Working together: • NHS Eastern Cheshire

Clinical Commissioning Group

• NHS South Cheshire Clinical Commissioning Group

• NHS Vale Royal Clinical Commissioning Group

• NHS West Cheshire Clinical Commissioning Group

Operational Planning / Commissioning Intentions

2019-20

NHS South Cheshire CCG and NHS Vale Royal CCG Governing Bodies,

7 February 2019

Published on 7th January, Headlines include key themes of: • Developing “out of hospital” care (Joining up Primary Care

and Community Services). • Redesigning and reduce pressure on emergency hospital

services. • Delivering personalised care. • Digitally-enabled primary and outpatient care. • Focus on population health and local partnerships with

local authorities through Integrated Care Systems (ICSs).

The NHS Long Term Plan

https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan.pdf

The NHS Operational Planning and Contracting Guidance

Describes the national requirements, for 2019-20, to implementing the immediate priorities in the NHS Long Term Plan. Key priorities include: • The need for system (STP/ICS) level plans by Autumn 2019 - describing

how the system will use its financial resources to meet the needs of its population and what the system will deliver in 2019/20, which should include specialised and direct commissioning as well as CCG and provider plans. The plan should make clear the underlying activity assumptions, capacity, efficiency and workforce plans, transformation objectives.

• Delivery of system control totals allowing parties within STP/ICS to vary contributions within this envelope. This includes Provider and Commissioner Sustainability Funding and development of System efficiency plans

• Plans for implementing guidance related to “no-deal” Brexit • Delivery of requirements in relation to the investment of the additional

financial allocations confirmed in the budget

https://www.england.nhs.uk/publication/preparing-for-2019-20-operational-planning-and-contracting/

NHS Standard Contracting/Tariff Guidance

The guidance includes: • Contracts need to be signed by 21st March • Penalties for both commissioners and providers for any >52 week referral to treatment

delay (£2500) • CQUIN (Commissioning for Quality and Innovation)has been reduced by 50% to 1.25%

(remainder added to the national uplift in tariff of 3.8%) • A Maternity Incentive Scheme to improve safety • A bundled tariff approach for emergency care The Finance and Contracting Working Together across Cheshire work stream is proposing: • Where NHS Provider contacts expire in March 2019 extend contracts for a 2 year term • For Any Qualified Provider contracts expiring in 2019/20 extend on a one year basis with

the option to extend by a further year • Maintain focus on local Capped Expenditure Programme approaches to delivery (i.e.

system based savings not cost shifting) • Consider inclusion of a termination notice period of 6 months in contracts where we

believe that we may wish to deviate from these terms • Finance and Contracting work stream looking at opportunities to share contract

negotiation workloads if this offers efficiencies e.g. shared schedules and specifications

https://www.england.nhs.uk/publication/preparing-for-2019-20-operational-planning-and-contracting/

The national planning guidance is consistent with the Cheshire Commissioning Intention JCC Level 1)

The Planning guidance is broadly aligned with the Cheshire CCG Commissioning Intentions which were agreed in September 2019. The primary areas within the Level 1 Joint Commissioning Committee work plan areas covered are: • Specialised Services will work with local systems to align spend at a system level.

The defined priority work areas for Specialised Services are; cancer treatment, mental health, learning disability and autism, cardiovascular, reducing mortality for critically ill babies, children and young people, long term conditions e.g. Hepatitis C, gender dysphoria, genomics and personalised care

• Procedures of Lower Clinical Priority – implementation of national guidance on the “17 interventions” and 18 items which should not be routinely prescribed that have been identified through the national review

• Develop the Clinical Assessment Service and Directory of Services through NHS 111 to reduce directions to A&E

• Delivery of the Ambulance standards including handover at A&E In the appendix a high level summary of the other (non Level 1) contents of the planning guidance are included

