hounslow ccg strategic objectives report 2019/20 · rag progress update rag tangible outputs...

Hounslow CCG

Strategic Objectives Report 2019/20

Quarter 3, 14th January 2020

Strategic Objectives (i)

2

Strategic

Objective

Code

Strategic Objective Description Delivery

from:

Delivery

by:

Updated

(date)

Updated

(name)

RAG Progress Update RAG Tangible Outputs Engagement Undertaken

19-1 Implement an enhanced Social prescribing

model which helps patients access support

from the Community & Voluntary Sector,

and includes health and life coaching for

those needing to make lifestyle changes

Apr-19 Oct-19 28/11/2019 Camille

Pegus

G 5 link workers have been recruited and are now in post.

They are currently being inducted, which includes

training arranged by NWL in collaboration with Bromley

by Bow Centre. Primary Care Networks (PCN) are

looking at High Intensity Users as the first cohort of

patients for link workers to engage. Practices in PCNs

have been asked to identify suitable HIUs to refer to Link

Workers.

G Under the current social prescribing offer: 981

patients have been engaged with about

accessing social prescribing from July 2018 to

February 2019. PCNs in partnership with 2

Voluntary Sector Organizations (VSO) will take

over delivery of this service from October. The

handover from the previous provider to the

incumbant VSO is due to take place on

02.12.19.

One Link Worker met with a Patient Participation

Group on 18.11.19. A follow-up meeting is due to

take place in February 2020. A steering group with

key stakeholders to support mobilisation of the new

model will commence in January 2020

19-2 Invest in Neurodevelopmental Services to

reduce waiting time to diagnosis and

access to support

Mar-19 Mar-20 26/11/2019 Susie

O'Neill

A Investment, mobilisation plans and reporting

requirements agreed with providers (HRCH and WLT),

and baseline data collected during Q1;

Q2 Progress report provided to Clinical Board in Oct

2019; HRCH have successfully appointed a locum team

for 12 months to work through the under 5s waiting list

backlog, and all permanent posts have now been filled

except the Paediatrician post which is cover by a locum;

WLT have experienced more significant challenges with

recruitment for the over 5s backlog team and the

permanent posts, most posts have now been filled by

Oct 2019 although the medical posts remain vacant and

the delays in recruitment mean that the trajectories for

improvement for the over 5s will need to be pushed

back.

WLT have implemented a caseload review and a new

care pathway including electronic screening to improve

efficiency;

The ASD Support guide for families has been shared

with the Parent Carer Forum and is being finalised for

publication.

A Under 5s waiting list reduced from 300 patients

waiting to 138 patients waiting at the end of

September, with forecast to completely clear

the waiting list by Feb 2020. Long-term staff

team is now in place so the waiting time for new

under 5s referrals should stabilise at 6 weeks to

first appt and max. 8 months to diagnosis;

Over 5s waiting list has stabilised as 489

patients waiting at the end of September, but

has not yet reduced due to recruitment delays

and 21% increase in referrals during Q1-2

compared to 2018/19, with waiting time

remaining at 31 months; improvement is

expected by Q4 as many of the new posts are

now filled as of Oct 2019.

ASD Stakeholder Workshop 09/05/2019

Engagement with Parent Carer Forum 20/6/19

Engagement with Parent Carer Forum 17/10/19

19-3 Develop jointly commissioned paediatric

Occupational Therapy and Speech &

Language Therapy service across the CCG

and LBH to improve quality and

accessibility

Mar-19 Mar-20 26/01/2019 Susie

O'Neill

A New integrated service launched 1st October 2019,

provided by HRCH with new integrated service

specification, developed in consultation with parents and

other stakeholders, to include the CCG commissioned

therapy provision and Local Authority commissioned

provision; 60% of new posts filled at November 2019

although largely locum staff; meetings underway with all

of the specialist school settings by end of term to collate

up-to-date data on provision needed; joint Therapies

Workstream will be scrutinising performance data from

Jan 2020, including stakeholder feedback, and informing

the SEND Programme Board of impact on quality and

accessibility.

Need to confirm the governance arrangements between

the CCG and LA for managing the contract.

