South Manchester

Clinical Commissioning Group

Strategic Plan

2014/15 – 2018/19

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Contents Page

Page Executive Summary 3 South Manchester Vision Hilda’s Story Plan on a Page Section 1: The Case for Change in south Manchester 8 1.1 Strategic policy context 1.2 Health in south Manchester 1.3 Evidencing our priorities Section 2: Our Plan 20 2.1 Our System Vision: Greater Manchester, the Southern Sector, Manchester and the CCG 2.2 Manchester strategic case for integrated care 2.3 Living Longer, Living Better 2.4 New integrated model of care: The role of primary, community and secondary care 2.5 South Manchester approach to Living Longer, Living Better: Neighbourhood Teams 2.6 Financial sustainability Section 3: Strategic Priorities 28 3.1 Strategic Delivery and Our Priorities 3.2 Strategic Priority 1: Delivering our new models of care 3.3 Strategic Priority 2: Improve Primary Care 3.4 Strategic Priority 3: Improve and reform the urgent care system 3.5 Strategic Priority 4: Improve and reform Planned Care 3.6 Strategic Priority 5: Delivery of the Healthier Together programme Section 4: Financial Sustainability 78 4.1 Strategic Priority 6: Delivering a financially sustainable health system 4.2 Risks Section 5: Cross Cutting Priorities 87 5.1 Cross cutting 1: Community Services and the Voluntary Sector 5.2 Cross cutting 2: Delivering a system focused on prevention 5.3 Cross cutting 3: Quality and outcome focused, Patient Voice, CQUIN 5.4 Cross cutting 4: Organisational Development and Communities 5.5 Cross cutting 5: Collaborative Commissioning 5.6 Cross cutting 6: Medicine Management Section 6: Engagement with Stakeholders 130 6.1 Call to Action Engagement 6.2 Engagement with Member Practices 6.3 Patient and Public Engagement 6.4 Partnership Working 6.5 External Partners

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Executive Summary

South Manchester System Vision South Manchester will continue to build on the relationship that has developed across health and

social care; we see this as the key vehicle to delivering better outcomes for our residents. We are

focused on our people, pride and place and as a system we are fully committed to helping our

population to live longer and live better.

This vision is shared between the GPs in the 25 practices across south Manchester and these

practices have come together to form the South Manchester GP Federation to focus on delivering

a more co-ordinated, consistent primary care offer for the whole population. South Manchester

Clinical Commissioning Group will continue to work in partnership with our patients, their carers

and families, our social care colleagues, community staff, hospital clinicians and managers as

collectively we have a responsibility to improve the health and wellbeing of our residents.

Patients, carers and families will notice an improvement in health outcomes because we will have

a systematic and targeted approach to how services are commissioned and delivered. There will

be new models of care that have a clear focus on;

The individual, their carers and families and not organisational structures

Empowering individuals, their carers and families enabling self-care and self-management

of conditions

A shared care approach between individuals and providers

Achieving the commissioned specified outcomes for individuals and the population as a

whole

In south Manchester we have reason to be optimistic about the future and our ability to face the

challenges ahead. We believe in having a co-ordinated approach to community based care,

centred on families, with the ultimate aim for our population to have personal power and

independence.

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Hilda’s Story: a true story of a real patient in south Manchester Hilda had been a patient of Dr Tamkin for thirty years and her story is Dr Tamkin’s personal foundation and motivation to lead South Manchester Clinical Commissioning Group to radically change the delivery of health and social care in south Manchester. South Manchester GPs along with key partners will do their utmost to ensure all our future Hilda’s get the best possible care. Hilda was a fiercely-independent 82-year-old, who had long made it clear that she wished to die in her own home in south Manchester. The fact that she did not achieve this, but ended her days in hospital, is an illustration of why health and social care services need to change. Despite a number of health problems, Hilda lived alone at home, with the support of daily visits from family members and from carers, who were left in no doubt that this was where she wanted to die. Even a diagnosis of cancer failed to change her mind. As her health condition deteriorated a stair lift was installed, to make access to all rooms in her home easier. One evening however, Hilda became tired whilst moving around upstairs, decided to lie down and rest on the landing and was unable to get up from the floor. What followed was a lack of common sense and insensible bureaucracy. When Hilda’s carers arrived, they were unable to help her up, because their protocols did not permit them to lift her. They had to make her comfortable and call the ambulance, even though she had told them she had not fallen. When they arrived, the ambulance staff responded to their protocol for falls, and took Hilda to the local A&E department, despite her protests that she had been resting and had not had an accident. Hilda then endured a three-hour wait, and a further three hours admitted to the Clinical Decision Unit, until she was finally admitted onto a ward. All this time she was insisting to those around her that she wanted to go home. Our vision for an integrated health and social care system for south Manchester will enable this to be possible in the future; Hilda would have been able to go home with the appropriate care she needed to support her. Instead, she spent the last five days of her life on three different hospital wards, during which time her condition began to deteriorate. Hilda knew she had not long to live and reiterated her wish to be allowed to spend her final days with her family at home. However Hilda spent her last seven hours being moved between two different wards. She finally passed away in hospital - the place where she had always been clear she did not want to end her days.

Let’s help prevent more stories like Hilda’s

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The south Manchester system will champion:

• Listening and responding to patient wishes

• Patients not being bounced around our systems because of either bureaucracy or lack of

common sense

• Integrated health and social care

• Use of information technology to support independent living and share knowledge about

an individual’s needs between professionals

• Multidisciplinary care planning for patients with long-term conditions, so that they know

who and when to contact for assistance as their condition changes

• 24/7 community emergency response and support

• A self-reliant population with information and access to healthy lifestyle activities,

preventing ill health or managing long term conditions

• Jointly trained staff across health and social care

With special thanks to Hilda’s family for giving permission to use her story.

Changing the Story: the vision Patients will notice an improvement in health outcomes because of clinicians’ freedom to

target and personalise care more effectively. They will also benefit from the removal of two

significant historic barriers - the first being the historic divide between primary care (GPs

and community services) and secondary care (hospitals and specialist care), and the second

being the traditional gap between health and social services. Through this integration of

services we can not only provide a better and more seamless service to patients, but also

provide those services more efficiently within the resources available. Patients will be

encouraged to take increased responsibility for their health and we will build a self-reliant

population with access to information and healthy lifestyle activities, preventing ill health

and managing long term conditions.

We, in south Manchester, have reason to be optimistic about the future and our ability to

face the challenges ahead. We have already brought in new ways of working, through our

Neighbourhood Teams (NT) working across the four GP patches: Withington and Fallowfield;

Didsbury, Burnage and Chorlton; Wythenshawe; Northenden and Wythenshawe. We have

extended access to primary care for the target population group frail older adults/adults

with dementia and end of life care for adults.

We seek transparent relationships with our residents through the established partnership

with our Patient and Public Advisory Group and continue to act upon the feedback received

from patients about their experiences when accessing and using services.

The newly established provider partnership in south Manchester will take on the

responsibilities of working together to develop and implement new models of care that

utilise the variety of skills and expertise that the partnerships holds. The new models of

care will have a focus on people, their families and neighbourhoods and working to a

common set of outcomes for the population.

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Given the UK’s economic situation, advances in medical care and a changing population

profile, the NHS as a whole no longer has the option of simply carrying on working as

before. In south Manchester we believe in working smarter, by uniting our staff, practices,

local community and providers of care to create a new vision of patient-centred services,

and treating everyone with dignity and respect at all times.

These are exciting times for Manchester and the south system is proud to be part of

creating a new reality where health and social care services are excellent, streamlined and

cost-effective and put the needs of patients at the heart of everything we do.

Dr Bill Tamkin, Chair, South Manchester Clinical Commissioning Group

Caroline Kurzeja, Chief Operating Officer, South Manchester Clinical Commissioning Group

Sir Howard Bernstein, Chief Executive, Manchester City Council

Dr Attila Vegh, Chief Executive, University Hospitals South Manchester

Dr Simon Baxter, Interim Chair, South Manchester GP Federation

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Section 1: The Case for Change

1.1 Strategic Policy Context In determining the health needs for south Manchester we recognise the need to understand

the population and current health status and have used a wide range of information to

consider where we need to focus and what our priorities should be. This includes:

The Joint Strategic Needs Assessment (JSNA) This describes the underlying demographics, current health and health needs of the south

Manchester population. The JSNA identifies key priorities for the city and each of its CCGs

and makes recommendations for commissioners about what needs to be done to address

these priorities.

The Manchester Health and Wellbeing Strategy The Health and Wellbeing Strategy is informed by the JNSA. It describes a radical, shared

vision for health, well-being and life chances in Manchester, with a major shift in the focus

of services towards prevention of problems and intervening early to prevent existing

problems getting worse and a shift towards services provided closer to home.

Public Health Outcomes Framework 2013-16 The framework focuses on increase healthy life expectancy and reducing inequalities. It describes the overarching vision for public health, the outcomes to be achieved and the indicators that will help us understand how well we are improving and protecting health.

National Comparative Data There are a wide range of sources of information including Programme Budgeting data and

Better Care Better Value metrics that support local health services; enables benchmarking

with our peers and lead to improvements in service quality and health outcomes. Significant

opportunities have been identified through benchmarking work particularly via NHS

Commissioning for Value.

Mental Health in Manchester The Mental Health Improvement Programme is our new commissioning vehicle for

continued improvement in the commissioning of mental health services in Manchester and

is central to our plans, in partnership with Manchester City Council. Our plans are informed

by the need to address the strategic and quality drivers outlined in the Manchester Mental

Health Independent Report (Mental Health Strategies, 2013) and the 2014-15 Mental Health

Commissioning Intentions.

