Part of NHS South East London: a partnership of Primary Care Trusts in Bromley, Greenwich, Lambeth, Lewisham, Southwark and BexleyCare Trust

Chair: Caroline Hewitt CCG Chair: Dr Hany Wahba Interim Chief Executive: Christina Craig

25 September 2012

Greenwich Clinical Commissioning Group

Integrated Plan2012/13Improving Health

1

Contents Page

Chair’s Foreword 5

Section 1 Greenwich 6

1.1. Introducing Greenwich 6

1.2. The Greenwich Context: Joint Strategic Needs Assessment 7

1.3. Partnership Working 13

1.4. Introducing NHS Greenwich CCG 19

1.4.1 The Greenwich Story 19

1.4.2 Current Challenges: South London Healthcare Trust 20

1.4.3 NHS Greenwich CCG Governance 21

Section 2 Improving Health 24

2.1 NHS Greenwich CCG Strategic Overview 24

Table 1 Key Health Challenges across Greenwich & South East London 27

Table 2 Outcomes & Measures to be achieved in tackling the 28

Strategic Priorities

2.2 NHS Greenwich CCG Strategic Priorities 32

Table 3 High level plans for the achievement of strategic priorities 33

2.3 Meeting our responsibilities in 2012/13 43

2.3.1 Performance Management 43

2.3.2 2012/13 Performance Priorities 43

2.4 Compliance with the National Operating Framework 46

2.5 Enabling Actions and Additional Service Delivery 47

2.5.1 Primary Care Engagement 47

2.5.2 Eltham Community Hospital 49

2.5.3 Heart of East Greenwich 51

2

2.5.4 CCG Organisational Development Plan 52

2.5.5 Sustainable Commissioning 52

Section 3 Financial Sustainability and the Case for Change 54

3.1 Financial Overview 55

3.2 Financial Position 2012/13 55

3.3 Financial Assumptions 56

3.3.1 2012/13 – 2014/15 Assumptions 56

3.3.2 2013/14 Allocation Assumptions 59

3.4 QIPP 60

3.5 Summary Income and Expenditure Plan 62

3.6 Investment Proposals and Cost Pressures 63

3.7 Ensuring Financial Delivery through Transition 64

Section 4 Delivery 65

4.1 Implementing the Plan and Commissioning Intentions for 2013/14 65

Table 4 Improving & delivering QIPP in 2012/13 and Commissioning 65

Intentions for 2013/14

4.2 What are we proud of? Success stories in delivering the Plan 70

4.3 Managing Provider Performance 76

Appendix 1 NHS Greenwich CCG Governance Structures and Responsibilities

Appendix 2 Table Demonstrating Compliance with National Operating Framework

Appendix 3 QIPP Programme Summary for 2012/13 Month 5

Appendix 4 Aspirations for Community Based Care

Appendix 5 More detailed table of Greenwich Commissioning Intentions 2013/14

Appendix 6 Managing Risk

3

Evidence for authorisation

Domain

ReferenceIntegrated

Plan Section

Document

Page Number

Additional

Comments

2012-13 integrated plan and draft commissioning intentions for

2013-1414Governance, decision-making and

planning arrangements where quality is a

priority and clinical views are foremost.

1.1 1.4.3, 2.1 p.21-26

CCG can demonstrate it has taken steps to

communicate its vision and priorities to

stakeholders, patients and the public.

1.4.1 1.3 p.13-18

CCG has mapped and analysed constituent

communities and groups.

2.1.1 1.2 p.7-12

CCG integrated plan aligns with JHWS(s)

and enables integrated commissioning,

depending on local timeframes.

2.1.2 2.1, 2.2 p.24-31

p.33-42

Systems in place to convert insights about

patient choice/s in practice consultations

into plans and decision-making.

2.4.1 1.4.3, 2.5.1 p.21-23

p.47-49

CCG has a clear and credible integrated

plan, which includes an operating plan for

2012-13, draft commissioning intentions

for 2013-14 and a high-level strategic plan

until 2014-15.

CCG has detailed financial plan that

delivers financial balance and any other

requirements set by the NHSCB and is

aligned with the commissioning plan.

QIPP is integrated within all plans. Clear

explanation of any changes to existing

QIPP plans.

CCG plan sets out how it aligns with

national frameworks and strategies,

including the NHS Outcomes Framework.

3.1.1 2.2, 2.3.2, 2.4,

4.1

3.5

3.4

2.1

2.4 & 3.4

p.32-42, p.43,

p.46 & Appendix

2, p.65-69 &

App.5

p.62

p.60 & Appendix 3

p.24-31, p.46 &

App.2, p.60

CCG can demonstrate that the process for

developing its plans and priorities was

inclusive and transparent.

3.1.2 2.1, 1.4.3, 1.3 p. 24-31, p.21-23,

p.13-18

4

Plans reflect JSNA, stakeholder

engagement, and evidence/data analysis.

3.1.3 1.3, 1.2 p.13-18, p.7-12

Where the area covered by the CCG is not

on track to meet the plan for 2012-13,

there is a clear and time-limited resolution

path to recover.

3.1.4 2.3, 2.3.2, 2.4,

2.2

p.43, p.46, p.32-

42

CCG has arrangements in place to

collaborate with neighbouring CCGs in

areas such as lead commissioning where

there is more than one CCG contracting

3.3 1.3 p.13-18

Health inequalities issues identified and

addressed in integrated plan.

4.2.3 1.2, 2.2 p.7-12, p.32-42

Where the need for integrated

commissioning has been identified by the

health and wellbeing board and in the

JHWS(s), CCGs are collaborating with the

local authority(ties) to develop shared

plans.

5.3 1.3 p.13-18

List of collaborative commissioning arrangements, joint commissioning draft

agreements or plans, including pooled budgets, Section 75 agreements where

appropriate

Plans clearly demonstrate where and how

the CCG is working with other CCGs to

meet QIPP, and can demonstrate that

stakeholders are aware of and understand

CCG priorities.

3.1.2 1.3 p.13-18

5

Chair’s Foreword: Clinically-led Commissioning in Greenwich

Being a GP commissioner in Greenwich Clinical Commissioning Group is a very exciting challenge

that allows us to transfer our frontline clinical experience into key commissioning decisions. This

means that what we learn from our day to day contact with our patients can then influence the

decisions we need to make to provide the best care for all the people in Greenwich. We can apply

our clinical knowledge to the data and information we have about the needs of patients and the

performance of our providers. We can ask questions and identify trends which help us to predict and

prevent difficulties arising in service provision. At the same time as utilising our clinical skills we have

the CCG support structure that will provide the professional background and knowledge that GPs do

not have. We have the right team in place and the proper governance, clear accountability,

partnership working and engagement with the public that means we are not only ready for

authorisation, but fully prepared for the new clinical commissioning world thereafter.

As a membership organisation we are well placed to engage the GPs in Greenwich in improving

services for our population both in terms of their management of their patients within general

practice, as well as through their role in demand management and referral. We have GP syndicates

in place that meet regularly to undertake peer review of patient care. We also have in place an

effective Commissioning Incentive Scheme which encourages and rewards high quality practice

which supports and enables the goals of NHS Greenwich CCG.

We are continuing to bring care out of hospital and closer to where patients live in the community.

We are identifying vulnerable people who are likely to fall ill and preventing crises before they

happen, thereby avoiding unnecessary hospital admissions for many. We started last year with the

fifteenth lowest rate in the country for unplanned admissions for conditions amenable to

ambulatory care i.e. conditions that could be better treated in the community and by March 2012

the results for ‘Better Care, Better Value’ Indicators showed that Greenwich is now the best in the

country.

Greenwich as a commissioning organisation has an excellent record of financial management over

the last 10 years, achieving all of its financial obligations at the same time as delivering high quality

care. With the GPs at the heart of our decision making we can make even better informed decisions,

making sure every penny will be spent in the best way to maximise healthcare for the people of

Greenwich.

Our strategy will be to continue to ensure we have the best configuration of services for our

population, with even more out of hospital care and more integrated care delivered in partnership

with the Royal Borough of Greenwich. In terms of hospital services our main provider, South London

Healthcare Trust, is facing a significant financial challenge and is currently being run by a special

administrator. A new strategy for South East London will be completed in October and we are

working with colleagues across south east London to secure the best possible outcomes for our

population.

This integrated plan outlines our commissioning expectations beyond authorisation whilst being a

key tool in our authorisation armoury in the meantime.

Dr Hany Wahba, Chair, NHS Greenwich CCG, September 2012

6

Section 1: Greenwich

1.1 Introducing Greenwich

Greenwich has a population of approximately 241,000 residents, according to the 2010 Greater

London Authority population projections for 2011. Greenwich is predicted to see the largest increase

in population of any South East London borough, with growth over the next five years of 13%.

Greenwich is also projected to have the biggest increase in births of any South East London borough,

with an 11% increase in the period 2011 to 2016. Whilst Greenwich contains areas of relative

affluence, it is mainly a borough with significant deprivation. Measured against the Indices of

Multiple Deprivation, the most common tool for examining deprivation levels in England, Greenwich

is rated as the 19th most deprived local authority out of 326 in England.

South London Healthcare Trust (SLHT) is the main provider of hospital services to Greenwich

residents, and also to the populations of Bexley and Bromley. In June this year SLHT was the first

trust to be put into the Regime for Unsustainable NHS Providers following the appointment of a

Special Administrator. There is now a process underway to secure clinically and financially

sustainable services for the long term for the people of south east London.

Greenwich residents are also served by other acute trusts across south east London. Guys and St.

Thomas’ NHS Foundation Trust (GST) primarily serves the population of Lambeth, Lewisham and

Southwark but activity does flow across the whole of south east London and it provides specialist

services for patients from much further afield.

King’s College Hospital NHS Foundation Trust (KCH) is one of London’s largest teaching hospitals,

providing a full range of general hospital services for over 700,000 people in the boroughs of

Lambeth, Lewisham and Southwark and providing specialised services that are available to patients

across a wider area.

Lewisham Healthcare NHS Trust, located in the centre of Lewisham, offers medical, surgical and

emergency services for the local community and specialised services for south east London and

beyond. It is in the process of applying for Foundation Trust status.

Oxleas NHS Foundation Trust provides a wide range of health and social care services and specialises

in caring for people with mental health problems and learning disabilities. It is the main provider of

mental health and adult learning disabilities services for Greenwich as well as forensic mental health

services. It is also the provider of community health services for Greenwich patients. Additionally,

Greenwich residents are served by South London and Maudsley Foundation Trust (SLaM) which

provides the most extensive portfolio of specialist mental health and substance misuse services in

the UK.

In South East London we have one of only five Academic Health Sciences Centres (AHSC) in England.

King’s Health Partners (KHP) is a partnership between King’s College London, Guys and St. Thomas’

7

Foundation Trust, Kings College Hospital Foundation Trust and South London and Maudsley NHS

Foundation Trust.

In Greenwich there are 45 General Practices made up of Personal Medical Services (39), General

Medical Services (3) and Alternative Provider Medical Services (3) contracts.

1.2 The Greenwich Context: Joint Strategic Needs Assessment

Greenwich faces some major healthcare challenges with significant health inequalities existing within the

borough. Overall, life expectancy is worse than the England average. Men living in the least deprived wards of

Greenwich can expect to live for an average of 7 years longer than those in the most deprived wards and for

women the difference is nearly 5 years.1 NHS Greenwich is one of 13 PCTs identified by the National Health

Inequalities Support Team that account for 40% of the national gap in life expectancy.

Population Size and Growth

The 2010 Greater London Authority population projections indicate there were approximately

241,400 residents in Greenwich in 2011. A large percentage of these residents (89.9%) were

registered with Greenwich GPs, meaning that 10.1% of Greenwich residents have a GP outside the

borough. Of the total residents living in Greenwich, 52% are female and 48% are male. In 2011 there

were approximately 275,000 people registered with Greenwich GP's. 260,385 (95%) of them are

Greenwich residents. 5% of Greenwich registered population reside in neighbouring boroughs.

Similarly some Greenwich residents (10.1%) will be registered with GPs elsewhere, most commonly

in Bexley and Lewisham. It may also be that this figure includes some "ghost patients" –patients who

have moved away or died without the GPs register being updated. Systems are in place to ensure

that GP's lists are updated when someone dies but in a very mobile population it is harder to track

when people move out of the borough.

Greenwich Resident Population Pyramid, GLA estimated resident + GP registered resident

population, 2011

Sources:Exeter GP Registrations Feb 2011, GLA, 2010 Projections for 2011

8

Diversity – Ethnicity

The GLA population projections indicate that the largest ethnic group in Greenwich is White (66%),

followed by Black and Minority Ethnic (BME) (34%). These proportions are in keeping with those for

London. The largest BME group in Greenwich is from Africa. This sub-group has increased to 13.2%

in 2011 (an increase of 106% since 2001). This means that in Greenwich there is a sizeable group in

the population who are new to the area and to the country. The next largest BME group is the Indian

population (4.7%) (see figure 1 below). This is the largest Asian population in the South East London

health sector.

Black Caribbean and Black African population are more prone to problems such as hypertension and

diabetes. People from Asian communities are high risk of diabetes and heart disease. Patterns of

risk factors such as diet and exercise and beliefs about disease may differ between different

communities.

Figure 1 Breakdown of population by main ethnic groups, Greenwich, 2011

Source: GLA 2010 Round Ethnic Group Population Projections

9

Diversity – Deprivation and Wealth

Greenwich contains the breadth and extremes of deprivation and wealth with a large percentage of

the population being amongst the most deprived fifth in the country while other parts of Greenwich

contain those who are in the most affluent fifth of the population in England. However, Greenwich is

mainly a deprived borough. The Indices of Multiple Deprivation, the most common tool for

examining deprivation levels in England, scores and ranks areas across 15 domains. On the ‘rank of

average rank' approach, where the average rank for the borough across all 15 domains is calculated,

and boroughs are then ordered according to this score, Greenwich is the 19th most deprived local

authority (LA) in England (out of 326 Local Authorities) in 2010. Alternatively it is possible to order

the boroughs by average score across the domains, in which case Greenwich has a score of 31.94

and comes out as the 28th most deprived of the 326. Areas of greater deprivation are located mainly

in the north and east of the borough but there are areas of higher deprivation across the whole of

Greenwich (Map 1). There is a well-established link between deprivation and ill health with

increased incidence and prevalence of disease amongst most deprived population groups with

increased risk of early death and shortened life expectancy.

Map 1: Greenwich Lower Super Output Area (LSOA) by deprivation quintile, 2010

Source: Indices of Multiple Deprivation 2010

10

Life Expectancy

Life expectancy has increased for both men and women according to the latest official set of figures

for 2007-09 (see figure 4). Life expectancy is also increasing in England as a whole and these figures

show that the life expectancy gap between women in Greenwich compared to England is now 0.4

years, a slight increase on the previous year although still part of an overall reduction in the gap over

the past four years. For men the gap increased each year from 2002-04 to 2005-07, and although

there has been some reduction in the gap from 2005-07 to 2007-09 the difference remains

significant and inroads small (see figure 3).

Figure 2. Life Expectancy at birth Greenwich and England 1996-1998 and 2007-2009

Index of Inequality

There are major health inequalities in life expectancy and healthy life expectancy (life lived without

disability or illness) with those living in the most deprived 20% of the borough experiencing

significantly shorter lives and more illness and disability. The Slope Index of Inequality (SII) can also

be used to reflect the socioeconomic dimension to inequalities in health. The SII can be interpreted

as the difference in life expectancy in years between the best-off and worst-off within a borough.

The SII results show the most deprived areas within a borough have lower life expectancy than the

least deprived areas. The extent of this inequality (as indicated by the value of the SII) differs greatly

between London boroughs. A low SII value indicates that there is a small gap in life expectancy

between the most and least deprived areas within a borough, while a high value indicates a greater

gap in life expectancy1.

Greenwich has very high inequality levels for both males and females, being above the London,

England and Deprivation Comparator average2 for 2005-09. Whilst data is not yet available for

comparison for 2006-10, local data for Greenwich show that health inequalities for males are

declining sharply whilst increasing rapidly for females.

1World Class Commissioning Assurance Framework, Health Inequalities Indicator: Analysis of the

Slope Index of Inequalities in Life Expectancy in London PCT’s, London Health Observatory, January2010.2

Deprivation comparators for Greenwich. Based on the rank of average ranks of IMD scores.Boroughs with similar deprivation to Greenwich are Haringey, Brent, Lewisham, Lambeth, Southwark,Hammersmith and Fulham.

11

Figure 3: Slope Index of Inequality (SII): Males 2001-05 to 2006-10

Source: NHS Greenwich, Public Health Intelligence

Figure 4: Slope Index of Inequality (SII): Females 2001-05 to 2006-10

Source: NHS Greenwich, Public Health Intelligence

Premature mortality

An important place to start is to focus on premature deaths i.e. deaths under the age of 75 years,

where there is potential for action that will prolong life especially through better management of

long term conditions (LTCs). While there is a trend for improvement there remains more to be

achieved for both men and women in Greenwich.

12

Figure 5 South East London Premature Mortality by Borough

Learning from local differences in health outcomes

As part of the overarching approach to QIPP in South East London, a “Staying Healthy” plan has beenimplemented over the last couple of years to support cluster-wide shared approaches andmonitoring of improvements in key areas of public health importance. The areas the planconcentrates on, linked to borough and cluster-wide JSNA priorities, are as follows:

Tuberculosis

Childhood Immunisations

Cancer Screening

Smoking Cessation

NHS Health Checks Programme Implementation

Obesity

Sexual Health

Through the Directors of Public Health (DPH) regular meetings in South East London, the plan hasmonitored and action to bring about improvements in performance considered. The group reviews aset of KPIs linked to performance in all of these areas which are updated on a quarterly basis. A DPHis identified as the lead for each of the areas listed above; their role is to review performance acrossthe cluster, support boroughs to share good practice and make recommendations aboutimprovement actions to be considered.

Where there are concerns about performance against these key priorities and targets are not ontrack to be delivered, action plans are escalated to the full Cluster Board meeting to provideassurance that arrangements are in place to make the necessary improvements.

With the move of Public Health to the local authority, local authority health scrutiny will play a rolein the governance of the system, whilst at the same time it will be for the CCG to hold the publichealth department of the Royal Borough of Greenwich to account for delivery of the Memorandumof Understanding on public health via the CCG governing body. The CCG will also have a right to askfor debate of these issues at the Health and Well Being Board.

13

1.3 Partnership Working

Engaging with Patients and the Public

In February and March 2012 NHS Greenwich CCG undertook a ‘Help Us Help You’ survey. The surveywas part of a wider consultation exercise around Greenwich Clinical Commissioning Group’sCommissioning Strategy Plan. The aim of the survey was to gain feedback from the general publicon the initiatives put forward in the Commissioning Strategy Plan. Participants were recruitedthrough various routes including the NHS Greenwich Health Panel, Twitter, Greenwich Council E-Panel’, Greenwich LINk and NHS Greenwich Have Your Say website.

The key findings are being taken into consideration in planning processes at Greenwich, and are

summarised below:

Priority Key themes

Improve services for people(children and adults) withlong term conditions

Agreement that services need to be better co-ordinated

Increase in the number of support groups, initiatives andprogrammes for self-management

Staff training on long-term conditions

Financial advice for people with long-term conditions

Provide more opportunityfor care in the community

Concern that waiting times for GP appointments would increase

Services should be physically and geographically accessible

Conflict with current over-reliance on A&E services

Co-ordinate the provision ofurgent and out of hourscare

Lack of information for residents and professionals

Mixed reports on quality of out of hours services

Over-reliance by professionals on A&E

Use of A&E due to lack of alternatives

Improve services for people(children and adults) withmental health problems

Strong preference for preventative and early interventioninitiatives

Concern over opening of Community Crisis House

CAMHS overburdened and lack of information on alternativeservices for support

Improve children’s services CAMHS and paediatric unit in QE in need of review

Concerns about quality at the special baby care unit

Early intervention and initiatives with schools

Improve the quality of endof life care

Increase and monitor staff training in terms of skills and attitudes

More information available on services and options

Service to be based around the needs of the individual

Additional priorities: toincrease quality

Increase and monitor staff training in terms of skills and attitudes

Better and more consistent information

Modernise communication methods

Waiting times are too long

Maternity services need to be improved

Bi-lingual health advocates and closer working relationships withlocal third sector organisations

Additional priorities:financial efficiencies

Modernise communication methods

Prioritise finance on ‘prevention rather than cure’

Agreement on improvements should be made to the waymedicines are prescribed

Introduce paid-for services in the NHS

14

The Royal Borough of GreenwichIn Greenwich we recognise the importance of putting in place strong joint commissioningarrangements with the local authority. Greenwich PCT and the Royal Borough of Greenwich have ahistory of working in partnership to meet their responsibilities for carrying out Joint Strategic NeedsAssessment (JSNA) and using high quality local and national data on patterns of health and disease.This joint approach will continue and be strengthened as NHS Greenwich CCG develops. The JSNAand other key data sources inform local plans which in turn inform commissioning decisions.Through the Health and Well Being Board and well-developed joint commissioning arrangementsbetween NHS Greenwich CCG and the Royal Borough of Greenwich, opportunities to integrate keyservices are considered across health and social care sectors, with integrated governance andmanagement a shared philosophy and common objective.

Using a joint commissioning approach leads to improved integration and delivery of front line

services. Joint Commissioning tends to be used to support people who need both health and local

authority service (social care/housing) support. To underpin this approach a number of joint

commissioning posts have been developed to support delivery and monitoring of commissioning

plans. Typically the services commissioned jointly with the local authority are:

Substance Misuse (Drugs & Alcohol)

Children & Young People Services and CAMHS (Children and Adolescent Mental HealthServices)

Adult Mental Health Services

Adult Physical and Sensory Disability Services

Learning Disabilities (Greenwich Council Lead Commissioners)

Older People and Dementia

Third Sector Services

Carers Support

Hospital & Community assessment teams and intermediate care services

Community Equipment and hospital stores

All these services are commissioned with the involvement of service users and carers.

There are benefits from undertaking joint commissioning. These are to:

Secure the best services

Ensure services represent good value for money

Ensure the greatest impact for service users

Ensure equity of access for all service users

London Wide Joint Commissioning

To ensure that our patients have access to high quality specialised care, such as neonatal intensivecare, complex arterial surgery and rare cancers, we work closely with the London SpecialisedCommissioning Group, clinical networks such as the cancer and the cardiac and stroke networks andLondon Health Programmes. Our clinical leaders are involved in developing cases for change, settingpriorities and in ensuring that the interface between local services and specialised services isdesigned and operates effectively. A separate commissioning strategy for London is published by theLondon Specialised Commissioning Group. As the NHS Commissioning Board assumes responsibility

15

for specialised commissioning and primary care commissioning the CCG will seek to engageconstructively with these agendas.

Joint Working across South East London and Commissioning SupportNHS Greenwich CCG has subscribed to collaborative working arrangements across all south eastLondon CCGs that are aligned with the common set of commissioning functions purchased fromSouth London Commissioning Support Unit (SLCSU). The diagram below provides, at high-level, theareas where CCGs wish to collaborate and how this relates to local and SLCSU activities. The modeloutlines initial priority areas for CCG collaboration, other areas where CCGs may wish to collaboratemay be added as new clinical commissioning arrangements develop.

Accountable CCG Governing Bodies

Area CCG Collaboration CCG Local SLCSU

AcuteLead Commissioner

(acting as host)Lead Contracting team

Multi-disciplinary contract

team

Non Acute

‘Common Standards, Local

Delivery’ – shared

programmes and common

approach to contracting

Local Commissioning and

redesignNone

Strategy

Strategic development -

(Six Borough / LSL and

BBG)

Local leadership of:

Integrated Plan,

Commissioning Intentions

and QIPP

Health intelligence to

support decision making

Risk

South east London Risk

Sharing agreement

Local CCG arrangements

within contracts and with

local authority

Support to derive risk

assessment / decision-

making

Other areasCommon Assurance

Committees

CCG Governance

Structures

Delivery of common

policies and reporting (e.g.

IFRs and Integrated

Performance reporting)

Key: Within CCGs Within SLCSU

The CCG also recognises that it will be necessary to collaborate to manage relationships with boththe National Commissioning Board (NCB) and the SLCSU. Our CSG, supported by the South EastLondon Chief Officers Group (COG), provides an effective forum to provide coherent and consistentinvolvement in the LCCC where each CCG will also be represented. The CCGs have elected a lead CCGChair (NHS Lambeth CCG) for this area.

