, Preparedness, Resilence, Response

ERT Enzyme Replacement Therapy

ESR Electronic Staff Record

FCEs Finished Consultant Episodes

FED Forum for Education and Development

FFT Friends and Family Test

FHS Family Health Services

FMC Facility Management Centre

FOI Freedom of Information

FTE Full Time Equivalent

FYE Full Year Effect

FYFV Five Year Forward View

GDPR General Data Protection Regulations

GGI Good Governance Institute

GMS General Medical Services

GOWM Government Office for the West Midlands

GP General Practitioner

GPAQ General Practice Assessment of Quality

GPFV GP Forward View

GPwSI GP with Special Interest

GU Genito-urinary

GUM Genito-urinary Medicine

H&QB Halesowen and Quarry Bank (Locality)

HCAI Healthcare Associated Infections

HCF Healthcare Forum

HEE Health Education England

HENIG Health Economy NICE Implementation Group

HF Heart Failure

HFMA Healthcare Financial Management Association

HIAO Head of Interal Audit Opinion

HIC Health Improvement Centre

HIS Health Infrastructure Strategy

HIV Human Immunodeficiency Virus

HPA Health Protection Agency

HPS/S Health Promoting Schools / Service

HPU Health Protection Unit

HR Human Resources

HSC Health and Safety Commission

HSCQC Health and Social Care Quality Centre

HSE Health and Safety Executive

HSMC Health Services Management Centre

HT Home Treatment

HV Health Visitor

HWBB Health and Well-being Board

IAF Improvement Assessment Framework

IAPT Improved Access to Psychological Therapies

IC Infection Control

ICAS Independent Complaints Advocacy Service

ICE Integrated Commissioning Executive

ICNA Infection Control Nurses Association

ICO Integrated Care Organisation

ICP Integrated Care Provider

IFR Individual Funding Request

IG Information Governance

IOSH Institute of Occupational Safety and Health

ISAP Integrated Support Assurance Process

IT Information Technology

IUCD Intrauterine Contraceptive Device

JCAB Joint Clinical Advisory Board

JCC Joint Commissioning Committee

JD Job Description

JSNA Joint Strategic Needs Assessment

KAB Kingswinford, Amblecote and Brierley Hill (Locality)