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Manchester Joint Strategy for Improving Outcomes for Children, Young People and Families The strategy highlights narrowing the gap in key health outcomes for children and young people as a priority for Manchester, along with the need to adopt a ‘whole family’ approach to supporting families with complex needs. Integrated Co-ordinated Care Our system of health and care is under more pressure than ever before. People are living for longer, but often they are living with several complex conditions that need constant care and attention, conditions like diabetes, asthma or heart disease require regular medication, monitoring and patient lifestyle advice. This is not related only to older people; children born with complex conditions are now living to adulthood, while those with learning disabilities and other groups have lifelong needs. All these people need continuous care and support, and the right systems and resource to enable that. High Quality Care for All - NHS Next Stage Review Final Report (June 2008) An overarching outcome from the review is the focus on bringing about change at local level, based on sound evidence and in partnership with patients and staff. The vision is that there is ‘an NHS that gives patients and the public more information and choice works in partnership and has quality of care at its heart. Click here to view the document Equity and Excellence: Liberating the NHS (July 2010) To achieve our ambition for world-class healthcare outcomes, the service must be focused on outcomes and the quality standards that deliver them. The Government’s objectives are to reduce mortality and morbidity, increase safety, and improve patient experience and outcomes for all. “We recognise the critical interdependence between the NHS and the adult social care system in securing better outcomes for people, including carers. We will seek to break down barriers between health and social care funding to encourage preventative action”. The paper sets out patient shared decision making as key and the principle of ‘no decision about me, without me’. Click here to view the document The Health and Social Care Act 2012 The Act puts clinicians at the centre of commissioning, frees up providers to innovate, empowers patients and gives a new focus to public health. The Act includes promoting better integration of health and care services. Click here for an overview of the Health and Social Care Act 2012 The NHS Outcomes Framework 2013/14 Sets out the outcomes and corresponding indicators used to hold the NHS Commissioning Board to account for improvements in health outcomes. Click here to view the document Everyone Counts: Planning for Patients 14/15 Empowered local clinicians delivering better outcomes; increased information for patients to make choices and greater accountability to the communities the NHS serves. Click here to view the document

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Quality, Innovation, Productivity, Prevention (QIPP) QIPP is key for the NHS to focus on improving quality and productivity to achieve better outcomes more efficiently. We have embedded QIPP into our core business and we are building on our existing successful QIPP programme, focusing on strategic plan priorities and partnership working with patients, providers and GP practices. Commissioning for Quality and Innovation Framework (CQUIN) The CQUIN payment framework enables commissioners to reward excellence, by linking a proportion of healthcare providers’ income to the achievement of local quality improvement goals. There are national, regional and local CQUINs with acute providers, community providers, mental health trusts and nursing homes. Click here to view document The NHS belongs to the people; a call to action This document sets out the challenges facing the NHS, including more people living longer with more complex conditions and increasing costs, whilst funding remains flat and there is rising expectation of the quality of care. The document clearly states that the NHS must change to meet these demands, making the most of new medicines and technology and confirming that it will not contemplate reducing or charging for core services. Click here to view the document The Better Care fund The Better Care Fund will provide £3.8 billion to local services to give elderly and vulnerable people an improved health and social care system. Published guidance provides local areas with the detail they need to complete plans for how they will use their portion of the fund to join up health and care services around the needs of patients, so that people can stay at home more and be in hospital less. Click here to view the document The Care Act 2014 The Care Act introduces legislation to provide protection and support to the people who need it most and to take forward elements of the Government’s initial response to the Francis Inquiry. The Care Act will give people peace of mind that they will be treated with compassion when in hospital, care homes or their own home. Click here to view further details and a link to the Act. Healthier Together This is a fundamental review of health and care in Greater Manchester including primary community and secondary care services and the impact on social care. The Healthier Together programme aims to develop a model of care that will help the NHS and other care providers in Greater Manchester provide quality services that are safe, accessible and sustainable for future generations. Click here to view the document

Manchester’s plans for integrated care are known as the ‘Living longer, living better’ (LLLB) programme. A ‘strategic outline case’ was published in June 2013. This document sets out the detail of key parts of the future plan, and tests the underlying assumptions behind a planned change; in this case in health and social care services. Integrated care arrangements are intended to put people in control of their own care, and to reduce avoidable use of hospital and other services, especially emergency services. Click here to view the document

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Staying Well, Living Well: Our five year strategy for improving primary care within Greater Manchester 2014-2018 This primary care commissioning strategy identifies how primary care will be different in the future, to patients and professionals. The Primary Care Commissioning Directorate, within NHS England’s Greater Manchester team is fully committed to the principles of the NHS and sees their core function as commissioning quality health services delivered as close to home as possible and in the most cost effective way. Their aim over the next five years is to work with CCGs other commissioners to deliver and transform, out of hospital care for all people of Greater Manchester. Click here to view the document

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1.2 Health in South Manchester

Population Demographics The estimated resident population for south Manchester in 2012 was 161,260. Compared with the population of England as a whole, the population of south Manchester contains a higher proportion of adults aged 20 to 34, but a lower proportion of older people. The most recent population projections suggest that the resident population of south Manchester is likely to increase by about 12,000 people (or 7.4 per cent) over the next 10 years (i.e. between 2012 and 2022). This is a slightly higher rate of increase than is projected to occur across Manchester as a whole (6.9 per cent). The following graph shows population projections for the next 10 years expressed as a ratio (where the figures for 2012=100). This makes it easier to compare population changes between different sized age groups.

The figures in the graph show that over the next 10 years, the area covered by the CCG is

likely to see increases in the population of children (0-14 years), adults of older working age

(45-64 years) and older people aged 65-74 years. The number of people aged over 85 years

is projected to increase by nearly 14 per cent, although the small number of people in this

cohort means that this increase translates into a relatively small absolute change of around

400 people across south Manchester as a whole.

Within south Manchester, the most populous wards are Sharston, Chorlton Park and

Burnage. According to the latest estimates for mid-2012, there are just over 30,000 children

aged under-16 living in south Manchester. Within the area the proportion ranges from just

under 9 per cent in Withington to 24 per cent in Burnage.

2012-based Subnational Population Projections by broad age group (change ratio)

South Manchester CCG 2012-2022

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2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022

Age Group

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0 to 14 15 to 24 25 to 44 45 to 64 65 to 74 75 to 84 85 & over

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About 11 per cent of south Manchester residents are estimated to be aged 65 or over. This

is higher than the city average of 9 per cent. As with children, the population of older people

varies substantially within the CCG. The proportion of the population aged 65 and over,

ranges from 6.9 per cent in Withington to 14.7 per cent in Brooklands.

Figures from the 2011 census highlight the ethnic diversity within the CCG. Overall, around

27 per cent of the population of south Manchester identified themselves as being from a

non-white British group. The largest ethnic groups (using the 2011 Census categories) are

“Other White” (4.2 per cent), “Pakistani” (4.0 per cent), “Irish” (2.7 per cent) and “Indian”

(2.3 per cent). Within south Manchester, the proportion of the population from a non-white

ethnic group ranged from 13 per cent in Woodhouse Park to 33 per cent in Burnage. People

from an Asian/Asian British group are most likely to live in Burnage whereas those from a

Black/Black British group (much smaller in number) are most likely to live in Chorlton Park.

Figure 1: Key health issues by patch (JSNA)

Burnage, Chorlton and Didsbury Fallowfield and Withington

High proportion of residents from a non-white ethnic group (Burnage)

Life expectancy is higher than the Manchester average

Burnage has a higher than average rate of low birth weight babies

The prevalence of obesity in year 6 children in Burnage is higher than the national average

Burnage has a higher proportion of adults with a limiting, long term health problem

Higher than average number of people killed or seriously injured in road accidents

Higher proportion of adults claiming benefits (Burnage)

Mortality rates higher than the national average

High proportion of residents from a non-white ethnic group (Burnage)

Prevalence of obesity in year 6 children is higher than the national average

Higher proportion of younger people and students

Proportion of adults “not in good health” is higher than the England and Manchester average

Mortality rates higher than the national average

Large population with mental health problems

Higher rates of sexually transmitted infections

High rates of smoking

Wythenshawe Northenden and Wythenshawe

Very high levels of deprivation

Life expectancy at birth is the lowest in Manchester

High rate of births

High rates of births to lone mothers

A higher than average rate of low birth weight babies

Prevalence of obesity in year 6 children is higher than the national average

Lower than the Manchester average level of academic achievement at GCSE

Proportion of adults “not in good health” is higher than the England and Manchester average

Higher proportion of adults with a limiting, long term health problem

Higher than average number of people killed or seriously injured in road accidents

Higher proportion of adults claiming benefits

Mortality rates for all disease higher than the national average

Particularly high rates of mortality for CVD

Prevalence of obesity in year 6 children is higher than the national average

Lower than Manchester average level of academic achievement at GCSE

Proportion of adults “not in good health” is higher than the England and Manchester average

Higher proportion of adults with a limiting, long term health problem

Higher proportion of adults claiming benefits

Mortality rates higher than the national average

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1.3 Evidencing Our Priorities

Below is a summary of the current position in relation to the priority areas we intend to

address through implementing this plan.

Life expectancy The latest figures for the period 2010-12 show that life expectancy at birth among women in

Manchester (79.5 years) is the worst in England, whereas for men (74.8 years) it is the

second worst. The gap between life expectancy at birth in Manchester and the England

average is currently 4.4 years for men and 3.5 years for women. Within south Manchester,

life expectancy at birth varies considerably across wards, with a gap of 8.4 years between

Didsbury East and Sharston.

Life expectancy at the age of 65 in Manchester is significantly below the national average. In

2010-12, 65 year old men in the city had a life expectancy of just under-16 years, whilst 65

year old women had a life expectancy of just under 19 years. Note that life expectancy is not

a guide to the remaining expectation of life at a later age, e.g. if life expectancy at 65 in a

particular area is 15 years, it does not follow that people aged 65 living in that area can

expect to live until the age of 80.

Health inequalities South Manchester is generally regarded as an affluent and desirable part of the city with

vibrant suburbs such as Chorlton and Didsbury. The Index of Multiple Deprivation (IMD)

2010 indicates that south Manchester has levels of deprivation substantially below the city

average. However, there are widespread variations within the area (particularly between

the areas north and south of the River Mersey) and there are significant pockets of

deprivation, such as Benchill, Baguley and Woodhouse Park, which are characterised by high

levels of worklessness, low skill levels and poor health. Overall, 37 per cent of children aged

0-15 years in south Manchester were classed as living in income deprivation. As above

variation across the CCG is significant with almost half of the children in Woodhouse Park

living in income deprivation compared to less than 10 per cent of children in Didsbury West.

Obesity Obesity is an important risk factor for a number of chronic diseases during adulthood, which

are the principal causes of death in England, including Coronary Heart Disease (CHD), stroke

and some cancers and is also associated with other life limiting conditions such as

hypertension and Type2 diabetes. The national Child Measurement Programme weighs and

measures children at school in reception and year 6. Figures for 2012/13 indicate that

around 12.5 per cent of children in Reception Year and 24.7 per cent of children in Year 6

were classed as being obese. Figures for 2009/10 to 2011/12 combined show that the

prevalence of obesity in Year 5 schoolchildren in south Manchester was 21.3 per cent (just

below the city average), with figures at ward level ranging from 24.6 per cent in Old Moat to

18.9 per cent in Didsbury East.

