71633548c5390f9d8a76 …



Area of PlanDescription / ResponseSTP and Operational Plan LinksMindful of the importance of STPs as both a different way of working and as the umbrella plans that shape the individual organisational Operational Plans, please outline how the STP Plans submitted on October 16th link to the Operational Plan priorities and activity numbers.The use of illustrative diagrams might be helpful to show the main connections.Throughout 2016/17 system leaders have been working across West Yorkshire and within Leeds to develop the West Yorkshire Sustainability and Transformation Plan (WYSTP) and the specific ‘place based plan’ for Leeds contained within the WYSTP. The WYSTP describes how Leeds and the wider West Yorkshire Health and Care system will address the triple aim as required by the NHS Five Year Forward View.The 2017-2019 Operational Plan for Leeds South and East CCG (‘the plan’) has been developed to underpin the delivery of the WYSTP.The Plan outlines our approach to delivering the key national priorities (the nine ‘must dos’) and local priorities as identified within the WYSTP and the Leeds Health and Wellbeing Strategy 2016-2021.West Yorkshire CCGs have established a programme office to take forward the ongoing development delivery of the West Yorkshire STP. The STP articulates how through a balance of CCG Led initiatives and West Yorkshire Wide (Healthy Futures) programmes the West Yorkshire Planning Footprint will secure the delivery of NHS Planning Priorities as prescribed within the 5 Year Forward View and associated planning guidance. The following summarises the gaps that are to be addressed through the West Yorkshire STP and associated ‘place based plan’ for Leeds.Health and wellbeing gap Deaths from cancer are the largest single cause of PYLL across the city, accounting for 36.3% of all Potential Years of Life Lost (PYLL)The PYLL from cancer is twice as high within the most deprived quintile Leeds compared to the least deprived quintile Suicides have increased, after a decline, and are now above the England rateHealth Inequalities within Leeds, for the big killers there has been a significant narrowing in the gap for deprived communities for cardiovascular disease, a narrowing of the gap for respiratory disease but no change for cancer mortality.Care and quality gap There are a number of aspects to the Care and Quality gap. In terms of our NHS Constitutional Key Performance Indicators (KPIs) the areas where significant gaps have been identified include: Mental Health (including Improving Access to Psychological Therapies)Patient SatisfactionQuality of LifeUrgent Care StandardsAmbulance Response Times A&E 4 Hour Waiting TimesDelayed Transfers of Care (DTOC)Finance and efficiency gapThe projected collective financial gap facing the Leeds health and care system (if we did nothing about it) is ?723 million by 2021. It reflects the forecast level of pressures facing the four statutory delivery organisations (Leeds City Council, Leeds Teaching Hospitals NHS Trust, Leeds and York Partnership NHS Foundation Trust and Leeds Community Healthcare NHS Trust) in the city and assumes that our three CCGs continue to support financial pressures in other parts of their portfolio whilst meeting NHS business rules. This is driven by inflation, volume demand, lost funding and other local cost pressures. West Yorkshire Sustainability and Transformation PlanThe West Yorkshire STP includes a range of programmes being led under the Healthy Futures Programme banner. These programmes aim to address shared issues across all West Yorkshire Systems where working together will offer greater benefits that those that could be achieved by individual organisations/places alone. Programme areas and key aims/outcomes for these programmes are outlined below-Cancer servicesStrengthen existing tobacco controls and smoking cessation services in line with reducing smoking prevalence to below 13% nationally by 2020Increase uptake of breast, bowel and cervical cancer screening programmesDrive earlier diagnosis by:Implementing NICE GuidanceIncreasing GP direct accessCommissioning sufficient diagnostic capacity to meet the current CWT standards and plan for delivery of 28 day faster Diagnosis Standard by 2020Ensure all parts of the Recovery Package are available to all patients. Ensure all breast cancer patients have access to stratified follow up pathways and prepare for roll out for prostate and colorectal cancer patientEnsure all cancer patients have access to a clinical nurse specialist or other key workersUrgent and emergency careA reduction in 999 ambulance conveyances to A&EA reduction in Accident and Emergency Type 1 attendancesA reduction in hospital admissionsReduction in out of area MH placementsCollaborative workforce solutions across West YorkshireMental health Reduce Mental Health in-patient admissionsEliminate all out-of-area mental health acute placements Reduce unnecessary attendance at A&E for crisis episodesReduce all inappropriate emergency service responsesReduce MHA detention in Police CellsReduce number of suicides across West YorkshirePrevention at scaleTobacco - To reduce smoking rates to 13% by 2020-21Alcohol - Reduce prevalence of health harms associated with alcohol whilst reducing alcohol related hospital admissions (by 3%)Obesity - Reduce the number of people currently at high risk of type II diabetes (non-diabetic hypoglycaemia) as identified by the NHS health check and in primary and secondary care from going on to develop type II diabetesWorkforce - To enhance the health & social care workforce contribution to place based prevention care and lifestyle behavioural changeStandardisation of commissioning policiesSupport delivery of the West Yorkshire and Harrogate targets in relation to smoking and obesity Support delivery of Referral to Treatment Time (RTT) standards Dovetail with the development of acute, mental health and provider collaborations to secure improvements in service deliveryImproved cost effectiveness in prescribingReduced variation in eligibility / Clarity for patients and the publicPlanned savings of ?50m delivered through consistent reduction in low value clinical procedures and interventions and ensuring patients are optimised for surgeryStroke (hyper-acute and acute rehab)Reduce Under 75 mortality rate from CVD Reduce hypertension QOF prevalence all ages national / West Yorkshire and Harrogate / CCGReduce premature mortality from stroke Reduce incidence of stroke Reduce median time between clock start and thrombolysis Increase proportion of stroke patients assessed by a stroke specialist consultant physician and nurse trained in stroke management within 24 hours of clock start Increase proportion of patients given swallow screen within 24 hours of clock start Increase proportion of patients scanned within 12 hours Implementation of 7 Day Standards (2, 5, 6 and 8) for stroke servicesSpecialist servicesCAMHS Tier 4 Beds: improve outcomes for CAMHS patients and reduce out of area placementsVascular: implement the optimum model of service provision across Yorkshire & Humber that best meets the needs of patients and improves patient outcomes, addresses inequality of access and ensures quality of service provision in line with the national specification Complex Neuro-rehab: Develop and agree a Yorkshire & Humber wide collaborative strategy for specialised rehabilitation for adults with acquired brain injury (ABI) which is intended to address under provision of level 1 or 2a facilities. This will improve patient experience and reduce delays. Service review completed Q3 2016/17HIV: review arrangements to ensure future resilience and sustainability of HIV provision and improve patient access.Specialist weight management: Identification and implementation of transformational opportunities for services and pathways prior to entry to tier 4 services set in the context of place based obesity strategies.Acute collaborationConsistent delivery of constitutional targets Improved patient experience Improved safety in services by consistent adoption of good practiceEnsuring services in West Yorkshire and Harrogate are more resilient Reduce reference cost variation Underpin delivery of acute provider cost improvement programmesOperational Plan and alignment with the Leeds Health and Wellbeing Strategy 2016-2021This section aims to provide assurance on the content and priorities of the three Leeds CCGs operational plans with the Health and Wellbeing Strategy for Leeds. The Health and Wellbeing Strategy for Leeds describes a five-year vision for Leeds and its people. The place based plan for Leeds, which is underpinned by the Leeds CCGs operational plans recognise the strong connection between people, populations and organisations to support Leeds in its aim to be a healthy and caring city for all ages, where people who are the poorest improve their health the fastest’.The place based plan for Leeds and underpinning Leeds CCG operational plans are aligned, where appropriate, with the priorities outlined in the health and wellbeing strategy for Leeds. As with the Health and Wellbeing Strategy, the Leeds CCG plans are founded in the joint strategic needs assessment and subsequent research and analysis, and both have benefited from the positive level of joint working evident across the city’s people and organisations. The following points provide specific examples of how the Leeds CCG plans support delivery of the health and wellbeing strategy 2016-21.Priority 1 - A Child Friendly City and the best start in life: CCG plans continue to support the delivery of the Maternity Strategy for Leeds (2015), which reflect the national ‘Better Births’ transformational report. This is integral to the effective delivery of the Leeds Best Start Plan. A key focus is the personalisation of maternity services and delivering an integrated perinatal mental health pathway. This is also integral to the Leeds Local Transformation Plan for children and young people’s mental health, as a key primary prevention priority. The Future in Mind: Leeds strategy and Local Transformation Plan (LTP) is a single overarching strategy to improve the social, emotional, mental health and wellbeing of children and young people aged 0-25 years which combines the requirements of the Department of Health (Future in Mind, 2015) and the delivery of the statutory SEND requirements of the Children & Family Act, (2014) in relation to pupils with SEMH. The strategy and plan were signed off by the Health and Wellbeing Board in October, 2016. The city recognises the pressures on the public purse and how in order to deliver improved outcomes for children and young people we need to work together. The strong emphasis on prevention and developing the emotional resilience of children, young people and their families, alongside strengthening access to local early help services and swift access to specialist services makes both economic sense and is the right thing to do for our children and young people. To support this agenda CCGs continue to invest in the LTP and to support parity of