A New integrated service launched 1st October

2019, first performance report due Jan 2020.

Therapies Stakeholder workshop with Parent Carer

Forum and wider stakeholders March 2019; service

specification consulted on during June 2019 with

CCG Clinical Board and SEND Programme Board;

feedback provided to the Parent Carer Forum on

17/10/19

Strategic Objectives (ii)

3

Strategic

Objective

Code


from:

Delivery

by:

Updated

(date)

Updated

(name)


19-4 Manage the implementation of the school

based Mental Health trailblazer

Jan-19 May-21

(Pilot)

26/11/2019 Susie

O'Neill

G All Educational Wellbeing Practitioners from Wave 1 in

post and on-track with their training. Successful bid for a

third Mental Health Support Team in June 2019, with all

staff in post by September 2019 (12 EWPs now in post

in total, spread across East, Central and West teams);

Supervisor roles have finally been filled in November

2019, interim supervision arrangements remain in place

and effective pending start dates;

Strong partnerships in place with 20 schools who are

hosting EWPs during the training year and helping to

shape the service model and a further 14 schools have

joined the project this term;

Effective engagement in place with Hounslow Youth

Council and CAMHS YP Panel to inform the service

model;

Data-flow in place and project reporting to NHS England

has been completed within required timescales;

Regular engagement with the University, London

Trailblazer network and our local partners. Hounslow

seen as a model of good practice, with a Ministerial visit

on World Mental Health Day in Oct 2019;

Work is ongoing to refine the long-term service model to

ensure that the service is accessible to all schools in the

borough from Feb 2020.

G Project plan in place and on track;

34 schools signed up to the project to date with

plans to roll out to all 80 schools by Feb 2020;

Successful bid for additional funding to

establish a third Mental Health Support Team in

June 2019.

Schools workshop March 2019; Hounslow Youth

Council workshop April 2019; site visit from NHSE,

DfE and HLP April 2019; London-wide workshop

March 2019; Engagement with CAMHS YP Panel

in June 2019; visit from Minister for Mental Health

Oct 2019; engagement with young people during

Takeover Challenge Nov 2019.

19-5 Improve the availability of and access to

primary care appointments through online

consultation, opportunities from the new GP

contract and implementation of allied care

professionals, stemming the growth in use

of the UCC as an alternative source of

primary care

Apr-19 Mar-20 26/11/2019 Chris Jack A Provider event held to showcase the performance of

various online platforms. This event took place with a

selected number of GP practices, who will work with the

CCG to review and select a provider to implement the

technical solution.

NWL procurement for online consultation being

undertaken with Hounslow in the first wave of CCGs,

solution still aims to be in place by March 2020

Primary care team currently reviewing MJOG smart app

which will be used to support patients to book and

manage their online appointments. The app also

promotes and signposts patients to suitable self-care

management tools.

Hounslow CCG currently provides extended hours in

primary care which is commissioned through three

distinct schemes. This is will form part of the extended

hours offer to PCNS in April 2021, programme of work to

review transition in 20202 underway

Extended access hubs continues to be reviewed, NWL

consistent financial envelop has been developed and

agreed, requirements and KPIs to be in place for

January 2020 with service roll out in April

A It is planned that 75% of Hounslow's population

will be able to access online consultation by end

of March 2020.

Primary Care networks established with clinical

directors in post from 1st July 2019

Extended hours service offered to all patients

across all 5 networks.

6 clinical pharmacist employed to work across

the 5 primary care networks

2 VSO selected to provide 5 Links workers (1

each) to work with each of the PCNs

Joint engagement with consortium, CCG and LMC

with practices and networks, including council of

members, locality meetings and 1-1 practice level

engagement.

Stakeholder awareness undertaken with locality

providers, including the community and voluntary

sector.

Patient and public engagement through PPE

committee and Locality PPGs.

Special education event taking place in September

2019, to engage with PCN to raise the awareness

of the role of link workers and how they can

support patients and general practices. The event

will also be used to share learning from colleagues

working in Bromley-By-Bow.

Workshop held with CCG, Hounslow Consortium

and London Brought of Hounslow colleagues to

discuss and design model of delivery for link

workers programme.