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Oral health Oral health is poor in Manchester with around 41 per cent of five year olds having some

experience of dental decay (National Dental Epidemiology Survey 2012). This represents a

reduction of 10 percentage points since the previous survey in 2008. There is some

inequality within the city and the proportion of five year olds living with experience of decay

is lower in South Manchester CCG than it is in North and Central Manchester CCG areas. In

2011/12 and 2012/13, there were over 1,220 admissions to hospital for dental extraction

among children aged 0-19 years in Manchester. This is the largest single reason for

admission in this age group.

Self-care habits that lead to good oral health also contribute to general health

improvements, particularly with regard to infant weaning and diet. Much hinges on better

parenting skills. General medical practice teams have a role in addressing many of the issues

that affect oral health in their patients. In place of school screening for oral disease targeted

initiatives allow preventively orientated general dental practices to link with local schools to

encourage routine attendance at the practice for non-attending pre-school children. Oral

cancer is increasing in prevalence and is strongly linked with smoking and excessive intake

of alcohol.

Cardiovascular disease Cardiovascular disease is a term that covers Coronary Heart Disease (CHD), Stroke and

Peripheral Arterial Disease. Data collected as part of the Quality and Outcomes Framework

suggests that in 2012/13 there were approximately 5,224 patients on the CHD registers of

GP practices in South Manchester giving an average prevalence of 3.1 per cent; higher than

the Manchester average of 2.7 per cent. A further 0.6 per cent of the registered population

were included on a long term condition register because they had experienced heart failure.

The reported prevalence of CHD among GP practices ranged from 5.2 per cent to 1.2 per

cent of the practice population.

The data also shows that in 2012/13 just over 2,500 patients are recorded as having had a

Stroke or Transient Ischaemic Attack (TIA), which is equivalent to 1.5 per cent of the

population compared to 1.3 per cent across Manchester. The reported prevalence of stroke

or TIA amongst GP practices ranged from 2.6 per cent to 0.3 per cent of the practice

population.

Cancer After CVD, cancer is the biggest cause of premature death and inequalities in life expectancy

in south Manchester. Nationally, there are inequalities in terms of differences in individuals’

cancer experience and outcome which result from their socio-economic status, race, age,

gender, disability, religion, sexual orientation, cancer type and area of residence and which

are replicated in Manchester. Whilst survival rates for most types of cancer have been rising

steadily for decades, they have increased faster among more affluent groups, with the

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inequalities gap widening. As a result, survival rates are worse for the most disadvantaged

groups.

There is strong evidence that different groups have different perceptions of the risk

associated with lifestyle factors such as poor diet and alcohol. These risks are strongly

associated with socio-economic status and contribute to local health inequalities.

Cancer outcomes are dependent upon early and accurate diagnosis and effective treatment.

Be Clear on Cancer is a public awareness campaign that explains the symptoms of a range of

cancers and encourage people with symptoms to see their GP. The campaign is run by Public

Health England in partnership with the Department of Health and NHS England. It is also

supported by Cancer Research UK.

South Manchester CCG supports the Be Clear on Cancer campaign by working with its

member GP practices to identify cancer symptoms earlier and refer people on to a

secondary care appropriately. Improvements in primary care are led by our Macmillan

cancer GP, promoting significant event audit in practice and providing peer support and

challenge.

Nationally, over 5 per cent of all cancers are currently diagnosed via screening. Uptake of

cancer screening is lower than the national average in south Manchester. In addition, there

is a lower uptake of screening among ethnic minority groups, which is independent of socio-

economic status. This is a key area of focus for the Macmillan Cancer Improvement

Partnership (MCIP) in which the CCG plays a lead role.

Long-term conditions (LTCs) Demographically more people, including disabled people with complex needs, are living

longer, and need help with managing long term conditions (LTCs), or as they become older

and frailer. The NHS Operating Framework 2013/14 highlights the integration transforming

care for people with LTCs as a critical challenge. Domain 2 of the NHS Outcomes Framework

specifically relates to enhancing the quality of life for adults and children with long term

conditions.

Reported prevalence for a number of disease areas in south Manchester compared with

national prevalence is low. Hypertension, depression and asthma are by far the most

common LTCs among adults registered with GP Practices in south Manchester. As this

dataset is reported prevalence there may be inaccuracies, for example, undiagnosed

patients who are not on a primary care disease register will not be included.

Children with long-term conditions In 2010/11 Manchester had a significantly higher emergency admission rate for children

with asthma than the England average, with a ranking of 147 out of 152 Primary Care Trusts.

Variation may be due to suboptimal management in the community, or Accident and

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Emergency, or different admission thresholds. Emergency admission rates are also

particularly high in Manchester for children with epilepsy, diabetes and bronchiolitis.

Analysis suggests that there is a positive relationship between deprivation and child

emergency admissions for asthma and epilepsy. Therefore hospital admissions are likely to

be highest in the most deprived parts of the locality, predominantly south of the River

Mersey.

Mental health Mental health problems will affect 1 in 4 people at some stage in their lives. The impact of

this on carers, families, and intergenerational relationships are even broader. It is estimated

that 70 per cent of people within the criminal justice system have a mental health issue, and

another concurrent problem such as substance misuse. Mental health can have a

devastating impact on individuals, their families and communities worsened by delayed

contact with mental health services, and social stigma and negative perceptions of mental

health further delay people seeking help before a crisis occurs.

The Manchester Mental Health and Well Being Commissioning Strategy 2009 -2014 sets out

the principles, direction and desired outcomes for the commissioning and development of

the mental health system in Manchester. The publication of the new national mental health

outcomes framework “No Health without Mental Health” (DH 2011) puts forward a “life

cycle” approach for the prevention, treatment, aftercare and recovery of people affected by

mental health and associated complex problems.

The current mental health system in Manchester will be further reviewed in 2014 so that

NHS services and the third sector have consistent access criteria and can support each other

via joined up care pathways. There will be increased emphasis on the mental health needs

of those with Learning Disabilities, to ensure parallel and aligned interventions, together

with a formal interface between the mental health and learning disability commissioning

governance structures.

Learning disabled people and people with autism In 2010/ 11 there were 1732 learning disabled adults known to Learning Disability Services

in Manchester. Between March 2002 and March 2006 the numbers of learning disabled

adults accessing services increased from 987 to 1410. This figure demonstrates a growth of

30 per cent during these years. Independent research conducted in 2007 predicted that the

population of adult users of specialised adult health and social care services for people with

learning disabilities in Manchester will show a top-rate year-on-year annual increase of

approximately 4.5 per cent. However, based on current population analysis there has been

a population increase averaging 6.3 per cent over 3 years. This is much higher than the

nationally predicted 1 per cent increase in prevalence. For younger people (age 18–29), the

increase in need is predicted to lie somewhere between 70 per cent and 129 per cent. For

older people (age 60+), the estimate predicts a 36 per cent increase in need. The evidence

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also suggests that the percentage of adult people from minority ethnic communities will rise

from 16 per cent to 22 per cent, of whom the two largest groups will continue to be people

from South Asian minority ethnic communities (estimated to rise from 8 per cent to 11 per

cent), and people from black minority ethnic communities (estimated to rise from 6 per cent

to 7 per cent). Out of the 417 confirmed Learning Disabled Health Checks undertaken

across Manchester in 2011/12, 238 were completed by GP practices in the South

Manchester CCG footprint.

There is an increase in case complexity driven by the increase in numbers of learning

disabled people with needs in terms of complex physical impairments (including technology

dependence), behavioural support, forensic issues and mental health.

The autistic spectrum describes a range of conditions which include autism, Asperger

syndrome, pervasive developmental disorder not otherwise specified (PDD-NOS), childhood

disintegrative disorder, and Rett syndrome, although usually only the first three conditions

are considered part of the autism spectrum.

In Manchester, the data shows that the numbers of learning disabled in Manchester is

projected to increase by 18 per cent from 3,650 in 2011 to 4,308 in 2030. The largest

increase is expected to be seen in the 35-44 age groups. The prevalence of Autistic

Spectrum Disorder in Manchester adults is predicted to be slightly higher than in all of the

comparator authorities. The prevalence per 1,000 of the adult population in Manchester is

also expected to rise between now and to 2030.

Carers The national refresh of the Carers’ Strategy: “Recognised, Valued and Supported Next steps

for Carers Strategy 2010” has informed the refresh of the local Manchester Joint Carers

Strategy 2012-2015 between health and Manchester City Council.

Currently over 60,000 Manchester residents are carers, approximately 12,000 of whom are

young carers. This number of carers is set to increase as the city’s demographics change. Life

expectancy is increasing, including for people with learning disabilities. However living

longer can bring greater health issues and social care needs and without adequate support

for carers’ health and social care costs are likely to increase.

Older people Age-Friendly Manchester (AFM) is a unique partnership between Manchester City Council,

the NHS, the voluntary sectors and most importantly Manchester’s older residents. This

partnership with older people has seen the creation of an ‘age-friendly city’ and as a CCG we

strive to maintain this through our approaches to how we commission services and out

expectations of providers of services for older people. We have made significant progress in

the actions outlined in Manchester’s Ageing Strategy 2010-2020. We aim to build on these

successes, ensuring older people continue to have access to support, information and

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services that enable them to maximise their potential and use the wealth of knowledge and

skills they have required.

Developing accessible timely and responsive service particularly for those older people with

multiple (often complex) health needs through their engagement and involvement in how

we will change the way in which services are delivered.

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Section 2: Our Plan

2.1 Our System: Health System Planning Units

Figure 2: Our 3 Planning Units: South Manchester CCG, Manchester, GM and the Southern Sector

In terms of planning units, South Manchester CCG manages the commissioning of health

services within the context of 3 spatial levels:

1. Manchester – Partnership between the three Manchester CCGs and the local

authority and co-ordinated through the work of the Manchester Health and Well

Being Board

2. GM Commissioning Leads – All 12 Clinical Commissioning Groups in Greater

Manchester

3. The Southern Sectors – Eastern Cheshire, Stockport, South Manchester and

Tameside & Glossop

Manchester Commissioning NHS North, Central and South Manchester CCG’s have retained a working relationship to manage the services commissioned on a city-wide footprint, which include: Mental health, Child and Adolescent Mental health services, Learning Disabilities, Voluntary Sector, Children’s, Maternity and Neonatal, Specialist, Cancer, End of Life Care, Carers and Continuing Healthcare.