NHS Greenwich CCG has been working together with the South London Commissioning SupportService (SELCSU) to develop arrangements for commissioning support during 2012/2013, and postauthorisation. In order to support CCGs as they prepare for authorisation, and to support thedevelopment of the CSU in such a way as to meet its own authorisation requirements, aMemorandum of Understanding (MoU) describes the proposed offer of the CSU to meet bothorganisations’ needs at this stage. It also recognises a shared commitment to co-develop the detailrequired to conclude a robust Service Level Agreement (SLA) by October 2012. The MoU andsubsequent SLA will govern the relationship between the two organisations, as they work in shadowform until March 2013, and from April 2013 onwards.

16

In order for the CCG and the CSU to demonstrate that sustainable plans for commissioning supportare in place to support authorisation, the parties have agreed to a four year partnership (transitionyear plus three years, with the possibility of further extension) that will be further described anddeveloped during 2012/13 and reassessed on an annual basis, subject to the terminationarrangements described in this document. Greenwich has opted for the Core Service offering,comprising:

Acute contract management (including quality)

Individual Funding Requests (IFR) management

Provider Performance Management

Advice & Support on Clinical Procurement

Performance and activity reporting and analysis

Financial Governance & Control, Counter Fraud

Financial Management and Planning

Estates and health and safety

Human Resources and organisational development

Purchasing (non-clinical)

ICT Support

Communications and Engagement

Joint Working with Bexley and Bromley CCGs

Bexley, Bromley and Greenwich work together to actively manage supplier relationships and clinicalengagement. They are focused on identifying opportunities to jointly work with providers to improveservices for the population, promote innovation, quality and cost effectiveness. For example, Bexley,Bromley and Greenwich are acting together to negotiate and monitor contracts with acute careproviders. Overlaps between Bexley and Greenwich QIPP initiatives which impact acute contractinghave been identified and incorporated in contracts. A specific concordat/proposed strategicframework that looks to the next three to five year planning cycle has been put in place with SouthLondon Healthcare Trust, and a Bexley, Bromley and Greenwich Clinical Contract Group isresponsible for negotiating the detail.

Other examples of working with providers include quality monitoring groups for South London

Healthcare Trust and Oxleas Mental Health. For instance, clinical leads across Bexley Bromley and

Greenwich are meeting with South London Healthcare Trust’s Orthopaedic and Rheumatology

Directorate to monitor performance and explore joint working arrangements across musculoskeletal

services.

The Bexley, Bromley and Greenwich Clinical Strategy Group has been established to drive forward

collaborative working; monitor, challenge and report progress of joint work streams; and identify

further areas which would benefit from a joint approach. This group is chaired by theCCG Chair of

Bromley, and membership comprises the CCG Chairs of Bexley Clinical Commissioning Cabinet and of

Greenwich Health, as well as the Managing Directors (Accountable Officers) of Bexley, Bromley and

Greenwich CCG’s and the Bexley, Bromley and Greenwich Programme Director.

A Clinical Strategy Commissioner and Provider Group have been established to facilitate

collaboration with providers. A Bexley, Bromley and Greenwich Stakeholder Reference Group has

also been established, reporting to the Bexley, Bromley and Greenwich Clinical Strategy Group.

17

Membership includes representatives from Bexley, Bromley and NHS Greenwich CCGs, LINks,

Voluntary and Community Groups, NHS Trusts and other providers. The Bexley, Bromley and

Greenwich Stakeholder Reference Group does not replace local stakeholder engagement and it does

not engage directly with patients and the public. Its role is to challenge and provide assurance over

the impact of proposed service changes that cut across the boroughs on engagement with the public

and patients, including local authorities and the development and support of patient choice.

The Shared Standards Programme Board has been established to provide strategic direction,

challenge and governance to the work of the team. This Board will work under the governance

framework established for the Bexley, Bromley and Greenwich Clinical Strategy Group, with overall

accountability to the Bexley, Bromley and Greenwich Clinical Commissioning Groups for achieving its

objectives within the timelines. The Shared Standards Programme has established its own dedicated

BBG Programme Management Office (PMO) which will work in close alignment with the Clinical

Transformation Implementation Programme PMO to ensure that dependencies are managed and

monitored accordingly.

The Programme has inherited 5 projects where BBG CCGs have been working together or sharing

their learning with one another since the summer of 2011. These work streams are being brought

into these new programme management structures and will be reported through the BBG

Programme Management Office. These work streams are the Elderly Care, Cardiology,

Musculoskeletal, Urgent Care and Diabetes pathways. An early step in implementing these new

governance arrangements is to review and prioritise projects i.e. those started and new proposals to

ensure that the BBG PMO and project management capacity focuses on those work streams likely to

deliver the greatest outcomes in the shortest time. This work will be complemented by the out of

hospital work streams linked to the consultation on the future of SLHT and the above approval

process by-passed. The overall Governance architecture is described in the diagram below:

18

Greenwich Partnership Working Case Study

NHS Greenwich CCG has forged such an effective, innovative relationship with the Royal Borough ofGreenwich, that it has been shortlisted for the Secretary of Health Award for Health Service Journalin recognition of strong examples of joint working between CCGs and local authorities.

The CCG regularly meets with representatives from the local authority and has begun to invite morestakeholders to these meetings, including patients’ representatives, voluntary sector organisations,community health providers and the acute provider to discuss the health needs for Greenwich.

NHS Greenwich CCG has also formed a close working relationship with the Bexley, Bromley andGreenwich clinical strategy group to discuss where there can be integrated services for cardiology.Greenwich has also held discussions with Lambeth, Southwark, Lewisham CCGs exploring possibleareas for joint working.

The CCG also asked a number of stakeholders including hospitals, and local authorities to undertake360 degree appraisals of the CCG services. These reviews proved extremely successful with the vastmajority of stakeholders offering positive feedback on the clinical strategy.

Patient engagement is also a priority of the CCG. Before any tender for a service, a market day isheld giving service users the opportunity to express their views. The CCG has also engaged with arange of ethnic, voluntary and age groups including the Greenwich voluntary sector heathorganisation, the black and minority ethnic health forum, and children and young people’s groupsto understand how various patients feel about the services on offer, and what improvements can bemade.

The CCG is working to address the historic health inequalities that exist within the borough, and isexploring how to change the tendering process to reflect the needs of the population, ensuring thaturgent care centres and GP services are situated in areas where the need is greatest. Healthoutreach programmes aimed at engaging with hard-to-reach groups have also been established.

The CCG has also worked with GP member practices, creating a borough wide forum for them to allattend. By working closely with GPs, the CCG is also able to increase patient engagement levels bymonitoring GP involvement with public and patients advisory groups (PPAGs).

19

1.4 Introducing NHS Greenwich CCG

1.4.1 The Greenwich Story

In 2004 The Audit Commission undertook a benchmarking exercise of average London PCT spend

against the key areas of General/Acute/A&E, Mental Illness, Prescribing, Community health,

Learning Disability, and ‘Other’. This benchmarking suggested a structural imbalance in Greenwich,

with the borough spending in excess of the London PCT average in the acute sector and an under-

utilisation of community health. The gap in the acute sector budget against commitments for

Greenwich PCT needed to be addressed. It was clear that:

Efficiency needed to be improved.

There was an overuse of hospital services

There was a need to move from fire-fighting and an over-concentration on secondarycare to an improved strategy, incorporatingo Spending more ‘upstream’ on prevention.o Spending more on intermediate care.o Changing ways of working to effect this change

Whilst the main provider, South London Healthcare Trust, embarked on a major cost reduction

programme, Greenwich commissioners began to implement the strategy of moving the delivery of

care out of hospital and as near to the patient as possible – a strategy that has delivered positive

outcomes and continues to this day.

This included a major capacity utilisation project aimed at both reducing costs and improving the

patient experience whilst also delivering the Local Delivery Plan target of achieving a reduced level

of emergency admissions. This took place on 2 levels:

Identifying the most regular vulnerable high users of service or ‘frequent flyers’ inaccordance with recent national directives and evidence-based practice. This embraced theLong Term Conditions Management focus on risk stratification and early intervention.

Looking at where the possible ‘step down’ service gaps may be with a view to assessingwhich acute sector services and further community support services could, in the future, beprovided out in the community for the same or less cost. This has meant:

o Ensuring that fewer people are admitted incorrectly by providing a better selectionof integrated service outside of hospital services, with a fully trained workforce, and

o Helping people to be, generally, ‘more healthy’ by providing more appropriate out ofhospital integrated services, restructuring of workforce and accessible facilities andproviding clear Public Health messages.

Greenwich priorities for current and future years continue to concentrate on reducing emergencydemand and developing integrated community services. Redesigning the pathways also involvesredesigning the workforce to better support the new service improvements. These new models ofintegrated care are producing innovative and exciting changes throughout the borough, resulting inbetter quality care for patients.

20

1.4.2 Current Challenges: South London Healthcare Trust (SLHT)

In June this year South London Healthcare NHS Trust was the first trust to be put into the Regime forUnsustainable NHS Providers following the appointment of a Special Administrator. Since then theTrust Special Administrator (TSA) team have been working together with clinicians, patients and thepublic, staff, partner organisations as well as others who are involved in health services in south eastLondon, including NHS Greenwich CCG, to address the significant financial challenges facing SouthLondon Healthcare NHS Trust (SLHT) in order to secure clinically and financially sustainable servicesfor the long term for the people of south east London.

Early analysis identified SLHT’s challenge as tri-fold with a need for us to collectively address all threeareas in order to reach a sustainable solution for the future. These are:

1. The need to improve operational efficiencies within SLHT2. The need to resolve the PFI challenges3. The need to better design the whole south east London health economy and the way all

health partners work together to ensure we get the best healthcare in the most sustainableway for our population.

CCGs in south east London are making planning assumptions for how they want to change the modelof care to deal with this challenge:

Shifting volumes from the acute to primary and community care

Reinvesting in primary and community care to achieve this

Reducing unit costs in community based care

By 29 October 2012, the TSA will publish a draft report outlining recommendations to securesustainable services across south east London. Consultation on the draft recommendations will befor a statutory 30 working days through November until 14 December after which the TSA willconsider the feedback and finalise his recommendations and report to the Secretary of State by 8January 2013, expecting his final decision on how health services in south east London can besustainably delivered to be made by 4 February 2013.

The Accountable Officer for NHS Greenwich CCG has been chairing one of the key Working Groupsthat is supporting the development of the TSA report. This is the Community Based Care (CBC)Working Group. The CBC working group is tasked with developing these plans by the middle ofOctober to feed into the final report on 29th October 2012.

Community Based Care is a key building block to the design of future health services in south eastLondon. It is critical that primary care is developed as the hub for multi professional service deliveryand ensure services in community based settings and hospital services are networked togetheraround patients. A number of workshops are being held to bring together community basedclinicians to further develop the vision for health services delivered outside acute hospital settings insouth east London. The workshops have examined access to good quality care, simplified patientpathways and integrated care for vulnerable groups. Early discussions have focused on recognisingthat there is a spectrum of different needs across the south east London area, and that there willneed to be clear borough-based, local delivery but delivered to shared standards designed aroundhealth outcomes.

The emerging strategy coming from the CBC working group fits well with the continuing Greenwichstrategy of moving services out of hospital, avoiding admissions and delivering care closer to thepatient, and the work to produce this Greenwich Integrated Plan has been closely linked in with thedevelopment of the TSA plan.

21

1.4.3 NHS Greenwich CCG Governance

The mission of NHS Greenwich Clinical Commissioning Group is to secure the best possible health

and care services for the population that we serve, specifically in primary care settings and in

hospitals as necessary. In doing this, we will work with patients and the wider public to develop the

services that we offer, reduce health inequalities and improve health outcomes.

In everything we do we seek to obtain the best quality we can – quality in terms of clinical

effectiveness, patient safety and patient experience.

The geographical area covered by Greenwich Clinical Commissioning Group is coterminous with theRoyal Borough of Greenwich and with Greenwich Teaching PCT. All the 45 general practices inGreenwich comprise the members of Greenwich Clinical Commissioning Group. The combinedregistered population of Greenwich’s 45 practices is circa 275,000.

Since September 2010, GPs from across Greenwich have been meeting together with colleagues atthe PCT and the Royal Borough of Greenwich to develop a vision for a Greenwich wide GP clinicalcommissioning group. The GP Commissioning Interim Steering Group was mandated to design aShadow Board structure for a Greenwich wide GP commissioning consortium, to organise anelection process for Shadow Board members and to implement the Shadow Board within anappropriate timescale. GPs in Greenwich were invited to nominate themselves for election duringDecember 2010, twelve candidates stood for the seven posts. A postal election process using theSTV voting system was administered by the Borough Returning Officer, supported by ElectoralReform Services. There were 109 valid votes cast, a turnout of 70%, and seven GPs were duly electedto form a shadow board.

Awarded ‘Pathfinder Status’, the Greenwich GP Commissioning Consortia Board (the Shadow Board)was duly established to lead the transition from PCT commissioning to GP Commissioning inGreenwich, guiding the Shadow Consortia through a two year process preparing the foundations forthe Greenwich GP Commissioning Consortia Board which is expected to come into effect from April2013. Building on a strong track record of local clinical commissioning the members of theconsortium have been able to demonstrate compliance with the three tests set by the secretary ofstate (relating to local GP leadership and support, local authority engagement and an ability tocontribute to the delivery of the local QIPP agenda) and have now worked with the NHS South EastLondon Cluster to develop the capacity and capability to assume delegated responsibility for someareas of commissioning in 2011/12, and for most aspects of commissioning since April 2012.

Members of the GP Leadership team have three key responsibilities that will allow them to operatewith increasing delegated responsibility over time:

A leadership, management and engagement role for their syndicates

A commissioning portfolio across the borough with responsibility for securing agreed QIPPplans in each area; and

A business portfolio across the borough with responsibility for ensuring the effectiveperformance management of each area of local commissioning.

22

A new organisational governance structure has been agreed, as per the diagram below, in order to:

assure the Governing Body;

to discharge delegated authority in decision making on behalf of the Governing Body; and

to effectively manage day-to-day operations on behalf of the CCG

The current leadership clinical responsibilities are as follows:

GP Lead Clinical Portfolio

Dr Hany Wahba Unplanned CareOverall Clinical Strategy

Dr Rebecca Rosen Long term ConditionsEnd of Life & Cancers

Dr Junaid Bajwa Mental Health

Dr Eugenia Lee Maternity, Women’s Health,Children

Dr Nayan Patel Planned care & utilisationreview

Syndicates

NHS Greenwich CCG has been keen to ensure that the CCG membership structures are kept simple,transparent and with as little bureaucratic process and structures as possible. As a result aGreenwich wide Forum has been established, comprising all Greenwich GPs and practices, with aflexible syndicated structure which groups together GP practices.

23

Syndicates have, therefore, been formed around ‘natural partnerships’ which share a combination ofgeographical proximity, shared or complimentary clinical skills, and/or information systems.Syndicates based on clinical areas of interest and clinical experience will influence commissioningand the provision of clinical services. Syndicates based on a geographical basis will ensure all thepopulation of Greenwich, whether registered with a GP or not, are represented. Coupled withshared information systems this ensures that the syndicates are able to take a pan Greenwichpopulation based approach and ensures best practice is shared throughout the Consortium.

One of the key functions of the Syndicates is to provide a mechanism whereby patient choice, firstexpressed in the patient’s consultation with their GP, becomes central to the planning and decisionmaking processes of the CCG.

The Greenwich wide Forum provides a key opportunity for GPs across Greenwich to meet andinfluence plans and strategies being developed by the Board.

Appendix 1 “ Greenwich Governance structure and responsibilities” shows the relationshipbetween the GP Board members, the GP syndicates and syndicate leads, clinical and corporateleads, their individual domains of leadership and the local CCG managers who support the Board.

A Constitution for the CCG has now been drafted that describes the organisational and legal form ofthe NHS Greenwich Clinical Commissioning Group. It is subject to any changes in law, and may needto be modified in response to evolving regulation and guidance. The aim of this Constitution is toestablish NHS Greenwich Clinical Commissioning Group as an organisation focused on improving thehealth and well being of the people of Greenwich and securing high quality health and care servicesfor that population. This Constitution is made between the members of NHS Greenwich ClinicalCommissioning Group and has effect from 1st day of April 2013, when the NHS Commissioning Boardwill establish the Group.

24

Section 2: Improving Health

2.1 NHS Greenwich CCG Strategic Overview

Based on local assessment our current strategy for Greenwich builds on the NHS South EastLondon Commissioning Strategy Plan 2012/13-14/15 ‘Better for You’, while incorporating thestrategic priorities identified in the Greenwich Health Clinical Commissioning Strategy 2012-2015, and by the latest Greenwich Joint Strategic Needs Assessment. It is also aimed ataddressing the five domains of the NHS National Outcomes Framework as follows:

Domain 1 - Preventing people from dying prematurelyDomain 2 - Enhancing quality of life for people with long-term conditionsDomain 3 - Helping people to recover from episodes of ill health or following injuryDomain 4 - Ensuring that people have a positive experience of careDomain 5 - Treating and caring for people in a safe environmentand protecting them from avoidable harm

Our Mission

Our mission is to meet the three key ‘must do’ challenges we have identified for Greenwich:

Tackling poor health and Long Term Conditions

Driving Improvement whilst sustaining the clinical and financial viability of the local health

economy

Managing pressures resulting from population changes and the economic downturn

Our Vision

Secure the best possible health and care services

Developed with patients & public, & in collaboration with health & social care professionals &

partner organisations

In primary care and community settings when possible & in hospital when necessary to reduce

health inequalities & improve health outcomes.

Our Principles

We will improve quality and the quality of patient experience by:

Improving health outcomes with a relentless focus on the seven main health conditions and

diseases in Greenwich and using evidence based approaches.

Reducing health inequalities by taking a preventative, proactive approach and focusing on

the health needs of black & minority ethnic communities and ‘hard to reach’ groups.

25

Simplifying clinical care pathways to ensure better quality care through aligned incentives

and integrated approaches and services.

Encouraging self-management of conditions wherever possible to reduce avoidable hospital

admissions and to increase patients’ confidence using evidenced based measures and

adopting best practice.

Improving collaboration to harness economies of scale and scope in order to do more or

better with available resources in the future through closer integration with Social Care,

Public Health and other partners.

Ensuring service development is better connected to and wraps around primary care by

commissioning service improvements that link to clinical processes in primary care.

Managing demand effectively through referral management, seeking to support patients to

make pathway choices and make best use of services in the community

Judicious use of integration and competition to enhance quality and offer more choice,

increasing choice through the ‘Any Qualified Provider’ policy and other commissioning

innovations.

NHS Constitution

CCGs have a legal duty to act with a view to securing health services that are provided in a way

which promotes the NHS Constitution and promotes awareness of it amongst staff and the public.

NHS Greenwich CCG is fully committed to this duty. The guiding principles of the NHS Constitution

are:

1. The NHS provides a comprehensive service, available to all

2. Access to NHS services is based on clinical need, not an individual’s ability to pay

3. The NHS aspires to the highest standards of excellence and professionalism

4. NHS services must reflect the needs and preferences of patients, their families and their

carers

5. The NHS works across organisational boundaries and in partnership with other organisations

in the interest of patients, local communities and the wider population

6. The NHS is committed to providing best value for taxpayers’ money and the most effective,

fair and sustainable use of finite resources

7. The NHS is accountable to the public, communities and patients that it serves

26

Our key challenges are:

Tackling 10 major causes of ill health and the resulting 7 main disorders and conditions identified

in our JSNA. These are:

Cardiovascular disease (heart disease, stroke)

Cancers

Respiratory disorders

Mental health

Falls and fractures in older adults

Alcohol related harm

Diabetes

Managing pressures from population changes (including new populations) and the

economic downturn

Driving improvement whilst sustaining clinical & financial viability of health economy

In response to this challenge, our key strategic priorities are as follows:

Staying healthy & health protection

A whole system approach, for children and young people focusing on prevention and developing

integrated care pathways and services

Improve mental health care

Improve long term conditions care

Co-ordinate the provision of urgent care and out of hours care

Increase capacity in high quality cost effective alternatives to hospital based planned care

Enhance end of life care

In delivering these priorities, it is recognised that easy access to high quality, responsive primary and

community care will be essential. We are working with colleagues across south east London, and

have collectively identified the following aspirations for community based care (more detail can be

found in Appendix 4):

Be supported to manage their own health and any illnesses that they have and feel

confident to do so

Have access to telephone advice and triage for all community health and care services 24

hours a day, seven days a week either through their General Practice or through a telephone

single point of access

Have access to primary care service/advice 24hrs, 7 days a week for urgent needs through a

combination of appointments and walk in services, telephone appointments, 111/NHS

Direct, same day urgent care,

Be provided with high-quality, evidence-based primary and community-based care,

delivered through primary care staff collaborating with each other and with specialist and

community services, delivering care in line with agreed quality standards and outcomes.

27

Table 1: Key Health Challenges across Greenwich and South East London

Greenwich

Challenges

South East

London

Challenges Example of local needs

Greenwich

Strategic

Priority

Cardiovascular

disease (CVD)CVD

A major cause of premature mortality with

variations in the outcomes for different people

CHD: Greenwich has higher mortality rates than

London and National average - linked to

deprivation

Improve long

term conditions

care

Cancer Cancer

Major cause of premature death and some rates

higher than the national average

Especially lung, breast and bowel

Staying healthy

and health

protection

Respiratory

disorders

Long Term

Conditions

Many COPD deaths are preventable and can lead

to excess demand on hospital beds if not managed

well.

COPD: standardised mortality rates are

significantly higher than the national average

associated with long-term smoking patterns.

Improve long

term conditions

care

Co-ordinate the

provision of

urgent care and

out of hours care

Mental health Mental Health

A significant cause of disability and distress

Depression and anxiety, dementia, conduct

disorder in children

Improve mental

health care

Falls and fractures

in older adults

Long Term

ConditionsMusculo-skeletal health

Improve long

term conditions

care

Alcohol related

harmHealthy Living

Many of the factors driving ill health are due to

how people eat, drink and take exercise

Staying healthy

and health

protection

DiabetesLong Term

Conditions

Diabetes: Black African, Black Caribbean and

South Asian ethnic groups are at higher risk of

developing diabetes, so a considerable percentage

of Greenwich and SEL population at high risk.

Improve long

term conditions

care

28

Table 2: Outcomes and Measures to be achieved in tackling the strategic priorities:

Greenwich

Strategic

Priority Rationale Outcomes Proposed Measures

Staying healthy

and health

protection

The Greenwich JSNA identifies 10

root causes for ill-health and poor

well-being in the borough. These

include health behaviours such as

smoking, physical inactivity,

alcohol and also include social

such as the requirements of

Greenwich’s new populations and

service quality issues in relation

to identification of people with

long-term conditions and optimal

clinical management of people

with those conditions and

excellent access to health

protection measures such as

immunisation, screening and

health promoting sexual health

services.

Continued improvement in

the number of people who

quit smoking and reduction

in those taking up smoking;

improved levels of physical

activity and reduced levels

of obesity; increased

detection of people with

long term conditions in

primary care and

improvements in their

management;

improvements in uptake of

screening programmes;

reductions in use of A&E

and in-patient care for

cardio-vascular and

continued improvements

in life expectancy for men

and women.

Smoking Quitters -

Number of 4-week

smoking quitters

that have attended

NHS Stop Smoking

Services

NHS Healthchecks -

Number of eligible

people who have

received an NHS

Healthcheck

Bowel screening -

Extension of bowel

screening program

to men and women

aged 70 up to 75

birthday

Prevalence of

Chlamydia in under

20 year olds.

A whole system

approach for

children and

young people

focusing on

prevention and

developing

integrated care

pathways and

services

The Greenwich JSNA identifies a

number of areas where children’s

services are in need of

improvement; improving

outcomes of pregnancy for

mother and baby, reducing

obesity and improving diet, and

improving the health of children

with additional needs and long

term conditions. Greenwich has a

young population and higher than

average birth rate. Child health in

the borough is impacted by the

level of deprivation and this is

seen in: the high rate of

obesity/poor fitness in children,

Reduction in inappropriate

emergency attendances,

reduction in CAMHS

waiting times, decreases in

child obesity. Impact on

Domains 2,3 & 4 of the

National Outcomes

Framework.