Development of Operational Plans Whilst we will continue to develop individual CCG operational plans that meet our local priorities and regulator assurance requirements we have designed a consistent approach to developing plans. This will: • Build on the commissioning intentions already agreed and we will work

collectively to add detail and agree when intentions/initiatives will be: – Done once across Cheshire – Share good practice but implement locally – Individual CCG or Place based

• The plans will have consistent content: – Working Together across Cheshire work streams will oversee the chapter relevant to

their area of focus – Based on a shared set of opening planning approaches/assumptions for developing

operational and financial plans and to inform contract negotiations (This recognises that our allocations, baselines and some priorities will differ)

• Cheshire wide planning/information sharing sessions for development of QIPP ideas has taken place

Operational Plan Document Content Introduction • National requirements (planning guidance) • The health needs of people living in

Cheshire • Approach and planning timescales Working Together Across Cheshire • Cheshire and Merseyside Health and Care

Partnership • CCGs Working Together across Cheshire • Working in partnership with Cheshire East

and Cheshire West and Chester Councils a) Joint Working Plans b) The Better Care Fund

• System Transformation and Integrated Care Partnerships

Achieving Financial Sustainability • Introduction (Taken from the context in Financial Recovery

Plans) • The CCG’s Financial Outlook for 2019/20 and beyond

(include allocation, control totals and planning guidance) • Quality Innovation Prevention and Productivity (including

Medicines Management, Right Care etc.) Securing Good Quality Services And Safeguarding • Our Approach to Quality and Safeguarding • Securing NHS Constitutional Standards in Commissioned

Services • Demand and Capacity Planning • Improvement and Assessment Framework • Delivery of NHS Constitutional standards Commissioning Intentions Engaging with Patients and our Public • Our plans to involve the public

High level milestones – Key next steps

Shared approach to development of Operational Plan developed and agreed by Joint Executive

Team 17/12

Deadline for

Contract signature

21/3

Governing Bodies approve

draft Operational

Plan Document

02/19

Key documents

published: 1. Long Term NHS

Plan (7/1) 2. CCG Allocations

(10/1) 3. System Control

Totals (16/1) 4. NHS Operational

Planning (10/1) 5. Consultation starts: -National Tariff (17/1) -Standard Contract (21/12)

Final National Contract published

22/2

National Tariff

published 11/3

Cheshire wide Commissioning

Intentions agreed by Joint

Commissioning Committee

30/9

Initial Planning Submissions (secondary care activity

levels) 14/1

Final Plans Submitted:

Operational Plan

Financial Plan 4/4

Governing Bodies approve

Operational and Financial Plans

(including budgets) 03/19

System Level

Strategy (Autumn)

System Level Operational

Plan submissions (template

based) 19/2

SEP 18

JAN 19

FEB 19

MAR 19

APR 19

Autumn 19

DEC 18

Level 2 Areas of Focus within National Planning Guidance

• Mental Health: – CCGs must increase investment by the rate of growth in their funding

(which must be specifically delivered by the same percentage increase in children and young peoples services)

• Primary Care and Community Services: – Continued investment including £1.50 for developing primary care

networks (PCNs). Networks must be established by June. – Investment should be greater than CCG overall uplift – A primary care strategy must be included in the system strategy due

by the Autumn – CCGs will need to undertake internal audits to assure of their

discharging of delegated commissioning functions – STP/ICS must ensure PCNs receive analytics (population segmentation

and risk stratification) in order to aid symptomatic and preventative programmes

Level 2 Areas of Focus within National Planning Guidance

• Urgent and Emergency Care: – Type 1 A&E will move to consistent “same day emergency care” (SDEC model to increase the

proportion of admissions discharged the same day from 1/5 to 1/3 (without increasing proportion of non SDEC 0 day admissions)

– Improved clinical pathways for most serious illness/injury – STP/ICS develop robust assumptions and “demand management” – Reduction in long stay patients (>21 days) and Delayed Transfers of Care – Continue the redesign of urgent care services including Urgent Treatment Centres