esteem. The Future in Mind: Leeds Programme Board is chaired by the elected member who is the executive lead for children (LCC).Priority 2 - An Age Friendly City where people age well: Through our work to develop new models of care integrated to better support older people and those with long term conditions and through our aim to improve diagnosis and support for people with dementia through increasing access to memory tests. The three Leeds CCGs have launched a plan to commission community intermediate care beds which will support people who have had an episode of ill health either at home or in hospital, and require a period of recovery prior to returning to their own home. The service will allow for recuperation, rehabilitation, providing active therapy, and optimising a person’s independence with personalised short-term goal and care plans and a provider will be appointed in summer 2017.Priority 3 – Strong, engaged and well-connected communities: Throughout 2016 Leeds CCGs implemented and tested social prescribing services, which offer support, over and above those provided by GPs and community services, to meet the holistic needs of patients. The services have helped develop a range of partnerships with Third Sector that support people and communities to improve their wellbeing by combating social isolation; providing opportunities for volunteering; acting as a “gateway” to advice, information, and services; and re-connecting people and communities. These services will continue to be provided throughout 2017. These services also enable CCGs to support delivery of priorities 5 and 6 of the new health and wellbeing strategy.Priority 7 - Maximise the benefits from information and technology: Leeds commissioners have been strong supporters of the Leeds Care Record and there are ambitious plans to build on this through 2017-2019. Leeds CCGs along with partners have developed a Digital Roadmap that describes an ambitious set of objectives to support the development and deployment of Digital Systems and Technologies alongside supporting our population to be able to maximise the benefits of those technologies to support their own care. Our Digital Roadmap underpins a range of service and system objectives including integrated care at the point of delivery and facilitating the integration of services and organisations and how those services interact with the people of Leeds. Priority 8 - A stronger focus on prevention: This is one of the highest priorities for NHS commissioners in Leeds and nationally. The place based plan for Leeds includes our plans to address health inequalities over the next five years with a focus on shifting investment from treatment to prevention, and from people/communities with better health to those with poor health and/or high prevalence of disease. Leeds CCGs are embedding the Right Care approach promoted by NHS England to refresh there understanding of the key areas of opportunity to address health inequalities through addressing variation in access to services and in clinical practice. Specific emphasis across all plans is being placed on improving earlier diagnosis and one-year survival rates of cancer (including increasing access to diagnostic services and implementing NICE referral guidelines. The Right Care and approach alongside the place based plan for Leeds Prevention workstream place significant focus on a range of pathways including Cardio Vascular Disease, Diabetes and Respiratory Conditions which all require a focus on supporting the public to improve their health through support for healthy living.Priority 9 - Support self-care, with more people managing their own conditions: The place based plan for Leeds, underpinned by CCG Operational Plans, includes two key workstreams focussing on self-care and proactive management of patients with long term conditions. The programmes contain a range of initiatives across a range of pathways that aim to support the population to better manage their health and conditions. In addition the CCGs are working towards a shift towards commissioning that result in developing New Models of Care that embed population health based approach in their ethos. This approach will embed an approach that commissions organisations on the basis of outcomes (this approach will also support Priority 8).Priority 10 - Promote mental and physical health equally: Leeds has an agreed strategy for Mental health, The strategy has been reviewed against recently published national guidance on best practice to ensure that services develop towards those nationally outlined priorities. Mental health is one of the key investment areas for the NHS and CCGs in 2017-2019. The NHS in Leeds already funds mental health services as a higher percentage of overall spend when compared with other areas. Leeds CCGs recognise mental health as a key contributor to lower health and wellbeing, As such Leeds, as required within NHS planning guidance must continue to invest disproportionately in addressing mental health. Plans in 2017-2019 will focus on a range of national priorities, which include improving the quality of care available in a crisis; reducing out of area treatments and improving community based mental health services. Integrating mental health expertise with primary and community care will be tested as part of the new models of care work.Priority 12 – Best Care, Right Place, Right Time: All CCGs are responsible for commissioning services which deliver the nine essential must do’s as identified in NHS England Planning guidance NHS Planning priorities focus on offering choice of a range of services within given access standards and that meet national defined quality standards. Our plans are being developed to meet a range of standards across all sectors. Details on our plans to meet the 9 ‘Must Do’ priorities are outlined below.‘Must Do’ 1: STPsDescribe how you will:Implement agreed STP milestones, so that you are on track for full achievement by 2020/21.Achieve agreed trajectories against the STP core metrics set for 2017-19.The West Yorkshire and Harrogate STP have agreed a range of milestones that will be delivered either through collaborative work coordinated through the Healthy Futures programme Office (milestones for those workstreams can be found within the published document) or through local work to be undertaken through a range of programmes that have will be coordinated and delivered on a Leeds Footprint. The place based plan for Leeds outlines a range of local programmes that the Leeds CCGs will collectively take forward to underpin the STP. Key health and service pathway programme areas identified within the place based plan for Leeds include:PreventionSelf-care and Proactive Care Efficient and Effective Secondary CareUrgent and Emergency CareIn addition to the above there are a range of enabling and complementary workstreams which include:InformaticsEstatesWorkforceNew Models of CareEach Programme is be led by an Executive Director or Very Senior Manager who will manage a multidisciplinary team charged with developing and delivering the programme. Delivery of these programmes will be overseen by a Leeds Leadership Executive, which includes Chief Executives and Accountable Officers from across Health Service and Local Authority. The Leadership Executive will manage the operational delivery of programmes on behalf of the Health and Wellbeing Board.It is recognised that delivery of the STP and place based plan for Leeds will require changes to the way that CCGs approach commissioning. The Leeds CCGs have undertaken a wide ranging review of how we commission services under the ”One Voice’ review banner. Implementing the recommendations of review will ensure that we develop the right capacities and capabilities to support delivery of the STP and place based plan for Leeds. We are still awaiting the anticipated STP metrics template from NHS England. However given the strong alignment between the West Yorkshire and place based plan for Leeds we are confident that our plans and submitted trajectories will be consistent with the proposed submissions.‘Must Do’ 2: FinanceDescribe how you will:Deliver individual CCG organisational control totals, and achieve local system financial control totals. Implement local STP plans and achieve local targets to moderate demand growth and increase provider efficiencies.Note:Demand reduction measures include: implementing Right Care; elective care redesign; urgent and emergency care reform; supporting self-care and prevention; progressing population-health new care models such as multispecialty community providers (MCPs) and primary and acute care systems (PACS); medicines optimization; and improving the management of continuing healthcare processes. It would also be helpful to outline how the Demand Management Good Practice is being taken into account in formulating your plans.Provider efficiency measures include: describe how you are working with your to improve efficiencies in areas such as pathology service and back office rationalization; implementing procurement, hospital pharmacy and estates transformation plans; improving rostering systems and job planning to reduce use of agency staff and increase clinical productivity; implementing the Getting It Right First Time programme; and implementing new models of acute service collaboration and more integrated primary and community services.Above all, please describe how you will ensure that the Financial Plans triangulate to the Activity Plans so that they are both deliverable and affordable.Leeds South and East CCG has a strong track record in managing financial resource. However the CCG operates within a seriously challenged health and social care economy; significant financial deficits within the two major acute Trusts and further reductions in the local authority’s funding. In addition the CCG has not received any additional growth despite the CCG and Primary Care being under target as Specialised Commissioning in Leeds is deemed to be 15% over target. This will increasingly require much greater collaboration in terms of financial planning across the whole system with shared understanding of impact of change for all partners.Our financial plans continue to underpin our own and the Leeds systems strategic priorities and have been updated to ensure we continue to use our resources to deliver: Key commitments identified within the 2017-19 operating frameworkLocal priorities as developed by the CCG working with partners that reflect local needs as identified through the Joint Health Needs Assessment; andPriorities identified through engagement with patients, public and clinicians at CCG level.The CCG plans to achieve these priorities whilst living within the agreed CCG Control Total, although this does require significant savings to be achieved through QIPP. In addition through our work within the West Yorkshire STP we are partners to the delivery of the system wide ‘control total’. Our finance plans (submitted separately) provide details on the investment and QIPP plans that support the delivery of these objectives.Analysis