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Forest of Dean Locality Development Plan of 20

FOREST of DEAN LOCALITY DEVELOPMENT PLAN

2013-15

1 PURPOSE

1.1 This Locality Development Plan has been produced to describe the specific health needs for the population of Forest of Dean, and sets out how the Locality Executive Group will lead work to address these needs over the next two years.

2 BACKGROUND

2.1 Gloucestershire Clinical Commissioning Group (CCG) was formally constituted in April 2013 as a requirement of the Health and Social Care Act 2012, replacing Gloucestershire Primary Care Trust (PCT) as the organisation responsible for the local NHS. A crucial aim of creating the CCG is to ensure a clinical focus on the commissioning of healthcare services for the county’s population.

2.2 The county of Gloucestershire covers a diverse range of populations,

from the very deprived to the very affluent, from people living in very rural areas to people living in one of two large urban areas where there are a significant number of immigrant populations. This leads to a countywide population with very different health and social care needs, spread over a large geographic area. In recognition of the need to understand and represent these differences, the CCG has formed seven Localities; one of these is for the Forest of Dean area. In each Locality lead GPs work alongside key partners to help determine how best to meet the needs of its population, informing the wider work of the CCG; this is known as the Locality Executive Group.

2.3 This document will seek to describe the local health needs for the

Forest of Dean Locality. As will be seen, it is clear that our population has specific health needs that need to be addressed. In order for us to understand these needs, the Public Health team has supported this work; the team will also work with us to identify the best ways of addressing them.

2.4 Two major strategies have recently been produced by the CCG (and its

predecessor PCT), working with Gloucestershire County Council. The first is the Health and Wellbeing Strategy, which sets out the priorities


for the improving health and outcomes of the population of Gloucestershire over the next twenty years, focusing on supporting preventative measures and self-care. The second, forming part of the Health and Wellbeing Strategy, “Fit for the Future” which sets out the priorities for the improving health and outcomes of the population of Gloucestershire over the next twenty years, focusing on supporting preventative measures and self-care. The priorities within this Strategy during 2013/14 are:

Reducing obesity;

Reducing the harm caused by alcohol;

Improving mental health;

Improving health and wellbeing into older age;

Tackling health inequalities. 2.5 The second major strategy, as the NHS response to the Health and

Wellbeing Strategy, is ‘Your Health, Your Care’, which sets out the vision for health and social care services and community support in Gloucestershire for the next five years.

2.6 This Locality Development Plan must be seen in the context of these

two important strategy documents – we do not intend to replicate them. The CCG has also produced an Annual Operating Plan for 2013/14, which sets out its work programme for the coming year. This Locality Development Plan therefore fits within this wider context as follows:

Achievement of these all these goals and action contained within these strategies and plans will be measured in a number of ways, including against the NHS Outcomes Framework.

Health and Wellbeing Strategy

Your Health Your Care

CCG Annual Operating Plan

Locality Development

Plans


2.7 Finally, whilst the CCG was only formally constituted recently, the

Localities have been working in shadow form for much of 2012/13. Key achievements identified by the Forest of Dean Locality GPs during this time include:

Working together, including:

Taking an evidence based population health view

Being able to look at overall spend and understanding how money is spent in the locality

Using peer review (e.g. on referrals and prescribing) to drive improved care

Using data on practices to understand variation between practices and reinforcing the shared responsibility to take action

Developing areas for learning and development and for clinical audit

Signposting between services more efficiently

Moving people to healthy lifestyle interventions Developing or working with partners to develop services, including:

Blood transfusion

Primary care podiatry

MUSKAT

Diabetic nurses

Minor operations

Dermatology

Exercise referral services

Weight 4 Life services

Eye clinic at the Dilke

Audiology at Lydney

Dialysis at Cinderford

Specialist advice services

Direct access radiology

3 LOCAL SERVICE PROVISION

3.1 The Forest of Dean Locality includes the main towns of Blakeney, Coleford, Cinderford, Drybrook, Lydney, Mitcheldean, Newnham-on-Severn, Westbury-on-Severn, Yorkley, Bream, Ruardean and Lydbrook. The Forest of Dean district population is 82, 200 and the locality population (registered with Forest of Dean locality commissioning group GPs) is 61,700. There are 11 GP Practices in the Locality.