South Manchester CCG

Tameside and Glossop

East Cheshire

NE Derbyshire

Stockport CCG Trafford CCG

Central Manchester CCG

Manchester – 3 CCGs Health &

Well-being Board

The Southern Sector 4 CCGs

GM Commissioning Leads – 12 CCGs

North Manchester CCG

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South Manchester CCG is the lead commissioner for the University Hospital of South

Manchester (UHSM). In this role the CCG has set up and is committed to the established

South Sector Leadership Board (SSLB) – this forum brings together the co-commissioners

and heads of organisations to manage the strategic direction of the south sector economy.

We work in partnership to commission acute services, diagnostic services, health protection

and palliative services.

Greater Manchester Commissioning We are an active partner in the Greater Manchester Clinical Commissioning community. The

collaborative work programme is led by the clinical chair, co-signed by the CCG Chairs and

agreed by the Clinical Strategy Board and features prominently on the our agenda.

The collaborative programme includes commissioning of the Christie Hospital, district and

tertiary cardiac services, North West Ambulance Services, hyper acute stroke services,

neurology and moving forward Healthier Together, which has the following programmes:

Urgent and Emergency Care (including acute medicine), Emergency General Surgery,

Primary Care (including LTCs), Children’s Services, Cardiac and Vascular, Cancer, Medicine

and frail elderly (including rehabilitation), Neurosciences.

The Southern Sector Several health economies across England are facing major structural challenges in delivering

high quality clinical services to patients in a way that is financially sustainable. The

challenges faced by these economies range from a need to find effective agreed solutions to

delivering more integrated care in the community to a need to consolidate and reconfigure

services in acute hospital providers to meet care standards. To support these economies

and accelerate the solutions to these challenges, the national bodies of Monitor, the NHS

Trust Development Agency (TDA) and NHS England have come together to provide a process

along with funded external support to bring the key stakeholders together to develop the

potential solutions.

Eastern Cheshire, Stockport, South Manchester and Tameside & Glossop have been

identified as such a local health economy and thus we are embarking on a piece of work for

the next 12 weeks until the end of June 2014 to do this; North Derbyshire and Trafford CCGs

will also be a part of this work as we review their plans and assess their impact on patient

flows through our modelling and options analysis. This work is intended to complement and

take account of the existing and future work through programmes such as Healthier

Together, Caring Together and the Southern Sector Provider Partnership, modelling the

impact of future changes to Specialised Commissioning and individual CCG and provider

initiatives.

The programme will involve:

Analysis and assessment of the baseline performance and financial viability of the CCGs and Trusts

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Development of a set of potential care models and service options to improve

performance, that draw and build upon the work of current programmes

Evaluation of these options using an agreed set of evaluation criteria, and

development of a holistic health economy strategy that will consistently and

coherently inform strategic plans across the sector

The programme of work to deliver this strategy commenced April 2014, and will run until

the end of June 2014.

2.2 Living Longer, Living Better: Manchester Vision for Integrated Care NHS organisations and the City Council in Manchester have been formally working together

to integrate health and social care services since 2010. ‘Integration’ has been adopted as a

tool to achieve the following goals:

Enabling Manchester people to live longer and live better – the title now given to the

integration work programme

Enabling patients and users of health and social care services to experience care

which is ‘planned with people who work together to understand me and my carers,

put me in control, co-ordinate and deliver services to achieve my best outcomes’ – a

definition of integrated care developed by National Voices, a national coalition of

health and social care charities in England

Enabling financial and other resources to be moved around the health and social

care system to avoid unnecessary costs, and to promote efficiency

As such, integration is a means to several ends in Manchester: better health, longer lives,

better care and better use of money, skills and estates. Integration itself has been

pragmatically defined across Manchester as the co-operation required between health and

social care services, at every level within the local care system, to build and develop services

in the community. One of the areas of work has been to reduce avoidable demand for

hospital admissions and treatment and to reduce admissions to residential and nursing

homes for people with long-term conditions. When we use the term ‘integration’ in this

strategic outline case we include the expectation that services will be more effectively co-

ordinated: this is a major issue for both our population, and our workforce. Within

Manchester, the three localities of North, Central and South, have developed and

implemented approaches to integration including their own services, tailored to the specific

needs of the local population.

2.3 Risk Stratification and Priority Groups: Living Longer, Living Better For this new ambition, we sub-divided the population of patients registered with GP

practices in the city (c. 540,000 people) into low, moderate, high and very high risk of

admission using a risk stratification tool known as the Combined Predictive Model (CPM).

The result of this analysis is shown in the figure 3.

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Two key points emerged from this analysis:

Expanding the current integrated care programme to include the 20 per cent of

patients at the highest risk of admission would draw in people classed by the CPM as

being at low or moderate risk of admission, as well as those at high or very high risk,

with the number at low risk being much greater than the number at high or very high

risk. Given the broad range of patients and risk levels within the 20 per cent it is

likely that a variety of care models will be needed to meet the differing needs of the

population sub-groups.

The progression from low through to moderate, high and very high risk of admission

is not a smooth one and there is clear evidence of the existence of steps between

each risk category (e.g., between low and moderate risk and between moderate and

high risk of admission etc.)

Figure 3: Risk Stratification of Manchester Patients

Following the endorsement of the Living Longer, Living Better programme by the Health

and Well Being Board it was agreed that the delivery of our integrated care models would

be based on develop effective models of care for the following population groups;

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Very high and high risk sub-groups

Adults and children who are at the end of their lives

Adults and children living with long-term conditions, and are unwell

Older people living with dementia and/or are frail elderly

Adults with complex needs - homelessness, long-term mental health, addiction,

trouble families

Moderate risk sub-groups

Children and adults with long-term chronic conditions, illness or significant

disabilities but who are generally functioning well.

Low risk sub-groups

Adults and children who are carers

Older people over 75 who are well

Children in their early years 0-4

School and college children who need promotion, information and support to

prevent accident and illness

Adults in work within our organisations who need to change lifestyles, and our

perception of how we care, in order to actively deliver and promote living longer

living better

These 10 population groups, crossing the low medium and high risk bands, we feel are the people we need to focus on to achieve the most impact in the next 5 years. Below is our Living Longer Living Better, Care Model Implementation Plan for the South System

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2.4 New Delivery Models: the role of primary, community, secondary and social care By designing care models based on a population approach that focuses on the individual, family and community there is a need for new delivery models to be designed that are co-ordinated, performance managed programmes of care, not individual standalone projects. We believe that there is strong evidence that this design of model best achieves the outcomes for the individual, family and community as it is based on organisations working together around identified needs. New delivery model(s) will need to be co-ordinated around the full range of a person’s needs and therefore cannot be achieved by one organisation alone, making every contact count. We want to promote new delivery models which enable organisations in our city to come together to offer, co-ordinate and integrated care by working together across sectors, boundaries and interfaces. Therefore we are not stating what the new delivery model(s) should be for the population groups identified, what we are stating are the care components that should be offered and the outcomes that we should aim to achieve. It will be for each of the organisation, with partners, to draft up new delivery models which will offer these care components and best achieve these outcomes. These new delivery model(s) will need to use the resources and expertise from a range of people and organisations. These may include primary care, mental health services, community services, social services, housing, planned secondary care, intermediate interface services, the third sector, business, education, sport and leisure, service users, carers, communities and faith groups. We need to aim for a shift of resources from services that do not offer the care model we are promoting to new delivery models to ensure that there is a sustainable system. Therefore, the new delivery models build into their design how they will shift resources to where they are most needed. We would aim for a shift of resources from the current urgent care models into the new delivery models for the very high, high and moderate risk groups. We will need all partner organisations, across sectors in the new delivery models will need to work to the same explicit shared goals and be measured against the same success criteria, goals and objectives. Depending on the population group we will need to have new delivery models that either deliver across the city, in our three localities, or in smaller defined communities to achieve the care model. We want to see far less reliance on organisational location of services. By using technology we can start to have a far more responsive and mobile workforce with the main focus for delivery being where a person lives, their home and their community. We want the new delivery models to be team based and not bound by organisations, institutions or locations. The teams may be long standing teams that will work together in defined team structures. Alternatively, they may be groups of practitioners who come together, possibly virtually for short episodes, form a team to address a particular need of an individual or community and then disband.

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Our new delivery models will move towards a far more socialised model of medicine, with interface management of specialist and generalist functions being needed. This will need a change of culture to enable team working which is dependent on knowledge of role and issue. We acknowledge that if we promote new delivery models it will mean that we will need to work differently across our organisations and this will impact on our traditional core business and how we work with partners. However, we believe that working together on focused programmes of delivery is the right and appropriate thing to do to deliver the best models of care for the people of Manchester. We will need to assess how the new delivery models may change what our core business is, in order to deliver care which is responsive to the goals and concerns of individuals and families and meet the agreed outcomes and measures for the service and system.

Figure 4: Manchester Approach to Care Delivery

2.5 South System contribution to Living Longer, Living Better Phase 1 of the Neighbourhood Teams pilot commenced in June 2013 across 13 practices in

two South Manchester CCG ‘patches.’ The remaining practices came on-board from March

2014 as we rolled out phase 2 of the pilot and now all 25 of our GP practices are engaged in

the pilot.

There are four Neighbourhood Teams in south Manchester; one per patch. The ‘core’ team

comprises GPs, Practice Nurses, Community Nurse Practitioners, Social Workers, Primary

Assessment Team Officers and Mental Health Practitioners, bringing together the four key

health and social care partners in south Manchester; South Manchester CCG, University

Hospital of South Manchester (UHSM), Manchester City Council (MCC) and the Manchester

Mental Health & Social Care Trust (MMHSCT). Wrapped around the core are specialist

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services, delivering specialist interventions for those patients that need them. The

Neighbourhood Teams bring together these core professionals into a single, patient-focused

team, delivering holistic, patient-centred care in a community setting. The teams work with

some of our most vulnerable patients, their families and carers to enable them to stay

healthier and maximise their independence.