undertaken as part of the development of the West Yorkshire STP has identified a significant gap between resources likely to be available to the health and care system and the ongoing costs of continuing to meet demand and expectations of patient and the public. For the city of Leeds this gap is estimated at ?300m.Given the size of the overall financial challenge, and the interdependence of all statutory organisations in delivering care across pathways, only the whole system changes identified within the STP and for Leeds will have the impact needed to retain financial balance within the local health economy. As such QIPP targets have been agreed to be delivered on a city-wide footprint by providers and commissioners through a combination of transformation and innovation and a continued focus on operational and organisational efficiency (including CCG running costs). To support sustainability as part of the West Yorkshire STP, the Leeds CCGs have developed a range of initiatives to transform services and reduce demand. The following summarises areas of work being progressed by the CCGs in Leeds.RightCare and Elective Activity: We have established a city wide group that has reviewed all areas of elective care where there are opportunities to review pathways initially focussing on MSK and Gastroenterology. We are seeking to build on work to date through engagement in the West Yorkshire Commissioning Standards workstream.RightCare and Prevention: Our prevention and proactive care workstreams include a range of action to address variation in practice across pathways including respiratory, CVD and diabetes. Our prevention programme within the STP is focussing on reducing impact of smoking and alcohol on demand for acute servicesSupporting Self Care and Proactive Case Management: Leeds CCGs have developed a programme to address the aim of increasing capacity of those in our population with Long Term Conditions to self-care and provider proactive support where necessary to those who need it. Our programme build on existing work such as Year of Care and our Patient Empowerment Projects to ensure we maximise opportunities to keep people at home and well.Urgent and Emergency Care Reform: Leeds CCGs are an active part of the West Yorkshire Urgent Care Vanguard. Our plans for development are outlined under section covering ‘Must Do’ 4.Progressing population-health new care models: Significant work is underway to reshape our community provider landscape to support the development of multispecialty community providers (MCPs). This included undertaking work to reshape how CCGs commission to support MCP development towards managing population health. All CCGs in Leeds have, individually, undertaken significant work with Primary Care to support their development over the past 2 years. Our General Practice Forward View plan will outline how we will bring together approaches to take forward their development towards our goal to develop new provider models.Medicines optimization: Leeds CCGs Medicines Management Teams work closely on a range of initiatives to optimise medicines use. Our teams are actively engaged with Primary Care to reduce variation and to support the ongoing development of effective prescribing. This includes active engagement in our RightCare programme and with the West Yorkshire STP Commissioning Standards Medicines Workstream that seeks to ensure that we adopt a best value approach to prescribing across CCGs. Elective Pathway Redesign: CCGs in Leeds have a long track record of redesigning care pathways. We continue to work with our providers to ensure best use of resources. Our Efficient and Effective Care workstream is seeking to deliver significant saving through a range of initiatives that build on proposals in Demand Management Good Practice as well as focussing on securing value for money e.g. reducing rate of procedure with limited evidence of clinical effectiveness. Our work will complement the work of the West Yorkshire Standardising Commissioning Policies Workstream.Triangulation of Activity and Financial Plans: Our financial assumptions are consistent with our activity plans. Both plans assume no growth across all PODs i.e. that we will maintain current activity levels over next two years‘Must Do’ 3: Primary CareA separate request has been made for a plan on the GP Forward View by October 21st that will cover this ‘Must Do’. It is included here for completeness but does not need to be repeated in the narrative for the Operational Plans.Describe how you will:Ensure the sustainability of general practice in your area by implementing the General Practice Forward View, including the plans for Practice Transformational Support, and the ten high impact changes.Ensure local investment meets or exceeds minimum required levels.Tackle workforce and workload issues, including interim milestones that contribute towards increasing the number of doctors working in general practice by 5,000 in 2020, co-funding an extra 1,500 pharmacists to work in general practice by 2020, the expansion of Improving Access to Psychological Therapies (IAPT) in general practice with 3,000 more therapists in primary care, and investment in training practice staff and stimulating the use of online consultation systems.By no later than March 2019, extend and improve access in line with requirements for new national funding.Support general practice at scale, the expansion of Multispecialty Community Providers or Primary and Acute Care Systems, and enable and fund primary care to play its part in fully implementing the forthcoming framework for improving health in care homes.As per the guidance issued by NHS England WY, we have included a short summary response to this section given the separate request for a plan on the GP Forward View.The Leeds CCGs have developed a city-wide plan for primary care in response to the General Practice Forward View, which includes plans for Practice Transformational Support, and the ten high impact changes. This plan has been submitted separately as required by NHS England.Our plans support the development of general practice at scale, the expansion of MCPs, and enable and fund primary care to play its part in fully implementing the forthcoming framework for improving health in care homes.Our local investment plans, meet and in many cases exceed the minimum required levels and embed our plans to tackle workforce and workload issues described within the GP Five Year Forward View.In addition to the comments above, please see the response to point d) below.We have yet to establish our approach as to how we would propose to improve access in line with national requirements however we will be beginning discussions with general practice members and other colleagues in Leeds during 2017/18 with a view to developing a staged approach to the advancement of this service in 2018/19.However the recent expression of interest from the national Vanguard team regarding West Yorkshire extended access pump priming funding in 2016/17 may well change our approach.Throughout 2016/17 Practices have established four collaborative hubs with each bringing together a group of Practices in a geographical location. The collaborative hubs have identified key work programmes for their population, introducing and testing new roles and service models. One of the four hubs is delivering elements of extended access at present, however this is at an early stage of development and does not fulfil the full definition of “extended access” as defined in the planning guidance. The CCG will through the evaluation of this programme and other work programmes in the collaborative groups track progress and where evidence supports outcomes will consider extending a work programme across the CCG.Furthermore, the CCG is supporting a Professional Leadership Programme run by the Leeds Institute of Quality Healthcare and this year’s focus of the programme is based on primary/community care with a focus on Rapid Response (Urgent Crisis Care). This is a priority for the Leeds heath care system and is identified in the place based plan for Leeds within the West Yorkshire STP. The learning from this programme will inform the future approach for Rapid Response however it is expected that links to extended access will be established.‘Must Do’ 4: Urgent and emergency careDescribe how you will:Deliver the four hour A&E standard, and standards for ambulance response times including through implementing the five elements of the A&E Improvement Plan. In a number of health economies, the emphasis will be on recovering to meet the standard and then sustain thereafter. Where this is the case an explicit indication of the timescales for recovery would be helpful.Meet the four priority standards for seven-day hospital services for all urgent network specialist services by November 2017.Describe the steps and actions that you will be taking in 2017-2019 in order to implement the Urgent and Emergency Care Review, ensuring a 24/7 integrated care service for physical and mental health is implemented by March 2020 in each STP footprint, including a clinical hub that supports NHS 111, 999 and out-of-hours calls.How do you plan to deliver a reduction in the proportion of ambulance 999 calls that result in avoidable transportation to an A&E department?Describe how you will initiate cross-system approach to prepare for forthcoming waiting time standard for urgent care for those in a mental health crisis.The increased demand for urgent care services continues to provide a challenge for the Leeds Health and Social Care Economy. Whilst numbers of attendances at A&E departments across Leeds 2016/17 have been comparable with the previous year we continue to have difficulties in delivering the national Emergency Care Standard.The Year to Date (YTD) position as at Oct 2016 is 89.06% with an aim through the A&E accelerator initiative to deliver the standard by the end of the financial year. The system has identified a range of issues that are contributing to non-delivery including: High attendances on individual days, regularly exceeding 650Higher acuity and complex needs leading to high admissionsMultifaceted and complex discharge processesIncreasing numbers of presentations that could be treated in primary care.These factors outline the need to develop alternative ways of working through new models of care. Our overall aim is to maximise the opportunities to shift more care into community settings. Robust city wide partnership working ensures a whole system city wide approach is taken to addressing the issues of meeting demand through moving care into the community. The Leeds Health Economy has a comprehensive A&E delivery plan that is assured by the System Resilience Assurance Board. The plan details a range of short and longer term initiatives to address the 5 mandated elements listed below:Streaming at the front doorNHS 111 – increasing the number of calls transferred for clinical adviceAmbulances – Decision on Dispatch (DoD) and code review pilotsImproved flow – enhanced patient flowDischarge – Discharge to access and trusted