Childhood obesity

in reception year

and year 6.

Maternity access -

% of women who

have seen a

midwife by 12

weeks and six days

of pregnancy.

Breastfeeding

prevalence at 6-8

weeks from birth.

Childhood

29

Greenwich

Strategic

Priority Rationale Outcomes Proposed Measures

two thirds of children/young

people requiring CAMHS services

are not able to access them, and

teenage pregnancy and sexual

health problems need to reduce.

There is an increasing number of

children in the borough with

autistic spectrum disorder and

few services. Greenwich has a

high percentage of Looked After

Children. Half of A&E

attendances are for children and

the majority of these could be

better managed in the

community.

immunisation rates

Improve mental

health care by

focusing on the

interface between

primary,

community and

secondary care,

increasing service

users’ choice and

access to services

that maximise

recovery, prevent

relapse and

admissions to

acute care and

maximise care and

support to people

in their own

homes.

JSNA indicates that levels of

mental ill health are high in

Greenwich, with one in three

people experiencing a mental

health condition. We also need

to drive further efficiencies from

mental health services to invest in

areas that need improvement

and deliver the six objectives for

improving health and wellbeing

as set out in the national strategy

‘No health without mental

health’. Users often express

dissatisfaction with the choice of

services locally and we need to

provide more options. For

example third sector provision.

Reductions in avoidable

referrals, improved waiting

times. Impact on Domains

1, 2 & 4 of National

Outcomes Framework.

Length of stay

(MH) - Average

spell duration for

non-same day MH

discharges

IAPT – Improving

Access to

Psychological

Therapies

Improve long

term conditions

care, through:

Prevention and

self-management

support/support

Significant increases in long term

conditions predicted, increasing

numbers of emergency

admissions for LTCs. Local JSNA

suggests that cardiovascular

disease (heart disease and

Reduction in emergency

admissions, increased

numbers of patients

actively case managed in

general practice. Impact on

Domains 1, 2 & 3 of the

People with Long

Term Conditions

feeling

independent and in

control of their

condition - % of

30

Greenwich

Strategic

Priority Rationale Outcomes Proposed Measures

to carers

Targeting

interventions

according to need

& extending the

range of services

available

Better

coordination

between providers

& integration

between health,

social and other

care

stroke), respiratory disorders,

mental health, diabetes and falls

and fractures in older adults are

five of the seven main disorders

and conditions prevalent in

Greenwich.

National Outcomes

Framework.

people with LTCs

who said they had

had enough

support from local

services/orgs

Co-ordinate the

provision of

urgent care and

out of hours care,

reducing

duplication

Better co-ordination, reduced

duplication and fragmentation

across the whole urgent care

system required. Improved

patient experience with clear

navigation of the system,

reducing the number of services

patients use inappropriately.

Need to reduce the volume of

patients who attend A&E

frequently and inappropriately

Reduction in A&E

attendances, reduction in

emergency admissions.

Impact on Domains 2, 3 &

4 of National Outcomes

Framework.

A&E Quality

Indicators -

Unplanned re-

attendance -

Unplanned re-

attendance at A&E

within 7 days of

original attendance

(including if

referred back by

another health

professional)

Emergency

readmissions

within 30 days

Increase capacity

in high quality

cost effective

alternatives to

hospital based

planned care –

linking these to

hospital services

in ways that avoid

fragmentation

and duplication.

Estimated that 40% of planned

care could take place in lower

cost community based settings

which are more convenient for

patients. Freeing up capacity in

local acute hospitals will enable

more care to be repatriated from

inner London hospitals,

facilitating greater local access for

patients and reducing costs.

Increase in number of

referrals made using

agreed pathways, decrease

in avoidable GP referrals,

and outpatient shift of

activity from acute to

community settings.

Impact on Domains 1,2,3 &

4 of National Outcomes

Framework.

Monitoring of

capacity through

MAR (Monthly

Activity Returns) by

providers.

31

Greenwich

Strategic

Priority Rationale Outcomes Proposed Measures

Enhance end of

life care through:

Better

coordination

between service

providers,

implementing an

integrated model

Enabling people to

die in the place of

their choice

Implementing best

practice pathways

and frameworks

Most people would choose to die

at home if possible, however

many people die in hospital. As

well as improving quality and

patient experience, community

based EOLC is significantly more

cost efficient

Number of people dying in

their preferred

place/normal residence.

Impact on Domain 4 of the

National Outcomes

Framework.

% deaths at home

(including care homes) -

No. registered deaths

at home/no. registered

deaths

32

2.2 NHS Greenwich CCG Strategic Priorities

As set out in Section 1 above, the CCG has identified seven strategic priorities for improving health.

To deliver the strategic aims identified the CCG has planned the actions it needs to take across the

strategic planning period. These actions can be broken down into those that are planned for

implementation in the year of transition (12/13), commissioning intentions for the following year

(13/14) that build on these foundations, and medium term strategic plans covering the period

through to 2017/18. The following table 3 sets out the high level plans for the achievement of these

strategic priorities:

33

Priority Rationale Principles Opportunity Impact

Staying Healthy &

Health Promotion

The main causes of premature death are

common across south east London. We

believe that by creating opportunities for

people to choose and maintain healthy

lifestyles we will make major contributions

to increasing life expectancy, reducing

health inequalities, reducing hospital

admissions and preventing and delaying

the development of long term conditions.

Smoking is a leading risk factor for the top

causes of premature death for our

population (CVD, some cancers, respiratory

diseases). Smoking contributes to other

conditions such as osteoporosis, cataracts,

childhood infections and digestive

disorders

Physical inactivity is a leading risk factor for

the main causes of premature death for our

population (CVD, cancers, and respiratory

diseases). Childhood obesity rates are high

in south east London

Babies who are not breastfed are much

more likely to develop illnesses such as

gastroenteritis and respiratory infections

requiring hospitalisation as children. In

later life they are more likely to develop

We will:

Employ strategies aimed at

the whole population as well

as focusing on specific local

patient groups

Tailor solutions to local

populations while at the same

time applying national and

London polices at a local level.

Work together across a

broader geography where this

is the most appropriate

approach to achieve better

outcomes

Seek to achieve maximum

benefit in health for our

populations reducing

inequalities in health

Tackling Obesity, Diet and

Physical Activity

Smoking

NHS Health Checks

Implement fall prevention

programme

Tuberculosis

Reduce the level of obesity in adults and

children reducing the impact on heart,

diabetes etc.

Increase the numbers of people quitting

smoking with NHS stop smoking services

in Greenwich, reduce the prevalence of

smoking amongst our population and

reduce smoking attributable acute

activity and premature mortality

Continue to implement the new NHS

Health Checks programme in Greenwich,

reducing the major risk factors for

vascular disease and reducing the

prevalence of heart disease, strokes and

diabetes within our population over

time`

In conjunction with London-wide TB

programme, improve the early detection

and effective treatment of TB in

Greenwich and reduce the burden of

disease within the population

In conjunction with London-wide Cancer

programme, improve coverage of cancer

34

high blood pressure and cholesterol levels

and associated illness.

Mothers who do not breastfeed have

increased risk of breast and ovarian

cancers and may find it difficult to

return to pregnancy weight.

Too many people die of alcohol related

problems in south east London.

Alcohol-related problems place a

major burden on health services in

primary care, A&E, acute and specialist

services and also across wider societal

areas of crime, accidents, domestic

violence and unemployment.

Cancer

Immunisations

Sexual Health

screening programmes in Greenwich,

increasing early detection of treatable

breast, cervical and bowel cancers within

and improving survival rates

To improve the coverage of childhood

immunisation and reduce the incidence

of outbreaks and cases

To improve sexual health within our

population by reducing late diagnosis of

HIV, reducing teenage conceptions,

improving the early detection and

treatment of chlamydia and improving

access to sexual health and contraceptive

services

35

Improving Children’s

Services

Greenwich has a young population and

higher than average birth rate.

Child health in the borough is impacted by

the level of deprivation and this is seen in:

the high rate of obesity/poor fitness in

children, two thirds of children/young

people requiring CAMHS services are not

able to access them, and teenage

pregnancy and sexual health problems

need to reduce.

There are an increasing number of children

in the borough with autistic spectrum

disorder and few services.

Greenwich has a higher than average

percentage of Looked After Children.

Half of A&E attendances are for children

and the majority of these could be better

managed in the community.

Take forward the 12 priorities

for improving the health and

circumstances of young

people identified in the

2011/12 Annual Report of the

Director of Public health and

Well-being.

Decrease current poor health

in children; focus on

prevention to ensure children

are able to make healthy

choices that will mean they

grow up into healthy adults.

Develop more integrated

pathways and services.

We will take a partnership

approach with Public Health,

community health services,

colleagues in education, the

third sector, children & young

people, families and carers

We will use social marketing

and ideas from young people

to make sure our message

and information about

services is targeted in the

most appropriate and creative

way to children and young

Prevention

Improving health outcomes

for mother and baby

Reducing obesity &

improving fitness

Developing an integrated

service for children with

complex needs

Asthma pilot

Raising awareness, increasing healthy life

choices targeting key health issues

including obesity and fitness levels,

sexual health, and psychological well-

being, health needs of children from

black and minority ethnic communities –

working closely with Public Health and

Education sector.

Improve detection and management of

diabetes and hypertension, reduce

smoking, reduce obesity, improve access

to dental care, improve detection and

follow up of serious infectious disease.

Reduce teenage pregnancy.

Multifaceted programmes to improve

diet and fitness.

Commission a lead provider to join up

care across providers and along a care

pathway for children with complex and

specialist needs, including psychological

care.

Improve the management at home of

asthma by children and their

parents/carers, reducing the number of

inappropriate emergency attendances

for children

Review and redesign of paediatric

pathway at Queen Elizabeth II Hospital:

36

people.

Review of Paediatric

Assessment Unit

Child and Adolescent

Mental Health services

Autistic spectrum disorders

improved provision and diversion of

activity to the Urgent Care Centre.

Service redesign

Scoping the potential for service

development to meet the increasing

number of children in the borough with

autistic spectrum disorders.

Improving Mental

Health Care

Levels of mental ill health are high in

Greenwich, with one on three people

experiencing a mental health condition.

We need to drive further efficiencies from

mental health services to invest in areas

that need improvement.

Users often express dis-satisfaction with

the choice of services locally and we need

to provide more options, particularly with

the third sector.

We aim to transform services

by:

Working in partnership with

our Local Authority

colleagues, within our Joint

Commissioning arrangements

and in consultation with

neighbouring BSUs across the

SEL sector in order to develop

local resources that promote

choice, ensuring access to

services that maximise

recovery, prevent relapse and

admissions to acute care

Identifying mental health

problems early and

intervening across all age

Community service redesign

and development of RMS

Acute service redesign

Develop models of integrated care in the

community (Team around the patient)

Single Point of Access to all Mental

Health Services in Greenwich by

introducing of a Referral Management

system (RMS)

Increase options for places of safety and

24/7 community services supporting

patients at home as an option to acute

care. We are proposing development o

we are opening a Community Crisis

House. The project will open in April

2012 and will provide 6 beds to patients

in need of intensive 24 hour specialist

mental health support who have been

assessed by the Crisis and Home

Treatment Team as needing additional

support to avoid admission to hospital.

37

groups

Building care and support

around outcomes that matter

to patients. For example

education, housing and

employment

Challenging Stigma and

Discrimination

Improving the interface

between primary and

secondary care services

Forensic Business Case and

third sector initiatives

Interface of primary and

secondary care

CAMHS

The unit will also have 6 self-contained

flats which will offer patients

accommodation and an intense

programme to support people in their

Recovery and Rehabilitation

We aim to reduce the number of

commissioned forensic beds and

explore forensic market alternatives

within the private/ third sector (MSU

OATS patients) we are supporting the

development of a Forensic Hostel (the

TILT project) to manage patients moving

from low and medium secure services.

We want to invest in services and skills at

the interface of primary and secondary

care services, to ensure more people can

be supported well in primary care,

including greater support for self-care.

This will enable us to take a more

integrated approach to the user’s whole

health needs, addressing physical health

needs also, in particular long-term

conditions. We are exploring developing

a syndicate that will focus on mental

health.

See Children’s services

Improving Long

Term Conditions

Currently, south east London has a high

and increasing level of emergency hospital

admissions which could be managed in

Prevention and improved self-

management support for

people with long term

Finding the Vulnerable Increasing case finding, capacity and

coordination of services to prevent

unnecessary admissions to hospital. In

38

care for all ages primary and community care, particularly

for patients with diabetes and respiratory

illnesses.

The Greenwich JSNA predicts significant

increases in the number of people with one

or more long terms conditions

conditions and support for

their carers

Focus on proactive,

preventative approaches

including patient education

and self-care/carer support so

that people can be managed

at home with confidence.

Targeting interventions

according to need &

extending the range of

services available

Better coordination between

providers & integration

between health, social and

other care, encouraging

adherence to Greenwich long

terms conditions pathways.

Improved medicines

management

Use and further develop risk

stratification tools to identify

people who are frequent

attenders at A&E or have

frequent admissions to

hospital to ensure they are

well supported by primary

and community care, reducing

Integrated primary care

model

Medicines management

particular: people who are taken to A&E

with blocked catheters, who are

admitted for short stays; patients who

receive IV therapies as an inpatient;

people admitted each year with flu

(pregnant women as well as vulnerable

older people); a range of other reasons

for admission which are amenable to

treatment at home – UTIs, falls, tissue

viability/ cellulitis and dementia. There

is a particular focus on reducing

admissions from care homes.

This service will include intermediate

care and an extended JET service, and

building up consultant led sub-acute

capacity in existing beds. Aimed mainly at

over 65s with UTIs, heart failure or COPD

who could better be managed out of

hospital. Capacity to be put in place

equivalent to two acute wards.

Improved wound management,

improved prescribing of SIP feeds,

scriptswitch

39

A&E attendances and

emergency admissions.

40

Co-ordinate the

provision of urgent

and out of hours

care

Better co-ordination, reduced duplication

and fragmentation across the whole urgent

care system required.

Improved patient experience with clear

navigation of the system, reducing the

number of services patients use

inappropriately.

Need to reduce the volume of patients who

attend A&E frequently and inappropriately.

Develop a comprehensive,

integrated urgent care system

for Greenwich, with effective

links and partnerships with

neighbouring urgent care

systems to ensure smooth

service for patients and

economies of scale across

local boroughs

Whole system redesign,

undertaken collaboratively

with neighbouring CCGs

Put in place incentives to

encourage better case

management of frequent A&E

attenders

Whole systems urgent care

model

Urgent Care Centre

Development of a whole systems model

for an integrated urgent care system

enabling the development of a

specification to tender for the whole

system.

The new urgent care centre at the Queen

Elizabeth site , which became operational

on 1 December, offers the opportunity to

ensure that patients are seen by the

most appropriate service for their needs

and reduces demand on the emergency

department

Increase capacity in

high quality, cost-

effective alternatives

to hospital based

planned care

It is estimated 40+% of planned care could

take place in lower cost community based

settings, which are more convenient for

patients.

Freeing up capacity in the acute hospitals

locally will enable more care to be

repatriated from inner London hospitals

which have higher costs.

Widening the scope and

capacity of primary and

community services as an

alternative to hospital based

care

Collaborative approach with

local providers and the Local

Authority

Improved medicines

management: shared

formulary with SLHT for high

cost drugs/high risk conditions

Referral management

booking scheme

Cardiology services

Diagnostics

Community Hospital

Phased extension of referral

management service pilot to cover all

referrals from all practices.

Pilot for providing integrated

comprehensive cardiology services in the

community

Review of direct access diagnostics to

reduce unnecessary testing.

Development of an effective model for

community hospital provision in Eltham.

The Eltham community hospital will be a

41

including cardiology,

introduction of new anti-

coagulation drugs, challenging

Payment by Results excluded

drugs, management of the

RAG list of drugs.

Provision

Medicines Management

key ‘enabler’ to help us to deliver on all

our priorities, providing additional

capacity for alternative community based

services. We will develop a full business

case and will work collaboratively with

Bexley and Bromley to ensure a

consistent approach to the shift in care

from SLHT to community hospitals.

Shared formulary with SLHT for high cost

drugs/high risk conditions including

cardiology, introduction of new anti-

coagulation drugs, challenging Payment

by Results excluded drugs, management

of the RAG list of drugs

42

Enhance end of life

care

Most people would choose to die at home

if possible, however many people die in

hospital.

As well as improving quality and patient

experience, community based end of life

care (EOLC) is significantly more cost

efficient than hospital based care.

We will continue to work in

collaboration with the

Greenwich and Bexley

Hospice and Marie Curie to

pilot the Marie Curie ‘choice’

model.

EOLC tender

Best practice

We have been working with the

Greenwich and Bexley Hospice to pilot

the Marie Curie ‘choice’ model. This

model provides integrated, community

based EOLC. We are still in the test and

evaluate phase of the pilot but already

the results are impressive, and once the

pilot and evaluation are complete we

anticipate tendering for this model of

care

Continuing to implement best practice

including the Liverpool Care Pathway and

Gold Standard Framework.

Part of NHS South East London: a partnership of Primary Care Trusts in Bromley, Greenwich, Lambeth, Lewisham, Southwark and BexleyCare Trust

Chair: Caroline Hewitt CCG Chair: Dr Hany Wahba Interim Chief Executive: Christina Craig

2.3 Meeting our Responsibilities in 2012/13

2.3.1 Performance Management

The CCG recognises the importance of robust performance management in support of our plans. To

this end a Governing Body has been established, as have a range of supporting committees as

follows:

Audit Committee

Remuneration Committee

Quality Committee

Risk Committee

Finance, Performance & QIPP Committee

Strategy & Commissioning Committee

In terms of commissioning and performance management of our plans, the Finance, Performance &

QIPP Committee takes the primary role in assuring the Governing Body on the progress in achieving

financial, service and QIPP elements of our plans, while the Quality Committee addresses service

quality across the full range of commissioned services. The Strategy & Commissioning Committee

oversees the development of our annual and longer term plans. Involvement from the wider GP

community is ensured by the syndicate structure whereby syndicates of six or more member

practices have been formed to develop and implement the work of the CCG at a local level.

Syndicates will meet regularly with the Governing Body, and all practices come together in the

Greenwich-wide GP Forum.

2.3.2 2012/13 Performance Priorities

During 2011/12 Greenwich performed well against a number of performance measures, notably:

Minimal MRSA bacteraemia.

Category A ambulance response times have consistently met the required standard as 75%

within eight minutes and 95% within 19 minutes.

The majority of cancer waiting time standards were met.

The proportion of people who have a stroke who spend at least 90% of their time in hospital

on a stroke unit met the required standard.

44

Smoking quitters

NHS Health Checks coverage was amongst the highest in the country

In 2011/12 there were also some areas where performance was below expected levels for

Greenwich:

Referral to treatment waiting times for admitted patients failed to meet the required

standard for the maximum wait for the 95th centile. This is a reflection of poor performance

at both South London Healthcare trust and at Guy’s & St Thomas’ Foundation Trust.

The target for a substantial reduction in C difficile cases was not met.

A&E performance was below the expected standard. The main provider for Greenwich

residents is South London Healthcare Trust, and in particular the Queen Elizabeth site in

Woolwich. Across the Trust and in Woolwich, the standard for 95% of patients being

admitted, discharged or treated within 4 hours was not met.

The 85% standard for the percentage of patients receiving first definitive treatment for

cancer within 62 days of an urgent GP referral for suspected cancer was not met (78.7% at

Q3)

An unacceptable number of breaches of Mixed Sex Accommodation standards occurred at

South London Healthcare Trust.

Greenwich priorities and additional challenges for 2012/13 acute areas in some cases lead on from

2011/12 issues:

Referral to Treatment – South London Healthcare Trust (SLHT) have a plan in place to

eliminate the admitted backlog and as at August 2012 have made significant progress in

clearing the backlog. While the backlog is being cleared it is anticipated that performance

will continue to fall short of target in the first half of the year. Guy’s and St Thomas’ NHS

Foundation Trust’s plan is to eliminate the admitted backlog by quarter 2, 2012/3. Both

Trusts have also made significant inroads in addressing diagnostics backlogs, which now fall

within the mandated tolerances.

Emergency Access- SLHT is working closely with the wider health care community to

improve appropriate use of emergency services, and maximise the use of community and

out of hospital provision. The successful re-tendering of the Urgent Care Centre (UCC) on

the Woolwich site in December 2011 has already resulted in an increase in throughput of the

UCC on that site, releasing capacity in the main Emergency Department. Further work is on-

going to improve urgent care pathways on the Woolwich site which will assist in reducing

the number of Mixed Sex Accommodation breaches, improve ambulance handover times

and reduce 60 minute handover breaches.

45

Reducing avoidable emergency admissions is a priority within our commissioning strategy

and QIPP plans, underpinned by a commitment to high quality primary care. In addition to

improvements in A&E and UCC services our approach is to identify patients at higher risk of

requiring urgent care together with disease specific case management. In quarter 4 of

2011/12 the NHS Institute for Innovation and Improvement ranked Greenwich No.1 in

England for the management of ambulatory care sensitive emergency admissions.

C Difficile – the 2012/13 objectives are challenging both at acute trust and PCT level. Acute

trusts will be participating in the NHSL Peer Review process to aid implementing best

practice examples from elsewhere.

62 day urgent referrals to treatment – Guy’s and St Thomas’ NHS Foundation Trust has

made improvements in the urology pathway earlier in the year and more recently in the

pathway for Lower GI, particularly access to colonoscopies through the use of the additional

endoscopy capacity on the St Thomas’ site.

CAT A - key events that could impact upon performance in 2012/13 are as follows:

o Olympics – separate funding has been agreed with the DH in order to maintain

business as usual and includes funding for an expected general rise in activity.

o Other large events – Queen’s Jubilee, Public Demonstrations

o Implementation of 111 – ambulance activity could potentially rise while new

providers bed in.

o Further Industrial Action

Mixed Sex Accommodation – Work with SLHT in 2011/12 appears to be delivering

improvement, with the Trust expected to meet this standard in 2012/13.

IAPT – Oxleas Foundation Trust have been commissioned to provide the IAPT programme

for adults through the Greenwich Time to Talk service. In addition to this psychological

therapies will be extended to Children & Young People. The CYP IAPT will not be a

standalone service as with the adult IAPT model. The development of CYP IAPT is a Service

Transformation Project for Child and Adolescent Mental Health Services (CAMHS). The focus

of CYP IAPT is on extending training to staff and service managers in CAMHS and embedding

evidence based practice across services, making sure that the whole service, not just the

trainee therapists, use session by session outcome monitoring

Immunisation – The priority in 2012/13 will be to improve performance in immunising

children over the age of 5 years. The Immunisations Strategy Group has been re-organised

with amended Terms of Reference and is reviewing a proposal for catch-up programme for

older children through Health Visitors. There will be engagement with primary schools and

early years providers to implement standardised collection of information on the

immunisation status of new entrants, exploring options for offering vaccinations to under-

vaccinated children, and identify opportunities to promote immunisation

46

Cervical Screening Test Results – Performance will be challenging across 3 out of the 4

providers in South East London in 2012/13. Performance has been an issue at South London

Hospital Trust, Guy’s & St Thomas’ Trust and King’s Hospital. Actions have already been

taken with SLHT moving letters sent out second class to first class to hit the 14 day

turnaround target. Improvements are being made to the lab and a concerted effort to

improve the Lab Information technology systems is planned.

Bowel Cancer Screening - The bowel cancer national awareness campaign due to start on

the 28th January will pose a risk to performance in 2012/13 across the cluster as projected

demand increases. Planning with the Acute Trusts to increase capacity has commenced and

performance leads will continue to work with the Cancer Screening Lead for South East

London and the South East London Cancer Network who are concentrating on the age

awareness and national campaign in Bowel Screening. Work streams have been identified

and are currently being worked through and the recently formed South East London Cancer

Screening Board will be reviewing performance and progress.

2.4 NHS Greenwich CCG’s Compliance with the National Operating

Framework 2012/13

The Operating Framework for the NHS in England sets out the planning, performance and financialrequirements for emergent CCGs operating under delegated responsibility in 2012/13. TheOperating Framework includes the broad financial and performance responsibilities and outlines theexpectations of commissioning organisations in respect of assuring the safety and quality of localhealth services.