• Referral to Treatment: – Patients right to choose is protected and providers, or CCGs, must contact patients waiting more than 6

months to offer an alternative provider • No patient should wait more than 52 weeks and penalties to both providers and commissioners will apply

– Total waiting lists must reduce below the March 2018 starting baseline – A marked reduction in waiting lists through streamlined care, use of technology and alternative

outpatient models • Productivity and Efficiency

– Reducing variation e.g. Right Care (cardiovascular, respiratory and one area of priority for local determination)

– Developing of robust and affordable estates strategies – Use of Innovation e.g. flash glucose monitoring will receive a national budget

Level 2 Areas of Focus within National Planning Guidance

• Cancer: – The respective Cancer Alliances (Cheshire and Merseyside and Greater

Manchester) will work on behalf of STP/ICPs to oversee and transform services with a continued focus on:

• The eight cancer waiting time standards • Preparing for the 28 day Faster Diagnostic Standard to be introduced in 2020

• Learning Disability and Autism – Continue to reduce reliance on inpatient care – Annual health check s (75% of people on register) – Learning from Deaths reviews

• Workforce – Providers workforce plans need to be updated to reflect the latest context

and challenges – Maximise recruitment opportunities and use of bank rather than agency

capacity – Focus on a range of opportunities to improve retention

Joint Commissioning Committee Approval – March 2019

Cheshire CCG Governing Bodies Approval – March 2019

Operational Plan NHS Eastern

Cheshire CCG

Operational Plan NHS South Cheshire

CCG

Operational Plan NHS Vale Royal CCG

Operational Plan NHS West Cheshire

CCG

Developing Commissioning Intentions for the Cheshire CCGs Cheshire Commissioning Intentions

approved at Sept 2018 Joint Commissioning Committee (Directors of Commissioning)

Cheshire Commissioning Intentions Shared with main Providers in Oct 2018

(Directors of Commissioning)

Commissioning Intentions Refined Development of work plan/resourcing/milestones

Dec 2018 – Jan 2019 (Directors of Commissioning)

NHS Long Term

Plan

Health & Wellbeing Boards – March 2019

Communication of Plans - April 2019 (Engagement & Comms Teams)

Planning guidance

Public Engagement

Stakeholder Engagement

Commissioning Programmes to Ensure Delivery 2018/19

Care Community Development

Primary Care Mental Health Learning Disabilities

Women & Children

Maternity Cancer & End of Life Care

Long Term Conditions &

Frailty

Elective Care

Urgent & Emergency Care

Key Principles

1. Integration

2. Care in the right place

3. Prevention/Self Care

4. £

Learning Disabilities (LD)

• Increase community shared lives (short breaks)offer for people. • Review of all inpatient respite and acute admission units in line

with Transforming Care. • Joined up assessment and review across providers, and current

contractual arrangements. • Joint commissioning arrangements and potential pooled budgets

with Local Authorities. • Promote choice and control through Personal Health Budgets

(PHBs). • Improve performance on key quality indicators:

– Annual Health Checks – STOMP (Stopping the Over Medication of People with LD, Autism or

both) – LEDER (Learning from Deaths Report)

Mental Health 1

• Development of an all age Mental Health Hub. • Lead provider model to ensure primary care mental heath along with

physical health is aligned in care communities. • On the day crisis support accessible 24/7. • Growth of community care in line with reduction of inpatient mental

health provision. • Review of current mental health assessment teams to reduce duplication. • Enhanced choice and control through Personal Health Budgets (PHBs). • Joint commissioning:

– single mental health framework for care provision to maintain market stability.

– early intervention. – high cost patients across Cheshire and Wirral.

Urgent Care and Emergency Care

• Explore the development of Urgent Treatment Centre(s) in the community.

• Commission integrated urgent care out of hours service aligning Urgent Treatment Centre(s), GP out-of-hours and GP extended access appointments.