assessor type modelsIn addition, the plan supports the delivery of seven day hospital services and CORE 24 (1 hour standard for mental health crisis).A dedicated Operational Delivery Group oversees the delivery of the initiatives with task and finish groups adopting a flexible approach to change leading from the front line. This approach will enable all of the learning to inform the wider strategic approach to implementing the Urgent and Emergency Care review across Leeds and the wider West Yorkshire STP footprint.The following initiatives are either underway or planned to support improvement in Urgent and Emergency Care Standard:Clinical Advisory Service (WY Vanguard). The development of a single point of access service which will deliver integration of a wide range of services including primary care in and out of hours with 999/111. This initiative will ensure that patient urgent care needs are met first time through a single point of contact. Leeds Integrated Discharge Service: A pilot service is currently being operated across 9 wards. A business case is in development to extend the service across all wards. Roll out will begin in Jan 2017 to coincide with changes in Adult Social Care reablement services.Yorkshire Ambulance Service continues to face a growth in demand. YTD there has been a 5.4% increase in demand based on last year (2.17% in Leeds). NHS England launched the Ambulance Response Pilot in October 2015 with YAS. Phase 1 of the pilot provided call handlers with an additional 120 seconds to make a decision on dispatch for all calls other than Red1. With phase 2 introducing revised coding categories for ambulance dispatch which are Red (8 minute response), Amber (19-30 minutes response) and Green (1-4hours response).The aim of the pilot is to ensure that the right resource is sent at the right time reducing the number of dispatches. To date the ARP pilot has had a positive impact on performance overall across Yorkshire and Humber including Leeds with a 1.8% increase in Red performance demonstrating a positive impact. From a quality perspective there has been no rise in serious incidents as a result of the ARP.YAS continue to work through their 2016/17 Performance Improvement Plan which includes demand management, operational efficiency, external review recommendations and paramedic pathfinder. Workforce continues to be the biggest challenge, with the aim to recruit 242 new members of staff over the next 2-3 years. The increased workforce will support resilience, support improved performance and expand the skill mix within their service to meet the increasing needs of patients and support the changing urgent care landscape. Wakefield CCG, lead commissioner are in the process of finalising the new governance structure and arrangements for the 999/111 Joint Strategic Commissioning Board. The newly established Board will oversee the 999 and 111 Contract and Quality Management Boards, along with any service improvements initiatives including all vanguard related work streams.‘Must Do’ 5: Referral to treatment times and elective careDescribe how you will:Deliver the NHS Constitution standard that more than 92% of patients on non-emergency pathways wait no more than 18 weeks from referral to treatment (RTT). If current performance is below 92% and/or a RTT Recovery Plan is in place, please describe when recovery to 92% will be reached and sustained thereafter, and how the Demand Management Good Practice Guide is being used to ensure sustained delivery.Deliver patient choice of first outpatient appointment, and achieve 100% of use of e-referrals by no later than April 2018 in line with the 2017/18 CQUIN and payment changes from October 2018.Streamline elective care pathways, including through outpatient redesign and avoiding unnecessary follow-ups.Implement the national maternity services review, Better Births, through local maternity systems.Leeds CCGs performance against the RTT standard has deteriorated in 2016/17. This deterioration is focussed in orthopaedics and spinal surgery, plastic surgery, ENT, dental services along with some general surgical specialities. There are a range of issues that are resulting impacting on non-delivery including: Lack of beds as a result of increased non-elective demandOutpatient pressures, particularly for regional specialties and where capacity is heavily dependent on middle grade workforce; and Lack of theatre capacity linked to ongoing difficulties in theatre recruitment and exacerbated through the agency spending caps.Leeds CCGs are planning to commission additional activity in 2017-2019 in areas where there is a waiting list backlog and/or where we have seen growth in demand. The key areas where we are planning additional activity are primarily: Cancer specialties and cancer diagnostic pathwaysSpecialties where backlog has been created due to non-elective pressures in 16/17; andDiscussions are ongoing with providers about the extent to which further growth is deliverable. In addition to purchasing additional activity we are also seeking to reduce demand in key specialities through working with associate CCGs to try to identify alternative pathways and providers for regional specialties, such as spinal surgery, and also working with NHSE to implement tighter pathways and choice offers in dental services.We are also, through our engagement in the Healthy Futures work, seeking to align commissioning policies to ensure that patients are optimised for treatment and to reduce variation in practice with regards to access to a range of clinical treatments that offer limited value for money.Leeds CCGs have a highly developed Independent Sector that provides considerable capacity across a range of surgical specialities. We will continue to work closely with local independent providers to secure delivery of capacity especially in key challenged specialities.We have a joint working group with Leeds Teaching Hospitals NHS Trust looking at e-referrals and outpatient capacity to reduce the slot issues which are impacting on GP willingness to undertake e-referral. We have already had some success in using e-referral for 2 week waits in the breast service and are looking to expand this.We are also working on pilots in some specialties to see how we can use indirect booking processes to improve the use of e-referral. We are trialling a process change in gastroenterology and upper and lower GI surgery at present. We are also considering gynaecology and cardiology pathways.We are also looking at increased use of Clinical Assessment Services and Advice and Guidance in line with the national guidance and to ensure that straight to test pathways are used wherever clinically appropriate.To avoid unnecessary follow-ups, we are reviewing and streamlining elective care pathways in a number of specialties and will implement commissioning policies for post-operative follow-up pathways for our most common conditions from April 2017. There is significant ongoing work on outpatient redesign in a range of services including rheumatology, gynaecology and orthopaedics. Within Leeds we are continuing to implement the Leeds Maternity Strategy (2015-2020), which was developed based on extensive consultation with women and families in Leeds, taking into consideration national and local drivers. There are 9 key priorities:Personalised Care – All women will receive care that is personal to their needs, where professionals work with them to plan and deliver care throughout pregnancy, birth and after the baby is born.Integrated Care – We will ensure that every woman feels that each stage of her care is coordinated, consistent and delivered in an integrated way. Access – Services will be easy to access to help women have their first midwife appointment early in pregnancy and to continue to receive all the care and support that they need throughout their pregnancy.Emotional Health – We will support the emotional and mental wellbeing of women who are pregnant and ensure that those who experience any emotional problems during and after their pregnancy are well supported and offered the best care.Preparation for Parenthood – We will support all parents to have a healthy pregnancy and to feel well prepared and confident for the birth and subsequent care of their baby. Choice – Women and their partners will have all the information that they need to make informed choices about their pregnancy and care.Targeted Support – We will ensure that those families, who need it, receive targeted support during their pregnancy and after the baby is born.Quality & Safety – We will strive to ensure that all women receive high quality, safe and responsive maternity care throughout their pregnancy, birth and post-natal care.Staffing – We will work in partnership to provide well-prepared, trained and confident staff in all our services to meet the needs of women and families.The 7 priorities and detailed recommendations “Better Births” have been incorporated into the Leeds Maternity Strategy Programme plan for delivery. In addition, a maternity information system will be introduced to improve safety and integrated care.We are working with partner organisations across West Yorkshire to agree the footprint of the local maternity system (aligned to the STP) and progress key collaborative workstreams; these will include looking at how to improve informed choice and standardise booking processes across a wider geographical area.‘Must Do’ 6: CancerDescribe how you will:Working through Cancer Alliances and the National Cancer Vanguard, implement the cancer taskforce report.Deliver the NHS Constitution 62 day cancer standard, including by securing adequate diagnostic capacity and the other NHS Constitution cancer standards. If this standard is not currently being consistently delivered then please describe the anticipated date of recovery.Make progress in improving one-year survival rates by delivering a year-on-year improvement in the proportion of cancers diagnosed at stage one and stage two; and reducing the proportion of cancers diagnosed following an emergency admission.Ensure stratified follow up pathways for breast cancer patients are rolled out and prepare to roll out for other cancer types.Ensure all elements of the Recovery Package are commissioned, including ensuring that:all patients have a holistic needs assessment and care plan at the point of diagnosis;a treatment summary is sent to the patient’s GP at the end of treatment; anda cancer care review is completed by the GP within six months of a cancer diagnosis.The Leeds Integrated Cancer Service Group (LICS) was established in September 2014 and reports to the Health & Wellbeing Delivery Group. The governance structure for this group is shown below.CEOs and Directors leading a range of organisations from across the Leeds Health Economy were invited to a workshop on the 14th November 2016 to sign up to the Leeds Cancer Strategy. This included discussion and debate on the level of ambition we need to set ourselves for Leeds and the priorities which we need to focus on to gain maximum impact for the Leeds population. This