On-going monitoring of the pilot, together with initial findings from an interim evaluation in

September 2013, has helped commissioners to understand the impact this new way of

working is having on patient care. Patient feedback is positive with patients reporting they

feel that their confidence has increased in living independently. A single point of contact and

more co-ordinated care is helping them to understand who to contact and when which

leads to a reduction in unnecessary hospital visits and admissions.

Our success so far;

1044 residents have been supported through the MDT case management process

(June 2013 – May 2014)

As of May 2014, we have 838 residents that are currently being case managed

(active on the Neighbourhood Team case load)

We have looked at activity data available up to 28th Feb 2014 concentrating on reductions in

secondary care activity. Results are as follows:

Figure 5: Impact of Neighbourhood Teams on the wider Health and Social Care System

Total number of patients joining the NT case load during June 2013 – Feb 2014: 532

A&E attendances 20% reduction in activity / 11% cost saving / £6826 cost saving

Non Elective

Admissions

18% reduction in activity / 22% cost saving / £188,245 cost saving

Outpatients 8 % reduction in activity / 6% cost saving / £2650 cost saving

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Section 3: Strategic Priorities and their delivery Our vision describes the aspirations for the organisation. This strategic plan, which as a CCG we recognise is ambitious, aligns to NHS England’s six characteristics of a high quality and sustainable system. The plan contains our work to deliver our Living Longer, Living Better care models and the transformation of health and social care services for patients in south Manchester. To bring structure and focus to our work, our ambitions are aligned through 6 strategic priorities and 6 cross cutting priorities outlined below.

3.1 Our Priorities

Strategic Priority 1: Delivering our Care Models Commission integrated pathways of care including the development of neighbourhood teams to improve care co-ordination for patients and carers across primary, community social and secondary care services. Patients will be supported to develop the skills and confidence to manage their long term conditions. Strategic Priority 2: Improve Primary Care Improve and reform the quality of primary care in south Manchester through continued support and clinical engagement from our member practices. We will aim to provide a standard range of services available to all patients within the CCG and will achieve this through the development of inter-practice referrals and additional services. We will continue to support practices in delivering good access to primary care services and aim to further improve the quality and completeness of primary care referrals through use of the referral gateway. An education programme for primary care will focus on the learning and development needs for clinical and non-clinical staff. We will promote medicines optimisation across primary care and providing medicines management support at practice level.

Strategic Priority 3: Improve and Reform the Urgent Care System Reform the urgent care system for patients through reducing unnecessary demand on the hospital emergency departments, ensuring same day access to general practice, developing ambulatory care pathways, improving the patient experience and better care planning for end of life. Strategic Priority 4: Improve and Reform Planned Care Improve the early detection, secondary prevention and management of people with long term conditions and support individuals to take greater responsibility for their health enabling them to manage their conditions more effectively to reduce time spent in hospital and promote independence. Focus on those conditions and specialities where south Manchester is an outlier and greatest improvements can be made.

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Strategic Priority 5: Delivery of Healthier Together programme The South system (through the CCG) is an active partner in the Greater Manchester Clinical Commissioning Group community. The work programme will see the progression of the “single services” that are shared across the geographical footprint. Strategic Priority 6: Delivering a financially sustainable health system The significant task of reducing and managing the City’s financial pressures, this priority outlines our financial ambitions and the targets that we aim to deliver over the next 5 years. Cross Cutting Priority 1: Community Services and the Voluntary Sector Review of community and voluntary sector services in order to make sure that these services align to the delivery of our Living Longer, Living Better care models.

Cross Cutting Priority 2: Prevention Primary prevention describes actions that are taken to reduce risk and avoid the development of disease. Secondary prevention describes actions that are taken, in early safe of disease, in order to reduce the impact, by stabilising or improving the condition, thereby halting or slowing deterioration. Tertiary prevention focuses on helping people to manage complex and long term health problems to prevent disability and maximise quality of life. We will ensure that appropriate levels of prevention are built into clinical pathways and commissioned services. We aim to build a health system that takes prevention seriously. Cross Cutting Priority 3: Quality and Patient Voice Quality is at the heart of everything we do as a Clinical Commissioning Group. It is the golden thread that runs through everything we do. We recognise that strong clinical leadership and engagement is critical in improving quality and improving outcomes for patients. As a Clinical Commissioning Group we also recognise that we need to think, plan and act differently to improve quality. Cross Cutting Priority 4: Organisational Development and Communities Our organisational development approach to shaping and delivering our strategy is essential for our success. It is predicated on embracing and managing change in response to our strategic priorities. We are building on the significant progress made to date and strengthening the capacity and capability of our workforce, at the same time enhancing our culture and capabilities.

Cross Cutting Priority 5: Collaborative Commissioning We have contributed to developing the NHS Greater Manchester Integrated Plan and remain committed to collaborative commissioning with colleagues across Greater Manchester. Cross Cutting Priority 6: Medicine Optimisation Medicines optimisation is about ensuring that the right patients get the right choice of medicine, at the right time. By focusing on patients and their experiences, the goal is to help patients to: improve their outcomes; take their medicines correctly; avoid taking unnecessary medicines; reduce wastage of medicines; and improve medicines safety.

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Strategic Delivery

Delivering our ambitions cannot be left to good will and partnership working alone as we need to be assured that services will be delivered to the highest standards, so outcomes will be measured and monitored. Therefore, we will need to create a different environment by which organisations can deliver integrated services to the agreed care model(s). To do this, the programme’s performance framework sets the aspirations and context within which service and quality improvements are required for the health and social care of Manchester’s population. Delivery of this strategy will be achieved through clear responsibilities and accountability, which is clearly articulated in our CCG constitution. In addition, it will require articulating our strategic and cross cutting priorities into a series of programmes and projects with designated clinical and management lead; ensuring clinical oversight and ownership in the delivery of this plan, and day to day drive for implementation. The Governing Body of the CCG will be accountable for exercising its statutory functions in relation to the strategy’s delivery. It will:

Set the organisational framework for strategic implementation

Set strategic priorities, oversee delivery, review progress and implement recovery plans where necessary

Oversee a robust approach to performance and risk management

Monitor the quality and safety of a services commissioned; working with regulators and involving the public in decision making

Hold accountable those individuals and organisation that provide healthcare to ensure patients are protected from harm

The revised Board membership now consists of the following leadership roles:

GP Chair

Chief Officer

GP Clinical Lead

Chief Finance Officer

GP Patient and Public Engagement Lead

GP Business Contract and Performance Lead

GP Quality and Performance Lead

Three lay members (Patient and Public Involvement and Audit and Governance)

Hospital doctor

Executive Nurse Over the past year we have appointed clinical leads to support our strategic priorities, lead the work and drive the implementation of programmes forward. All our commissioning work is informed by the needs of, and driven by the views of, our local population and clinical leaders. These arrangements are underpinned by a robust governance framework.

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We have adopted an integrated approach to patient care, improving communication and joint working across the health and social care economy so that we develop services which are safe, effective and provide an excellent patient experience. For each strategic and cross-cutting priority Clinical and Management leads will be accountable (see figure 6). They will report through the CCG Clinical Commissioning Committee on a monthly basis with quarterly reporting to the South Manchester CCG Board and would be expected to report on:

Performance against Key Performance Indicators (KPIs)

Delivery against key milestones

Areas of underperformance and mitigating actions

Key risk Figure 6: SMCCG Clinical Leadership Framework

MSK

Mental Health

Children

Urgent Care

Long Term Conditions

Patient and Public Involvement

Medicine Management

IT

Cancer / Macmillan

End of Life Care

Education

Diagnostics

The NHS Operating Framework set out the planning, performance and finance requirements

for NHS organisations to meet and these principles have been embedded within the

development of our framework for managing the delivery of this strategy. The NHS

Outcomes Framework (13/14) provides a set domains and underpinning indicators that will

enable us to track the progress we make in improving quality and patient outcomes. For

each of our strategic priorities, we have mapped where our improvement interventions will

make an impact against key targets and outcomes framework including; the Manchester

Health and Well-being priorities and the NHS outcomes framework (highlighted below in

figure 7 and 8). This work forms the basis for our performance management framework.

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Figure 7: Links between Our Priorities and Manchester’s Health and Wellbeing Priorities

Figure 8: Links between Our Priorities and the NHS Outcomes Framework

The remainder of this section outlines the detail behind our strategic and cross-cutting

priorities. For each we present a simple visual setting out:

Our vision

The key programme and projects within each priority

Specific programme targets and goals

The strategic impact

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Vision

• Enabling Manchester people to live longer, and live better;

enabling patients and users of health and social care services to

experience care which is ‘planned with people who work together

to understand me and my carers, put me in control, co-ordinate

and deliver services to achieve my best outcomes’

Interventions

• Delivery of the Enhanced Neighbourhood Team Pilot

• 14-16: Frail older adults, adults with dementia and end of life care

• 15-16: People with Long Term Conditions (well and unwell); Adults

with complex needs; Older people +75 and well

• 16-19: Childrens; Carers; Adults in Work

Goals and Targets

• 70% of very high, high and medium risk patients have care plans in

the community to reduce Emergency Department attendance

delivered by Neighourhood Teams

Strategic Impact

• Increase the number of people supported in the community

• Improved level of patient experince

• A simplified and integrated care model between primary,

community and secondary care,

• Fewer emergency admissions, fewer Emergency Department

attendances and fewer excess bed days

Strategic Priority 1: Delivering our new models of care

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3.2 Delivering our new models of care

Frail Older Adults and Adults with Dementia

Our vision for frail older people and people with dementia living in south Manchester

acknowledges the “good health adds life to years” concept (WHO 2012) and the promotion

of good health, prevention and health improvement.

We recognise the valuable contributions that older people bring to their community, as well

as the care and support requirements for those who need it. Working with our Older Adults

we will break down stereotypes because poor health is not the only concern people have as

they grow older. Stigmatising attitudes and common stereotypes often prevent older people

from participating fully in society.

Older people make important contributions as family members, volunteers and as active

participants in the workforce and are a significant social and economic resource. We

understand that the needs of this population group are diverse and we will commission

services that focus on this diversity and will strive to enable choice and independence,

provide care closer to home and improve quality of life.

Improvements in health and social care provision over the last 20 years have in turn led to

increased life expectancy with many older people leading independent and healthy lives.

We know, however, that health challenges remain for older people in our community with

long term conditions such as heart disease, stroke, cancer, diabetes, and chronic lung

disease.

We also recognise the challenges that arise from a significant proportion that will be

experiencing a mental health problem such as depression or those suffering from dementia.