A further central objective in 2012/13 is that CCGs work with PCT Clusters and other keyorganisations to ensure a successful last year of transition to the new system of commissioning. Inaddition to the responsibilities noted above, there are a number of key areas that require particularattention during 2012/13. Details of these requirements and the actions the CCG and its partners aretaking to deliver them in 2012/13 are included in the table in Appendix 2 “Table demonstratingcompliance with the National Operating Framework”

47

2.5 Enabling Actions and Additional Service Developments

2.5.1 Primary Care Engagement

Good quality General Practice is a key enabler of delivery of all of NHS Greenwich CCG’s strategicpriorities - staying healthy, developing integrated care pathways and services, improving mentalhealth and long term conditions care, co-ordinating the provision of urgent and out of hours care,providing high quality cost-effective alternatives to hospital based planned care and enhancing endof life care.

General practice can do this by providing easy and responsive access to patients as early in thepatient journey as possible and preventing patients seeking alternatives such as A&E; through careprovided for their registered population as an alternative to hospital outpatient care; care co-ordination for their particularly vulnerable patients with complex issues preventing potentialemergency admissions; and through their referrals to specialist care which drives the overall patientflow and resource distribution for the whole local health system.

A fully effective primary care service that is responsive to its registered population's needs, is pro-active about promoting health and well-being, prevents ill health and avoids crises in people withlong term conditions not only will provide high quality services for their patients but will also behighly cost-effective.

NHS Greenwich CCG is already working with its member general practices through visits, dataanalysis, syndicate peer review and the Greenwich Commissioning Incentive scheme to reviewpatients on the register and improve care for patients at highest risk of hospital admission. Insupport of the aspirations for improved community based care set out in Section 2.1, we willpromote initiatives to improve productivity and release clinical time. We will continue to help GPs tounderstand the important role that general practice plays in commissioning, and in the whole healthsystem of Greenwich.

How NHS Greenwich CCG is working with its constituent GP Practices

(i) Syndicates

NHS Greenwich CCG adopted a Syndicate structure as way of ensuring effective communicationsbetween GP member practices and the CCG Board, and as a way of encouraging the adoption of bestclinical practice to the benefit of patients. The primary role of a Syndicate is to peer-lead andsupport member practices with changes in clinical practice resulting from local service re-design.Membership of a syndicate also enables its member practices to access commissioning incentiveschemes. Syndicates act as focal points for the review of clinical care as it relates to commissioningincentive schemes and will support member practices in achieving the changes required by eachscheme.

In order to ensure commitment to this new way of working, the CCG allowed the Greenwichpractices to determine the configuration of their syndicates, rather than prescribe a particularmodel. All Greenwich GP Practices are members of one of five Syndicates. Each Syndicate is led by aSyndicate Lead selected by their peers. The role of the Syndicate Lead is to represent the views of

48

the syndicate to the Governing Body via the GP Executive-Link Representatives, and to serve as aconduit through which information about the CCG’s activities is disseminated to the syndicatemember practices. Syndicate leads also act as champions for understanding and addressing healthinequalities and population health outcomes.

The Syndicate structure is operating robustly, with each Syndicate meeting at least four times a year(with some meeting more frequently) and their Leads meeting with a named CCG ClinicalCommissioner every two months. In addition the Syndicate Leads, as a group, meet with the GPExecutive every two months. A Syndicate Development Manager supports their work as does amonthly newsletter.

Other benefits from the Syndicate structure1. The Syndicate arrangements were intentionally designed to help practices meet QOF targets and

PMS key performance indicators and as a result this single structure has enabled practices tomeet these new demands.

2. Prior to the establishment of Syndicates there had not been a strong history of GP practicesworking together within Greenwich. By placing an emphasis upon engagement during the firstyear of its operation strong syndicate relationships have been developed.

3. Syndicates were also linked to named members of the Public Health team enabling relationshipsto be developed ahead of future initiatives to ensure primary care resources are used formaximum patient benefit that will utilise data from this service.

(ii) Commissioning incentive scheme (CIS) for GPs

The aim of the scheme is to encourage and reward high quality practice by Greenwich GPs and tosupport the goals of the Greenwich Clinical Commissioning Group. Payment is dependent onachievement of all outcomes. Greenwich has implemented two schemes so far. The current schemehas built on the experience and learning from the Commissioning Incentive Scheme of 2011-12.

The 2011/12 CIS focused on detailed clinical reviews and care planning for patients at high risk of illhealth and hospital admissions. The reviews stimulated multidisciplinary working between practicesand community services, but did not result in clearly defined goals for this work.

Part 1 of the 2012/3 scheme focuses on engagement. Building stronger relationships with peers andcolleagues is fundamental to providing an integrated care environment and achieving improvedoutcomes for Greenwich patients. Part 2 of the 2012/13 CIS asks practices to consider themanagement and diagnosis of patients with cancer. Practices are asked to reflect upon thosepatients recently diagnosed or referred on a 2 week wait and consider any learning from thisexercise. Part 3 of the 2012/13 CIS aims to build on and improve last year’s scheme and crystallisesome of the benefits by:

Promoting practice systems to support care planning for high risk patients and to linksbetween the practice and other services

Improving patient selection to ensure reviews are focused on patients with complex healthand / or care needs

Promoting multi-disciplinary meetings between GPs, other practice staff and members ofcommunity health and social care teams

The CIS strengthens the requirements of syndicates to review problems faced by high risk patientsand develop local solutions to address them.

49

As previously, the CIS of 2012-13 has been designed to complement two other current initiatives:QOF requirements to establish peer review groups and local key performance indicators in PMScontracts.

Through the Commissioning Incentive Scheme (CIS), Syndicates reviewed the care of 495 patientswith complex conditions. The majority of Practices surveyed at the end of 2011-12 found that thesereviews had improved GPs understanding and the multi professional management of complexpatients. The relationship between relatives and carer and the GP in a patient’s care had alsoimproved.

(iii) Further Support for General Practice

Greenwich will continue to identify what further support and resources are needed to enablegeneral practice to play their full part in commissioning and delivery of planned and unplanned care,in addition to their day-to-day general practice work. We will build both capacity and capability inpractices through good back-up support and investment in on-going training.

We will help practices to improve the quality of their referrals through the Referral Managementand Booking Scheme. Through the syndicates and syndicate leads, and the Commissioning Incentivescheme, we will support general practice to improve their patient registers and review care plans forpatients with Long Term Conditions. In order to provide high quality care for complex Long TermConditions the role of the GP is not one just of reaction – but also being a vital, integral part of awider multi professional, multidisciplinary community team.

We will also help general practice to improve the quality and management of primary care mentalhealth services and referrals as the quality of the services available within general practice can bevariable, and the knowledge of what is available for GPs to refer to can be limited.

We will commission a secondary care service that is responsive to primary care needs and whosespecialist opinions will aid general practice decision making.

(iv) Improvement in primary care

Through building capacity and capability we will also address variability and poor practice inprescribing, referring and clinical practice and improve access and responsiveness of generalpractice, particularly for BME groups in response to general practice patient surveys in London.

2.5.2 Eltham Community Hospital

The bedrock of effective NHS care is primary care services. This is where the majority of healthcare is

provided and good quality primary care improves primary and secondary prevention, ensures that

people are seen in the right setting and drives the overall productivity of the health service.

Integrated primary and community services can deliver significant benefits and Greenwich is

committed to developing programmes of work in these areas. To improve the sustainability of the

health economy in BBG there needs to be a reduction in the reliance on acute hospital based

services for patients who can be cared for in community settings. Greenwich has a strong track

record of investing in community services and has been highly effective at avoiding hospital

admissions. However there are still far too many people in acute beds who do not need these more

50

specialist services. From detailed analysis of the bed use in 2011-12 and an audit of every patient in

an acute and intermediate care bed, it appears that some 30 acute beds could be saved through

improved productivity, more integrated services and optimising patient pathways.

GCCC has adopted a principle of ‘in the community when possible, hospital when necessary’ to

facilitate a consistent approach to tackling this problem. However, there are constraints on the

amount, location and suitability of available clinical space in Greenwich. Lack of capacity in out of

hospital settings will be a limiting factor to Greenwich being able to implement its QIPP from 2014

onwards.

The older population of Greenwich who experience long term conditions, cardiovascular disease

(CVD) and cancer predominantly live in the south of the Borough, in Eltham. There are no health

centres there where GP practices and community services are co-located as investment has hitherto

focused on the more deprived but younger populations in the north. The limitations of practice

accommodation have precluded the development of extended primary care services in current

Eltham GP practices. All the new services implemented to improve productivity have been

developed in the north of the borough (e.g. dermatology, gynaecology and minor surgery services,

diabetes clinics and Time to Talk service) Therefore, additional primary and community services are

required in the south of the borough in an easily accessed setting. Greenwich Teaching PCT owns a

site near Eltham High Street on which the Eltham Community Hospital is planned, which is easily

accessible to the local population and will offer the following facilities:

2 GP practices (incl. extended hours)

Out-patient consulting rooms

Day surgery theatre suite

Diagnostic suite – low complexity

40 intermediate care sub-acute beds

Consulting rooms/base for community/mental health services

These facilities will enable the provision of a wide range of readily accessible services with

extended hours of opening, including:

General Practice consultations

Practice Nurse appointments for immunisation and vaccination, screening services and

minor procedures

Family planning service (day and evening consultations)

Child and adult asthma clinics

Child and adult minor ailments

Dermatology and diabetes management

Integrated Community and Social Care services, including Physiotherapy, Occupational

Therapy and Podiatry

Mental health services

The hospital will be designed/developed by Bexley, Bromley and Greenwich LIFT Ltd (LIFTCo) under

the exclusivity agreement with the PCT entered into in March 2005. The hospital will be built on a

site owned by the PCT which has been valued by the Valuation Office Agency at £3m. The LIFT

51

contract form will be a Land Retained Agreement (“LRA”) with a 25-year concession. The adoption of

the LRA form means that the ownership of the land is retained by the NHS. LIFTCo provides expertise

in health facilities planning and management. The hospital has been designed by architects

Broadway Malyan, who specialise in the planning and architectural design of healthcare buildings.

Recent projects include Fareham Community Hospital and Harrow Mental health Centre. They bring

a wealth of experience to this project ensuring that the design is a hospital fit for the delivery of 21st

century health care services, capable of offering maximum flexibility in use.

2.5.3 Heart of East Greenwich

The Heart of East Greenwich is an initiative, in partnership with the Royal Borough of Greenwich and

the Homes and Communities Agency, to regenerate the site of the former Greenwich District

Hospital. As part of this initiative, Greenwich proposes to develop a replacement Health Centre

(1573sqm). The new Health Centre will occupy a single floor within the Greenwich Centre which also

includes a leisure pool, library and other Council services, with affordable housing on the upper

residential floors. The site occupied by the existing Health Centre is part of the wider redevelopment

and planning consent has been given by the Council for both the reprovision of the Vanbrugh Health

Centre into the Greenwich Centre and the redevelopment of the former health centre site for

housing (private and affordable).

The existing Vanbrugh Health Centre adjacent to the former Greenwich District Hospital site,

accommodates the Vanbrugh 2000 practice and a range of Community Health Services currently

provided by Oxleas NHS Foundation Trust. Overall, the current building is also in very poor condition

and considerable sums are being spent to keep the building in a useable condition. It is therefore

imperative that an alternative solution is found to accommodate the services in the longer term.

The new health centre will provide the full range of primary and community services needed by the

local populations of East Greenwich, Peninsula ward, Blackheath and Charlton. These will include a

strong emphasis on healthy living (quit smoking, healthy diet, exercise and self-management of long

term conditions) achieved through partnership working with the Royal Borough of Greenwich.

The registered population to be supported by the Vanbrugh practice is planned to increase to circa

12,000 as a result of the residential elements of the Heart of East Greenwich Development alone. In

addition, the wider local population is due to increase substantially over the next 10 years (to 2025).

Epidemiological studies have shown that the population in the area (especially Peninsula and

Charlton wards) have relatively high health care needs.

The new facility will provide a high level of flexible, generic accommodation. Generic clinical spaceswill take the form of consult/exam rooms, shared across all services and utilised on a planned,programmed basis. General areas such as waiting spaces, group rooms and open plan offices will bedesigned in such a way as to encourage and enable use for, and by, a range of Third-Sector andCommunity organisations for healthcare promotion and group working.

52

2.5.4 CCG Organisational Development Plan

As an emerging organisation, the CCG recognises the need for organisational development as a key

enabler for achieving our plans. To this end our Organisational Development Plan sets out our

approach to this. The key objectives of the plan are:

Objective 1: To develop a strong clinical and multi-professional focus across GCCG

initiatives, which brings real added value

Objective 2: To develop and embed meaningful engagement approaches and outcomes

with patients, carers and communities, translating new insight into highly competent

commissioning activities

Objective 3: To develop our implementation and monitoring skills and competencies for

leading clear and credible plans to deliver QIPP within financial resources, in line with

national requirements and local joint health and wellbeing strategies

Objective 4: To adopt and work within proper constitutional and governance arrangements

to deliver all duties and responsibilities, and commission effectively

Objective 5: To develop robust collaborative arrangements with our colleagues in Bexley

and Bromley, and beyond, for commissioning at scale, which will deliver consistent

standards in local delivery

Objective 6: To take all appropriate steps to continue to develop ourselves and the next

generation of clinical commissioners into great leaders of the Governing Body, who

individually and collectively make a difference in commissioning for the population of

Greenwich

2.5.5 Sustainable Commissioning

Greenwich is committed to the NHS Carbon Reduction Strategy. We recognise the imperative of

driving the sustainability vision through greater resource efficiency, reducing emissions and

environmental impact, and delivering positive impact on the local health economy by improving

productivity. Some examples of the schemes which are helping to deliver a more sustainable local

health system include:

Urgent Care redesign, enabling more efficient and effective use of resources to treat urgent

care needs

Rollout of schemes that promote care at home and in the community, for example the

piloting of the Marie Curie ‘choice’ model for end of life care in Greenwich

Capital developments – ensuring sustainable and energy efficient designs in development of

future healthcare premises.

53

In line with the guidance of the NHS Sustainable Development Unit a plan will be developed in

2012/13 to incorporate:

1. Energy and carbon management

2. Procurement and food

3. Low carbon travel transport and access

4. Water

5. Waste

6. Designing the built environment

7. Organisational and workforce development

8. Role of partnership and networks

9. Governance

10. Finance

This plan will address sustainability both in how the CCG operates as an organisation in its own right,

and in terms of how it contracts for services from providers of healthcare.

54

Section 3: Financial Sustainability and the Case for Change

As set out in Section Two, NHS Greenwich CCG has ambitious plans to improve local health services.

Greenwich faces continuing growth in demand and cost of health services, driven by:

Population growth

Demographic changes

The expansion of available health technologies

Increased expectations

We have assumed funding will increase by 2.4% in line with GDP deflator estimates. There is an

unprecedented level of financial challenge facing the NHS over the next few years as funding is

unlikely to cover the costs of growth and other pressures. A step change will be required in the

approach to development and delivery of Quality, Innovation, Productivity and Prevention (QIPP)

plans. This requires clinically led system and service redesign both in Greenwich and across the

wider health economy. This will include primary care clinicians working in conjunction with acute

clinical colleagues to improve care pathways and patient experience, eliminate duplication and

improve productivity.

We must secure significant efficiency and productivity savings over the next three years to provide

the financial resource to support delivery of our vision and the supporting strategies. Our 2012/13-

2014/15 Commissioning Strategy Plan predicted that if projecting forward on a PCT basis, the ‘do

nothing’ scenario would result in a deficit in 2014/15 of £16.9 million in Greenwich.

For NHS Greenwich CCG, in order to achieve the required 1% surplus in 2013/14 and 2014/15, QIPP

savings totalling just under £12 million will be needed. The Greenwich approach to this challenge is

to ‘front load’ the QIPP requirement with approximately £8m of savings in 2013/14 and £4m of

savings in 2014/15.

We are not assuming that our allocation will be affected by any pace of change policies designed to

move CCGs to their capitation target, although we understand that this is under review and that the

Advisory Committee on Resource Allocation will be reporting on this shortly.

In summary, our annual resource allocation is projected to fall below the level of costs we expect to

incur unless significant changes are made. In order to ensure a sustainable health economy and

operate as a financially responsible CCG, we will need to reduce unnecessary costs and commission

models of care and clinical pathways that are increasingly efficient, whilst maintaining quality and

clinical effectiveness. This section sets out our high level strategic financial plans and assumptions,

which allow us to model how our strategic priorities will be delivered.

55

3.1 Financial Overview

In 2001 Greenwich Teaching PCT (GTPCT) came into being, inheriting budgets that found them in

financial difficulty. As a result, Greenwich PCTs first five years (2001 to 2006) were dominated with

turning round a very difficult opening financial position due to overspending and being over-

committed. Since then, the PCT has consistently met its financial responsibilities, including

achievement of required surpluses. During 2011/12 the emerging CCG had delegated responsibility

for all non-acute spend and the PCT continued to meet its financial obligations. Greenwich ended

the year in financial balance and achieved the required surplus of 1% (£4.77m). At the same time,

Greenwich made QIPP savings of just under £10m which were reinvested in local services.

The CCG has had developed a strong track record in financial management, holding delegated

responsibility for approximately £432 million (87%) of the total PCT budget in 2012/13, covering all

areas except public health and primary care. For 2012/13 and beyond, NHS Greenwich CCG has

developed plans to deliver surpluses in line with the 1% surplus requirement although it should be

noted that this is dependent on the return of 2011/12 surpluses. A number of risks and

opportunities are inherent in plans which are set out further below, including:

The delivery of QIPP savings initiatives.

Access to 2% non-recurrent funds – providing opportunities for delivery and risks if funds are

not forthcoming to facilitate the delivery of QIPP initiatives.

Successful negotiation of contractual agreements.

The impact of changes to Payment by results (PbR) tariff, including for mental health

providers.

Return of surpluses

3.2 Financial Position 2012/13

As at the time of compilation of this plan, our forecast position at year end is consistent with our

profiled plan and we remain on target to achieve both the required 1% surplus of £4.71m and full

delivery of net QIPP savings of £9.9m. The main areas of financial risk within the 2012/13 plans are

QIPP delivery, and in-year over performance at acute trusts, which has been a problem historically.

The main mitigations against this are an earmarked acute contingency reserve and the 0.5% general

reserve, and a cap and collar arrangement which limits our exposure on our main acute contract

with SLHT. Any further risks are expected to be managed through underspends in non-acute

budgets.

56

3.3 Financial Assumptions

During the financial year 2011/12 an updated set of financial plans were developed, both at the levelof the NHS South East London Cluster, and at a local level in the Greenwich Commissioning Strategy2012/13-2014/15, ‘Improving Health’. These were drawn up in line with NHS London CSP guidance inrespect of assumptions around uplifts, tariff, efficiency and other inflationary cost changes, requiredcontingencies and surpluses. The plans also reflected a locally developed financial model sharedacross cluster and the emerging CCGs, as well as detailed activity projections. The plans were furtherrefined in light of the 2012/13 Operating Framework guidance and further work to set detailedbudgets and contracts. This section incorporates the 2012/13 Operating Plans and updates these toreflect latest assumptions around the impact of organisational transition on future budgets from2013/14 onwards.

3.3.1 2012/13 – 2014/15 Assumptions

A summary of uplift assumptions are set out below:

Acute

Clie

ntG

roups

&

Com

mun

ity

Prim

ary

Care

(12

/13

on

ly)&

Pre

scribin

g

Corp

ora

teB

udg

ets

Oth

er

Budg

ets

an

d

Reserv

es

Net

2012/13

Recurrent uplift 2.80%

demographic Growth 1.40% 1.40% 1.40% 0.00% 0.00% 1.25%

Non-demographic growth 1.66% 0.80% 0.00% 0.00% 0.00% 0.99%

Total population & incidence growth 3.06% 2.20% 1.40% 0.00% 0.00% 2.24%

Prescribing growth 6.00%

Tariff/ Inflation Uplift 2.20% 2.20% 1.00% 2.50% 0.00% 1.88%

Tariff efficiency assumption/ Price

Efficiency applied (4.00%) (4.00%) 0.00% 0.00% 0.00% (2.97%)

57

Acute

Clie

ntG

roups

&

Com

mun

ity

Prim

ary

Care

(12

/13

on

ly)&

Pre

scribin

g

Corp

ora

teB

udg

ets

Oth

er

Budg

ets

an

d

Reserv

es

Net

2013/14

Recurrent uplift 2.42%

demographic Growth 1.40% 1.40% 1.40% 0.00% 0.00% 1.25%

Non-demographic growth 1.66% 0.80% 0.00% 0.00% 0.00% 1.07%

Total population & incidence growth 3.06% 2.20% 1.40% 0.00% 0.00% 2.31%

Prescribing growth 6.00%

Tariff/ Inflation Uplift 2.50% 2.50% 1.00% 2.50% 0.00% 2.14%

Tariff efficiency assumption/ Price

Efficiency applied (4.00%) (4.00%) 0.00% 0.00% (0.00%) (3.16%)

2014/15

Recurrent uplift 2.64%

demographic Growth 1.90% 1.90% 1.90% 0.00% 0.00% 1.68%

Non-demographic growth 1.66% 0.80% 0.00% 0.00% 0.00% 1.04%

Total population & incidence growth 3.56% 2.70% 1.90% 0.00% 0.00% 2.72%

Prescribing growth 6.00%

Tariff/ Inflation Uplift 2.50% 2.50% 1.00% 2.50% 2.50% 2.12%

Tariff efficiency assumption/ Price

Efficiency applied (4.00%) (4.00%) 0.00% 0.00% (0.00%) (3.12%)

58

Further details on uplift assumptions are provided below:

Recurrent Uplifts - PCT Revenue Resource Limit (RRL) uplifts are as per confirmed allocation

uplifts of 2.8% plus a further 0.18% in respect of reablement.

Tariff and Generic Uplifts - Tariff uplifts have been assumed at a net -1.8%, including a built

in 4.0% efficiency assumption. This has been applied to acute, mental health and community

spend.

Demographic & Non-Demographic Growth - Detailed work has been undertaken to review

planning assumptions related to demographic and non-demographic acute growth for the

CSP. The objective has been to ensure robust and realistic borough based planning

assumptions related to population and incidence factors, which take account of

demographic growth estimates and historic acute demand trends. To do so the following

process has been undertaken :

o A public health review of population growth assumptions (including GLA and ONS

figures) for acute services.

o A review of historic demand trends by borough for acute services, with supporting

trend analysis completed for the following key areas of acute activity – outpatients,

elective, A&E attendances, and emergency admissions, maternity and other.

Brought Forward Surpluses - Forecast surpluses for 2011/12 have been assumed to be

carried forward into 2012/13.

Full Year effect of 2011/12 outturn - The full year recurrent impact of 2011/12 forecast

outturn expenditure has been included within 2012/13 expenditure plans, including the

costs of reinstating PCT contingencies at 0.5% of recurrent resource limits.

Investment Proposals and Cost Pressures - Investments and cost pressures have been

included in financial plans for 2012/13. While detailed expenditure plans are in place for

2012/13, these remain draft pending the release of all detailed planning guidance for

2012/13 and also further progress in the negotiation of 2012/13 contracts.

QIPP Savings Initiatives - Existing detailed QIPP savings plans have been reviewed by CCGs

with support from Cluster teams. New QIPP schemes have been initiated and included in

financial plans. In total QIPP savings schemes across in 2012/13 total £13.1m. However

schemes have been RAG rated to deliver savings of £9.9m and it is this total that is assumed

to be delivered within financial plans.

2% Non-Recurrent Funds - Plans assume and include use of the 2% funds in full as an enabler

for QIPP delivery and to effectively manage the transition to the new commissioning

environment.

59

Readmissions and reablement funds - New reablement funds allocated to PCTs in 2012/13

have been earmarked for investment. In addition it has been confirmed that the 2011/12

policy of non-payment for some emergency readmissions and matching reinvestment for

post discharge care will continue in 2012/13.