3.2 In addition to the main acute hospitals in Gloucester and Cheltenham

and the GP Practice sites, local NHS health services are also delivered from The Dilke and Lydney community hospitals

4 WHAT ARE THE ISSUES WE FACE? 4.1 The NHS and Local Authority in Gloucestershire produce a Joint

Strategic Needs Assessment (JSNA) – this is a strategic planning tool which brings together the latest information on the health and well-being of people living in Gloucestershire. It highlights the medical conditions that particularly affect the population of the county and its Localities. It also highlights population changes over the coming 20 years.

The population is increasingly ageing, as with other areas in Gloucestershire.


The Forest of Dean has a significant proportion of people in the more deprived but not the most deprived groups. The profile means that there is a significant deprivation but not in the lowest category meaning the problems of deprivation are represented in the Forest of Dean locality but are not identified as a problem nationally. The gap in life expectancy between the most deprived and least deprived is growing, with life expectancy for the most deprived women decreasing.


The issues highlighted from the JSNA for the Forest of Dean include:

Highest rate of obesity in the county running through all age groups (this is combined with known high rates of inactivity)

High prevalence of long term conditions including CVD, COPD and diabetes

Poorer outcomes for women including an overall higher than average rate of premature mortality;

Raised alcohol specific mortality;

Increased COPD mortality and

Mortality from suicide and undetermined injury. Of particular concern is the falling life expectancy for the most deprived women.-


Breast feeding rates for the Forest of Dean are reported to be low in the majority of practice populations and the Forest of Dean also has a greater than average number of low birth weight births. Obesity continues to be a significant issue for the locality both in children and adults with significantly higher than average childhood obesity. Within the JSNA data, there appears to be wide variation between practices in relation to the reported prevalence of long term conditions such as dementia, CHD and COPD as well as access to services which needs to be understood.

4.2 In addition to the JSNA intelligence, the CCG information team has

reviewed activity data from commissioned services to assess where there are significant variances from expected levels; this has highlighted areas for further consideration.

This data also demonstrates variation in use of services, and therefore spend, by practice population. Key areas to note are:

Increases in <1 day length of stay emergency admissions as well as admissions for children

Also noted was:


Higher outpatient activity in palliative medicine and oncology as well as dermatology

Increased elective admissions in breast surgery, clinical haematology, rheumatology and cardiology.

The majority of practices are seeing admissions for stroke, COPD, heart disease and diabetes above the average for the CCG.

4.3 As well as the information provided through the JSNA and CCG activity

data, we want to strengthen this with understanding the views of people working alongside our patients in the community, so we have also worked with our local GPs, nurses and managers and Forest of Dean District council to better understand the needs of our population, and priorities for improvement as well as services provided by our partners that support delivery of improved health outcomes for the population.

4.4 We face an unprecedented financial challenge over the coming years,

at the same time as increased demand for our services, within the context of a fast-ageing population. At present around 17 % of the population are aged 65 and over; this is expected to grow to 30% over the next 20 years. We will therefore need to provide services that are simple to access, integrated and cost-effective.

4.5 This Plan therefore incorporates all the intelligence we have gathered

into a comprehensive statement of local health needs and priorities, shown below in section 5.

Management costs table and overall budget to be added Previous achievements

The Forest of Dean held an event to review the previous year and share information to shape plans for the future. There were several benefits identified form previous commissioning work and these are outlined below:

Working together

Cooperation and sharing ideas

Understanding of how the money is spent

Peer review (referrals and prescribing)

Outliers – being able to use data about your practice that demonstrates it is an outlier to reinforce and share responsibility

Evidence based population view

Better involvement of patients in decisions

Being able to look at overall spend


Peer pressure

Learning areas (individual and practice)

Informs audit

Services

Blood transfusion

Primary care podiatry

MUSKAT

Diabetic nurses

Minor ops

Dermatology

Exercise referral

Eye clinic at the Dilke

Weight for Life

Use of community hospital beds improved

Audiology at Lydney

Dialysis at Cinderford

Signposting between services

Moves people to healthy lifestyle interventions

Specialist advice services

Direct access radiology

FoD sensory services

Falls services


5 LOCAL HEALTH NEEDS The table below outlines the key areas of need or priorities identified for the locality and the ideas and options discussed

NEED/ISSUE SOURCE IDEAS/OPTIONS ** ACTION LEVEL* WORK ALREADY

UNDERWAY?