We also appreciate that for many older people, loneliness and social isolation is a significant

problem which can lead to both physical and psychological problems.

Overall, the population of the UK is growing in size and becoming increasingly older. Older

people represent the single largest group of NHS service users. Nationally, two thirds of all

acute hospital beds are occupied by people over 65 and account for one-half of emergency

admissions. Over the period 1985-2010 the number of people aged 65 and over in the UK

increased by 20 per cent to 10.3 million; in 2010, 17 per cent of the population were aged

65 and over. The number of people aged 85 and over more than doubled over the same

period to 1.4 million.

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In South Manchester the picture looks like this:

Population ageing will continue for the next few decades and by 2035 the number of people aged 85 and over is projected to be almost 2.5 times larger than in 2010, reaching 3.5 million and accounting for 5 per cent of the total population. The population aged 65 and over will account for 23 per cent of the total population in 2035 (Office for National Statistics, www.statistics.gov.uk).

The chart below describes the projections for South Manchester:

Interim 2011-based Resident Subnational Population Projections (Broad Age Bands)

South Manchester Clinical Commissioning Group Year Population (thousands) 65-74 75-84 85+ 65+ 2011 8,802 6,252 2,791 17,845 2012 9,052 6,225 2,896 18,173 2013 9,237 6,238 2,972 18,447 2014 9,373 6,209 3,057 18,639 2015 9,495 6,206 3,135 18,836 2016 9,617 6,209 3,205 19,031 2017 9,733 6,184 3,299 19,216 2018 9,819 6,207 3,377 19,403 2019 9,855 6,284 3,441 19,580 2020 9,961 6,311 3,530 19,802 2021 10,090 6,332 3,633 20,055 Note: Data for Manchester has been apportioned to CCGs based on figures derived from ONS mid-2011 population estimates at PCO level. Source ONS Crown Copyright

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We have already learned from alternative models of care and will continue to do so and over the next five years, through the implementation of the new delivery models of care for older people and people with dementia. Accepting that this will challenge our system to think differently, be aware of what older people in south Manchester say they want and need and, in particular, continue to work together with our partners and older people in a strategic way, to provide services that are developed with and for older people, taking into account:

carers, family, friends and social networks;

needs and aspirations;

services that are timely, proactive integrated and co-ordinated;

approaches that are preventative and anticipatory;

focus: person centred care;

outcome focused;

new ways of working that are flexible, responsive and forward looking There are around 800,000 people in the UK with a form of dementia. It is estimated that by 2021 there will be one million people with dementia in the UK. This is expected to rise to over 1.7 million people with dementia by 2051 (Alzheimer’s Society Dementia 2012 report). We know that one in four hospital beds is occupied by a person with dementia and that two thirds of all people living in care homes have a form of dementia. We acknowledge that it is not only the older person who can suffer with dementia although it is a condition rare within the under 65 age categories. We know that dementia is often under reported; a ‘hidden’ condition and our vision will be to ensure that people with dementia living in south Manchester will be known, competently assessed and referred to specialist services in a timely manner such that appropriate treatment plans can be started early in the pathway. We will explore alternative and innovative models of care and assessment and will ensure that care home provision in our community is expertly resourced and equipped to manage the needs of people with dementia. We will align our vision to the Greater Manchester Healthier Together programme and the core concepts:

Improve the health and wellbeing of people in Greater Manchester

Reduce inequalities of access to high quality care

Improve people’s experiences of health care services

Make better use of healthcare resources

Promote self-care and empowerment

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An overview of our improvement interventions for Frail Older Adults and Adults with Dementia

From a commissioning perspective we will commission a system in south Manchester that will deliver care, support, advice and guidance to and with people in their neighbourhoods. We need to gain a greater understanding of our population of frail older people and people with dementia, not only their presenting health needs but the triggers or characteristics that are the reasons for this population group attending or being admitted to hospital. To do this we will:

Establish who are our older people who live alone and who are potentially isolated (building on the work already underway through Age Friendly Manchester)

Identify older people who are frail by implementing a frailty assessment tool that can be used by individuals, carers, families and practitioners across the health, social and voluntary sectors

Implement a shared care approach for the care of all older people

Identify the carers of frail older people and people with dementia to assess their health and well being

Build on the improvements made during 2013/14 in the screening and diagnosing of dementia

Our new delivery model for frail, older people and people with dementia has looked at the specific interventions required for different levels of care. The below diagram (the Frailty Pyramid) illustrates the high level model and key features for the south Manchester population from prevention and early intervention to specialist care in the hospice or hospital.

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Our Improvement Interventions: Enhanced Neighbourhood Teams We will build on the now established Neighbourhood Teams a multi-disciplinary, integrated approach centred on the 4 GP patches, by developing and implementing new approaches such as detailed in the examples below:

Frail older

people

and

people

with

dementia

delivery through integrated multi-disciplinary teams (building on the teams already on roll out)

specialist teams to provide more outreach to communities including consultants

24/7 district nursing and reablement / intermediate care

early identification of frailty using a frailty tool and GP register

one assessment / care plan - co designed with the person and their families and shared across all agencies

Adults

with long

term

conditions

shared assessment and care plan (owned by the patient)

care close to home

community assets to support self-awareness and care and the development of community volunteer infrastructure

integrated multi-disciplinary teams (building on the teams already on roll out) consisting of GP, community nursing and social work

response across 24 hours, access to pharmacists out of hours, North West Ambulance Service (NWAS)

specialist outreach teams linked to other care groups – enabling education of the patient, carer and workforce

build on self-care approach

People at

the end of

life

one care co-ordinator for consistent care

one year before end of life and support to families and carers after their relative dies

24/7 support

bringing care close to home or at home - this also includes residential and nursing homes

generic integrated team consisting of GP, community nursing, social work

access to equipment, assistive technology

flexible team to respond as required to changes in need

key worker for consistent and co-ordinated care who will be the link across primary and secondary care, wishes are followed by all agencies including out of hours and NWAS

step up and down support as needed

bereavement support

Listed below are key specific enhancements to our Neighbourhood Teams that have a clear focus on community based care for our frail older people and people with dementia:

Ensuring specialist nurses (e.g. heart failure, COPD, diabetes, dementia) are integrated with the teams and work to proactive as well as rapid, responsive care pathways avoiding duplication of effort and overlap of services

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Monitoring the urgent care dashboard within primary care to identify attendances of frail older people and people with dementia into Accident and Emergency; this information can then be shared with the neighbourhood teams to support discharge

Providing memory clinics in primary care across our four patches for dementia patients building on the model currently being piloted in one of our GP practices (Barlow Medical Centre)

Exploring the roles of dementia support advisors and Admiral nurses within the new model for dementia care

Expanding the use of telecare/telemed/telehealth solutions and maximising the opportunities that technology affords to facilitate increased community based care

Developing new systems to enable effective communication between services and appropriate shared access to patient information (with consent)

Introducing a specific out of hour’s response for the frail older people and people with dementia group with direct links to the neighbourhood teams; this will provide a dedicated team who will build the necessary relationships, provide interventions where necessary. The team will also be able to support and advise care/nursing homes to prevent avoidable admissions

Provision of additional capacity for intermediate/respite care

Providing community based facilities at patch level, maximising primary care estate to enable care closer to home, providing interventions ranging from ambulatory care, diagnostic, rapid assessments through to community based activities promoting active lifestyles, health and wellbeing

Up-skilling the community workforce to provide interventions, e.g. IV therapies, intravenous fluids/bloods in the community setting rather than the hospital

We will commission a system that includes the role of the community geriatrician to support general practice and care homes, both residential and nursing, within the locality. This role will build on models which show that geriatricians working in the community, making home visits, undertaking early assessments and monitoring the population have had successful outcomes and avoidance of hospital admissions. Community geriatricians within their role can also advise and support the community workforce on how best to manage the needs of frail older people and people with dementia in the community setting. We will build on the work already underway with Manchester City Council on the Age Friendly Manchester, engaging with the voluntary and third sector to develop innovative ways of working with and for frail older people and people with dementia.

End of Life Care (EoLC) Our goal is for people to live longer and better, and when they are at the end of their life to die with dignity in the place of their choice. In order to ensure that patients and carers are supported during EoLC we have a dedicated programme of work. A number of key developments are to take place over the coming year to support people at the end of their lives to remain in their own home and ultimately to die in their preferred place of care.

40

This diagram gives an illustration of how the key enablers align to the six-step end of life care pathway.

Our Improvement Interventions: End on of Life Care

Enhanced Macmillan Specialist Palliative Care team An enhanced Macmillan Specialist Palliative Care team will be a component part of the

Enhanced Neighbourhood Team new model 2014/15 and will provide an extended hours

service 9.00am–9.00pm seven days per week starting in June 2014 with additional specialist

palliative care nurses working in the community.

The other component parts of the Enhanced Macmillan Specialist Palliative Care team will

provide additional support from allied health services within occupational therapy,

41

physiotherapy and social work dedicated to palliative care and palliative care consultant

time in the community. In addition a sitting service provided by a collaboration of voluntary

sector partner organisations will give support to both patients and carers. The focus of this

model is to enable patients to be managed in the community and should an admission occur

the team will support early discharge from hospital.

Electronic Palliative Care Coordination Systems (EPaCCS) We plan to roll out across all 25 south Manchester practices during the summer of 2014.

This system will be accessed by multiple organisations including practices, out of hours

service, hospices, hospitals etc., with the aim of sharing patient advanced care plans. This

will drive up quality in patient experience and will avoid patients having to repeat their

wishes multiple times which can cause distress.

Advanced Care Planning The aim of the training is to enhance confidence and skills in initiating and managing

advance care planning conversations in order to promote patient centred care. The training

is open to professional staff involved in advanced care planning or end of life care and is

aimed at GPs, senior nursing and social care colleagues managing such patients. We have

secured funding for 150 places across primary, community and secondary care. Sessions

will run throughout 2014.

End of Life Care Facilitator Roles One facilitator will continue to lead on the roll out of the 6 Steps Programme, supporting

implementation and evaluation and providing education to care homes in south Manchester

with the objective of improving patient quality within homes. An additional role is to be

recruited in 2014 to support practice implementation of Electronic Palliative Care Co-

ordination Systems (EPaCCS) and to support practices on the requirements of the Macmillan

Cancer Improvement Partnership in Manchester programme (as detailed within the Cancer

section of this document).