KLOE Key Lines of Enquiry

KPI Key Performance Indicators

LAA Local Area Agreement

LAC Looked After Children

LACYP Looked After Children and Young People

LAT Local Area Team

LD Learning Disability

LDP Local Delivery Plan

LDR Local Digital Roadmap

LEA Local Education Authority

LeDeR Learning Disabilities Mortality Review

LIFT Local Improvement Finance Trust

LIG Local Implementation Group

LIS Local Improvement Scheme

LIT Local Implementation Team

LMC Local Medical Committee

LNG Local Negotiating Committee

LPS Local Pharmaceutical Scheme

LRF Local Resilience Forum

LSCB Local Safeguarding Children’s Board

LTC Long Term Conditions

LVD Left Ventricular Dysfunction

LVSD Left Ventricular Systolic Dysfunction

MAPA Management of Actual and Potential Aggression

MASH Multi-Agency Safeguarding Hub

MAU Medical Assessment Unit

MBC Metropolitan Borough Council

MCP Multi-speciality Community Provider

MDT Multi Disciplinary Team

MIAA Mersey Internal Audit Authority

MIMT Major Incident Management Team

MIRE Major Incident Response Executive

MLSOs Medical Laboratory Scientific Officers

MOU Memorandum of Understanding

MPAG Maternity Performance Assurance Group

MRSA Methicillin Resistant Staphylococcus Aureus

MSS Medium Secure Service

NCA Non contract activity

NCB National Commissioning Board

NCM New Care Model

NCRS National Care Record System

NELHI National Electronic Library for Health Information

NFI National Fraud Initiative

NGMS New General Medical Services

NHS National Health Service

NHSCPT NHS Community Practice Teacher

NHSCSP NHS Cancer Screening Programme

NHSE NHS England

NHSI NHS Improvement

NHSP National Healthy Schools Programme

NHSR NHS Resolution

NICE National Institute for Clinical Excellence

NMC New Model of Care/Nursing and Midwifery Council

NOF New Opportunities Fund

NPfIT National Programme for IT

NPSA National Patient Safety Agency

NRF Neighbourhood Renewal Fund

NRLS National Reporting and Learning System

NSF National Service Framework

OAT Out of Area Treatment

OBD Occupied Bed Day

OD Organisational Development

ODM Oesophageal Doppler Monitoring

OJEU Official Journal of the European Union

OOH Out of Hours

OPH Office of Public Health

OSC Overview and Scrutiny Committee

OT Occupational Therapist

PACS Primary and Acute Care Systems

PAF Positive Assurance Framework

PALS Patient Advice and Liaison Service

PAM Patient Activation Measures

PAS Patient Administration System

PAU Paediatric Assessment Unit

PBP Practice Based Pharamcists

PbR Payment by Results

PC Personal Computer

PCCC Primary Care Commissioning Committee

PCDSG Primary Care Development Steering Group

PCOG Primary Care Operational Group

PCSP Personalised Care & Support Plan

PDF Portable Document Format

PDR Personal Development Review

PDS Personal Dental Services

PDSA Plan, Do, Study, Act

PDU Professional Development Unit

PE Pulmonary Embolism

PEAK Database holding the main registered details of patients and associated referral, contact,

caseload, outpatient, inpatient, MH Act and clinic information.

PEAT Patient Environment Action Team

PEPP Pooled Budget External Placement Panel

PFI Private Finance Initiative

PGD Patient Group Directives

PHB Personal Health Budget

PHE Public Health England

PHSO Parliamentary and Health Service Ombudsman

PICU Psychiatric Intensive Care Unit

PID Project Initiation Document

PIN Prior Information Notice

PMLD Profound and Multiple Learning Difficulties

PMS Primary Medical Services

PNA Pharmaceutical Needs Assessment

POD Prescription Ordering Direct

POPs Patient Opportunity Panels

PPA Prescription Pricing Authority

PPG Patient Participation Group

PQQ Pre-Qualification Questions

PSA Public Service Agreement

PSHE Personal and Social Health Education

PSIAMS Personal Social Impact Action Measurement System

PTCA Percutaneous Transluminary Coronary Angioplasty

PWB Personal Wheelchair Budget

Q&A Questions and Answers

Q&S Quality & Safety

QA Quality Assurance

QIB Quality Improvement Board

QIPP Quality, Innovation, Productivity and Prevention

QMAS Quality Management and Analysis System

QOF Quality and Outcome Framework

QPDT Quality and Practice Development Teams

RACPC Rapid Access Chest Pain Clinic

RAG Red, Amber Green (rating)

RAS Respiratory Assessment Service

RCA Root Cause Analysis

RCGP Royal College of General Practitioners

RES Race Equality Scheme

RHH Russells Hall Hospital

RIDDOR Reporting of Injuries, Diseases and Dangerous Occurrences Regulations

RMO Responsible Medical Officer

RRL Revenue Resource Limit

RTT Referral to Treatment

SAP Single Assessment Process

SAR Safeguarding Adult Reviews

SAR Subject Access Request

SCG Sedgley, Coseley and Gornal (Locality)

SCIE Social Care Institute for Excellence

SCR Serious Case Review

SDMP Sustainable Development Management Plan

SDU Sustainable Development Unit

SEPIA Mental health computer system

SFBH Standards for Better Health

SFI Standing Financial Instructions

SI Serious Incident

SIC Statement of Internal Control

SLA Service Level Agreement

SoMe Social Media

SPA Single Point of Access

SQPR Service Quality Performance Review

SQRM Safeguarding Quality Review Meeting

SRE Sex and Relationship Education

SRG System Resilience Group

SSD Social Services Department

SSDP Strategic Services Development Plan

STI Sexually Transmitted Disease

STP Sustainability and Transformation Plan

STRW Support, Time & Recovery Worker

SWL Stourbridge, Wollescote and Lye (Locality)

SWOT Strength, Weakness, Opportunity and Threat

TB Tuberculosis

TCT Transforming Care Together

TIA Transient Ischaemic Attack

TP Teenage Pregnancy

TPT Teenage Pregnancy Team

TTO To Take Out

UCC Urgent Care Centre

UCSCs Urgent Care Sensitive Conditions

UHBT University Hospital Birmingham Trust

Vaccs & Imms Vaccinations and Immunisations

VSM Very Senior Manager

WAN Wide Area Network

WCC World Class Commissioning

WIC Walk in Centre

WMAS West Midlands Ambulance Service

WMCA West Midlands Combined Authority

WMHTAC West Midlands Health Technology Advisory Committee

WMSCG West Midlands Strategic Commissioning Group

WMSSA West Midlands Specialised Services Agency

WTE Whole Time Equivalent

YHC Young Health Champion