Update on all programmes cascaded to members

through monthly GP newsletter

Strategic Objectives (iii)

4

Strategic

Objective

Code


from:

Delivery

by:

Updated

(date)

Updated

(name)


19-8 Develop plans for Chiswick and Brentford

hubs

Mar-20 27/11/2019 Chanel

Herdman

A Chiswick: The Chiswick general practices have agreed

the size of the new build and the plan is to decant the

existing 3 practices to Stamford Brook whilst building

takes place. These plans are to be signed by the

planning application group.

The pre-application is now open and the recently held

engagement event feeds into the full application which is

anticipated to be submitted in December.

The Brentford hub remains at an early discussion stage

with potential service users. NHSPS are working with

service users to work out the service charge lease

documentation for their current occupied buildings.

G Chiswick: NHS Property Services have

completed the pre-application phase and are

holding further meetings with councillors which

have been positive. The practices are on

collaborative working including shared space,

staff and clinical systems to reduce cost and

workforce inefficiencies.

Brentford: Practices are in discussion about

collaborative working and have employed a

clinical pharmacist to this end.

Chiswick:

A patient engagement event took place on 23/10

run by NHS Property Services, Hounslow's CCG

engagement team and consultants Meeting Place

Communications. Engagement is being carried out

following the pre-application stage.

Brentford: Regular user group meetings are being

with general practices, community and mental

health providers.

19-9 Reduce avoidable non-elective admissions

and ensure urgent and emergency care is

delivered in as integrated and cost effective

fashion as possible (focusing on Feltham

where needed)

Apr-19 Mar-20 22/11/2019 Chris

Richards

A 1. A&E Transport: Transport proposal was presented to

the investment scrunity panel and was approved. WM to

implement as quickly as possible.

2. ICRS in ED: Resource previously used for extended

hours will be diverted to provide a presence in ED from

9th September 2019. The team are seeing

approximately 60 patients per month but the challenge

remains discharging the patient before they are

transferred to an assessment area.

3. Discharge to Assess: Following the workshop a

working group has been set up working towards a single

discharge to assess pathway. Discussions with social

care are ongoing and it has been agreed to complete a

PID to aid these discussions.

4. High intensity users: A workshop was held on the 29th

October with representation from across the system.

The group have idnetified some possible ways forward

for a system wide approach. These will be worked up

and plan to test in the new year.

A 1. Measurements:

With respect to measurements, this objective

will be measured through:

A. Delivery against planned QIPP reductions in

NEL admissions

B. NWL High Intensity User Dashboard

2. Other Outputs:

A. Data development for transport related

discharges at the front door

B. Audit/Review of other discharge options i.e.

discharge lounge versus obs bay

C. Integrated Discharge Function in place by

the 1st October 2019. KPIs to be agreed by the

working group and will then subsequently be

reported on.

1. Multi -agency working with WMUH, HRCH, LBH

and the CCG (and more specifically CHC team) to

develop a single discharge pathway for all

Hounslow patients with the full support of all

partners. Patient focus group was held in June to

understand issues relating to discharge from a

patient perspective.

2. Multi-agency group (HRCH, local authority,

voluntary sector) in place to provide support to very

high intensity users of the WestMid emergency

department. A separate workstream group is also

working to develop a long term view of tackling this

issue by developing a co-produced community

based solution. This has involved looking at how

each service defines a high intensity users and

what the data tells us about this cohort. 3. Several

meetings have been held with ED consultants at

WM and other members of the MDT to inform them

of the plan and to establish good working

relationships.

Strategic Objectives (iv)

5

Strategic

Objective

Code


from:

Delivery

by:

Updated

(date)

Updated

(name)


19-10 Working with developing localities to

integrate services and reduce gaps

between primary care mental health teams

and the recovery teams, so reducing

numbers of patients who present in crisis

Apr-19 Mar-20 02/01/2020 Toni

Camp /

Claire

Allen

G Hounslow Locality Partnership Group meetings, focused

on integrating services across Hounslow's health and

care partners, are well-established and have ongoing

representation from West London Trust (WLT). A key

focus of their work programme is progressing the locality

mutli-disciplinary teams, be linked to the Primary Care

Networks.