Unified Do Not Attempt Cardiopulmonary Resuscitation (uDNACPR) policy We are linking with local stakeholders to work towards approval and implementation of the

unified policy. A stakeholder event will be used to facilitate roll out across organisations

(hospital, out-of hours service, nursing home, residential home, hospice) in the summer of

2014. The use of the policy will support the patient advanced care plan and will stop

patients being resuscitated particularly on transfer from one care setting to another.

It is hoped that, once adopted, this will lead to:

Reduction in number of inappropriate CPR attempts

An improvement in communication of decisions amongst staff and patients / carers

Greater co-ordination, use and recognition of uniform documentation to limit

unnecessary intrusion by professionals at time of expected and natural death

Rise in patient outcome measures, such as dignity and family satisfaction

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Transforming End of Life Care in Acute Hospitals We will be working with the local acute trust to promote the Transform Programme which

aims to improve end of life care within acute hospitals across England enabling more people

to be supported to live and die well in their preferred place. To support hospital trusts in

reaching these goals, the Transform Programme encourages the use of existing tools and

resources and in particular the implementation of key enablers:

Advance care planning

Electronic Palliative Care Coordination Systems (EPaCCS)

AMBER care bundle

Rapid Discharge Home to Die Pathway

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Vision

• Proactive, effective primary care offer, increased access for

patients; focus on population health to reduce variation in

outcomes for south Manchester patients

Interventions

• Delivery of the South Manchester GP Federation 7 Day model pilot

• Management of GP Enhanced Services

• Delivery of commissioning for value, GEM Deep Dive

recommendations - Respiratory and CVD

• GP Practice Engagement Scheme

• GP Referral to outpatient first attendance reduction pilot

Goals and Targets

• Reduce GP referred Outpatient First Attendances by 6.9%

• Reduce variation through managing GP high level Indicators

• Improve access to primary care

• Increase number of patients proactively managed in the

community

Strategic Impact

• Improved level of patient experience

• Early identification and management of long term conditions

• Increase in the number people supported to self-care

• Fewer emergency admissions, fewer Emergency Department

attendances, and fewer excess bed days

• A simplified and integrated care model between primary,

community and secondary care

Strategic Priority 2: Improve Primary Care

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3.3 Improve Primary Care Primary Care is the first point of contact for the majority of patients and service users to access health care. Primary care independent contractors include general practice, community pharmacists, dentists and optometrists and are all important in delivering healthcare services for the local population. Whilst the CCG does not currently have direct responsibility for commissioning primary care services, it does have responsibility for improving the quality of primary care. We recognise that some of the care provided for patients in south Manchester is excellent and we know that people value our primary and community services. However, we know that the range and quality of services provided is inconsistent across the patch and patients do not all receive the same offer. Our primary care services are under increasing pressure from growing demand, patient

expectations, competition for the provision of enhanced service and increasing regulation

along with new contractual requirements. In south Manchester, primary care has started to

move towards a different model of primary and community based care; but it is

acknowledged that this programme of work needs to be accelerated to improve quality,

reduce health inequalities and ultimately deliver better patient outcomes.

We recognise that we have ambitious plans for developing better integrated, patient

centred, care services outside hospital and will continue to work with our partners to

progress these. To achieve these plans we need to make sure that our primary and

community services are fit for purpose. This means that we need to adopt new ways of

working and change the way services are organised.

We aim to ensure that excellent, high quality, primary and community care is available for

all patients in south Manchester. We also aim to increase the range of services available

outside hospital and improve the consistency and equity of access to these.

Patch Configuration South Manchester CCG comprises of 25 member practices that were brought together to

work in four patches. The four geographical patches (based on Local Authority Wards figure

9) are represented by clinical leaders from each practice, and through their work they that

look at how improvements can be made to patient services, to meet the needs of their local

populations and improve patient pathways and experience of care. Throughout this

strategy, practices will continue to work in patches collaboratively to:

Improve access to primary care services

Improve the quality of primary and community services

Share learning and best practice

Develop plans to improve services and the health of our population

Optimise medicines management

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Improve the early diagnosis and management of long term conditions

Support the development of new and existing pathways of care

Support succession planning and the identification of future clinical leaders

Figure 9: CCG Boundary and Patches

Primary care services will need to work very differently and at scale so that they are in a

position to be able to provide the services that the CCG wishes to commission in the future.

Accessibility to primary and community care will form a key element of this and services will

need to integrate to ensure that a more coordinated, consistent offer is available for all

patients.

Improving access is a core element of the urgent health care system and reducing the

pressure on our Emergency departments. The most recent national GP Patient Survey

highlights that only two practices in south Manchester achieved the NHS England aim of

90% of patients either very or fairly satisfied with the general practice opening hours.

Results of the survey also show south Manchester to be below the national average in

patients’ experience in getting through to someone over the phone at the surgery or their

ability to see or get to speak to someone.

Locality based models of care are already in place with the development of neighbourhood

teams in each of the patches. These models will be developed further to ensure that care is

centred on the local population and support a holistic approach to managing patients. This

will enable working at scale, sharing of resources and ensure accessibility to high quality,

cost effective services. To deliver these services differently will require new ways of working

and use of the wider practice team. We will need to develop the skills of other health care

professionals including practice nurses and health care assistants to enable delivery at scale

and ensure sustainability.

46

An overview of our Improvement Interventions in Primary Care We will implement a programme of work as outlined below across all practices in south Manchester that will align to the Greater Manchester Primary Care Strategy 2014-18 and support the delivery of a new integrated health care system. The operating plan for 2014-19 identifies the specific priorities for change over the next five year period and provides a framework for developing and implementing these initiatives in more detail.

Domain

Priority Model

Involvement in Care Shared Care

planning

Patient access to health care records

Shared decision making

Link to self-care, advice and information

Multidisciplinary Care Elderly patients

over 75

Proactive finding, surveillance and management

including 3 month reviews, screening, holistic

assessment, health checks, vaccinations, medication

reviews, implementation of frailty tool

GP coordinator of care

Link to community/ domiciliary geriatrician

GP follow up post discharge – link to post discharge

care model

Long Term

Conditions

Proactive identification and management including

screening, health checks

Population coverage of core and extended services

Defined model for housebound patients

(multidisciplinary support including OT, Physiotherapy,

Pharmacist)

Link to neighbourhood teams / virtual ward / expert

generalists

Increased use of pharmacists to support management

of less complex patients, medication reviews and flu

vaccinations

Self-Care advice

and information

/ Education

Develop and improve self-care programmes including

expert patients

Group educational sessions

Use of mobile phone applications

Supporting people back to work – link with Fit 4 work

scheme

Increase referral for active lifestyles

Access and

Responsiveness

Responsive

Access

Consistent responsive access model incorporating

quality standards for same day triage

Implementation of patient access programme

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Elderly patients access to a named GP

Enhanced care for patients in care homes

Implementation of telemedicine to enable home

monitoring and improve self-care

Increase use of minor ailments enhanced service

Extended Access

Implementation of a 7 day model to include GPs at the

front end of the Emergency Department weekdays and

weekends

Increased access to diagnostics, through remote

monitoring, for example for hypertension

Flexible Access

Increased use of technology to provide flexible access

through telephone/remote consultations, Skype,

online booking of appointments and prescriptions

Out of Hours Dedicated rapid response for frail/elderly patients

Increased Out of

Hospital Services

Extended

Services

Investment GP led extended services for the elderly

and those with long term conditions with a focus on

respiratory and cardiology

Population coverage for all extended services with a

priority focus on dementia, complex patients, frail /

elderly

Enablers In order to deliver the improvements we want to see over the next five years we need to

address the enablers that will support the changes.

Workforce

Development of skills for GPs, Practice Nurses and other health professionals

Clinical leadership and succession planning

Development of the wider primary care teams and skill mix including pharmacy,

optometry and dental services

Premises

Working with our local provider in the development of the Withington Community

Hospital estate to support the implementation of community based services

Maximise the use of GP estate that will support locally based care delivery

Information technology

Continuation of the programme for the implementation of EMIS Web across all

practices in south Manchester

Continuation of the plans for an integrated approached for sharing information

across health, social and community care

Further development of the shared integrated health care record

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Flexible IT solutions to support face to face consultations, consultations between

clinicians, information sharing with patients and remote monitoring

Online access to patient records

Contracts

Standard NHS contracts for extended services with clear quality and performance

indicators

Use of the procurement approach and competitive tendering

Use of quality incentives

Contract levers, procurement and incentives

Primary Care Commissioning South Manchester CCG is proactivity considering the recent call for expression of interest to

develop new arrangements for co-commissioning primary care services by NHS England. In

line with our plans to invest £12m in primary care (between 2016 /17 – 18/19), this

potential for co-commissioning primary care will support our plans for delivery of a core

primary care offer for patients in south Manchester seeing improved access but

fundamentally addressing variation in outcomes.

South Manchester GP Federation: Seven Day Model We have recently commissioned South Manchester GP Federation (SMGPF) to develop and

improve access and responsiveness through a Seven Day Model pilot which will be tested

through 2014/15.

In order to support the delivery of services aligned to national and Greater Manchester

priorities the Seven Day Model will focus on caring for patients aged over 65 years with 2 or

more long term conditions (LTCs). The service will be implemented from July 2014 and aims

to improve patient care whilst also reducing the level of non-elective spend. The service

model will co-locate a GP at the front end of UHSM’s emergency department (ED) as a

senior clinical decision maker to have a greater influence on identifying and managing

avoidable admissions of patients.

In parallel with this presence within ED the new service will provide flexibility based on

patient needs and geography for the GP to operate outside the Trust. This will include

following patients up that have been discharged to their homes on the same day to provide

continuity of care, undertaking community visits and proactively supporting patients that

may be at risk of admission.

Where appropriate a patient’s care will be delivered in a community setting and will require

close working and an integrated approach with other services such as GP out of hours

services, the Enhanced Neighbourhood Teams and other community and voluntary sector

services.

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Following analysis of ED attendance data and patterns in regard to

admissions/readmissions, the Seven Day Model service has been designed to cover peak

times weekdays and weekends and will aim to reduce 3 non-elective admissions every day

in the pilot period.

This new model of working will provide improved links within the community for acute

physicians working in partnership to shift activity from acute to community care where

appropriate.