event provided the mandate to proceed with the setup and delivery of the Leeds Cancer Strategy. Following the submission of a proposal to Macmillan in September 2016, Leeds has successfully secured funds for 2 years to resource the development of a Programme Management Office (PMO) which will ensure that Leeds has the required workforce and infrastructure to support the delivery of the Leeds Cancer Strategy for the next two years. This will enable Leeds to establish a robust framework for managing and monitoring the delivery of a comprehensive programme of work, ensuring the sustained realisation of the Leeds vision for Cancer services beyond the initial 2 years of Macmillan funding. The Leeds Cancer Strategy and Action plan is aligned to the priorities within the National Cancer Strategy 2015-2020 and with the West Yorkshire priority areas. There are 5 proposed work streams: Prevention, Awareness and Screening uptakeEarly DiagnosisLiving with and Beyond CancerPatient ExperienceHigh Quality, Modern serviceWork is currently underway to ensure that each of the work streams is underpinned by a detailed delivery plan that describes the ambitions, key metrics and actions we need to deliver as a Leeds Health Economy over the next few years until 2020. Our plans embed the need to increase focus on prevention, improve early diagnosis and one year survival rates as well as reducing the number of cancers diagnosed following an emergency admission. We are establishing the governance and reporting mechanisms for each of these work streams, which will report on a bi-monthly basis to the LICS group.Leeds CCGs continue to deliver on the majority of the cancer standards. However, despite intensive work CCG performance against the 62 day access standard has deteriorated in 16/17. This deterioration is due to:A significant increase in the numbers of two-week wait patients referred in recent months as GPs are encouraged by NICE NG12 guidance to use a 3% Positive Predictor value (PPV) threshold value to underpin the recommendations for suspected cancer pathways. We have worked in partnership with Leeds Teaching Hospital Trust (LTHT) to ensure the clinical two-week wait pathways and outcomes reflect the NICE NG12 recommendations and these are almost fully implemented now in LTHT. LTHT continues to receive a high number of referrals after day 38 from other providers, despite significant local work on key pathways between providers over recent years the rate of referrals after day 38 as not yet improved.We have undertaken a complete diagnostic capacity review across all providers including the independent sector which demonstrated initially that there was insufficient capacity at LTHT to meet demand. In response to this, Medinet (an independent sector provider) have been used to provide additional capacity within LTHT to bridge the gap. The Leeds CCGs have reviewed non cancer pathways to ensure appropriate patients can be directly referred from primary care to the independent sector. Actions planned to increase diagnostic capacity and improve performance include:Leeds CCGs have commissioned additional direct access endoscopy capacity from Living Care at Thorpe Park, which will provide capacity to deliver an additional 3,000 scopes per year.There is also capacity at Living Care to offer LTHT an additional 80-120 scopes per month through inter-provider transfers if LTHT can guarantee an increased level of referral on a monthly basis.Additional capacity will also be available at Westcliffe Health Innovation in early 2017.Leeds is one of six pilot sites across England for the ACE project (Accelerate, Co-ordinate and Evaluate), which is focusing on a new referral pathway and delivery model for patients with non-specific symptoms, where GPs suspect cancer however presenting symptoms do not fit 2ww criteria.The initial pilot is planned for a period of 12 months, starting in January 2017, with a planned rollout to approx. 40 general practices across Leeds, reaching an approx. population of 200,000. Practices have been identified, ranked by deprivation scores therefore targeting populations within areas of need and where we know issues with access to services exist which impacts on delays to diagnosis and survival rates. Through the evaluation of ACE we will gather data and feedback to demonstrate reduction in referral to diagnosis, more costs effective use of resources and reduction in patients receiving cancer diagnoses in A&E.Leeds is also an early adoption test site for the 28 day faster diagnosis standard, with a focus on prostate, head and neck and gynaecology pathways. Leeds, along with 4 other test sites will develop the standards and data definitions which will form the basis for the standard nationally by 2020. Our main aims are to increase early presentation, detection and treatment of cancer which will result in improvements on the proportion of patients diagnosed at stages 1 and 2 and a reduction in emergency presentations. We have established a Prevention, Awareness and Screening workstream to focus on increasing the awareness of the signs and symptoms of cancer (mainly breast, bowel and lung) and cancer screening programme participation.By increasing the uptake of screening patients will be identified at an earlier stage of their cancer so this will improve the number of patients identified at stage 1 & 2. The number of patients being diagnosed following an emergency admission will reduce as more patients are diagnosed at an earlier stage. We implemented stratified follow-up pathways for low risk breast cancer patients in January 2016 so that low risk patients now receive a Patient Education Programme instead of having traditional follow ups. Patients will continue to have annual mammograms as requested by the multi-disciplinary team. This is currently being evaluated and the model most likely will be tweaked to ensure we provide and meet patient needs that have been identified through patient evaluation of the programme. Once the model is finalised early in 2017 we will roll out by gender specific. Female groups will be for Breast, Gynaecology and female Colorectal. Male groups will be established for Prostate and male Colorectal.Leeds CCGs have commissioned all elements of the Recovery package. This includes working with Leeds Teaching Hospitals NHS Trust to implement a holistic needs assessment and care plan at the point of diagnosis and ensuring the completion and delivery of a treatment summary to the patient and the GP at the end of treatment.In addition we are delivering pilot project funded by Macmillan Cancer Support relating to Cancer Care Reviews which involves testing different models with a group of GP Practices and evaluating outcomes. We have funding to test out a model of a Practice Based nurse delivering reviews across 4 practices, at the same time we will be using existing good practice and learning from the delivery of the reviews to inform a rollout plan across Leeds from Q3 2017/18.‘Must Do’ 7: Mental HealthDescribe how you will:Deliver in full the implementation plan for the Mental Health Five Year Forward View for all ages, including:Additional psychological therapies so that at least 19% of people with anxiety and depression access treatment, with the majority of the increase from the baseline of 15% to be integrated with physical healthcare;More high-quality mental health services for children and young people, so that at least 32% of children with a diagnosable condition are able to access evidence-based services by April 2019, including all areas being part of Children and Young People Improving Access to Psychological Therapies (CYP IAPT) by 2018;Expand capacity so that more than 53% of people experiencing a first episode of psychosis begin treatment with a NICE-recommended package of care within two weeks of referral.Increase access to individual placement support for people with severe mental illness in secondary care services by 25% by April 2019 against 2017/18 baseline;Commission community eating disorder teams so that 95% of children and young people receive treatment within four weeks of referral for routine cases; and one week for urgent cases; andReduce suicide rates by 10% against the 2016/17 baseline.Ensure delivery of the mental health access and quality standards including 24/7 access to community crisis resolution teams and home treatment teams and mental health liaison services in acute hospitals.Increase baseline spend on mental health to deliver the Mental Health Investment Standard.Maintain a dementia diagnosis rate of at least two thirds of estimated local prevalence, and have due regard to the forthcoming NHS implementation guidance on dementia focusing on post-diagnostic care and support.Eliminate out of area placements for non-specialist acute care by 2020/21.Note:If CCGs are not consistently achieving the various mental health standards then the Plan needs to clearly outline when this will be the case.The Leeds MH Framework (2014-17) is the Leeds Strategic Plan to improve mental health across the city. Although this plan was developed in 2013/14 i.e. prior to the publication of the Mental Health Five Year Forward View (2016), the Leeds plans are consistent with the priorities outlined in that document. Over the last two years the Leeds system has worked on four cross cutting themes as follows:Information Redesign of Community Based MH Services Children and Families Crisis and Urgent Care All of our work streams have contributed to significant local transformation with the emphasis on improving patient experience, increasing parity of esteem, particularly in the urgent care pathway, and developing improved self- management and public awareness. Our statutory and third sector partners are working through a 16/17 shared CQUIN on the development of more integrated care pathways, to reduce length of stay and increase options for interventions that contribute to recovery. We have recently benchmarked our current position against the MH FYFV priorities and believe we have sound foundations for all the key priority areas. Our commissioning intentions for 2017-2019 reflect those areas that require further development to meet the requirement of the FYFV. We have undertaken a two year review of our Framework implementation and agreed that we will undertake more targeted work on physical health outcomes for those with SMI as a priority in 17/18. Local IAPT access rates still remain lower than required. In 2016 NHSE IST reviewed the Leeds systems provision and identified a number of changes that could be made to improve uptake of service. The service providers have instigated changes in line recommendations with to improve efficiency of the service. As a result the service has seen a significant increase in the uptake of cCBT, improved patient tracking systems and waiting list management. However, some of the solutions for IAPT access are more systemic – Leeds CCGs will put greater focus during 17/18 on a range of measures in order to improve the flow of the right people to IAPT and increase service efficiency. The CCGs have