Meanwhile community MH services across the NWL ICS

are being transformed in line with the vision in the NHS

Long Term Plan. This follows a successful bid, led by

the two MH Trusts, for NHSE Wave 1 Transformation

Funding. For the WLT patch (Hounslow, Ealing and

H&F) work on the detail of the new integrated service

model is well advanced and a phased implementation

programme is underway. For Hounslow additional staff

will be coming into post from Q4 and the completion

date is Autumn 2020. The new service has been named

MINT (Integrated Network Teams) and will remove the

current divide between primary and secondary mental

health care, bringing together staff from a range of

backgrounds including peer support workers. While this

new way of working will operate across the WLT patch,

there is allowance for some local variation and each

CCG has its own MINT implementation group. In

Hounslow the first meeting took place in December -

close linkage is being established with the Hounslow

Locality Partnership Group so ensure join-up with the

wider integrated offer being rolled out in the PCNs.

G Heart of Hounslow commenced a Locality MDT

pilot in summer 19, attended by teams from

HRCH and GP Leads. MH representation at

these Locality MDTs has been established via

WLT's Hounslow PCMH team; and will develop

further as the new MINT service takes shape.

Patients, carers and providers are key

stakeholders in the Locality Partnership Group.

WLT has so far held three major stakeholder

events on the transformation of community MH

services in 19/20 which have shaped the

development of MINT and a fourth workshop is

planned for late March/early April. The local MINT

Implementation groups also include appropriate

stakeholder representation.

Strategic Objectives (v)

6

Strategic

Objective

Code


from:

Delivery

by:

Updated

(date)

Updated

(name)


19-11 Increase screening rates across all national

programmes: cervical, breast, bowel,

through improved action by primary care to

follow up those who do not take up their

invites

Apr-19 Mar-20 28/11/2019 Anindita

Debnath

Dr.

Richard

Baxter

G As part of primary care 2019/20 wrap around contract,

practices are remunerated to support improvement of

screening rate across all national programmes.

CCG effectively encouraged practice engagement with

RM partners offer to contact bowel screening defaulters.

PCPC continue to support practices in this for bowel,

cervical and breast.

Status alerts active in single clinical system to prompt

bowel, cervical, and breast defaulters. Half of practices

in Hounslow using comprehensive recall in month of

birthday process which includes Cervical, and Bowel

defaulters.

ALOHA study involving 12 practices offering more

acceptable cervical screening method to defaulters

active and recruiting well.

Network meeting recognition that bowel screening

default for patients of reduced capacity (e.g. those with

Learning Disabilities) has safeguarding implications.

Joint comms between CCG, safeguarding and LD team

to at least LD homes being drafted to this effect. A

cervical screening task and finish group has been set up

with CCG and LBH PH membership – the group will

gather behavioural insight information about Hounslow

residents who do not attend cervical screening and will

design/support implementation of more focused/targeted

scheme.

A The screening element in the primary care wrap

around contract was introduced in 2018/19.

Gradual improvements in uptake are shown in

breast, cervical, and bowel cancer screening

for Hounslow patients in 2019/20. Screening

rates against national benchmarks, however,

have not been achieved.

On-going engagement with Practices and

Hounslow Consortium as part of contract

implementation and management.

CCG communication and engagement team

developed a patient/public engagement plan for

2019/20 to support improving cancer screening

rate at Hounslow.

CCG facilitates a Local Cancer network group with

membership from stakeholders such as public

health, local trusts, patient reps., NHSE, Cancer

Research UK. The group's focus is to co-design/

develop a multi-pronged approach to improve

cancer outcomes for Hounslow residents, including

increasing screening rates.

CCG actively participate in the NWL Primary care

cancer Board to benefit from collaborative work

with CCGs and partners to support improve

screening rate. Series of workshops against

cancer strategic objective planned in January 2020

at Feltham locality. Promotional material (i.e.

cancer early detection /screening booklet) will be

developed after the Feltham event in Jan 2020.

LBH Public Health contributed £10,000 towards the

screening promotion or training in 19/20 and also to

produce promotional material.