3.3.2 2013/14 Allocation Assumptions

The CCG will operate with a 2012/13 baseline commissioning budget of £383.7m as detailed in the

following baseline submission to NHS London in July 2012 (this is subject to review):

Commissioner Spend against RRL Plan 2012/13

£m

Total PCT revenue resource limit 2012/13 503.8

NHS Commissioning Board (102.1)

Public Health – Local Authority (16.2)

Public Health England (0.7)

NHS Property services (1.1)

2012/13 CCG revenue resource limit baseline 383.7

The baseline CCG budget of £383.7m consists of recurrent resources of £375.4m and non-recurrent

resources of £8.3m

60

3.4 QIPP

As outlined above, NHS Greenwich CCG faces significant pressures due to factors that increase the

demand for and the cost of health services against a background of a much reduced rate of increase

in NHS funding. In order to meet this challenge, and continue to meet the requirement for a 1%

surplus each year, NHS Greenwich CCG needs to achieve significant productivity gains over the next

three years as per the table below:

Greenwich clinical leaders have worked in conjunction with local commissioning staff, South East

London commissioners and key providers to develop the 2012/13 QIPP programme. As at the time

of complication of this document the 2012/13 QIPP programme is on track to deliver the required

savings. The plan and year to date progress are detailed in the Appendices to this plan but the key

features are as follows:

The 2012/13 QIPP plan requires productivity savings of £9.9m

Of this total, approximately £3.6m of savings were secured through negotiated contract

savings on block contracts.

For the remaining initiatives, where there is a greater degree of uncertainty and therefore

risk of underperformance, a stretch target of approximately 150% of the target figure has

been set. Overall this results in a stretch target of £13.1m against the plan of £9.9m. This

should provide flexibility if there is shortfall on individual initiatives.

New initiatives are developed on a continual basis, both to act as ‘Plan B’ schemes to cover

any shortfall on the programme, and also to support the annual planning cycle and the

development of commissioning intentions.

At the time or writing, the CCG is on track to deliver its QIPP programme in full for 2012/13.

The governance of our QIPP programme consists of a number of key elements:

Each initiative has a named manager and a designated clinical lead drawn from amongst the

elected GP clinical commissioners, and initiatives are aligned to our strategic priorities.

All new initiatives are subject to the QIPP Gateway process, which ensures that business

cases for new initiatives meet the required quality standards as well as producing a

productivity benefit.

The programme is reviewed through regular operational QIPP meetings, and is further

scrutinised by the CCG Finance, Performance & QIPP Sub Committee as well as the

Greenwich Clinical Commissioning Committee. The CCG is also held to account on QIPP

delivery through bi-monthly stock take meetings with South East London cluster colleagues,

in their shadow National Commissioning Board performance management capacity.

These governance arrangements ensure that grip is maintained on the delivery of the QIPP

programme, both in terms of financial savings, but crucially also in respect of quality.

61

The following table sets out the QIPP programme requirements up to 2014/15. It translates our

original plans which were completed on a Primary Care Trust basis, into a high level plan which

outlines the QIPP requirement from each receiving organisation. It is expected that receiving

commissioning organisations will assume responsibility for on-going QIPP savings commensurate

with existing published plans :

CCG Primary

Care

Specialised

Commissioning

Total

£'000 £'000 £'000 £'000

Forecast Surplus/ (Deficit) 2011/12 4,770

QIPP savings requirement 2012/13 (8,892) (1,000) - (9,892)

QIPP savings requirement 2013/14 (6,117) (1,000) (700) (7.817)

QIPP savings requirement 2014/15 (2,857) (500) (554) (3,911)

Total QIPP savings requirement (17,866) (2,500) (1,254) (21,620)

"No Change" Forecast Surplus/ (Deficit) 2014/15 (16,850)

Appendix 3 shows a summary of the QIPP Programme for 2012/13 for Month 5.

62

3.5 Summary Income and Expenditure Plan

Financial plans have been updated for each the three financial years 2012-13 to 2014/15 based on

NHS London planning guidance and locally developed investment and QIPP plans. Changes to

income and expenditure are set out below:

2012/13 2013/14 2014/15 Total 2012/13 - 2014/15

£'000 £'000 £'000 £'000

Income

Recurrent Uplift 13,383 9,085 10,151 32,619

Prior Year Surplus brought forward 4,612 4,710 4,830 14,152

Total Income Changes 17,995 13,795 14,981 46,771

Expenditure

Net Generic Uplifts

Tariff and generic uplifts 8,658 8,154 8,190 25,002

Efficiency with Tariff (13,629) (12,065) (12,078) (37,772)

Net Tariff/ Generic Uplift (4,971) (3,911) (3,888) (12,770)

Demographic & Non-Demographic Growth

Demographic Growth 5,698 4,704 6,434 16,835

Non-demographic growth 4,506 4,024 3,990 12,520

Total Population & Incidence Growth 10,204 8,728 10,424 29,356

Investment Proposals and cost pressures 8,043 10,225 6,472 24,740

QIPP Savings Initiatives (9,892) (6,117) (2,857) (18,866)

Change in Recurrent Expenditure 13,285 8,965 10,151 32,401

Surplus/ (Deficit) 4,710 4,830 4,830 14,370

Planned surplus as % of Recurrent RRL 1.02% 1.26% 1.22% 1.16%

63

3.6 Investment Proposals and Cost Pressures

CCG investments and cost pressures have been included in financial plans for all years. For 2012/13

this includes detailed expenditure plans in line with the 2012/13 Operating Plan. Further details are

included below:

2012/13 2013/14 2014/15

Total Total Total

Applications £'000 £'000 £'000

Contingency Reserve changes 7,287 4,493 2,604

Additional Non Acute Contingency 0 1,575 0

Prescribing Uplift 1,255 1,385 1,265

Non recurrent Investment Pool 268 181 202

QIPP Investment Proposals 2,712 751 401

Tariff Uplift not in line with national averages(net) 488 0 0

Cancer 500 1,000 1,000

Carers 500 500 500

Health Visitors 400 400 400

IAPT 100 100 100

Children & Young People (Business Case) 153 0 0

Known tariff changes 58 0 0

MFF – GSTT payment cap 160 0 0

LAS 250 0 0

Reablement (matched to increase in funding) 794 0 0

CQUIN increase from 1.5% to 2.5% 3,117 0 0

Total Expenditure before QIPP savings 18,042 10,385 6,472

64

3.7 Ensuring Financial Delivery through Transition

The complexities of transition pose a challenge in terms of managing financial risk. The CCG intends

to mitigate financial risk through a variety of mechanisms:

A 0.5% general contingency reserve

£1.4m reserve for client groups

Assumed return of 2% non-recurrent funds

Additionally NHS Greenwich CCG is collaborating with other SE London CCGs to mitigate and

effectively manage financial risks, working together and with other health partners and public

sector organisations. A range of risk management approaches are encompassed within our overall

risk sharing framework including actions through;

Individual CCG financial controls and governance through budgetary and other risk and

contingency management frameworks

Risk sharing with local commissioning partners, including local government, such as through

joint commissioning arrangements

Risk sharing with providers through contractual agreements to incentivise service change

and QIPP delivery

Risk sharing and pooling across CCGs to reflect approaches to sharing risk in specific

commissioned services and to support the delivery of shared programmes

Mutual Financial Aid to support delivery of individual CCG financial targets in the short term,

assist recovery and sustain on-going strategic direction without destabilising the health

economy.

A framework for financial risk management across SE London CCGs has been defined and set out in

terms of a stratified approach, as follows:

Risks managed by individual CCGs and through local shared arrangements joint

commissioning arrangements

Risks managed through collaborative CCG risk sharing commissioning arrangements

Risks managed through Mutual Financial Aid arrangements to ensure all CCGs in SE London

can support each other achieve their annual financial outturn targets in a way that supports

the SEL health economy to support sustainable underlying financial balance. Arrangements

to be incorporated into a Memorandum of Understanding setting out the conditions under

which Mutual Financial Support is given or received and the obligations on the partners.

65

Section 4: Delivery

4.1 Implementing the Plan and Commissioning Intentions for 2013/14

Table 4 below summarises the plans to improve quality and deliver QIPP in 2012/13, and the

Commissioning Intentions for 2013/14. Further details are available in Appendix 5.

Strategic

Priority

Plans to improve quality and

deliver QIPP in 2012/13

CCG Commissioning Intentions 2013/14

Staying healthy

& health

protection

Reduce the level of obesity in adults and

children

Increase the numbers of people quitting

smoking with NHS stop smoking services in

Greenwich

Continue to implement the new NHS

Health Checks programme in Greenwich,

reducing the major risk factors for vascular

disease `

In conjunction with London-wide TB

programme, improve the early detection

and effective treatment of TB in

Greenwich

In conjunction with London-wide Cancer

programme, improve coverage of cancer

screening programmes in Greenwich

Improve the coverage of childhood

immunisation

Improve sexual health by reducing latediagnosis of HIV, reducing teenageconceptions, improving the early detectionand treatment of chlamydia and improvingaccess to sexual health and contraceptiveservices

Future delivery of ‘Staying Healthy & Health

Protection’ priorities for Greenwich to be undertaken

by the public health function now being transferred

to the local authority. Close partnership working

between the CCG and the local authority, including

through the Health and Wellbeing Board and

Memorandum of Understanding will be put in place

to ensure this strategic priority continues to be

delivered.

Primary and secondary prevention will be

incorporated into all work streams led by NHS

Greenwich CCG. Contract levers such as CQINs will

be used to incentivise improving outcomes and

reducing inequalities. NHS Greenwich CCG has

adopted the Greenwich Health and Wellbeing

Strategy and is showing leadership in its

implementation with partners in Greenwich,

Improving

Mental Health

Care

Deliver Acute service redesign reduction in

acute bed services and an increase in

community based care

Identify Single point of access to MH

services through introduction of a referral

management system.

Use contract levers, or market testing, to seek out

innovations in provision that bring together mental

health with community health services (No Health

without Mental Health). and improve quality

Re-balance of acute care beds for older adults with

community provision including integrated care at

home including home treatment services for

66

Establish a short break Service

Support a Shared Care Model of servicedelivery

Continue to Increase Access toPsychological Therapies (IAPT

Work jointly with partners in the LocalAuthority to test the market for a ComplexNeeds Recovery Service

Develop an Integrated Care System forOlder people and Dementia

Undertake a review of Child andAdolescent Mental Health

patients with Dementia

Undertake a strategic review of the Assertive

Outreach Team

Continue to develop a potential model for a Referral

Management System with a Single Point of Access

providing, advice, telephone consultation, screening

& triage to most appropriate services.

Provide a more community based, flexible and

integrated Children and Adolescent Mental Health

Service (CAMHS) model (see also Commissioning

Intentions for Children and Young People)

Expanding the IAPT service at Greenwich Time to

Talk to focus on patient with LTC, medically

unexplained symptoms and difficult to reach groups.

Provide evidence based IAPT interventions for

patients with Learning Disabilities

Support General Practice to improve the Quality

and Management of General Practice Mental Health

Services and Referrals.

Reduce out of area placements and develop services

closer to people at home in Greenwich

Children andYoung People’sServices: Awhole systemapproach,focusing onprevention anddevelopingintegrated carepathways andservices

Procurement of an Integrated Care Service

for children with complex needs –

(completed)

Deliver a Prevention programme with

focus on obesity and fitness levels, sexual

health, psychological well-being, the health

of children from BME communities and

improving health outcomes for mother and

babies.

Undertake a strategic review of Child and

Adolescent Health Mental Health Services

(CAMHS) - (completed)

Deliver the Integrated Care Service for children with

complex needs

Provide a more community based, flexible and

integrated Children and Adolescent Mental Health

Service (CAMHS) model (see also Commissioning

Intentions for Mental Health)

Review current acute paediatric models of provisionand commission a service that meets the full rangeof acuity of needs that arise from a service modelagreed with the provider. Review to includecontracting methodology.

Review Maternity Services in order that Greenwich

commissions the best possible model in line with

national guidance

Review Unplanned Care for Children and assess

efficiency of multiple access points for children with

minor illness.

Continue with prevention programme for children

67

with a focus on obesity and fitness levels, sexual

health, psychological well-being, the health of

children from BME communities and improving

health outcomes for mother and babies (to be

delivered by public health function within local

authority)

Improve long

term conditions

care

Finding the Vulnerable. Increase casefinding, capacity and coordination ofservices to prevent unnecessary admissions

Deliver Integrated Primary Care Model –(intermediate care, an extended JointEmergency Team (JET) service, &anintegrated health and social care team).Capacity to be put in place equivalent totwo acute wards.

Expand rapidly intermediate care at homecapacity. Business case in development fornext stage of the model.

Work with general practices to reviewpatients on the register and improve carefor patients at highest risk of hospitaladmission, building on the initialengagement of GPs into clinicalcommissioning.

Provide specialist care to Greenwich

residents living with COPD through the

specialist community COPD Service

Deliver specialist, multi-professional

community Diabetes Service through

community diabetes clinics and home visits

to patients who are housebound.

Pilot Diabetes ‘Evidence Into Practice’

project - A GP practice based programme

that provides facilitated, structured

management of people with diabetes.

Improve wound management, improved

prescribing of SIP feeds, scriptswitch

deliver through a Medicines Management

programme.

Commissioning for Transformational Change. We

will be working across BBG to commission at scale

for selected LTC services, applying evidence of best

practice in the BBG context, working to shared

standards but with local adaptation and

implementation to modify the overall approach to

suit local needs. (See work with Bexley and Bromley

to implement the Plymouth model of diabetes care

below).

Our Finding the Vulnerable programme will

continue to target a range of patient and population

groups who – for reasons of physical and or

psychological ill health – may find it harder to access

health care or use health services for potentially

avoidable problems

Support the role of the GP. Work with general

practices will continue to aim to reduce variation in

general practice treatment of people with Long

Term Conditions. We will be finding ways to focus

their attention on complex patients at high risk of

Emergency Admissions.

Continue to build on the success achieved by theCOPD service leading to a reduction in the use ofacute services and possible admission.

Support Patient Self Care by ensuring pathways

include education and self care after diagnosis.

Consider psychological support to deepen patient’s

ability to cope, self-manage, incl. links to IATP

Target specific long term conditions in line with our

overall focus on transferring care into community

settings, working to develop a range of innovative

LTC clinics working in an integrated way with

specialists, GPs and other clinicians.

Build on the success of the Diabetes into Evidence

programme at delivering improved clinical

outcomes, continuing support and skills

development for primary care teams will

compliment the development of the new BBG

68

diabetes model.

Commission with Bexley & Bromley a new Diabetes

Model of Care that makes a clear distinction

between what is done in an acute trust and what is

not done, adopting the Plymouth model.

Review Stroke service and early supported

discharge for stroke

Review the delivery of Asthma care in primary care

to identify ways to improve the quality of the

service with a view to implementing an integrated

early supported discharge service

Co-ordinate the

provision of

urgent care

Develop a Whole systems Urgent Care

Model for an integrated urgent care system

enabling the development of a specification

to tender.

Deliver an Urgent Care Centre providing

both minor illness and minor injury services

within the Emergency Department and

operates from 8am until 10pm, seven days

a week,

Continue to deliver a Greenwich Virtual

Admissions Avoidance Team (VAAT)

consisting of representatives from

community services including the JET, Falls

Team, COPD Service, Continence, Long

Term Conditions and District Nursing.

Continue to deliver a Joint Emergency

Team (JET) of health and social care staff

providing swift assessment and

management of clients that require urgent

intervention.

Identify opportunities to improve access and

responsiveness in general practice to prevent

patients going directly to A&E

Continue to focus on reducing A&E attendances

from Care Homes

Identify a process for GPs to access clinical support

from secondary care specialists - Clinical

consultation, advice and supervision to help care for

difficult cases rather than admit

Discuss with London Ambulance Service the

potential to redirect ambulance patients to the

Urgent Care Centre instead of A&E – this has now

been agreed and will enacted in 12/13, ready for

13/14.

Increase

capacity in high

quality cost

effective

alternatives to

hospital based

planned care

Deliver a Referral Management & BookingService (RMBS) to reduce and improve thequality of referrals by implementing clinicalreferral pathways and triaging referrals.

Commission an Integrated CardiologyService pilot, in conjunction with Bexleyand Bromley CCGs, for an integratedcardiology service across the 3 boroughs,

Develop a full business case for communityhospital provision in Eltham. The Elthamcommunity hospital will be a key ‘enabler’to deliver our priorities and provideadditional capacity for community based

Continue to deliver the RMBS. Review and analysedata from the RMBS service to identifyopportunities for improvement including helpingGPs to follow pathways better, introducing morerobust and objective challenge procedures and toprovide more services in the community

Implement the Integrated Cardiology Service

Build capacity and capability in General Practice toinclude on-going training &good back-up support.At same time reduce variability and poor practice inprescribing, referring and clinical practice

69

services.

Undertake a review of direct accessdiagnostics to identify and reduce anyunnecessary testing.

Deliver improvements in MedicinesManagement including a shared formularywith SLHT for high cost drugs/high riskconditions, new anti-coagulation drugs,challenging payments by results excludeddrugs & management of the RAG list ofdrugs.

Implement other alternatives to hospitalbased care delivered in the community,identified as part of QIPP

Identify unused capacity in primary care settings –both in-hours and out of hours

Develop a GP engagement and marketing strategyto help GPs understand their role as a key enabler ofimproving service provision in Greenwich

Undertake a Review of how existing resources arecurrently utilised and identify how they could beutilised more effectively and efficiently withinexisting contracts.

Undertake a speciality by specialty ‘Outpatient CareAudit’ to identify potential to transfer OutpatientCare to community care based settings.

Reduce unnecessary follow ups in secondary,community & primary care. Adopt practice of ‘nofollow-ups unless there is a specific reason i.e.clinical or patient request’ to reduce the number ofunnecessary follow ups and Do Not Attends. Thiswork is being led through the Transformation Boardacross BB&G which is driving the changeprogramme at SLHT in this area.

Undertake Pathway Redesign in Primary Care for

Ophthalmology and Dental Services. Skilled primary

care practitioners, such as dentists and

optometrists, are well placed to deliver part of the

patient pathway in primary care instead of in

secondary care.

Enhance end of

life care

Pilot an integrated model of care which

aims to reduce inappropriate hospital

admissions and enable more patients to die

in their place of choice. Consists of a

palliative care co-ordination centre, a rapid

response unit, multi visit personal care and

support service & planned night care

service.

Implement best practice pathways

Procure the piloted end of life care model so that itbecomes a substantive service available to thepopulation of Greenwich in the last year of life.

Continue to implement best practice including the

Liverpool Care Pathway and Gold Standard

framework

Community

Services

n/a The contract with Oxleas NHS Foundation Trust forcommunity services comes to an end on 13 March2013. The contract will be extended for 6 monthsand it is intended to go out to tender to reprocurecommunity services early in 2013/14

70

4.2 What are we proud of? Success stories in delivering the Plan

Integrated Care System

Greenwich is in the process of drawing together existing care provision by primary, community,acute health and social care into and integrated care system. The aim is to ensure that patientsexperience integrated care, designed around their needs, and delivered by health and social careprofessionals with the necessary skills and qualifications. The first stage of this development hasbeen a rapid expansion of capacity to deliver intermediate care at home as part of the step up andstep down provision of nursing care, supporting both hospital admission avoidance and promptdischarge. Fully integrated community services provided by Oxleas and the Royal Borough ofGreenwich Social Services acting as one integrated team. This innovative approach has beenrecognized nationally when the team won the national prestigious National Health Service Journalaward for team engagement and was chosen by the Secretary of State as the overall winner ofwinners recognising the significant improvement in patient care that this has brought.

Outcomes: As at August 2012, capacity to support 53 people at home has been put in place, from a

base of approximately 25, i.e. a doubling of capacity, contributing to reduced length of stay for

medically fit patients (see below).

Referral Management & Booking Service (RMBS)

The Greenwich RMBS aims to reduce and improve the quality of referrals by implementing clinical

referral pathways and triaging against them, ensuring appropriate pre-diagnostic work is completed

prior to referral, re-directing activity to appropriate community services and challenging

inappropriate referrals. The service has been introduced on a phased basis, and currently 34 out of

45 practices are live on the RMBS, equating to approx. 3,900 referrals per month, and will handle

approx. 5,000 referrals per month by April 2013. Of 4,193 referrals triaged to date 2,925 (70%) were

71

referred onto secondary care, with 401 being returned to the GP (c.10%) and 867 referred to an

alternative community service (c.20%).

Outcome: established an improved process of referring patients from primary to secondary care withfewer wasted patient journeys and increased choice.

Other direct benefits of the service include:

Real time referral information by practice, GP, specialty and clinic type

Increase of Choose and Book utilisation across Greenwich from 28% to 60% to date

The RMBS has developed into a tool to enable other QIPP referral initiatives to be implemented, for

example procurement of Any Qualified Provider (AQP) alternatives to hospital based care for Minor

Surgery, Dermatology and Gynaecology that have improved access and patient choice.

Greenwich Virtual Admissions Avoidance Team (VAAT)

Established in 2009, the Greenwich VAAT consists of representatives from community services

including the JET, Falls Team, COPD Service, Continence, Long Term Conditions and District Nursing.

The team works collaboratively with London Ambulance service and primary care services to prevent

unnecessary A&E attendances and hospital admissions and has developed a range of clinical

pathways including lower limb cellulitis, continence (UTI), COPD, falls, blocked catheters and

palliative care. The team engages in rapid assessment and decision making and close liaison with

other health and social care services.

Outcome: The team has supported LAS in achieving a 33% reduction in the number of patients that

are conveyed to hospital overall, in the last year, the highest reduction anywhere in London.

Joint Emergency Team (JET)

JET was established in April 2011 as a multidisciplinary team of health and social care staff providing

swift holistic assessment and management of clients that require urgent intervention within 24

hours of the referral, responding to all urgent referrals within 2-4 hours. Interventions include re-

ablement at home or access to intermediate care rehabilitation with a range of high clinical and low

social and low social and high clinical services.

Outcome: In its first year JET has prevented a total of 521 A&E attendances 448 unnecessary

hospital admissions.

Urgent Care Centre

Following the successful pilot of an Urgent Care Centre at the Queen Elizabeth Woolwich site, a UCC

has been procured from the Hurley Group and commenced in December 2011. The service provides

both minor illness and minor injury services within the Emergency Department and operates from

72

8am until 10pm, seven days a week, with extra sessions commissioned on an ad hoc basis to cover

periods of anticipated increased demand, e.g. during the Olympics, bank holidays.

Outcome: Since the service went live there has been a significant shift in activity, with A&E activity

down substantially compared to the same period the previous year, and the A&E achieving

sustained improvement in waiting times. A significant shift in activity has occurs as per the graph

below, while at the same time A&E performance at the QEW site has seen sustained improvement

(95.51% at QEW w/e 22/07/2012)

Lower Limb Service

The LLS is able to prevent hospital attendance and admission by seeing patients in clinics, LEG

Groups and their own homes, and if necessary admitting patients to intermediate care beds for

intravenous antibiotics. The LLS has worked with London Ambulance Service to develop pathways

for patients with cellulitis to ensure that they are transported to hospital if necessary but referred to

LLS if this is more appropriate. Treatment is provided where appropriate and preventative advice for

those who have come through the acute phase.

Outcome: Admissions avoided in 2011/12 – 89

End of Life Care

A Greenwich Care Partnership operates alongside and supports existing core services (GP’s, district

nurses, specialist nurses etc.) to provide high quality care for patients with end of life needs in the

Royal Borough of Greenwich. Three organisations – Greenwich and Bexley Community Hospice,

Marie Curie Cancer Care and Oxleas Community Health Services are working in partnership to

provide this integrated model of care which aims to reduce inappropriate hospital admissions and

enable more patients to be cared for and to die in their place of choice by ensuring that appropriate

health and personal care services are available and that their families and/or careers have sufficient

practical and emotional support. The service consists of four integrated elements:

A palliative care co-ordination centre

A rapid response unit

Multi visit personal care and support service

Planned night care service.

Quantitative outcomes: Pilot still subject to evaluation, but currently the service that 52% of

patients referred to the service were able to die in the place of their choice, and a greater % of

people are dying at home or in a hospice.

73

Urgent Care Centre

An Urgent Care Centre is based on the Queen Elizabeth Woolwich site in A&E, and is run by the

Hurley Group.. The service provides both minor illness and minor injury services within the

Emergency Department and operates from 8am until 10pm, seven days a week, with extra sessions

commissioned on an ad hoc basis to cover periods of anticipated increased demand, e.g. during the

Olympics, bank holidays. Since the service went live there has been a significant shift in activity, with

A&E activity down substantially compared to the same period the previous year, and the A&E

achieving sustained improvement in waiting times.