undertaken an 18 month co-productive approach to remodelling the community based MH (CBMH) offer for the city (both primary and secondary) to whole system patient flow. We are aiming to improve the efficiency of our IAPT service in 17/18 by the implementation of a newly developed CBMH model that includes:Introduction of new public facing information system called MindWell – that provides on-line access to IAPT and direct option of self-management, and self-navigation. This went live in October 2016.Piloting of Primary Care Liaison roles to offer extended assessment and brief intervention as alternative to IAPT for those who previously might have been referred but did not take up the offerCloser working with CMHTs to offer Step 2 IAPT groups for those suitable for interventionCollaboration of primary and secondary providers to improve the integration of the pathway to improve efficiency of the Single Point of Access (SPA), shared resources and reduction in in appropriate referrals and bounce back to primary careWork on the findings of local IAPT/LTC pilot to improve mental health training, screening and take up of IAPT for those in LTC pathways Developing improved integration of Psychiatric Liaison Outpatient Service already provided by LYPFT and not currently connected to IAPT service Participation in Wave 2 of the Employment Advisor IAPT initiative. Review impact of plans above on IAPT access and targets (17/18)Leeds is a long standing member of the CYP-IAPT programme (since wave 3). The city is reviewing data across the partnership of school clusters provision, the third sector and specialist CAMHS to understand current percentage of CYP with a diagnosis accessing evidence based services and will inform the development of a trajectory of improvement. Leeds is fortunate to be working with CORC to promote CYP-IAPT principles across the partnership to ensure whole system evidence based support and services and shared outcomes.Leeds has an established Early Intervention in Psychosis (EIP) service delivered by the 3rd sector (Community Links) and supplemented by acute support from LYPFT. We have provided NR funding in 16/17 to extend the age range in line with national requirements. Ensuring that this funding is made recurrent is on our commissioning intentions for 17/18.The EIP service is currently commissioned using two service contracts (3rd sector and LYPFT. Leeds CCGs are proposing to move to lead provider model (our changed approach is planned for 17/18)Two week wait times already achieved:14-35 age range the position at the end of August 2016 was 81.8%>35 age range the position at the end of August 2016 was 80%.Additional capacity is planned to deliver the full NICE compliant package of care, as the current service model does not yet cover the ARMS element. Leeds has a well-established Individual Placement and Support model commissioned by Leeds CCGs & Leeds City Council from Leeds Mind called WorkPlace Leeds. The service has contributed to the national task force (DH and DWP) review with regards to support options for people with MH issues. Leeds was recognised as an area of good practice within this review. In 15/16 the service supported 304 people and through that support moved 92 into jobs. In addition 138 people were supported by the Job Retention element of the service with a 94% success rate. The NHS funded element of the work is an IPS model integrated into secondary MH services.The current service level is insufficient to meet demand. Whilst a benchmarking exercise is planned for 17/18 CCGs are already in discussion with our provider about how they might also be involved in the IAPT Employment Advisors initiative (of which Leeds is a partner).The creation of a distinct community based eating disorder service for children and young people was a key priority for the first year of the Leeds LTP. Support for CYP with eating disorders had previously been offered through the generic CAMHS service and via three specialist teams within the city. The additional funding allocation has created an opportunity to enhance and transform the existing service and reconfigure the teams into one citywide team. Work is well underway to deliver this exciting development:The service model, pathway and funding is agreed and commissionedChildren and young people are receiving the agreed pathway of careRecruitment is virtually complete with the vast majority of staff in post Currently the numbers of new referrals into the service are lower than predicted. The provider is working with the commissioner to understand why this is the case and utilising the capacity in the meantime to develop the pathways, protocols and resourcesA permanent estate is still to be confirmed however, the team is located in a single centre to enable team coherence and development and is operating a hub and spoke model to deliver the service from the centre and three clinics across Leeds.Experienced and interested paediatricians have been identified; this arrangement is agreed and contracted via the inter-provider agreement already in place between the community trust (the CAMHS NHS Provider) and acute trustData systems are in place for reporting into the baseline collection process during 2016 in readiness for the access and waiting times standard (as per guidance)In recognition of the evidence pointing to the effectiveness of Family Based Therapy (see guidance p20), 5 staff have been identified to complete this training and the necessary supervisionBody Dysmorphia Disorder Training has been delivered by staff from South London and Maudsley to the team and wider CAMHS workforce in May 20166 places have been secured for CBT-E training. Three practitioners have started the course and have training cases. A further three will start the course in early 2017. They will be qualified within the next 18 monthsOutcomes measures routinely used include EDE-Q, SDQ, CHI, Goal Based Outcomes, as well as Session by Session monitoring, RCADS or other symptoms trackers where appropriate, physical health monitoring, including % age weight for height, in line with best practice guidanceThe service has expressed an interest in joining the new Quality Network for Community CAMHS- EDBoth parents and CYP (current and past service users) are involved to ensure the service is strongly informed by users of the service. This involvement will continue through the implementation and delivery of this service. CYP were involved in the recruitment of new staff and are advising as to clinic letters, premises, timing of appointments and the name of the serviceThe team is keen to establish links with BEAT and their young ambassadors with a view to develop young Leeds ambassadorsDevelopment and delivery of the service model includes colleagues from the CAMHS Transitions team and intensive outreach team, recognising how critical these interfaces areConsultation and a training programme for universal settings, such as school-based staff commencedPlans are in development to deliver awareness training to primary care (by the NHS CAMHS provider of the CEDS-CYP)The Leeds Mental Health Strategy suicide prevention work stream is overseen by a strategic multi-agency partnership that meets quarterly led by Public Health. This strategic suicide prevention group oversees the citywide suicide prevention plan for the city. This plan is informed by a detailed Suicide Audit. This ensures that resources are directed towards appropriate evidence-based interventions. Key outcomes from this work have included:Additional Investment identified Commissioning of a bespoke Suicide Bereavement ServiceInsight informed approach to commissioningProduction of National Media guidelines Gold standard Audit process given by PHE in their guidelinesKey actions for next two years:Refresh of the suicide action plan for 2017-20PHE master class events - Suicide prevention (co- producing)Engagement with primary care to support their key role in Suicide preventionEnsure greater targeting of resources at high-risk groups and Increased working with the 3rd sector to support development and delivery of plans Crisis Services: Leeds currently has a dispersed Crisis service that includes Street Triage, Nurse in Police Control Room (DCR), Section 136 Suite, Crisis Assessment Services, Crisis Assessment Unit and Intensive Community Service (providing home treatment) all provided by LYPFT. It is supplemented by a User Led Crisis Service that includes a helpline (open 6pm – 2am 365 days a year) and safe house open 6pm – 2am x 5 days per week. A benchmarking exercise for services is planned against the functions required of a CRHBTT. Elements of our current model are reliant on NR funding i.e nurses in DCR and additional capacity funded through SRG to extend provision from User Led Crisis Service – both for safe haven, and for Connect Helpline. Retaining ongoing funding for these services has been identified as a commissioning priority for 17/18. Liaison: Leeds has a well-established psychiatric liaison service that includes Acute Psychiatric Liaison Services (ALPS) based in A&E, psychiatric liaison in-reach and outpatient service and an all age in-patient liaison service. Our provider (LYPFT) has been fully engaged in the West Yorkshire Urgent Care Vanguard/STP work that has included a benchmarking process against Core 24. Leeds is not yet compliant on all CORE 24 elements. Elements of our existing in-patient liaison services are reliant on non-recurrent funding. Securing funding is a commissioning intention within current planning round.A review was undertaken by LYPFT in 16/17 to assess the service against Core 24 standard and a remodelling and service development plan agreed. Commissioning intentions for 17 -19 include proposals for recurrent funding to meet the Core 24 all age 24/7 requirements. This will not deliver the 1 hour waiting time within the first two years, without additional resourcing. LSE ONLYTBC – MH additional investmentThe number and rate of people diagnosed with dementia have continued to improve over last 12 months. There are currently 6,095 people diagnosed with dementia on Leeds GP dementia registers (Sep 2016 with a diagnosis rate of 76.4% (combined Leeds CCG position). There is variation between the CCGs (with Leeds North showing underperformance against standard), but this is believed to be an artefact of the technical definition, which uses Office of National Statistics population estimates for CCGs’ geographical ‘footprints’. It is understood that from April 2017, the calculation may revert to using registered GP practice populations. Local calculation suggests that this will reduce slightly the Leeds-wide diagnosis rate, but improve the Leeds North CCG figure, so that all three Leeds CCGs would then achieve above the NHS England ambition for 66.7% diagnosis rate. The CCG IAF introduces four bandings of performance for dementia diagnosis rate. By March 2020, it is expected that Leeds as a whole will achieve the top banding, at or above 76.7% diagnosis rate. This is subject to the new technical definition from April 2017 being confirmed and diagnosis rates being recalculated accordingly. The embedding of GP-hosted memory clinics and the Memory Support Worker service are expected to sustain and improve diagnosis performance.Waiting times: Local pathway improvements and monitoring via KPIs have already achieved progress for patients seen by LYPFT Memory Service. 