Respiratory and other LTC admissions

JSNA and locality activity information

Review inter practice variation : data recording issues and/or differential practice identified

Outcome based contracts for LTC not activity

Use of preventative services including smoking cessation and exercise on referral/healthy lifestyles courses

Locality CCG

Yes

Mortality rates: Diabetes <65 JSNA Review recording of this information to identify whether a real issue – looks to be a construct of data recorded on death certificate but requires investigation

CCG information Yes

Emergency admissions: large variation between practices and significant increase on last year in particular for >65 and <15


“lower” level services: social support (loneliness key issue) befriending scheme

Good signposting and possible links via village agents or other “connectors” /buddying system from practices to services/clubs etc

Integrated health and social care including rapid responses (services to include MH/dementia)

Locality and District council CCG/locality CCG/Locality CCG/locality

Yes Yes (need ICT plan for FoD)


Night sitting

Befriending

Care home admissions (take part in QP/CES)

Review Care Home Support Team contract

Advanced care plans and putting plans on Adastra

Key worker working alongside individuals and develop fuller understanding of individual’s needs

CCG locality/individual practices individual practices or group of practices

Women: health outcomes and lifestyle

JSNA Health education and patient contracts Health checks – develop innovative approach including changing location and delivery mode Looking at links to self-esteem/time available to women Checking practice not differential in relation to women e.g. do not expect them to present with COPD

Practices and public health Practices

lbw and breast feeding

JSNA None as yet

Public health

Childhood obesity

JSNA Review previous services for which uptake poor and consider new approach e.g. prescribing these with follow up – patient contracts? Green gym At school initiatives e.g. walk to school etc

Public health/district council

Adult obesity JSNA Health education and patient contracts CCG and locality


Obesity county wide QP

Exercise on referral/Weight management schemes

with District councils and public health

CVD


Intermediate service? Advice service Address long waits Diagnostic issues Cardiac rehabilitation referral scheme

Potential service redesign within CVD clinical programme:? locality lead

Care for older people


See emergency admissions above Dementia friendly communities and befriending scheme Work with carers’ partnership

FoD DC

Inter practice variation JSNA and locality activity information

Ongoing learning, peer review etc. Utilise QOF QP for COPD to drive peer review and learning

Locality and practice

Mental health – suicide rates (NB small numbers)

JSNA Request review by mental health clinical programme of crisis services and lower level support services (accessibility and continuity of care) MH intermediate service development

CCG GP lead CCG GP lead


The locality executive has reviewed the areas identified and prioritised developments for the year 2013/14 as below:

Forest of Dean Locality Priority action plan for 2013/14

Priority action area

Proposed scheme

Lead partner (s)

Lead locality exec GP

Lead manager CCG or other agency

Expected outcomes/impact

Support /links required to develop scheme

Timescale

1 Emergency admissions

Pilot central point for information/resources/advice to ensure successful referrals to and information about social isolation, carer support, low level support and healthy lifestyles issues. (meeting 30-7-13). Linking to all initiatives such as village agents, District Council

Public health Village agents District council

Martin Gibbs

Michele Le Mero (public health) Justine Rawlings

Reduction of admissions associated with lack of lower level support/tipping point Reduction of repeat GP visits Improvement in quality of life

Potential funding to develop approach links to existing ABCD/community capacity approaches Support of GP practices to monitor impact on GP visits

Scoping to 31/10/13 Develop business case/KPI etc to 31/12/13 Pilot 1/1/14


befriending, healthy lifestyles initiatives etc. To be worked up with input from GPs

2 Adult obesity

Support the countywide CCG QP scheme

CCG leads Public health District council

Paul Weiss

Craig Robinson/Wayne Douglas/Sue Weaver

Increased uptake of weight management services Increased understanding of “what works” Possible training (e.g. motivational interviewing) to increase referral levels

Referral routes and services Practice nurse training

Information to practices 15/8/13 Expanded services available 31/8/13 MoM pathway available 30/9/13 Practice nurse training 31/12/13

3 COPD and emergency admissions

Survey, peer review and action plan aligned to the QP 4-6 for QOF and involving ALL practices (adaptation of QP 4-6)

Respiratory clinical programme

Paul Weiss

Duncan Thomas

Reduced inter practice variation in COPD admissions admissions greater uptake of available services in the community greater uptake of available services in the community

Respiratory clinical programme lead and locality development lead to assure acceptable as QP

Survey issued 31/7/13 Review results with all practices 25/9/13 Implement recommendations 31/3/14


Review as approach to other LTC and reducing admissions for FoD Respiratory rehabilitation programme