Quantitative outcomes: A significant shift in activity has occurred(see graph below), while at the

same time A&E performance at the QEW site has seen sustained improvement (95.51% at QEW

w/e 22/7/12)

Falls Team

The Falls Team is a community based specialist service working with older adults in their own homes

(including care homes) to prevent falls and injuries, working jointly through a dedicated social care

link for falls. The team has received a number of awards; from the Chartered Society of

Physiotherapists for its case finding approach, and from the Health Service Journal (HSJ) in 2010 as

part of the successful admission avoidance team, and again from the HSJ in 2011 as part of the

integrated health and social care staff engagement award.

Quantitative outcomes: of 210 reviews carried out in 2011/12 86% had not fallen in the following

6-9 months, and there were zero serious injuries or fractures.

Diabetes – Community Services

74

Greenwich has commissioned a specialist, multi-professional community diabetes service from

Oxleas NHS Foundation Trust for patients with Type 2 diabetes requiring Tier 3 services who may

previously have been referred to hospital. The service is delivered through community diabetes

clinics in a number of different locations and through home visits to patients who are housebound,

and aims to:

Case-find new patients and improve clinical outcomes

Shift outpatient activity to community settings.

Reduce A&E attendances and non-elective acute admissions

Outcomes: The service went live in 2011/12 and has succeeded in shifting activity to the

community as indicated by the graph below:

Diabetes National Audit

The Diabetes National Audit identifies key findings about the quality of care for people with diabetes

and in 2011/12, through a supported programme to practices, Greenwich's participation rate

increased from 8.7% to 93.3% thus facilitating the availability of valuable comparative data. The data

has shown many improvements across the board as a result of a number of initiatives implemented

by commissioners including the development of diabetes guidelines, the extension of the

community diabetes services and the Evidence into Practice programme.

Quantitative outcomes: From a previous bottom quintile position, Greenwich PCT has moved to

the 2nd quintile for achievement of all NICE recommended diabetes care processes with over 55%

of individual care processes being in the first two quintiles. In terms of achievement of

NICE recommended treatment targets, Greenwich has moved from ranking in the

bottom quintile to the 3rd quintile overall and is now above the national average for BP at target

level and HbA1c <6.5%.

75

Evidence into Practice Diabetes project (award winning project)

A GP practice based programme that provides facilitated, structured cardio-metabolic risk

management of people with diabetes and supports the sharing of best practice. The programme is

designed to improve the health outcomes of people with diabetes through the implementation of

national and/or local guidelines.

Quantitative outcomes: The pilot indicates a decrease (5%) in outpatient diabetic medicine

attendances and circulatory admissions (1%) as compared to increases of 11% and 13%

respectively in the non-pilot group, as well as relatively fewer CHD and stroke admissions for the

pilot group - anticipated savings following roll out to all practices c. £730k.

Impact of the EVIDENCE into PRACTICE™ programme on Diabetic 25 Medicine Outpatientattendances and CVD admissions in NHS Greenwich pilot sites (14) compared to non pilotsites (32). Figures standardised per 1000 patients with diabetes.

Data on File NHS Greenwich, September 2011

Outcomes:Evidence into Practice: Pilot

NHS Health Check PLUS Programme

Programme targeted at 40-74 year olds without known CVD. Aims to assess risk of heart disease,

stroke, kidney disease and diabetes and support people to change lifestyle and provide treatment

where necessary to reduce that risk.

Quantitative outcomes: 20,797 health checks have been undertaken in 10-12, No 1 in London, 3rd

nationally for coverage - based on findings in 1000 sample cohort, we have found estimated 3219

people with high CVD risk (>20%), 357 people with previously undiagnosed diabetes, 915 with pre

diabetes, 4167 with elevated BP, rate of increase in CVD disease registers largest in sector.

NHS Greenwich has made major changes to health provision across the borough and has created the

turnaround necessary to improve healthcare for those in Greenwich from 2012 onwards. This

turnaround is characterised by a systematic understanding of the following:

Whole system sign up

Using every contract lever to implement and sustain change

True ‘live’ partnership and joint working

Recognising and hearing the clinical voice, and Achieving cost benefits without compromising quality or value44 69,304 460 0.7

People with diabetes 3,330 3,500 170 5.1Hba1c at target 715 890 175 24.5BP at target 1,195 1,308 113 9.5

76

4.3 Managing provider performance

Mental Health/Community Services

As commissioners we set the agenda for our regular performancemeetings with our main providerof Mental Health and Community Services, Oxleas NHS Trust, as well as asking for additional itemsfrom the trust to assure quality of services delivered. The performance reporting and activity data isin a format that is reviewed annually , as part of our contract negotiations with Oxleas, and this hasbeen undertaken with Bromley and Bexley CCG colleagues, and has resulted in being modified overtime to meet the needs of our patients and our changing requirements.

For example, for services commissioned for adult mental health (including over 65’s), CAHMS, IAPTand LD, CCG commissioning managers meet with Oxleas once a month with a standing agenda thatincludes: Performance and activity reporting, SI’s and complaints and delayed discharges/transfersof care and key indicators within each service line including acute bed/demand management andaccess to Crisis and Home treatment teams, Memory assessments in older adults and number ofpatients in recovery having accessed IAPT.

For CAHMS and LD–a schedule is in place where the Business managers from Oxleas CAHMS, LD,Older adults and IAPT present, at scheduled times across the year, to commissioners a more detailedperformance report. During 11/12 In the case of CAHMS – this is how we picked up that there wereissues with referral being accepted by the service and this precipitated our drive to review CAHMSservices.

Acute Contract DevelopmentWhilst CCGs in South East London (SEL) have responsibility for initiating the 13/14 QIPP planningprocess, the South London Commissioning Support Unit (CSU) provides support to translate CCGQIPP proposals into 13/14 activity and finance plans with acute providers.

Once NHS Greenwich CCG confirms their Commissioning Intentions for 2013/14, specifically anysignificant changes to acute contracts and planning assumptions for 2013/14, the CCG will meet withthe CSU to agree the approach and set out a high level and a detailed timetable. A formal letter willthen be sent to the acute providers outlining parameters and priorities for 2013/14 negotiations,including;

six months’ notice for any significant change in contract, including notification of termination ofcontracts.

overall process and timetable

process for determining agreed service developments

The CSU will translate the CCG Commissioning Intentions into contract proposals, including theutilisation of contracts levers, tools and techniques as appropriate and agreed activity planningassumptions. Following negotiating meetings the CCG will agree indicative financial envelopes foracute contracting, including reserves. The trusts will issue a costed response to the CCGs proposals,leading to an agreed sign off of the core contract related contract documentation and final costedproposals.

Acute Contract Management

77

The management of the delivery of the acute services contract is delivered by the CSU through anumber of mechanisms including a Senior level Contract Management Board that includes theAccountable Officers of the SEL CCGs and a Joint Transformation Board.

For example, for the South London Healthcare Trust (SLHT) current contract:

• Greenwich’s contract for 2012/13 assumes delivery of 2% acute productivity savings (c.£14m impact on SLHT). Delivery of these savings is monitored by the joint ClinicalTransformation Group (CTG), jointly led between SLHT and the Bexley, Bromley and NHSGreenwich CCGs.

• The CTG is responsible for monitoring delivery and recommending/taking corrective actionwhere necessary. Leads have been identified for each of the productivity opportunities andplans are reviewed at the CTG meetings.

• Where an opportunity looks likely to under deliver the Trust, with the support of thecommissioners, will need to identify or expand delivery of the remaining opportunities toclose the gap

• The CTG reports to the Contract Management Board where Greenwich is represented bythe Accountable Officer and the GP Acute Contracting lead.

Annabel/SharonDomain 1

GREENWICH HEALTH

Lauren/Sim/Sherry D

R

REBECCA

ROSEN

Oxleas

Community

Contract

Long Term

Conditions

Dr K J

an-M

ohamed

– Clin

ical L

ead

Sar

ita A

dams –

Non

Clin

ical L

ead

KEY TO

SYNDICATES

1 - Woolwich/Thamesmead

(Flamsteed)(Pateur)

2 - Excel/Waverley

(Halley)(Lister)

3 – GPCC

(Bradley)(Fleming)

4 – Eltham

(Maskelyne)(Crick)

5 - Blackheath/Charlton

(Pond)(Watson)

Mental

Health

Business

Intelligence

DR HANY W

AHBA

Governance/

H&WBB

Clinical

Strategy

DR

NAYAN

PATEL

SLHT

Contract

Monitoring

Planned

Care &

Utilisation

Review

Dr Sajiv Gupta –

Clinical lead

Prithipal Bhambra

– Non clinical Lead

DR

NAYAN

PATEL

Quality

(interim

Dr Rosen)

End of Life

& Cancers

(interim

Dr Rosen)

Vacant

Dr K

risha Subbarayan

Clinical Lead

David Jam

es –

Non clinical Lead

Vacan

t

DR

EUGENIA

LEE

Safeguarding

Adults

(interim

TBC)

Unplanned

care

(interim

Dr Wahba)

Health &

Wellbeing

Partnership

Maternity,

Womens

Health,

Children

Dr Paul M

cGarry -

Clinical L

ead

DR

JU

NA

ID

BA

JW

A

Dr Y

an

n L

eF

eu

vre

–

Clin

ical L

ead

Kevin

Ryan

–

Non C

linic

al le

ad

Domain

6

KEY TO DOMAINS

1 = strong clinical and multi-

professional focus, which

brings real added value

2 = Meaningful engagement

with patients, carers and

communities

3 = Clear and credible plans to

deliver QIPP within financial

resources, in line with national

requirements and local joint

health and well being strategies 4 = Proper constitutional and

governance arrangements to

deliver all duties and

responsibilities, and

commission effectively

5 = Collaborative arrangements

for commissioning and

appropriate commissioning

6 = Great leaders who

individually and collectively

can make a difference

Domain 3

Domain

5

Domain

4

Domain

2

Sharon

Davidson

All CCG

Managers

Alun

Baylis

Andrew

Thomas

Abi

Ademoyero

Chris

Costa

Irene

Grayson

Nicola

HavutcuAlison

Goodlad

Langley

Gifford

Sandra

Wallace-Millwood

& Mousumi

Kumar

Yvette London

& Kerry

Cleaver

Version 6

12-09-12

Nigel

Evason

Nicola

Havatcu

Chris

Costa

Nicola

Havatcu

Clinical

Project

LeadsPool Clinical Project Lead = Dr Vijay Bajpai

Dr Ngozi

Nwanosike

Dr Meena

Bajpai

Dr Ram

Aggarwal

Dr Ram

Aggarwal

Dr Mukul

Agarwal

(Planned Care

and IFR)

Dr Ranil Perera

(RMBS)

Dr

Gurpreet

Singh

Vacant

Appendix 2 Table demonstrating Greenwich CCG’s Compliance with the National Operating Framework 2012/13

Directive Requirement Progress

Dementia & Care of

Older People

OF Reference:

Section 2.08

Quality accounts.

Work with GPs to ensure improvements ingeneral practice and community servicesincluding improvement of diagnostic rates.Ensure participation in and publication ofnational clinical audits.Outline initiatives to reduce inappropriateantipsychotic prescribing.Continued drive to eliminate Mixed SexAccommodation.Reporting of inappropriate admission rates.Non payment for emergency readmissionswithin 30 days of discharge from electiveadmission.Ensure providers are compliant with NICEquality standards and information published inprovider

Ensure providers are compliant with NICE quality standards andinformation published in provider quality accounts: Theestablishment of Quality Meetings with Oxleas ensures that there is on-going review of the progress being made in respect of the delivery ofservices benchmarked against NICE quality frameworks andindicators agreed in the Quality and Safety Improvement Plan andCQUIN goals. Over the next year we will continue to monitor progressagainst the CQUIN indicators and the three quality domains – PatientExperience, Patient Safety and Clinical Effectiveness and work withservice users and carers to insure information is shared andappropriate training is available for health care professional.Work with GP’s to ensure improvements in General Practice andCommunity Services including improvements in Diagnostic rates:The provision of the Memory Assessment Service has seen anincrease in the number of diagnostic assessments in the last year and itis estimated that 46% of the predicated number of people withDementia in Greenwich receive a diagnosis. This number is expectedto increase as GP’s become more aware of the need for earlydiagnosis, patients, Carers and relatives respond to high profilecampaigns promoting the need for diagnosis and early treatment andhealth care professionals in acute settings receive Dementia trainingEnsure participation in and publication of national clinical audits:We are seeking to improve participation in national audit and wouldhope to confirm a programme of participation in national audits over thecoming year. Our local provider of Mental Health Services hasparticipated in the national POMH-UK audit of prescribing antipsychoticmedication for people with DementiaOutline initiatives to reduce inappropriate prescribing of anti-

psychotic medication: Following the POMH-UP audit, GP reviews inrespect of prescribing has commenced in partnership with Oxleas.Following completion of the reviews, if necessary, an Action Plan will beconstructed to support the need for regular monitoring and review.Continued Drive to eliminate Mixed Sex Accommodation:Reporting of inappropriate admission rates. Local mental healthservices are compliant with privacy and dignity requirements andelimination of mixed sex accommodation. Any breach in same sexaccommodation requirements is received in the reporting data fromproviders and monitored through the course of our contract monitoringarrangements.Non-payment for emergency admissions within 30 days ofdischarge from elective admissions: We have agreed proposals in2011/12 contracts for non-payment for emergency readmissions within30 days of discharge from elective admissions and propose a similaragreement for 2012/13 with commensurate re-investment in schemesto prevent inappropriate readmission.

Carers

OF Reference

Section 2.11

Publication by 30 September 2012 of LocalAuthority and PCT Cluster joint needsassessment with agreed plans policies andidentified budgets with Local Authorities andvoluntary groups to support carers.

To include identification of total budget to

support carers breaks and indicative number of

breaks available within the budget.

The Current Carers Strategy (2011/2012) will be reviewed and arevised version will be signed off by the Joint Commissioning Group inJune 2012 and published by September 2012. The Local Authority willlead on this process, with full engagement of NHS partners, thevoluntary sector, user groups and other stakeholders. The work will bemonitored through the Joint Commissioning Group for Older Adults andreport into the BSU/ clinical commissioning group.

The council has Service Level Agreements (SLAs) in place as follows:

Greenwich Carers Centre: provides information advice, advocacyand building social capital for carers. Adults and Older PeopleServices provides £148k funding and Children's Services funds£74k;

Crossroads provides a Carers Dementia Cafe - £19,500 from Adults

and Older People Services Volcare provides a Sitting Service - £37,000 from Adults and Older

People Services

Carer’s can benefit both directly and indirectly by the services providedto the cared for person. Therefore, the current support package inplace for the cared for person will be considered to ensure the carer’sneeds have been properly reflected in the service users PersonalBudget. Funding for carers was earmarked in 2011/12 in line with the2011/12 operating framework. Year to date, the uptake against thisallocation equates to approximately 50%. We currently fund:

Bedded respite services for people with learning disabilities andmental health

Additional hours of home care support to relieve carers of peoplewith continuing health care

Specialist respite services for people with complex and severehealth needs

Top up of placements within care homes for short breaks

Greenwich have a four year allocation towards developing andsupporting services for carers of £547, 755. £3,492 per annum isdirectly pooled with the local authority and the remainder supportshealth and social care clients packages of care as well as carersevents. We currently fund:

Bedded respite services for people with learning disabilities andmental health

Additional hours of home care support to relieve carers ofpeople with continuing health care needs

Specialist respite services for people with complex and severehealth needs

Top up of placements within care homes for short breaks

An Older Adults Joint Commissioning Plan and revised governance

structures are being reviewed and will be in place by April/May 2012.

This will not be age specific and will include dementia and cognitive

impairment workstreams.

Military & Veterans

Health

OF Reference

Section 2.12

Work with the London Armed Forces Networkto ensure the principles of the Armed ForcesNetwork Covenant are met for the armedforces, their families and veterans.

Ensure that the Ministry of Defence/NHSTransition Protocol for those who have beenseriously injured in the course of their duty isimplemented in any commissioned service.

PCT Clusters, and organisations they

commission from, should be supportive

towards those staff who volunteer for reserve

duties.

Greenwich has historically had strong ties with the military. Woolwichbarracks is home to two battalions and living quarters for currentservice personnel. Currently a small station command team is based atWoolwich barracks while the Princess of Wales troop are overseas –approximately 500 soldiers. Their families and about 200 - 300 childrenare at home in Woolwich. The King's troop (Ceremonial), a small unitwith about 36 horses - arrived on Feb 6th 2012.

We support the London Armed Forces Network with our Local Authorityto ensure that we understand any impact of having a military barracksin the Borough and the needs of current and ex-service personnel thatmay need support form statutory services outside of Ministry ofDefence provision.

Greenwich has formed links with military health leads within theborough and begun to map out how we can support them with theirdelivery of healthcare for physical and mental health. Defencerepresentatives that oversee healthcare delivery across South EastLondon. We will also assess the numbers of service personnel thatretire on health grounds within the Borough, the needs of the families ofservice personnel and veterans and ensure that we link moreappropriately with our Local Authority colleagues across housing,education, adult and children’s services.

We have developed IAPT in Greenwich with local veterans being a

priority target group. We will review activity to ensure appropriate takeup of services. PTSD treatment is available from our local secondarycare provider and additional services are purchased from otherspecialist providers if local services are not appropriate.

We commission quick access to prosthesis for current and ex-servicepersonnel and work with sector leads to ensure access to individualand exceptional treatments. Existing services provided withinGreenwich will link with future Pan London and National strategies.

We are currently reviewing care services available to service personnel

and their families and working with our local GP practices within

Woolwich to support existing health services provided by the MoD and

to ensure appropriate access to services for ex veterans within

Greenwich and South East London.

Health

visitors/Family Nurse

Partnerships

OF Reference

Section 2.13

Work towards delivering provider-based2012/13 trajectories due to be issued by NHSL5th December 2011 in line with theGovernment commitment of an additional 4200by April 2015.

Maintain existing delivery and continue

expansion of the Family Nurse Partnership

programme in line with the Government

commitment to double capacity to 13,000

places by April 2015.

We intend to commission an additional 14 health visitors in the 2012 -2013 financial Year. We will commission these HV’s from two of ourcurrent Providers, Greenwich Community Health Services and theValentine.

Mental Health IAPT to meet 15% prevalence with recoveryrate of at least 50%.

Focus needed on minority groups, older

We will be continuing to support our providers to deliver a programmethat promotes Recovery and Wellbeing and challenges healthinequalities particularly amongst difficult to reach groups such as older

OF Reference

Section 2.23

people, people with serious mental illness andlong term conditions.

Reduction of mortality from physical illness inthose with mental illness.

Focus on joint working with National OffenderManagement Service.

Focus on mental health prevention in lookedafter children and other young people at risk.

QIPP achievement monitored against MHPerformance Framework covering new casesof psychosis served by EIT, gatekeeping ofacute admissions by crisis teams, 7-day postdischarge follow up for those on CPA.

Elimination of mixed sex accommodation

Continue to meet expectations within No Health

Without Mental Health and NHS

adults, people with a learning Disability, ethnic minority groups in thecommunity and patients who have a Dual Diagnosis.

This year we have also supported the permanent appointment of anEmployment Coordinator based within our IAPT service at GreenwichTime to Talk. IAPT in Greenwich is provided by Oxleas FoundationTrust at the Greenwich Time to Talk service and we are in the third yearof the contract. The service has achieved a recovery rate of 48% andfeedback from Service Users and GP’s continues to be positive. We areconfident that there will be an improvement in Recovery Rates over thecoming year through targeted projects in respect of Long TermConditions and the provision of Mindfulness Training to staff whichspecifically supports people with recurrent depression and chronicphysical health conditions such as chronic fatigue.

Over the coming year more work is needed to build on existingprogrammes to support people with Long Term Conditions and worktowards improving access to services influenced by EDS. To achievethis we will be supporting the interim appointment of a worker to startnetworking and set up collaborations with GP’s and Long TermCondition Primary Teams and acute hospital physical health Teams.We have recently agreed to jointly fund a post with the London Boroughof Greenwich which has seen the appointment of a Coordinator to theService User Involvement Group. This post will improve service userrepresentation and feedback to the Mental Health Partnership Board.

We are continuing to support local providers to identify andcommunicate with the numerous BME communities and GreenwichTime to Talk have begun some targeted work in respect of the Tamiland Somalian communities to raise awareness and improve access toprimary care and psychological services.

The CCG supports the Shared Care Model of service delivery whichsits alongside the Recovery Model and the Health and WellbeingProgramme that has been adopted in the borough. In reality thistranslates into a more holistic assessment of a mental health serviceusers’ needs including their physical health and new approaches toscreening and treating long term conditions within primary andsecondary care.

The CCG has supported the Business Case to increase the provision oflow secure Forensic hostel accommodation at the Goldie Leigh site anda corresponding decrease in the number of Forensic bedscommissioned from Oxleas. This development will come on line in2012/2013.

The CCG is currently reviewing services for Children and Young Peoplewith a view to ensuring greater continuity of care, improvingrelationships between families and services and focusing attention onprevention and early intervention.

Local mental health services are compliant with privacy and dignityrequirements and elimination of mixed sex accommodation. Any breachin same sex accommodation requirements is received in the reportingdata from providers and monitored through the course of our monitoringarrangements

Public Sector

Equality Duty (PSED)

OF Reference

Section 2.4

Include assurance that due regard is given to

the Public Sector Equality Duty (PSED), both

specific and general, and that equality

objectives are integrated into the plan

considering using the Equality Delivery System

as the framework.

Greenwich CCC signed up to the EDS as part of the PathfinderDelegation application process. An indicative grading process has beencompleted and the outcome published according to the requirementsset out. An engagement programme with local interest groups and thepublic is being delivered which has helped to provide a self-assessmentand objective setting process for our 12/13 action plan.

A major challenge in Greenwich is the limited resources available to

ensure that meaningful engagement with all protected groups takesplace.

The Equality Impact Assessment has recently been re-designed inorder to include all protected groups and will be used in theconstruction of all QIPP plans.

Safeguarding

(Children)

OF Reference

Section 2.43

Ensure a sustained focus on robustsafeguarding arrangements

To work in partnership through LocalSafeguarding Children Boards (LSCBs) andensure ongoing access to the expertise ofdesignated professionals.

Work with developing CCGs to ensure they are

prepared for their safeguarding responsibilities.

Greenwich hosts a quarterly executive safeguarding children and youngpeople meetings. This meeting is chaired by the Managing Director andsafeguarding arrangements are discussed and agreed. Thesafeguarding risk register is presented and updated at this meeting. Asafeguarding report informing the meeting of health providers' staffingand safeguarding arrangements is presented. The meeting raisesissues and assures that section 11 duties are being delivered.GSCB (Greenwich Safeguarding Children Board) reports andworkgroup reports are taken and discussed at our Board also updateon the Children Trust Board is received. An assurance reportis provided to the Board quarterly on Provider progress andperformance, and a new scorecard is in development.

In Greenwich we work very closely with the GSCB. The DesignatedNurse is based with the GSCB staff part time and the newly appointedDesignated Doctor is planning to base himself there one half day aweek. Both the Designated Doctor and the Designated Nurse attendthe workgroups and the Designated Nurse chairs the health work groupwhich has an excellent attendance. The Designated nurse and Doctormeet regularly with the independent chair of GSCB and GSCBmanager. Our clinical expertise is called upon and utilized regularly.

CCGs will need to ensure that relationships are built and maintained

with local agencies to safeguard children; this should be achieved

through the GSCB and the designated professionals who have local

knowledge. The CCGs will need to be aware of their section 11 duties

and ensure these duties are executed appropriately and that systems

are maintained to evidence this. They will need to maintain the data

bases to ensure that appropriate level of training is delivered and that

safeguarding children remains a priority focus.

Safeguarding(Adults)OF ReferenceSection 2.43

Ensure a sustained focus on robustsafeguarding arrangements.

Work with developing CCGs to ensure they areprepared for their safeguarding responsibilities.