91% of patients had their first appointment for memory assessment within 8 weeks of GP referral (Q1 16/17); and 56% of patients were diagnosed within 18 weeks of referral.Our Leeds ambition by March 2020, 100% of patients will be seen within 8 weeks, and diagnosed within 12 weeks. Our provider will be expected to evaluate the pathway to optimise the timescale and support throughout assessment and diagnosis. A trajectory is being set to increase the proportion of patients having diagnosis within 8 weeks, subject to the ability to do this within a positive patient and carer experience.There is a potential issue with the forthcoming NHS England guidance, which expected to target diagnosis within 6 weeks. Locally, 8 weeks has been used in order to allow diagnosis to include reporting of brain imaging, which has a 6-week standard response time. If the guidance stipulates 6 weeks, then Leeds will have a choice of being at variance from national guidance, or investing in a quicker ‘queue’ for radiology for patients having memory assessment. There is a risk that running an additional queue (‘dementia’ as well as ‘urgent’ and ‘non-urgent’) would decrease overall efficiency of specific diagnostic services.Face-to-face annual review: The CCG IAF includes a simple percentage measure of the proportion of patients on GP dementia registers have had a face-to-face review of the condition and care plan. In Leeds, dementia is one of the long-term conditions included in the Year of Care approach, introducing holistic and person-centred goal setting and action planning. As part of our approach Memory Support Workers give GP practice teams a simple pathway to support and implement agreed actions. The CCG IAF performance has 4 bandings. Data published in Sept 2016 indicates that Leeds North CCG and Leeds S+E CCG both achieved top banding (79.5% and above having face-to-face review) with Leeds West just falling into the lowest banding (75.6%). When combined Leeds-wide performance achieve the second highest banding (79.2%, Improving performance require support from GP practices. However there is little incentive for GPs to achieve this as they receive maximum QOF points for reviewing 70% of patients as opposed to the higher rates required to achieve national target rates). Despite this, with the development and embedding of the Year of Care approach, and the sustaining of the MSW service, Leeds aim to have city-wide annual reviews in the highest of the four bandings.Post-diagnosis care: The revised Leeds dementia pathway, launched in February 2016, has the Memory Support Worker in a care navigator and named contact role for everyone living with dementia in Leeds, working with colleagues in specialist NHS roles and primary care to create a post-diagnosis care plan. The MSW role enables Leeds to offer 100% of people with dementia reliable access to post-diagnosis support, integrating primary, community and specialist support. Continued funding of the MSW service (currently funded on a NR basis) has been highlighted as a priority commissioning intention for 17/18.Eliminate Out of Area Placement (Acute): LYPFT have undertaken a Rapid Improvement Event supported by the System Resilience Assurance Board to assist with the review of systems that support improved discharge and system flow – all of which contributes to the reduction in out of area placements. LYPFT are developing a new clinical strategy to drive service structure and delivery. Programmes of work have been developed to improve flow across many services in LYPFT.The CCG has established a process to monitor OAPs by bed type, which includes (at individual patient level):how many out of area placements are madethe reasons for out of area placementsthe duration of out of area placementsthe cost of out of area placementsCurrent rates of OAP show a slow reduction from a high of 13 in August to just 2 in October 2016. We will be setting a target trajectory for LYPFT for the next two years.‘Must Do’ 8: People with Learning DisabilitiesDescribe how you will:Deliver Transforming Care Partnership plans with local government partners, enhancing community provision for people with learning disabilities and/or autism.Reduce inpatient bed capacity by March 2019 to 10-15 in CCG-commissioned beds per million population, and 20-25 in NHS England-commissioned beds per million population. Consideration needs to be given over as to how the CCG will prepare for these developments.Improve access to healthcare for people with learning disability so that by 2020, 75% of people on a GP register are receiving an annual health check.Reduce premature mortality by improving access to health services, education and training of staff, and by making necessary reasonable adjustments for people with a learning disability or autism.Transforming Care Partnership (TCP) Leeds has established a Transforming Care Partnership and developed an integrated strategic commissioning and delivery plan designed to deliver the TCP in Leeds over the next three years. The outcomes to be achieved by the plan over the next three years include:Close 50% of the hospital beds used by people with complex learning disabilities and/or autismPrevent specialist hospital admissions where possible for people with complex learning disabilities and/or autismDevelop effective pathways through transition for young people with complex learning disabilities and/or autismEnsure people with complex needs relating to their learning disability and/or autism can be supported in the community.In order to support this process, a number of different work streams have been established to oversee the development and implementation of the local Transforming Care Plan. The Leeds Plan has been approved by NHSE and progress in objectives is reported on a monthly basis, and the required trajectory on bed reductions has been established. Work is underway to understand the financial commitment required to deliver the plan. The financial implications will be factored into commissioning intention discussions. Our plans recognise the need to reduce the number of people with Learning Disabilities in acute beds. Our plans include reconfiguring services to reduce overall bed requirement by 50%.A project over two years, completed in 2016 focussed on improving access to health checks, providing training and education to GP practice staff across the three Leeds CCGs, and guidance to ensure that reasonable adjustments are made to support accessing health checks.Work has been undertaken to improve the general practice audit to establish the current rate of take up of Annual Health Checks. Data gathered will be used to set improvement plans for each CCG as part of the prevention element of the place based plan for Leeds (local delivery plan for WYSTP).Our transforming care plan includes a range of measures to improve access to health services, education and training of staff, and making necessary reasonable adjustments for people with a learning disability or autism.‘Must Do’ 9: Improving quality in organisationsDescribe how you will:Ensure all organisations have plans to improve quality of care, particularly for organisations in special measures.Drawing on the National Quality Board’s resources, measure and improve efficient use of staffing resources to ensure safe, sustainable and productive services.Participate in the annual publication of findings from reviews of deaths, to include the annual publication of avoidable death rates, and actions they have taken to reduce deaths related to problems in healthcare.The CCG recognises the three core components of quality i.e. patient safety, patient experience and clinical effectiveness, as well as the more recent additions of responsiveness and well-led. The CCG’s commissioning intentions will ensure that providers are supported to manage additional demand for services associated with public health and primary care initiatives as well as demographic changes. The CCGs in Leeds have developed and agreed a Quality Framework, which sets out the approach and intentions of the CCGs in the commissioning and monitoring of quality and services. It forms the blueprint for the quality teams across the city in how we commission and monitor for quality in services and is mapped against the requirements of the NHS national contract for health services and other national requirements, as well as planning for the development of new requirements.The strategy is owned by the medical and nursing executive directors of the three Clinical Commissioning Groups and has oversight by the respective Quality and Assurance committees of each CCG. It is published on our website to inform the public of our intentions and ambitions in support of our statutory duties.The strategy sets out how we set, monitor and improve standards of quality in the services that we commission through the following mechanisms and processes:We meet regularly with senior teams from our major providers to assure us that they are meeting the required standards of quality and safety. This includes assurance on staffing levels, skill mix and bank/agency usage. We cross-check this information with other measures of quality to ensure that quality care is not compromised.We monitor mortality rates, and seek assurance that providers have robust governance mechanisms in place to review deaths and identify issues for improvement. We seek assurance that providers respond appropriately to national reports.We make sure that all contracts we hold with providers contain clear standards which reflect good quality care, i.e. that are:SafeEffectivePositive patient experienceResponsiveWell led (culture and leadership)We meet regularly with commissioners from around the region and CQC, to share information and to understand quality in health and social care services across West Yorkshire.We work with providers to develop CQUIN schemes to improve the quality of care through allocation of additional funding. (e.g. This year our community and acute trusts are working together to improve care for patients with COPD and acute and chronic heart failure).We listen to feedback from our patients using concerns and complaints, and from websites like NHS Choices and Patient Opinion and also information through our Patient Advice and Liaison service (PALs)We work with CQC and other partners so that we can share concerns about our local providers and understand any risks to patients and decide what action needs to be taken.We are working with our GP members to develop and implement new ways of providing services, led by GPs and other healthcare professionals, with the aim of providing services that are better focused to the health needs of local communities and providing more services away from hospitals.We work with our providers to understand the types and numbers of incidents that happen in our Trust. We look for patterns and trends and also review any investigations to make sure they are of high quality.We carry out quality visits to different hospitals and departments and we speak to patients to understand their experiences. We also speak to staff about how it feels to work in the service. We also check that the environment is clean and tidy and that patients have the information they need in different formats.In order to ensure that people receive the most effective care possible and that is in line with nationally agreed standards (NICE), we ask our providers to demonstrate how they assess their services for compliance with these standards, and as commissioners we also use them as the benchmark when designing or changing pathways of care.Activity figures rationaleProvide a narrative rationale for the submission of your activity figures for elective and non-elective activity, including assumptions in relation to baseline activity levels, projected outturns and what modelling has been used to underpin the activity numbers submitted. Specific reference needs to be made to the Waterfall diagram on the planning return and how this illustrates the bridge from 2016/17 outturn to the plans for 2017/18 and 2018/19.