4 Care home admissions

Support the countywide care home CES

Care homes Care home support team

n/a Helen Bown/Helen Goodey

Reduce admissions from care homes Improve completion of care plans Improve prescribing

Practices signed up 31/7/13 Event for practices 25/9/13 Begin service 31/10/13

5 Women’s health outcomes

Carry out research with public health into women’s health behaviours and needs within FoD using localized research and methods and joint working with district council including work based surveys etc

Public health District Council

Pam Curtis

Michele Le Mero Justine Rawlings

Reduce smoking amongst FoD women Reduce alcohol consumption Increase identification of and treatment of COPD in women

Public health already commissioned someone experienced in this who did similar within men’s health

Agree project brief 31/8/13 Set up project group 30/9/13 Carry out research 31/12/13 Review findings and agree action plan/proposals 31/1/14


6 Childhood obesity

District council Public health

Andy Edwards

Sue Weaver (public health, GCC)

Provision of interventions to reduce obesity: review pilot of obesity prevention programme “HENRY” which includes:

Training early years providers to support families (not structured programmes) in their general work

Delivery of group parenting skills courses with up to 10 families via children’s centres (commissioned as part of GCS health improvement delivery team)

May need to fund schemes Will need PH to report in results from pilots

Timescales for Forest of Dean to be confirmed


(3 in Forest of Dean)

Review pilot of work in Cheltenham to deliver programmes to schools as part of attaining healthy schools status

7 CVD Review potential to develop community based pathway with GPs and available diagnostics under auspices of CVD clinical programme

CCG CVD clinical programme group

Tristan Lench

Duncan Thomas

Reduction of acute o/p; attendances/admissions; Increase in advice and guidance

CVD clinical programme group Heart Failure service

Meet with CVD lead and locality GP lead 30/9/13 Agree project brief 31/10/13

8 Diabetes Provide information to triangulate and test data that FoD significant outlier in relation to life expectancy <75 associated with

CCG information lead

Roy Sharma (tbc)

Roy Hewlett Clarification if FoD has an issue that requires action

Information leads

Data available for review 30/9/13


Diabetes

5.1 * We will not be working alone in addressing the needs of our population. As can be seen in the YHYC strategy, there are

many actions that are already underway and are planned at a countywide level by the CCG that will help. The identified needs and issues will be addressed at a number of levels, and the amount of input required of the Locality Executive Group will vary accordingly:

LEVEL LOCALITY INPUT

CCG/Countywide

Provide lead person(s), where relevant

Locality

Lead the identified workstream

A group of two or more Practices

Support as required

Individual Practice

Support as required

5.2 ** At the time of writing, these are the list of ideas/options generated by local clinicians and managers for how the

need/issue could be addressed. It is vital to note though that no decisions have yet been made, they are not exhaustive and further work is now required to agree a long list of options, assess them and determine the preferred commissioning intentions.

5.3 Health issues are often closely linked to other ‘social’ factors, such as employment, education, and housing). Therefore, we

are committed to working in partnership with the Local Authority and third sector partners to both find and implement solutions

6 NEXT STEPS 6.1 Once this Plan has been approved by the CCG Board, the following will occur:


a) The Locality Executive Group will use this Plan to determine what it’s work programme will be for 2013/14, focusing on delivery of a few key priorities. This will include determining which CCG-wide projects it will need to support [NOTE: IT MAYBE THAT LOCALITIES WILL WISH TO INCLUDE THEIR WORK PROGRAMMES IF ABLE TO DEVELOP IN THE TIMESCALES];

b) For the workstreams led by the Locality, determine preferred service models through a comprehensive option appraisal process, then work to formulate detailed plans;

c) Develop a Locality Communications and Engagement Plan, working in partnership with CCG colleagues. Meetings with

all member practices will be held every 2 months in addition to PLT sessions. These will involve GPs and practice managers from member practices as well as representatives from public health and form the District Council. The Forest of Dean Locality executive us also in the process of recruiting a lay member for the locality executive. Key stakeholders will include:

Local GP Practices and their staff;

Gloucestershire Care Services;

Gloucestershire Hospitals NHS Foundation Trust;

Gloucestershire County Council;

Local voluntary organisations;

Local MPs/councilors;

District council health and wellbeing lead

Public health

d) Ensure this plan is reviewed at regular points and refined as appropriate, at least every 12 months.

[INSERT AUTHOR NAME] [INSERT AUTHOR TITLE]

On behalf of [INSERT NAME] Locality


[INSERT DATE]

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