Areas of focus are to ensure annual reviews of all vulnerable adults out

of area by Sept 2012 and to work with nursing homes to improve

pressure area care reducing grade 3’s and 4’s by 50% by acute

providers targeting homes by Nov 2012 .

The Adult safeguarding lead at cluster in post, with Greenwich

safeguarding lead relating to borough safeguarding boards.

Adult safeguarding processes and procedures in place in all Trusts and

primary care.

Adult safeguarding meetings in place to prepare Clinical commissioners

identified as adult safeguarding leads for safeguarding responsibilities.

Any Qualified

Provider

OF Reference

Section 3.21

Extend patient choice of community and mentalhealth services to AQP in 3 service lines perCluster between April and September 2012.

Outcome-based service specifications shouldbe developed with input from CCGs and

Arrangements for Any Qualified Provider are being taken forward by

NHS South East London during 2012/13. An Implementation Group

has been established to cover the three areas which have been

selected for market testing across the cluster. The Implementation

Group with have the following remit:

patients.

The nationally developed provider qualificationquestionnaire should be used to qualifyproviders.

Include further service lines as per Governmentannouncement (expected in December).

a. To oversee the implementation of AQP implementation across SELb. To actively seek to improve the quality of local healthcare throughprovision of extended choice to patientsc. To ensure that the specifications are outcome focused and relevantto local needsd. To ensure the programme is within procurement guidelines

The three areas selected for AQP implementation across SEL are:• Hearing Services• Continence Services• Wheelchairs

There will be Working Groups for each of the service areas, with inputfrom boroughs, and the Working Groups will adapt the nationalspecifications to reflect local pathways, and determine the detailedprocess for commissioning the chosen services on an AQP basis.Greenwich CCG have already successfully procured 3 communityservices in 2011/12 under the AQP process in gynaecology, minorsurgery and dermatology. This has brought 4 new providers ofhealthcare into the Greenwich health economy, providing greaterchoice for patients and out of hospital services closer to home. The newservices are being rolled out in March and April 2012. Operational andstrategic lessons learned will be applied during 2012/13 in futureservice development areas.

Informatics

OF ReferenceSection 3.26

Include evidence of consideration of informaticscapability and capacity necessary to supportthe transition.

Include a credible proposal for giving patientson-line access to their medical records, startingwith their GP records.

Greenwich CCG uses the Cluster ICT team covering Greenwich,Lambeth, Lewisham and Southwark.

The Cluster is reviewing its informatics capability (including informationmanagement, technology and governance) to ensure that it remains fitfor purpose for current and emerging organisations. Greenwich CCGhas engaged in work with the emerging Commissioning Support Unit to

Provide an achievable trajectory for providingSummary Care Records by March 2013 to allresidents who have been written to.

shape the future of ICT provision both in 12/13 and beyond. This workwill continue to inform the service offer from South LondonCommissioning Support Service programme, which will oversee thespecific development of a capable informatics service to supportemerging Clinical Commissioning Groups.

The Primary Care Directorate is working with primary care contractors,emerging Clinical Commissioning Groups and the LMC to ensure thatgiving access for patients to their GP records, and moving forwards totheir full medical record, is considered a key priority. The ICT functionwill continue to engage with clinical system providers to ensure that a)the technical capability is in place across all GP practices within SouthEast London, and b) that a deployment plan will be created inpartnership with GPs and patients to ensure that access is granted inline with national, regional and locally agreed timetables. Progress indelivering this capability will be overseen by the Cluster’s ICT SteeringGroup, supported by a Primary Care ICT Programme Board.

There are 267 practices of which 114 practices have uploaded SCRcovering 768,000 patients (41%). SEL has a project board set up tooversee SCR which meets monthly to review progress against plans.Resource has been authorised to deploy SCR to LSL-G has thenecessary required staff allocated to deliver EMIS Web and SCR withdedicated project managers, clinical transformation leads and technicalleads, and RA. Bexley & Bromley manage their deployment withcurrent resources. SEL has a Communications Strategy that sets outthe communications plan with the key stakeholders. There remains afurther 153 deployments to be completed by 31st March 2013 with 19being deployed by 31st March 2012.

Innovation Evidence the PCT Cluster is preparing toimplement the Innovation Review. Pleaseoutline the key milestones that will ensure

The CCG will review the baseline review due to be completed by NHSSouth East London with provider trusts for the local health economy.The aim of this review is to focus on identifying opportunities for high

implementation of the review with particularreference to compliance with list of high impactinnovations and accelerating adoption anddiffusion of innovative best practice.

impact innovations. The expectation is that this will have beencompleted by autumn 2012 and that this will inform the CCGOperational Plan for 2013/14.

Olympic/ParalympicGames-time delivery

Deliver business as usual performance levels,whilst meeting any increase in demandassociated with the Games (“Games Effect”) atGames-time.

Meet the bid commitments by providingLOCOG with the necessary ambulance andparamedic resources at all LOCOG Eventsand through the Designated Hospitals (Non-designated hospitals if clinically appropriate)providing free healthcare for the accreditedmembers of the Games Family.

Provide appropriate contingency for healthresilience at Games Time in compliance withDH guidance as part of the contribution to theOlympic Security and Safety Programme.

As a host Olympic Borough, Greenwich had to ensure that business asusual performance levels were maintained, whilst meeting any increasein demand associated with the Games (“Games Effect”) at Games-time.

All the Olympic objectives have been successfully achieved.

Appendix 3 - QIPP Programme Summary – Month 5

The 2012/13 QIPP programme has achieved savings at month 5 of £3.465m which is in line with our planned trajectory.

Our financial trajectory for the year is profiled to reflect the impact of the various initiatives as they are introduced through thecourse of the year.

Within the programme, some initiatives have been identified where the projected annual savings may not be achieved. Thepotential gap, if no mitigations were in place, is estimated at £473k. Key mitigations for this include:

o Recovery plans for bringing initiatives back on track

o Stretching the achievement of other initiatives

o On-going development and introduction of so called ‘Plan B’ initiatives. These are introduced as and when theycan generate benefits, and already this year Plan B initiatives sufficient to cover the shortfall on other initiativeshave been introduced, consisting primarily of further contract efficiencies in non-acute commissioning (£400k), andan additional medicines management initiative (70k). These new schemes will also provide us with additional fullyear savings for QIPP in 2013/14, and £386k out of this total has been applied to line 4.1.1 to cover the shortfallon that initiative.

The table below lists each individual scheme and shows their current financial performance, together with their present RAGrating for financials and milestones.

1

Stretch

Target

£'000s

Risk Rated

Plan

£'000s

Planned

YTD

£'000s

Actual

YTD

£'000s

Variance

YTD

£'000s

Forecast

Outturn

£'000s

Financial Milestones

Staying Healthy & Health Promotion

1.1 A step change in tackling smoking 139 139 58 58 0 139

1.2 Develop a systematic approach to prevention in primary & secondary care 225 225 94 94 0 225

1.3 Tackling obesity, diet and physical activity 15 15 6 6 0 15

Total 379 379 158 158 0 379

Improve Mental Health Care

3.1 Local efficiency on Oxleas 480 480 200 200 0 480

Total 480 480 200 200 0 480

Improve Long Term Conditions care for all ages

4.1 Finding the Vulnerable 200 200 25 0 25 200

4.1.1 Finding the Vulnerable -Stretch 386 386 220 220 0 386

4.2 IPCM / Integrated Care at Home 1,000 500 83 0 83 600

4.3 Medicines Management LTC 650 325 90 178 (88) 325

4.4 Diabetes Primary / Community based services 224 224 52 117 (64) 480

4.5 Long Term Conditions (copd) 56 56 23 0 23 0

4.6 MSK - new (T & O) 398 398 66 90 (24) 398

4.7 Falls 49 49 8 0 8 47

Total 2,963 2,138 568 604 (36) 2,436

QIPP Programme Summary 2012/13 - Month 5

Programme / Project

Financial Impact RAG Rating

2

Stretch

Target

£'000s

Risk Rated

Plan

£'000s

Planned

YTD

£'000s

Actual

YTD

£'000s

Variance

YTD

£'000s

Forecast

Outturn

£'000s

Financial Milestones

Provision of urgent & out of hours care

5.1 Urgent Care Centre 0 0 0 380 (380) 912

Total 0 0 0 380 (380) 912

Alternatives to hospital based planned care

6.1 Decommissioning outpatients through RMBS 504 504 195 256 (61) 504

6.2.1 Cardiology incl community services & clinics 418 268 0 0 0 135

6.2.2 Heart Failure - Community Matron Service 65 65 27 0 27 65

6.3 Anticoagulation services in primary care settings 71 71 6 0 6 71

6.4 Community Efficiencies 1,699 1,699 708 708 0 1,699

6.5 Primary Care QIPP 1,000 1,000 417 417 0 1,000

6.6 Orthodontics 200 100 23 24 (1) 96

6.7 Minor Oral Surgery 36 36 15 214 (199) 386

6.8 Dermatology outpatient activity to community 39 39 7 29 (22) 141

6.9 Gen Surgery outpatient activity to community 14 14 0 0 0 47

6.10 Gynaecology outpatient activity to community 167 167 31 13 18 121

6.11 Ophthalmology outpatient activity to community 174 174 49 66 (17) 174

6.12 Medicines Management planned care 500 250 69 16 54 250

Total 4,887 4,387 1,548 1,743 (195) 4,687

Programme / Project

Financial Impact RAG Rating

QIPP Programme Summary 2012/13 - Month 5

3

Stretch

Target

£'000s

Risk Rated

Plan

£'000s

Planned

YTD

£'000s

Actual

YTD

£'000s

Variance

YTD

£'000s

Forecast

Outturn

£'000s

Financial Milestones

Enhance end of life care

7.1 Patients who choose to die at home 211 211 35 35 0 211

Total 211 211 35 35 0 211

Corporate

8.1 Estates rationalisation / additional schemes 442 442 184 292 (108) 700

0 Total 442 442 184 292 (108) 700

Stretch Targets

Further QIPP Schemes (Plan B) / Use of QIPP Earmarked Reserves 0 0 0 54 (54) 17

OP first to follow up - Lewisham 71 36 15 0 15 0

OP first to follow up - Kings 94 47 20 0 20 0

OP first to follow up - Guys 243 122 51 0 51 0

Medicines Management Planned Care 0 0 0 0 0 70

Additional Initiatives 1,287 624 260 0 260 0

CAMHS 250 125 52 0 52 0

Direct Access Diagnostics 300 150 63 0 63 0

Forensic 250 125 52 0 52 0

Urology outpatient activity to community 17 17 7 0 7 0

New community outpatients service (28) (28) (12) 0 (12) 0

Outpatients first to follow-up - SLHT 1,275 638 266 0 266 0

Total 3,759 1,854 773 54 719 87

Total 13,122 9,892 3,465 3,465 0 9,892

QIPP Programme Summary 2012/13 - Month 5

Programme / Project

Financial Impact RAG Rating

4

Appendix 4 – Community Based Care Aspirations

Our aspirations1 for community based care: people living inSEL will….

Page 2

Easy accessto high quality,responsiveprimary &communitycare

▪ Be supported to manage their own health and any illnesses that they have and feel confident to do so

▪ Have access to telephone advice and triage for all community health and care services 24 hours a day, seven days a weekeither through their General Practice or through a telephone single point of access

▪ Have access to primary care service/advice 24hrs, 7 days a week for urgent needs through a combination of appointmentsand walk in services, telephone appointments, 111/NHS Direct, same day urgent care,

▪ Be provided with high-quality, evidence-based primary and community-based care, delivered through primary care staffcollaborating with each other and with specialist and community services, delivering care in line with agreed quality standardsand outcomes.

Timely,convenientand effectiveplannedcare acrossprimary andsecondaryservices

▪ Have access to personalised support and information, in the right formats to inform choice and decisions

▪ Experience consistent quality of care and access to services including radiology, phlebotomy, ECG and spirometry as a result ofagreed SEL-wide standards and protocols

▪ Be able to access most planned care including routine outpatient appointments, diagnostics, pre-assessment and post-operativefollow-up appointments in settings closer to home, or via telephone/web-based consultations, so that travel to outpatients at theacute sites is for specialist diagnostics and consultations only

1 All the below themes apply directly to Mental Health

DRAFT

Integrated carefor people withLTCs, the frailelderly andpeopleneeding EOLcare:

▪ Receive better targeted and more personalised care appropriate to their needs, as a result of SEL-wide real-time population riskstratification

▪ Play an active part together with their health professionals in developing a care plan that sets out what they and the healthprofessionals who support them will do to ensure that they are as healthy as possible and what should happen in the event ofproblems

▪ Have a named ‘care coordinator’ who will work with them to coordinate care across health and social care

▪ Know that their GP is working together with a multi-disciplinary group of other health professionals to co-ordinate anddeliver care, incorporating input from primary, community, social care, mental health and specialists

▪ Be provided with any tests, equipment or advice that they need within 4 hours if there is a risk that otherwise they will need to beadmitted to hospital

▪ Be confident that if they are admitted to hospital, staff based in the community will be working from the day of their admission withtheir hospital staff to make sure that as soon as they are ready, they can come home, with any equipment, additional funding oradditional services such as rehabilitation in place, with every patient who is medically fit to be discharged leaving hospital within24 hours of the decision being made

Appendix 5 Greenwich Commissioning Intentions 2013/14

Priority Key Features 2012/13 Commissioning Intentions2013/14

Rationale

ImprovingMental HealthCare

CCG spends £55m on Mental HealthServices delivered mainly by OxleasFoundation Trust and some services fromSouth London and Maudsley FoundationTrust.

Year on year contract efficiencies havebeen built into the mental health contractwith Oxleas.

A reduction of £720k was made in 2011/12with £480k reductions each year from12/13 to14/15.

A number of initiatives are being developedto support the achievement of theefficiencies including acute serviceredesign (closure of 1 acute inpatient ward)

Single point of access to MH servicesthrough introduction of a referralmanagement service.

Establishment of a Respite Service

Support for a Shared Care Model of servicedelivery - Greenwich is seeking to improvethe interface between Primary and

Use contract levers, or

market testing, to seek

out innovations in

provision that bring

together mental health

with community health

services.

Reduction in Beds forolder adults

A major influence on Commissioning Intentions for

13/14 will be the “No Health Without Mental Health”

Implementation Framework, and how Greenwich aligns

the commissioning intentions with the six shared

objectives.

Given that the ‘market’ may not have a ready solution,implementation will remain a commissioning –ledprocess to design a specification and stimulate ideasbased on the available evidence.

We have invested heavily in the memory assessmentservice at the Memorial and this has meant that peopleare behind diagnosed and offered treatment earlier inthe pathway. What that has translated into has beenreduction in bed numbers across BBG in the last yearand we varied the contract in year to reduce down tounder 20 beds. There could be savings plus some newinvestment in a more robust Crisis and Home Treatmentservice to maintain and manage patients with Dementiaat home for longer. This would fit with our overalldesire to change the direction of travel away from areliance on acute beds and more robust community

secondary care and work

Increasing Access to PsychologicalTherapies (IAPT). We are committed tothe further development of the service andaim to improve access to employment,promote health and welling and develop aLong Term Conditions service

Complex Needs Recovery Service. Inseeking to improve the pathway andpatient experience we are working jointlywith partners in the Local Authority to testthe market in support of the procurementprocess

Older people and Dementia. Greenwich isworking with partners to support thedevelopment of the Integrated Care Systemwhich aims to draw together currentservice elements into a unified model thatincludes primary care, community care,social and acute care.

Child and Adolescent Mental Health -Greenwich are undertaking a review ofCAMHS in the borough which will build onthe key findings of the CAHMS needsassessment, evaluate the ability of theservice to meet the current and futureneeds of Children and Young People andreview quality and outcome measures.

Assertive Outreach TeamStrategic Review

services.

There is a concern that this team has beenunderperforming. We commission 124 places but theteam has been running at about 100 patients. Thisunderperformance coincides with an increase in thenumber of patients occupying acute beds in excess of60 and 90 days which has amounted to around 15-20patients in the last few months – a caseload for a CareCoordinator and the equivalent of a ward at Oxleashouse. Despite our suggestions that these patientswould probably benefit from a more assertive approachin engagement and facilitating discharge this has notbeen reflected in activity and we have formallyrequested a review of the team’s performance.Outcomes to be reviewed include length of time in theteam, diagnosis, impact on readmissions to hospital anddemographics. Review to be carried out in partnershipwith the Local Authority who contribute social careinput to the team.

Review to take into consideration the work that hasbeen underway to promote alternative models inmanaging and delivering care to children with complexneeds. This Team Around the Child (TAC)approach/model has been successful in terms ofengagement, monitoring and rehabilitation withoutcomes which have been successful in movingchildren out of hospital within an integrated package of

Develop a potentialModel for a ReferralManagementSystem with a SinglePoint of Access providing, advice, telephoneconsultation, screening& triage to mostappropriate services

Provide a more

community based,

flexible and integrated

Children and Adolescent

Mental Health Service

(CAMHS) model (see

also Commissioning

Intentions for Children

and Young People)

care. It may be possible to promote this model withinthe Assertive Outreach Team in order to monitor andsupport robust engagement and recovery of adult MHservice users and move them through the acutepathway more quickly.

There are currently a high proportion of inappropriatereferrals particularly from GP’s, lack of clarity aboutreferral and access protocols and scattergun approachto referrals due to lack of knowledge about whichservices exists, eligibility criteria and accessrequirements. Potential for a significant shift in referralpatterns with such a model.

As a consequence of a number of concerns, togetherwith the Local Authority we undertook a strategicreview of Greenwich CAMHS in 2012 to review thequality of services and their ability to deliver outcomesfor Children & Young People. Strategically we want toinclude CAHMS in our drive to improve integration,particularly for vulnerable groups. As a result of thereview, for 2013/14 we intend to:

Develop a Referral Management System formental health that includes CAMHS

Re-tendering of theComplex needs andRecovery Service

Expanding IAPT atGreenwich Time to Talk

Develop a seven day a week CAMHS servicewhich illustrates the shift away from a relianceon an acute bed base for children in crisis and amove towards more robust community basedservices supporting children at home for as longas possible or until the crisis is over.

We have just completed the PQQ stage of this processand there is a shortlist of 7. We have re-specified toensure that the model of service delivery is outcomefocused and based on a recovery pathway with clearachievements designed to move people towardsindependence and more mainstream service. Theservice, to date, has been characterised by

delays in the patient pathways with averagelength of stay being 2 years - some have beenin the placements for five years

an absence of a move on/recovery plan

low expectations – from service users and theirCarers and, in some cases, staff

patients ‘opting out’ of their care plan/ADL’swhich we think should be renamed ‘Supportand Recovery Plan’.

We are currently expanding the existing service toensure difficult to reach groups such as BME groups,older adults and people with a learning disability are

Review the data on IAPTactivity

Provide evidence basedinterventions forpatients with LearningDisabilities

Support General Practiceto improve the Qualityand Management of

able to access IAPT services. We will be working withOxleas to develop a long terms conditions service with aview to establishing the delivery of psychologicalinterventions to patients with a co morbid diagnosis ofmental health and chronic fatigue, musculoskeletaldisorders, diabetes and angina.

We have not yet taken any efficiencies out of the IAPTenvelope which is a separate contract to the main blockwith Oxleas. We will review potential to unbundle whatwe commission from SLAM and spend the moneylocally here – e.g. CBT for Chronic Fatigue, chronic pain,CBT for some patients on the autism spectrum, coupleand sexual therapy/psychotherapy.

We recognise that mainstream IAPT services are notaccessible or available to people with a LearningDisability and have funded a pilot to ensure thatpatients with a Learning Disability are able to access arange of evidence based interventions includingCoaching and adapted CBT centred approaches foranxiety and depression. This approach is in keeping withour drive to develop local services for local residentsand move away a reliance on block commissioningfrom SLAM.

The quality of the services available within generalpractice can be variable and the knowledge of what isavailable for GPs to refer to can be limited. QualityInitiatives that could be promoted within general

General Practice MentalHealth Services andReferrals

practice include:

Creating a Mental Health Directory, utilisinginformation technology, of available services both inhours and out of hours, including third sectorCreating primary care management plans, including selfcare and self management, for patients based aroundtheir individual ‘mental health condition’Consider potential for Annual Health Checks to includeMental Health assessmentImproving referral pathways within general practice fora number of conditions including:

AlcoholSubstance misuseLearning DisabilitiesCAMHSGHLiSDepressionPsychosisEating DisordersIAPTMINDSelf Harm

Also there is a need to link in the development ofMental Health pathways and referrals with theGreenwich community based Referral Management andBooking Service.

Improve long

term

conditions

care

.Finding the Vulnerable - increasing case

finding, capacity and coordination ofservices to prevent unnecessary admissionsto hospital. There is a particular focus onreducing admissions from care homes.Integrated Primary Care Model - Thisservice includes intermediate care and anextended Joint Emergency Team (JET)service, an integrated health and socialcare team providing rapid assessment andmanagement and building up consultantled sub-acute capacity in existing beds.Aimed mainly at over 65s with UTIs, heartfailure or COPD who could better bemanaged out of hospital. Capacity to be putin place equivalent to two acute wards.

Expansion of intermediate care at homecapacity - The first stage of thisdevelopment has been a rapid expansion ofcapacity to deliver intermediate care athome as part of the step up and step downprovision of nursing care, supporting bothhospital admission avoidance and promptdischarge.

Business case in development for nextstage of the model.

Work with general practices - throughvisits, data analysis, syndicate peer reviewand Commissioning Incentive scheme toreview patients on the register andimprove care for patients at highest risk of

Commissioning forTransformationalChange

Integrated Primary CareModel

Finding the Vulnerable

Supporting the role ofthe GP

We will be working across BBG to commission at scalefor selected long term conditions services. The aim willbe to apply evidence of best practice in the BBGcontext, working to shared standards but with localadaptation and implementation to modify the overallapproach to suit local needs.( See work with Bexley andBromley to implement the Plymouth model of diabetescare below).

This highly effective service will continue to bedelivered and is expected to deliver an additional £1mrecurrent efficiency saving in addition to providing highquality care for patients either in their homes or in thelocal community.

Targeting vulnerable groups: Unlike our neighbouringboroughs, Greenwich has a relatively young population.Along side our frail elderly residents are those with MHand drug and alcohol problems. Our FTV programmewill continue to target a range of patient andpopulation groups who – for reasons of physical and orpsychological ill health – may find it harder to accesshealth care or use health services for potentiallyavoidable problems.

Work with general practices will continue to aim toreduce variation in general practice treatment of peoplewith Long Term Conditions, building on the initialengagement of GPs into clinical commissioning. We willbe finding ways to focus their attention on complexpatients at high risk of Emergency Admissions. Reducing

hospital admission.

COPD Service - The Chronic Obstructive

Pulmonary Disease (COPD) Team provide

specialist care to Greenwich residents living

with COPD. Patients are given the tools to

self-manage their condition and stay in the

best health possible with a combination of

clinic appointments and visits in their own

home when necessary. Pulmonary

Rehabilitation, a seven week course of

twice weekly education and exercise, is also

available for patients. Patients who feel

unwell can call the service for assessment,

treatment and advice, which allows

patients in a period of ‘exacerbation’ to

remain at home, monitored by the COPD

team, avoiding an unnecessary hospital

admission. The team also manages the

oxygen prescription service for patients

registered with a GP.

Diabetes Service - Greenwich hascommissioned a specialist, multi-professional community diabetes servicefrom Oxleas NHS Foundation Trust forpatients with Type 2 diabetes requiring Tier3 services who may previously have beenreferred to hospital. The service isdelivered through community diabetesclinics in a number of different locations

Delivering COPD service

Patient Self Care

LTC Clinics

Diabetes ‘Evidence Into

variations in general practice will be supported byfurther development of the Commissioning IncentiveScheme, dissemination of syndicate level data sets andfurther development of the RMBS.

Greenwich will continue to build on the successachieved by the COPD service. GPs are now aware thatwhen their COPD patients begin to degenerate thatthey can contact - and get an immediate response from- the community based COPD service, leading to areduction in the use of acute services and possibleadmission.

As part of the LTCs pathways, such as childhoodasthma, following a prevention of re-admission episodeGPs carry out a 6 week check. At this point there shouldbe a focus on offering self-care and self-managementsupport to the patients. In some cases this isoverlooked and our intention in 2013/14 is to develop asupport package (drawing on best practice) that willimprove this aspect of the pathway.