(see additional guidance notes in YH regional team guidance)Where the activity numbers submitted do not meet the NHS Constitutional Standards, or have a recovery trajectory, we would particularly welcome some specific commentary to provide the reasons and associated assurance around this.In particular, specific consideration should be given to the following questions:-Are the levels of commissioned activity shown in the activity plans the same as those built into the financial plans?Can the CCG describe expected activity reductions (i.e. efficiency savings) that have (a) been agreed with the provider and built into contracts, (b) are outside of the contract agreement?How do planned activity changes compare to nationally expected activity assumptions, and if there are differences, can they be explained?Are activity levels and growth assumptions consistent with those modelled into the STP plans (and if there are material differences, can they be explained?)Leeds CCGs have made working assumptions around the growth in activity to support the delivery of key national priorities as part of developing the place based plan for Leeds. Our demographic growth analysis indicates that, based on need, as a city we should anticipate a growth of 0.8%. However the change in demographic has not proved a particularly useful indicator when assessing potential growth in acute services. As such our process for assessing likely demand over the coming 2 years has included A review of information contained in nationally available tools such as IHAMLocal assumptions with respect to growth in activity and referrals over 3 yearsReview of activity required and backlogs to be addressed to meet national priorities e.g. cancer, RTTA review of policy changesThis review has led to the following proposals which includes projected ‘do nothing’ growth figures:POD ‘do nothing’ growth projectionsOPElect A&E Non-Elect North1.55%2.42%1%2.29%South and East1.61%2.14%1%2.30%West1.62%2.22%1%2.26%Proposed QiPP0.6%0%1%1.5%Summary Net Growth1%2.3%0%0.8%IHAM 2016/174.7%1.8%2.3%2%Our approach with respect to planning (and completion of waterfall diagram) is to factor in anticipated “do nothing growth”. We have, where applicable, factored in impact of a range of initiatives that fit into the categories required within the submission to reach the proposed eventual value as summarised in row Summary Net Growth. We have made the same assumptions re growth and QiPP for each of the tow financial years 2017/18 and 2018/19.Given issues with respect to reconciling contract currencies, as with previous years we are basing growth on SUS forecast outturn as opposed to contract currencies. This approach is one of the key reasons why the IHAM and local assumptions do not always alignA&E Attendances: Our plans anticipate a ‘do nothing” of 1% for each of the coming two years. Our plans are to commission outturn activity (effectively a 1% pa reduction in demand against trend). The reduction in demand vs trend will be achieved through a combination of the following initiativesUrgent Care Vanguard (111, 999 and OOH redesign)Extended Primary Care – Improving access to GP evenings and weekendsSelf care – working with public to avoid unnecessary attendancesGP in A&E (triage and redirection of patients within emergency department) TBCPublic engagement re right place, right timeEmergency Admissions: The growth in emergency admission over recent years is difficult to assess due to changes in coding and counting. As with A&E we have reviewed demand trends and are between 2.2%-2.3% growth. We believe that we will address some of this demand, reducing overall demand back to 0.8% through a range of initiatives that includeUrgent Care Vanguard (111,999 and OOH redesign)Enhanced Care Home Schemes (keeping people well to avoid admissions)New Models of Care (proactive case management)Integrated Discharge Services - Admission Avoidance in A&EFalls Service Development– Reducing falls in home and care settingsDeveloping Neighbourhood Teams - Rapid Access to Community ServicesRight Care – Focus on respiratory disease to reduce acute exacerbations of COPDRight Care – Reduce impact of alcohol through healthy living servicesRight Care – Proactive Management of CVD and DiabetesOutpatients: As with non-elective assessing growth trends over recent years is difficult to assess due to changes in coding and counting. However a review of demand indicates a “do nothing’ 1.5%-1.6% growth overall across all OP. Achieving our target of 1% growth in outpatient will be a challenge given the focus nationally on early referral for cancer symptoms. However we believe we can reduce impact of this to reduce overall demand to around 1% pa through the followingRight Care – Reviewing variation in referral rates across GP PracticesRedesign of Pathways - Increasing use of diagnostics prior to referralRedesign of Pathways - Reducing follow ups, Fair and Equitable Access – Healthy Futures Commissioning Standards Initiatives (medical optimisation of patients, Review referral rates for procedures of limited clinical effectivenessImpact of new tariffNote: We are anticipating some above demographic demand activity growth as a result of the implementation of the Cancer Strategy. However we believe that some of this growth will be offset by reduction in numbers of routine referrals i.e. net zero impactElective: Our growth is projected at between 2.2%-2.5%. This growth is largely as a result of the impact of addressing waiting list backlogs and the need for greater number of endoscopies to meet growth in diagnostics are anticipated within the WY STP cancer plan. At present we are working through potential impact of a range of initiatives but do not feel we are yet in a position to factor in these as QiPP plans. Areas that we are reviewing include:Redesign of Pathways - Increasing use of diagnostics prior to referralRedesign of Pathways - Reducing follow ups, Fair and Equitable Access – Healthy Futures Commissioning Standards Initiatives (medical optimisation of patients, Review access rates for procedures of limited clinical effectivenessWe believe our proposed growth plans are realist and reflect our current contract offers to our providers. At this stage we have made conservative estimates of the impact of QiPP and will review these over next month as we progress our discussions with our providersAlignment with financial plans: Our activity plans for 2017-2019 are broadly consistent with our financial planning assumptions. Further work will be required as we progress our contracting discussion to ensure that both our finance and activity plans reflect any developments towards agreeing our contracts Alignment of Activity Plans with our provider: Our ‘do nothing’ plans broadly align with our provider planning assumptions for Leeds CCGs as commissioner (overall). However there may be some differences with regards provider assessments of impact of STP and assumptions with regards to their market share of commissioner activity i.e. provider plans may estimate growth due to increasing their own market share which may mean non alignments between growth assumptions between CCGs and providersComparison with National Activity Projections: We have reviewed our activity projections (do nothing) with those published through a range of national tools such as IHAM and also assumptions within ‘do nothing’ STP financial plans. In 2015/16 we undertook a significant amount of work to ensure that where our plans varied from national assumptions we could articulate reasons for variance. We believe our ’do nothing’ projections are as accurate as possible given available information.Consistency of activity levels and growth assumptions with STP plans: Our activity and growth assumptions are broadly consistent with those submitted by our finance teams as part of STP financial process as at Oct 2016.Risks to not agreeing contracts with Provider(s)Learning from 2016/17, and reflecting the emphasis in the planning guidance on spending less time on adversarial and transactional relationships, we are keen to understand where there may be any risks to contracts not being signed in the timescales prescribed for contract signature. Could you please flag up any issues that may adversely affect the ability of the CCG to reach an agreed contract with their provider(s) by December 23rd 2016.Key to our plans is the need to reach a settlement with our main provider, Leeds Teaching Hospitals NHS Trust. This will need to balance the need to support the Trust in the short term with the need to invest in a range of key primary, community care and mental health initiatives that will enable the city of Leeds to transform services and as such reduce our dependency on hospitals in the longer term. The STP requires CCG growth money to be used fund community and MH services; there is a risk that HRG4+ and the cost of coding changes which reflect no additional activity, will impede the delivery of STP plansThe ongoing discussions with acute providers regarding HRG4+ and changes to Specialist Identification Rules are hindering negotiations with our mental health and community providers as commissioner purchasing power is at risk .Furthermore, increases in provider control totals present a barrier to the necessary partnership working.Negotiations are ongoing with all other major providers, including our Independent Sector and AQP providers. These negotiations are being undertaken within the context of a challenging financial environment and as such it is difficult to articulate the level of risk and challenges associated with the sign-off of finance and activity plans at this stage. However at the present moment we are hopeful of reaching a shared understanding within the given timeframe. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download