19-12 Reduce proportion of patients diagnosed

following an A&E attendance

Apr-19 Mar-20 28/11/2019 Anindita

Debnath

Dr.

Richard

Baxter

G CCG has successfully secured 2019/20 funding for

Macmillan Cancer GP role, who will support primary

care education agenda to improve cancer diagnosis at

primary care. CCG promoting uptake by practices and

networks of the national cancer diagnosis audit. Two

Hounslow PCNs qualified for receiving funding for the

NCDA.

CCG has commissioned FIT test to diagnose bowel

cancer at primary cancer. June data shows out of total

42 FIT tests requested by Hounslow GPs, 12% referrals

were indicated – suggesting an opportunity for early

diagnosis of bowel cancer.

CCG also informed Hounslow GPs about Acute

Diagnostic Oncology Clinic at Chelwest. The clinic is for

investigating Vague Symptoms to rule out any cancer.

C the Signs is a multi-platform tool for all healthcare

professionals to support early identification of patients at

risk of cancer. Hounslow CCG is one of the 4 NWL

CCGs who is successful in a funding application

process to pilot CtheSigns at primary care. The funding

is available for one year, the project is due to go live in

Feb 2020.

A This objective will be measured as a reduction

in proportion of patients diagnosed with cancer

following A&E attendances. There is, a lag to

the data which is published on a national level.

Local data demonstrates that there has been a

reduction in the total number of admission

episodes with an emergency admission

method; however this data is caveated because

patients already on the National Cancer

Register cannot be excluded in the local

dataset. The highest number of episodes in the

local dataset appears to come from Brain &

CNS, GI Upper and Lower, and Haematological.

CCG is working closely with Chelsea and

Westminster Trust cancer team to identify ways to

reduce A&E presentation of cancer (CCG Clinical

Board presentation by Trust on 28th May)

CCG communication and engagement team

developed a patient/public engagement plan for

2019/20 to support improving cancer screening

rate at Hounslow. Cancer specific HEAT

presentation will be done on 4th Dec to support

primary care education about cancer diagnosis.

Strategic Objectives (vi)

7

Strategic

Objective

Code


from:

Delivery

by:

Updated

(date)

Updated

(name)


19-13 Participate in NWL outpatients programme

including implementing eRS across

Hounslow referrers

Mar-20 01/12/2019 Max

Carter

A Testing of the telederm app is nearing completion and

the app is now being rolled out in Hounslow with a plan

for remaining CCGs. The full business case for telederm

is currently being updated and includes the purchase of

dermatoscopes.

Adoption of A&G remains challenging in some areas with

sustainability concerns being raised by providers.

Wave 3 workshops completed.

Agreed process for:

* Return of referrals without referral letters (routine

and 2ww - reflecting NHSD advice)

* Returned referral disagreement process

* Long term management of pathways (6 monthly

review)

A Triage for 4 of 5 wave one specialities is

ongoing - self reported data and ERS sourced

data is showing increasing return rates. 100%

triage is being achieved across Wave 1 with

exceptions in Rheumatology at CW.

Ongoing teleconferences and meetings with

Providers and Commissioners are being held to

share learning and understand risks to progress

Clinical Leadership has been identified for Wave 3

workstreams and dates for workshops confirmed

A clinical engagement event for Dermatology was

convened- with 15 attendees.

Strategic Objective Measures

8

19-5: Urgent Care Centre attendance

19-6: Primary Care Extended Hours Utilization

19-9: NEL QIPP performance

19-11: Cancer screening uptake

19-12: Cancer emergency presentations

19-5: Urgent Care Centre Attendance

9

The graph and table to the right

show the number of UCC

attendances at the West Middlesex

Hospital UCC as of September

(Month 6). This demonstrates that

there has been a year on year

increase in activity with the highest

activity being recorded in 2019/20.

By making primary care

appointments available through

online consultation and promoting

the use of extended hours GP

appointments, the expectation was

that UCC activity would remain static

from the 2018/19 baseline.