Targeting specific long term conditions-in line with ouroverall focus on transferring care into communitysettings, working to develop a range of innovative LTCclinics working in an integrated way with specialists,GPs and other clinicians. There will a specific focus on –asthma and stroke initiatives and the development ofintegrated cardiology in Greenwich.

Building on the success of the pilot, a roll out of this

and through home visits to patients whoare housebound, and aims to case-find newpatients and improve clinical outcomes,Shift outpatient activity to communitysettings and reduce A&E attendances andnon-elective acute admissions..Pilot Diabetes ‘Evidence Into Practice’project (award winning project) - A GPpractice based programme that providesfacilitated, structured cardio-metabolic riskmanagement of people with diabetes andsupports the sharing of best practice Thepilot indicates a decrease (5%) inoutpatient diabetic medicine attendancesand circulatory admissions (1%) ascompared to increases of 11% and 13%respectively in the non-pilot group, as wellas relatively fewer CHD and strokeadmissions for the pilot group - anticipatedsavings following roll out to all practices c.£730k.

Medicines Management – Improvedwound management, improved prescribingof SIP feeds, scriptswitch

Practice’

New BBG DiabetesModel of Care

Stroke service and earlysupported discharge forstroke

Improve Asthma Care

approach to all practices in Greenwich has been

implemented and been very successful at delivering

improved clinical outcomes. The continuing support and

skills development for primary care teams will

compliment the development of the new BBG diabetes

pathway.

The Diabetes Working Group (DWG) has reviewedoutcome and commissioning data and is proposing thatBBG implement a model of care which has becomeknown as the Plymouth Model. This makes a cleardistinction between what is done in an acute trust andwhat is not done. It assumes a diabetes specialist hastwo roles: as a doctor with specialist skills for high-enddiabetes and as an educator. The model clearly sets outthe 6 conditions that require diabetologist‘s care andthe support role for the community.

CQC have raised concerns about this service and interms of utilisation of acute services the currentdelivery incurs long length of stays, This work has begunalready and will continue to be developed.

There is a need to review the delivery of asthma care inprimary care to improve the quality of the service toensure the right care is being delivered in the right way.GPs may need support to help understand better whatshould be done, and what could be done differently.

Co-ordinate

the provision

of urgent care

and out of

hours care

Whole systems Urgent Care ModelDevelopment of a whole systems model foran integrated urgent care system enablingthe development of a specification totender for the whole system.

Urgent Care CentreThe service provides both minor illness andminor injury services within the EmergencyDepartment and operates from 8am until10pm, seven days a week, Since the servicewent live there has been a significant shiftin activity, with A&E activity downsubstantially compared to the same periodthe previous year, and the A&E achievingsustained improvement in waiting times.

Greenwich Virtual Admissions AvoidanceTeam (VAAT) consists of representativesfrom community services including the JET,Falls Team, COPD Service, Continence, LongTerm Conditions and District Nursing. Theteam works collaboratively with LondonAmbulance service and primary careservices to prevent unnecessary A&Eattendances and hospital admissions andhas developed a range of clinical pathways.The team has supported LAS in achieving a33% reduction in the number of patientsthat are conveyed to hospital overall, in thelast year, the highest reduction anywherein London.

Identify opportunities toreduce costs in Out ofHours and Walk inCentres and rationaliseprovision

Identify opportunities toimprove access andresponsiveness ingeneral practice

Continue to focus onreducing A&Eattendances from CareHomes

Identify a process forGPs to access clinicalsupport from secondarycare specialists

Commissioning of WICs passes to CCGs from next year.Current provision risks fragmentation of primary careboth in-hours and out of hours, with a lack ofintegration and potential duplication. WICs operate onexpensive cost per case not block contracts.

Variability in access exists in practices, from very goodto not so good. It will be necessary to work withNational Commissioning Board local London Team whohold the primary care contract. Patients who can’t getsame day access may take themselves to A&E. Alsoconsider marketing strategy for patients, some of whommay hold the perception that their practice does notoffer same day appointments when in fact they do.

More proactive work needed between JET team andpalliative care to provide frail elderly with mostappropriate care at end of life stage.

It is often the case in general practice that swift accessto a consultant/senior registrar opinion could reducereferrals from primary to secondary care and decreaseattendances at A&E. We would wish to commission asecondary care service that is responsive to primarycare needs and identify a way that takes this forward.

Joint Emergency Team (JET)a multidisciplinary team of health andsocial care staff providing swift holisticassessment and management of clientsthat require urgent intervention within 24hours of the referral, responding to allurgent referrals within 2-4 hours.Interventions include re-ablement at homeor access to intermediate carerehabilitation with a range of high clinicaland low social and low social and highclinical services. In its first year JET hasprevented a total of 521 A&E attendances448 unnecessary hospital admissions.

Discuss with LondonAmbulance Service thepotential to redirectpatients to the UrgentCare Centre instead ofA&E

This is being done elsewhere in London. LAS work in re-directing ambulances and giving specialist adviceas opposed to taking patients to A&E could be veryeffective in keeping work within primary care both inhours and out of hours. We are not working on this inGreenwich and it would be good to consider whetherwe can initiate some work on this.

Increase

capacity in

high quality

cost effective

alternatives

to hospital

based

planned care

Referral Management & Booking Service(RMBS) - aims to reduce and improve thequality of referrals by implementing clinicalreferral pathways and triaging againstthem, ensuring appropriate pre-diagnosticwork is completed prior to referral,redirecting activity to appropriatecommunity services and challenginginappropriate referrals. The service hasbeen introduced on a phased basis, andcurrently 34 out of 45 practices are live onthe RMBS,

Integrated Cardiology Service – a pilot hasbeen commissioned, in conjunction withBexley and Bromley CCGs, for an integratedcardiology service across the 3 boroughs, inpartnership local providers. The aim is to

Support for GeneralPractice

Good quality General Practice is a key enabler of themove of services out of hospital. Consideration needsto be given to what support and resources are neededto enable general practice to play their full part incommissioning and delivery of planned and unplannedcare, in addition to their day-to-day general practicework.

Greenwich CCG is already working with generalpractices - through visits, data analysis, syndicate peerreview and Commissioning Incentive scheme to reviewpatients on the register and improve care for patients athighest risk of hospital admission.

Further work in support for general practice in2013/14 could include:

implement the service from April 2012.Two key elements of the service relate toinnovation in patient self-management andin the use of Information technology tocreate an integrated clinical record andshared access to clinical information.

Community Hospital Provision –development of a model and a fullbusiness case for community hospitalprovision in Eltham. The Eltham communityhospital will be a key ‘enabler’ to help usdeliver our priorities and provide additionalcapacity for community based services.. Weare working collaboratively with Bexley andBromley to ensure a consistent approach tothe shift in care from SLHT to thecommunity.

Diagnostics – review being undertaken ofdirect access diagnostics to identify andreduce any unnecessary testing.

Medicines Management – sharedformulary with SLHT for high costdrugs/high risk conditions includingcardiology, introduction of new anti-coagulation drugs, challenging payments byresults excluded drugs and management ofthe RAG list of drugs.

Other alternatives to hospital based caredelivered in the community, identified as

GP engagement andmarketing strategy

Utilisation Review

Scoping out what aspects of Greenwich’s futurecommissioning intentions general practiceneeds to deliver.

Build capacity and capability in practices

Invest in on-going training

Provide good back-up support

Identify unused capacity in primary caresettings – both in-hours and out of hours

Maximise the expertise and experience ofgeneral practice clinicians – there is evidence isthat they make good clinical decisions thatresult in reduced investigations and reducedacute utilisation

At same time reduce variability and poorpractice in prescribing, referring and clinicalpractice

Improve access and responsiveness of generalpractice

A model needs to be developed that can help GPs tounderstand the important role that general practiceplays in commissioning, and in the whole health systemof Greenwich. This can be described as a “hub andspoke” model with general practice as the hub andmulti professional community-based teams providingsupport for primary care, with access to diagnostics anda secondary care opinion as the core acute offer.

A second Key Challenge for Greenwich is to utilise

part of QIPP include: Heart failure service delivered by

Community Matrons

Anticoagulation services provided inprimary care settings

Minor Oral surgery

Dermatology outpatient activity

General surgery outpatient activity

Ophthalmology outpatient activity

Gynaecology outpatient activity

Outpatient Care Audit

Review data fromReferral Management &Booking Service toidentify opportunities toprovide more services in

existing resources more effectively by identifying areasfor improvement within existing contracts that do notrequire significant investment.

The QIPP challenges that have already been identifiedin the alternatives to hospital based planned care havethe potential to make savings that are relatively small(approximately 2%) in relation to the money that isspent in the main contracts of care with Greenwich’sproviders.

The intention for 13/14 will be to not only continue asappropriate the existing QIPP objectives that areproving to be effective but also to establish a morestringent monitoring process to systematically reviewcurrent contracts through a business case that modelsthe impact, opportunity costs and cost benefits ofcurrent contracts based on a set of core principles.

Also in line with the systematic approach to looking atexisting services, a speciality by specialty ‘audit’ couldbe undertaken of the potential to transfer OutpatientCare to community care based settings.

There should be full coverage of practices by the end ofNovember. The RMBS is a rich source of data about theappropriateness of referrals and any service areas thatcould be redesigned and provided differently.

the community

Aim to reduceunnecessary follow upsin secondary care, andpotentially also incommunity and primarycare.

The data will be analysed to identify opportunities forimprovement including helping GPs to follow pathwaysbetter, and introducing more robust and objectivechallenge procedures.

We will identify what % of referrals are discharged after1 appointment and identify a way to reduce these typeof referrals either through challenge by RMBS or re-design of the pathways .

Consideration also needs to be given to referrals thatcome into secondary care from other providers e.g.community, AQPs and whether these can also bemanaged.

Every year within secondary care there are 37 millionfollow-up appointments. A significant proportion ofthese have been shown to be clinically unnecessary,create inconvenience and anxiety for patients, andwaste resources. 75% of all DNAs are for follow-upappointments.

Common practice has been to invite patients for afollow-up ‘just in case’. If that practice is changed to ‘nofollow-ups unless there is a specific reason i.e. clinical orpatient request’ this would reduce the number ofunnecessary follow ups and DNAs.

As well as limiting follow-ups another aspect is toconsider where follow-ups can be delivered, which

Pathway Redesign inPrimary Care forOphthalmology andDental Services

healthcare professional such as nurses, can do thefollow-up and how it is delivered. Telephone calls orweb-based services could be used to replace thetraditional visit.

We will identify ways of reducing follow-ups eitherthrough contracts or through redesign of the pathway.

In addition to GPs, specially skilled primary carepractitioners, such as dentists and optometrists, arewell placed to deliver part of the patient pathway inprimary care instead of in secondary care.

For example ophthalmology is a high volume speciality.Optometrists with a Specials Interest could undertakeglaucoma follow ups in primary care, or work ups forcataract operations.

Dental procedures currently carried out in secondarycare could be moved back to GDPs in primary care.These could include minor oral surgery, orthodonticsand periodontics.

A procurement exercise could be carried out for dentalprocedures carried out under general anaesthetic.

Children and

Young

People’s

Services: A

whole system

approach,

focusing on

prevention

and

developing

integrated

care pathways

and services

Integrated Care Service for children withcomplex needs – Greenwich ClinicalCommissioning Group has recentlyundertaken procurement of an integratedmodel of specialist community healthservices for disabled Children and YoungPeople

The service comprises:

Children’s Community Nursing;

Continuing Care and End of Lifepathway;

Dietetics; and

Attention Deficit HyperactivityDisorder Service [ADHD].

This service assesses and manages theneeds of children with:

Acute and short-term to long termconditions;

Disabilities and complexconditions, including thoserequiring continuing care andneonates;

Life-limiting and life-threateningillness, including those requiringpalliative and end-of-life care; and

C&YP with complex dietary needsand who have been identified asrequiring an assessment for ADHD,or diagnosed with ADHD

Oxleas Foundation Trust has been awarded

Delivery of Integrated

Care Service for children

with complex needs

Provide a more

community based,

flexible and integrated

This service is in the very early stages of delivery and wehave built in robust KPI’s and performancemanagement/monitoring requirements. In addition wehave stipulated that there will be evaluated in March2013. The ISCS will also work collaboratively withstakeholders to develop shared care pathways and jointworking in areas such as child and adolescent mentalhealth, sickle cell [pain management] and diabeticservice.

Expected Benefits

Reduce the number of children admittedinappropriately to hospital.

Reduce the length of in-patient stay whenadmission is unavoidable.

Promote services users satisfaction with healthservices as a whole.

Improve clinical pathways by developing jointworking between primary and secondary careproviders and clinicians.

Reduce health inequalities by improving accessto the service.

Improve child/young person and familyexperience and participation in community life.

As a consequence of a number of concerns, togetherwith the Local Authority we undertook a strategicreview of Greenwich CAMHS in 2012 to review the

the contract and the service transferredfrom SLHT to Oxleas on 1

stSeptember 2012

Prevention – focus on obesity and fitness

levels, sexual health, psychological well-

being, the health of children from BME

communities and improving health

outcomes for mother and babies.

Redesign of Child and Adolescent Health

Mental Health Services. A number of

concerns have been highlighted with

CAMNS including gaps in the service and a

current model of delivery thought to be too

clinical and restrictive As a result, together

with the Local Authority, Greenwich

undertook a strategic review of Greenwich

CAMHS which was completed in spring

2012. The aim was to review the quality of

services and their ability to deliver

appropriate outcomes for Children & Young

People.

Children and Adolescent

Mental Health Service

(CAMHS) model (see

also Commissioning

Intentions for Mental

Health)

Review Acute PaediatricService

Review Maternity

Services

quality of services and their ability to deliver outcomesfor Children & Young People. Strategically we want toinclude CAHMS in our drive to improve integration,particularly for vulnerable groups. As a result of thereview, for 2013/14 we intend to:

Develop a Referral Management System formental health that includes CAMHS that willresult in improvement of referral pathways,information sharing, advice and consultation,screening and triaging.

Develop a seven day a week CAMHS servicewhich illustrates the shift away from a relianceon an acute bed base for children in crisis and amove towards more robust community basedservices supporting children at home for as longas possible or until the crisis is over.

Review current acute paediatric models of provisionand commission a service that meets the full range ofacuity of needs that arise from a service model agreedwith the provider. Review to include contractingmethodology.

Maternity services are a high area of spend forGreenwich. There are a high number of births whichreflects the relatively young population, with a lot oflate bookers and a relatively high number of follow ups.

Review Unplanned Care

for Children

A new Payment by Results pathway funding system formaternity services is to be introduced in April 2013.Under the new system, the commissioner will pay aprovider for all the pregnancy-related care a womanmay need for the duration of her pregnancy, birth andpostnatal care, and that in general there will be nofurther payments for individual elements of activity,although there are a small number of clearly identifiedexceptions. This presents an opportunity to review thecurrent provision of maternity services.

Parents often utilise multiple access points for children

with mainly minor ailments which results in the children

being seen 3 to 4 times for a single cold for parents

seeking antibiotics via GP, walk in centre, A+E and

Grabadoc GP Out of Hours.

Enhance end

of life care

A Greenwich Care Partnership operatesalongside and supports existing coreservices (GP’s, district nurses, specialistnurses etc.) to provide high quality care forpatients with end of life needs inGreenwich. Three organisations –Greenwich and Bexley Community Hospice,Marie Curie Cancer Care and OxleasCommunity Health Services are working inpartnership to provide this integratedmodel of care which aims to reduce

Subject to evaluation of

the pilot the intention is

to roll out the pilot

through procurement

Implementing best

practice pathways

Enhance the quality of End of Life care through:

Better co-ordination between service providers,

implementing an integrated model

Enabling people to die in the place of their

choice

Continuing to implement best practice including the

inappropriate hospital admissions andenable more patients to be cared for and todie in their place of choice by ensuring thatappropriate health and personal careservices are available and that their familiesand/or careers have sufficient practical andemotional support. The service consists offour integrated elements:

A palliative care co-ordinationcentre

A rapid response unit

Multi visit personal care andsupport service

Planned night care service.

The pilot is still subject to evaluation, butcurrently 52% of patients referred to theservice were able to die in the place of theirchoice, and a greater % of people are dyingat home or in a hospice.

Liverpool Care Pathway and Gold Standard framework

Appendix 6: Managing Risk

Strategic Corporate Risk Register

The CCG recognises the importance of robust risk management and to this end a 2012/13 risk

register has been populated with key strategic risks. The CCG monitors risks through relevant

committees and in the Greenwich Clinical Commissioning Group. For example, financial risks are

scrutinised in detail at the Finance, Performance & QIPP Committee. The overall distribution of risks

is monitored as well, with the aim being to shift risk ratings downwards over the course of the year

through close monitoring of action plans. The figure below indicates the risk distribution as at 13th

September 2012, and shows the number of risks at each level and the target distribution of risk:

0

2

4

6

83

4

6

810

12

15

target

current

As at 13th September 2012, the risk register holds a total of 21 open risks as follows:

New Entries There has been one new risk entry.

ID Description Controls C L Rating

(Current)

Rating

(Target)

Action Action

Due

Date

73 Risk: Acute contracts may

over perform 12/13

Cause: e.g. Unanticipated

demand; failure to

implement service

changes; changes in

coding;

Consequence: Usage of

financial reserves

earmarked for service

transformation

Contract management

board;

Contract monitoring;

Cap and collar

arrangements on SLHT

contract;

Provider and

commissioner QIPP

plans;

Funded for population

growth;

Potential pressure of

RTT backlog accounted

for within agreed

contract values.

4 3 12 8 TBC

High Risks >12

ID Description Controls

Rat

ing

Targ

et

Rat

ing

ActionAction Due

Date)

49 Risk: Clinical

commissioners may

not have the activity

information needed to

manage performance

of acute and non-acute

providers

Cause: Lack of timely

accurate acute

contract monitoring

data; Underdeveloped

data sets within non-

acute settings

Consequence:

Financial over

performance; risks of

over or under

commissioning as

compared to spend

Local monitoring of

acute activity and

finance at point of

delivery level;

Contract management;

Incentive scheme for

peer review;

Cap and collar

arrangements.

PBR data assurance

(Audit Commission)

Mental Heath PBR

Data meetings re:

community contracts

(Oxleas)

15 10 Establishment of

robust contract

monitoring

systems by cluster

information

department

Roll out of

practice level

acute activity and

finance derived

from SEL contract

monitoring

30/06/2012

(Sollis has

been

implemented

but is not yet

ready for use

as not all the

required data

has been

uploaded)

31/08/2012

47 Risk: Service change is

implemented but does

not realise expected

outcome - reduction in

acute activity and/or

patient take up of

community pathway

Cause: Failure to

appreciate level of

demand; failure

effectively to

communicate service

change to stakeholders

and patients; patient's

do not choose to adopt

new service

Consequence: QIPP

Robust modelling and

testing of schemes

prior to approval;QIPP

gateway

process;Monitoring by

Finance QIPP

Performance

Committee;Referral

management and

booking service that

identify opportunities

for new service

utilisation and engages

clinical commissioners

in utilisation

monitoring;Incentives

in place to encourage

good quality of referral

and management of

patients;Agreed

flexibility with Oxleas

to review QIPP

15 15 Implement plans

to communicate

with GPs where

programmes are

not delivering

Engagement with

Communications

Team to ensure

small number of

key messages are

focused on to

ensure delivery

Ensure included in

headlines for

stocktakes

30/9/12

30/9/12

30/9/12

ID Description Controls

Rat

ing

Targ

et

Rat

ing

ActionAction Due

Date)

savings not made due

underutilisation or

conversely, over

utilisation of acute

servicesShared Risk

Owner: Alison

Goodlad

investments;Working

to stretch targets to

ensure delivery.

67 Risk: Special Measures

imposed upon SLHT as

a result of

Unsustainable Provider

Regime may negatively

impact upon

performance and

quality of

servicesCause: Focus

on financial recovery,

service reorganisation,

loss of knowledge and

continuity from senior

management team as

the Board is stepped

down, lack of

confidence in service

by patients may lead

them to choose

alternative providers

exacerbating financial

problems and reducing

viability of the

service.Consequence:

Reduction in the

quality and safety of

services (5); Multiple

complaints; Failure to

meet contract KPI's

and performance

standards; (4)

Administrator

continues to have the

statutory duty of

quality Clinical Strategy

GroupQuality Sub

CommitteeSLHT

Contract Management

(SEL)SLHT Clinical

Quality Review Group

(monthly)BBG Quality

Network and joined up

working : meeting

monthly

15 10 Implement BBG

process to

triangulate soft

intelligence and

patient

experience data

Implementation

of metrics (being

led by Cluster);

metrics now

agreed but

awaiting

implementation.

06/08/2012

20/09/2012

Risk Review

There are no risks outside their review date.

Risks Reviewed since 21st August ’12.

ID Description Current

Rating

Review

45 Risk: Further significant organisational change will

destabilise an already emergent organisation

Cause: Loss of corporate memory with egress and/or

instability of permanent workforce. Strong need to

build established teams of permanent staff in order to

develop more sophisticated and streamlined

approaches for clinical commissioning.

Consequence: Capacity shortages and an inability to

deliver services or retain organisational memory

6 ↔ 13/9/12 ~ Risk reviewed: no

changes. Structure in the

process of being appointed to.

Slot in's now complete.

68 Zero Tolerance Risk!

Risk: Failure to seek assurance and ensure issues

addressed with regard to capacity issues within

Greenwich Community Health Services School Nursing

Team

Cause: Failure to address and seek assurance of interim

arrangements in provider meetings;

Consequence: Failure of provider to identify and

manage potential safeguarding issues; National media

coverage with >3 days service well below reasonable

public expectation. MP concerned (questions in the

House); Total loss of public confidence (5); Failure to

prevent / identify safeguarding incident (5)

6 ↔ 13/9/12 ~ Risk reviewed.

Awaiting confirmation that

final post appointed to before

closure.

72 Risk: Not achieving the agreed access initiative

performance levels relation to the bariatric 52 week

wait

Cause: Poor gateway design; application of treatment

policy; increased activity to maintain waiting list;

Consequence: Negative patient experience;

8 ↔ 13/9/12 ~ Risk reviewed. No

changes - review in one

month.

50 Risk: Failure to make sufficient preparations for the

Olympics in 2012

Cause: Competing priorities

8 ↔ 13/9/12 ~ Risk reviewed, Risk

time limited and no adverse

outcomes and now

ID Description Current

Rating

Review

Consequence: Lack of preparedness and damage to

reputation

recommended for closure.

61 Risk: Failure to have in place mechanisms/process to

gain assurance of quality from providers

Cause: Lack of organisational capacity, insufficient

capture of data on quality indicators

Consequence: Failure to identify provider quality issues

which will affect patient care

10 ↔ 13/9/12 ~ Risk reviewed and

action added. Score

unchanged.

65 Zero Tolerance Risk!

Risk: Insufficiently rigorous Adult safeguarding

arrangements;

Cause: No 'dedicated' nurse for adult safeguarding in

current structure;

Consequence; Lack of assurance across all

commissioned services; Incident leading to death;

10 ↓ 5/9/12 ~ Reviewed risk: GP

lead now recruited to help

lead on Safeguarding. SAF

being completed. Once

complete specific risks to take

the place of this risk on the

register.

44 Risk: Inability to build capacity identified in the OD plan

which is a requirement of authorisation

Cause: Conflicting priorities impacts upon capacity to

undertake development activity; failure to identify need

in PDPs; failure to have JDs in place

Consequence: Capability in staff is underachieved;

failure to achieve authorisation

12 ↔ 13/9/12 ~ Risk reviewed. One

action completed. Review in

one month

Closed Risks

One risk has been closed since risk register last reviewed by GCCC on 21st August ’12.

ID Description Controls C L Rating Rationale

48 Risk: Acute contracts may over

perform in 11/12

Cause: e.g. Unanticipated

demand; failure to implement

service changes; changes in

coding;

Consequence: Usage of

financial reserves earmarked

for service transformation

Contract

management

board;

Contract

monitoring;

Cap and collar

arrangements on

SLHT contract;

Provider and

commissioner QIPP

plans;

Funded for

population growth;

Potential pressure

of RTT backlog

accounted for

within agreed

contract values.

5 3 15 5/9/12 Risk realised. Growth

allowed for in 12/13 financial

plans.