• Integrate wider primary care with urgent care to: – rationalise the service offer – reduce duplication – flex the workforce to provide urgent and primary care

services which meet the needs of the local population.

Elective Care

• Implement the virtual hospital. • Standardise elective care pathways through single

referral guides. • Reduce unwarranted variation, ensuring NICE

guidelines are implemented. • Develop new outpatients models to deliver care

within the community settings. • Embed SAFER Patient Bundle. • Ensure all referral management schemes are working

effectively.

Maternity

• Commission a seamless community to acute maternity offer for women across Cheshire.

• Implement the recommendations of the National Maternity Review 'Better Births'.

• Consistent approach for peri-natal mental health across Cheshire.

• Improve access and awareness of current secondary and community maternity services.

• Further develop joined up acute maternity services as per Health Care Partnership (HCP).

Women and Children

• Further integrate Children's services with Local Authorities building on current contracts, bringing care closer to home through Children’s Centres.

• Develop community children's clinics across the care communities reducing unnecessary hospital admissions.

• Develop a single Autism diagnostic pathway and model across Cheshire.

• Review the SEND (Special Educational Needs and Disability) assessment offer to combine processes across health and social care. Linking support closer to schools and communities.

• Commission pre and post diagnostic support children collectively with partners.

Primary Care

• Workforce - Continue to work with Practices to develop a workforce plan that: – recognises new staffing models – includes a robust retention plan – attracts new GPs into the area.

• Releasing Time For Care - Commissioning this Programme further to develop new

ways of working, releasing clinical time and supporting Practices. • Primary Care At Scale: Continue to support at scale working, collaboration and

resilience in General Practice.

• Access to Primary Care 8am to 8pm, 7 days a week by developing a lead provider model for delivery.

• Primary Care Charter – less onerous, more focused. • Flexibility in GP appointment time per patient.

Primary, Community Care and Long Term Conditions

• Develop an integrated model of extended access services. • Support community commissioning models such as mental

health first, DVT (Deep Vein Thrombosis), diagnostics, tele dermatology, cardiology, diabetes , respiratory.

• Care Community Development – Support Practices as part of the

development of Care Communities ensuring General Practice has an integral role in this approach to managing place based health care.

• Commission Out of Hospital offers enhancing care in the right

place.

Cancer

• Delivery of national Cancer Standards and Cancer Outcomes outlined in the national Cancer Strategy and Cancer Waiting Times Standards.

• Develop and Implement a Cheshire Cancer Strategy across the 4 CCG’s • Work closely with The Christie and The Clatterbridge Cancer Centres with their

transformation programmes. • Reduce the overall growth in the number of all cancer cases – Work towards

supporting the Action on Cancer programme across the 4 Cheshire CCG’s. • Improve survival of people diagnosed with cancer. • Improve the quality of life of patients after treatment and at the end of life

– Risk stratify follow-up care for people at the end of treatment for cancer – All patients to receive an end of treatment summary and follow up plan – Health and Well-being clinics to be available for all cancer patients – Work with Macmillan to develop cancer care in the community aligned to

care communities – Work towards an Acute Oncology Service expanding from 5 to 7 days a week.

End of Life (EOL)

• Care Coordination at EOL: Develop and implement innovative models of proactive and timely EOL care, introducing new partnerships across organisations, that joins up and coordinates care and services to support people at EOL who chose to die at home. More coordinated commissioning arrangements and service specifications to be put in place.

• Community Development: Establish Community Development Programmes /

projects to support individuals in their last year of life and those important to them e.g. befriending schemes, compassionate community / volunteer led support

• End of Life Collaborative Plan to be developed from 2020 onwards across the 4

Cheshire CCGs in line with population health needs and nation EOL Ambitions Strategy.

• Advanced Care Planning across all providers, and aligned with The Cheshire and

Mersey Advanced Care Planning Framework.