Hounslow CCG

Month 2014-15 2015-16 2016-17 2017-18 2018-19 2019-20

April 4,924 4,556 4,785 4,896 5,496 5,988

May 5,072 4,764 5,390 5,342 5,901 6,275

June 4,846 4,839 4,712 4,997 5,422 5,539

July 4,702 4,745 4,778 5,619 5,424 6,151

August 3,876 4,314 4,174 4,697 4,703 5,198

September 4,322 4,361 4,615 4,914 5,031 4,438

October 4,444 4,550 4,989 5,241 5,202

November 4,232 4,703 4,958 5,383 5,382

December 5,320 4,739 5,079 5,831 5,985

January 4,371 5,045 4,860 6,050 6,045

February 4,189 5,129 4,410 5,254 5,999

March 4,967 5,756 5,211 6,135 6,259

Total 55,265 57,501 57,961 64,359 66,849 33,589

Year on Year increase 4% 1% 11% 4% 0%

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UCC Attendances 2014-15 2015-16 2016-17 2017-18

2018-19 2019-20 average

19-6: Primary Care Extended Hours Utilization

10

The graphs to the right demonstrate that proportion of Extended Hours appointments used has increased by more than 30% since April 2018 (M1 2018/19). The utilisation of appointments improved in July 2019 (M4 2019/20) and has remained relatively stable since. The proportion of Did Not Attend (DNA) appointments ranges from 7-11% in the last 12 months. There have been on average 4,300 Extended Hours appointments made available per month. The number of available but unused appointments has improved in the last quarter.

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Extended Hours Appointments - Actual Utilization

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19-9: NEL QIPP performance

11

The graphs below show the planned and actual activity and cost reductions for all QIPP

projects affecting Hounslow. The figures were reported in the Month 8 reporting period.

Activity and cost increases must be recovered by projects in-year to demonstrate any net

savings. Some recovery is anticipated by year-end, but forecast for this financial year is that

the planned reductions will broadly be missed.

The top 3 projects forecast to deliver reductions in avoidable NEL admissions are: ICRS in

ED; High Intensity Users; NWL Diabetes.

0102030405060708090

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M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

Month 8 Report: Year to date Month 8 Report:Forecast

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Reduction in Avoidable Non-Elective Admissions

Series1 Actual Activity Reductions

19-11: Breast Cancer Screening Uptake

12

The graph below shows the proportion of eligible patients which have been screened for Bowel Cancer in the previous 42 months. QOF eligibility criteria changed in Month 1 of 2019/20 which reduced the proportion of patients who were recorded as having been screened. Since then there has been a positive increase in the rate of screening, just short of the national benchmark of 70%.

40%

45%

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M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M1 M2 M3 M4 M5 M6 M7

2018/19 2019/20

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f El

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atie

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nth

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Breast Cancer Screening Uptake

Hounslow Patients National Benchmark

19-11: Cervical Cancer Screening Uptake

13

The graph below shows the proportion of eligible patients which have had

Cervical Cancer screening in the previous 5 years. QOF eligibility criteria changed

in Month 1 of 2019/20 and this change was implemented by Month 2. As a result

of the new criteria, performance has worsened compared to 2019/20 but has

improved only slightly each reporting month. The national benchmark of 80% has

not yet been achieved.

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Cervical Cancer Screening Uptake


19-11: Bowel Cancer Screening Uptake

14

The graph below shows the proportion of eligible patients which have been screened for Bowel Cancer in the previous 2 years. In Month 1 2019/20, QOF eligibility criteria changed which marginally reduced the proportion of patients who recorded as having been screened. A gradual, steady increase in performance has been reported since the start of 2019/20. The national benchmark of 60% has not yet been achieved.

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Bowel Cancer Screening Uptake


19-12: Cancer emergency presentations – National Data

15

The graph below shows the proportion of malignant cancers which present as an

emergency. The data shows that a sharp increase of emergency presentations in Q1

2018/19 has steadily improved in Q3 and Q4. This performance indicator is

published quarterly by the National Cancer Intelligence Network and data is

available 9 months behind actual activity due to cross-referencing HCIN data with

the National Cancer Register.

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Cancer: Emergency Presentations

Hounslow Quarterly Hounslow 1 Year Average England 1 Year Average

hounslow ccg strategic objectives report 2019/20 · rag progress update rag tangible outputs...

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