Commissioning for Value (CfV) & Greater East Midlands (GEM) Commissioning Support Unit ‘Deep Dive’ South Manchester CCG has engaged with the CfV collaboration between NHS Right Care,

NHS England and Public Health England. Through a review of existing, local, health data the

CfV Focus Packs produced in November 2013, highlighted our top priorities (opportunities)

for transformation and improvement; the best opportunities to improve healthcare for

individual CCG populations, improving the value that patients receive from their healthcare

and improving the value that populations receive from investment in their local health

system.

Following this analysis we have commissioned the Greater East Midlands (GEM)

Commissioning Support Unit to undertake a ‘deep dive’ analysis which aimed to identify

particular conditions where clinical improvements could and should be targeted, which

would also deliver cost savings for the CCG. The two priority areas for South Manchester

CCG were identified as respiratory and cardio-vascular disease (CVD). A key focus for us

during 2014/15 will therefore be all respiratory conditions. CVD will be our focus in 2015/16.

The South Manchester CCG Primary Care Quality Group (PCQG), chaired by the GP Clinical

Lead for Primary Care, meets with the purpose to help improve quality and address

unwarranted variation. PCQG will begin to work up robust delivery plans for CVD in Quarters

3 and 4 of 2014 to ensure early implementation next year. The CCG will continue to work

collaboratively with UHSM colleagues to examine pathways in more detail to identify

evidence of opportunities for improvement and will link this to other work undertaken in

primary care to build the evidence and business case for change.

GP Practice Engagement Scheme (PES) In response to the GEM ‘deep dive’ data analysis the PCQG developed the PES for 2014-15

which concentrates on the key focus of respiratory conditions. The scheme has three

overarching components:

Engagement and education

Managing demand

Prescribing and medicines optimisation

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Practices are encouraged to participate in the scheme with the requirement to improve

systems for the management of respiratory patients. It is suggested that they address this

by:

Improving the pro-active management of people with respiratory conditions and

prioritise appropriate patients for management via the Neighbourhood Team multi-

disciplinary team meetings to be managed by the community ASPIRE (respiratory)

service

Develop a system to provide best practice in respiratory management. This should

include replenishment of rescue medication packs to appropriate patients with

COPD as part of a self-management plan for exacerbations

Creation of self-management plans for patients with asthma who are on high dose

inhaled steroids such as Seretide 250 or equivalent

Improving uptake of flu and pneumonia vaccines for respiratory groups - in particular

for those patients with COPD and asthma

GP referred Outpatient First Attendances (GPOFA) An additional component of the Practice Engagement Scheme (PES) addresses the need to

proactively manage demand for secondary care referrals by reducing GPOFA back to the

same level as 2012/13. This has been based on a target of a 6.9% reduction for the majority

of practices where referrals have increased year on year. The PES proposes that all

secondary care referrals should be reviewed within the practice clinical team before they

leave the practice to ensure that maximum primary care work up is completed and referrals

go to the most appropriate service. Any changes to referrals are documented and learning

shared at patch meetings with other GP colleagues and practice managers.

Avoiding Unplanned Admissions Enhanced Service For 2014-15 NHS England is offering an Enhanced Service (ES) which aims to improve

current systems within practices to proactively manage vulnerable patients to support

decisions relating to hospital transfers or admissions and reduce avoidable admissions or

Accident and Emergency attendances. There are clear links within the objectives of the ES to

the South Manchester GP Federation Seven Day Model particularly around improving the

discharge processes and sharing of relevant information to help inform future

commissioning decisions.

It will be incumbent upon practices to ensure that the systems and processes that are

required as part of the ES are robust and that they dovetail with the Enhanced

Neighbourhood Team and the Seven Day model.

The CCG will support the implementation of the ES by:

Agreeing to manage locally through implementation :

- Risk stratification tool

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- Practice by pass numbers – collection & dissemination

- Practice level admissions and discharge data

- Incident reporting mechanism re admissions/discharge processes

- Agreement of practices with nursing/care home populations to review sample of

admissions and A&E attendances

Through reporting and monitoring: - quarterly reporting templates – dissemination and collection - quarterly monitoring of practice achievement - quarterly list of ‘approved’ practices submission to the Local Area Team

Where there are perceived gaps in the enhanced service as to what South Manchester CCG seeks to implement locally through its Enhanced Neighbourhood Team model, an Enhanced Service+ (ES+) may be considered as a financial incentive to address the shortfalls and ensure that the local models are implemented successfully. The Manchester Integrated Care Gateway (MICG) We will continue with the service provided through the MICG to manage referrals from

primary care resulting in a reduced demand on secondary care and improvement in quality

care.

The referral process is standardised giving CCGs greater visibility of referrals and allows

them to be clinically assessed and, where appropriate, redirected to community services

including diagnostics. The clinical triage process also enables on-going education through

advice and guidance being fed back to referring practices where necessary. This system

allows the CCG to audit referrals and understand referral trends.

By optimising the referral management process through the supply of real-time referral

intelligence, the MICG can provide higher quality referrals where patients are seen more

appropriately, closer to home and with shorter waiting times.

The MICG manages the booking system by contacting patients within a 14 day timeframe

agreed as part of the service level agreement and service model. An operational group

meets on a monthly basis to oversee performance and governance of the referral processes

and to agree development of the service in response to suggestions from NHS North,

Central and South Manchester CCGs.

This service also assists in delivering QIPP through financial savings achieved as a result of

deflected referrals from secondary care whilst increasing overall control of referrals.

GP High Level Indicators GP high level indicators are structured to reflect the five domains of the NHS Outcomes

Framework: reducing premature mortality, enhancing quality of life for people with long

term conditions, providing effective recovery after acute illness or injury, enhancing patient

experience, and assuring patient safety; they include a variety of analytical and reporting

52

functionality for local use and allow quality and outcomes to be measured at the level of

practices, CCGs, and Area Teams and to be benchmarked against national data.

Collaborative discussions between GP practices, CCGs and the local area team help to

prompt questions, both in relation to the quality of services that practices provide for

patients and the impact on wider outcomes. Quality assurance and quality improvement

cannot rely on data alone and require careful consideration of contextual factors. Some

levels of variation will be natural. The data may, however, help to identify unwarranted

levels of variation that require remedial action.

The PCQG has a role in supporting practices to improve quality and to ensure that, where

practices have more than five outliers (either by practice or across indicators), those

practices will be supported in producing action plans to address these areas. Where

practices do not have outliers they are asked to focus on maintaining quality and again

share any good practice with their peers.

Working closely with the Commissioning Support Unit (CSU) Business Analyst the CCG

produced data by patch areas so that each patch could see at a glance how they compared

with their neighbouring practices. Patch meetings are used to share good practice and ideas

about improving services for patients.

New models of general practice working with other primary and community services will

provide a more integrated system of health care that will support improved health

outcomes. To create capacity for general practice to focus on providing care for patients

with more complex needs we will use opportunities to work with other primary care

providers particularly community pharmacies in the management of long term conditions, in

line with NICE guidance such as asthma, hypertension and diabetes. For the majority of

patients with long term conditions, care will be provided by integrated primary and

community care with access to specialist support only where needed.

The South Manchester GP Federation will build community based expert generalists within

the four patches able to manage complex patients with chronic conditions. Future models of

care will ensure that GPs continue to lead multidisciplinary teams with health and social

care professionals to improve coordination of care supported by specialists in the

community. Developing the skills of GPs, Practice Nurses and other healthcare professionals

to provide care for patients with complex conditions and meet the needs and expectations

of patients is crucial, and will increase patient access to services and enhance care. This, in

turn with the implementation of new pathways of care will reduce reliance on our acute

sector services.

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Vision

• Universal, continuous access to high quality urgent and emergency

care services; in practice whatever our urgent / emergency care

needs, whatever our location, patients get the best care, from the

best person, in the best place at anytime.

Interventions

•Re-design of Accident and Emergency provision - Front of Hospital:

Trafford New Deal, Acute Fraility Pathway, GP Front Door, access to care

records of neighbourhood team patients

•Develop a discharge to assess model

•Developing out of hospital care to manage people in the community: Rapid

Response, Community Geriatriacian, NWAS Care Plans

•Implement the perfect week

Goals and Targets

• Reduce 3 Non Elective Admissions a day through GP front door

• Eliminate 4 hour breaches

• Reduce NEL from Emergency Department to be in line with national

average

• 50% of very high, high and medium risk patients have care plans in

community to reduce Emergency Department attendances

Strategic Impact

• Management of urgent care demand and control expenditure

• Fewer emergency admissions, fewer Emergency Department

attendances and fewer excess bed days

• A simplified and integrated care model between primary,

community and secondary care

• Improved level of patient experience

Strategic Priority 3: Improve and Reform Urgent Care

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3.4 Improve Urgent & Emergency care system

Based on the national vision and local diagnostics our urgent care strategic and operational

plans have been developed to incorporate national policy direction, best practice and

evidence base where available.

Our vision for urgent and emergency care aligns closely to our plans for reforming

community services and developing integrated health and social care including primary and

vertical integration with secondary care. Alongside proactive care planning to support

people in the community, the urgent care system in south Manchester will look very

different as represented in the diagram below. The involvement of community services and

primary care in urgent care reform and a single point of access that will provide a timely and

appropriate response by services including admission avoidance and facilitated discharge

through the seven day GP model and Enhanced Neighbourhood Teams working closely with

acute services.

Figure 10: Urgent Care Model

Specialisms:Breast

Cardio thoracic

Plastics

Trauma

Upper GI

URGENT CARE CENTREGP front End

Hospital

Tertiary

Centre

Secondary

Care Wards

Private

Wards

• Acute physicians.• Social care• Experienced GPs• Mental health• Geriatrics• Direct / telephonesupport

All walk ins

and acute

referralsFORUM

• Community clinics

• Joint clinics

• 7 day working

Primary CareWCH

• Outpatients• Diagnostics• Appliances• Community clinics• Mental Health• Social Care• Self – care

• Pharmacy• Independent/ voluntary groups• Inter-practice referrals • 7 day working –Primary/ Secondary care• Rehab

Nursing homesStep up

and down beds.

Tele diagnostics

PRIMARY CARE25 GP Practices 167,575 patients

(registered population)

Community Based Services

Aligned commissioning intentions of CCGs.

Shared acute/non-acute pathways.

Consistent offer from Primary Care re. LTCS.

Consistent offer from Social Care.

Established Neighbourhood Teams (NTs).

Identified key workers.

Reduced secondary care.

Increased resources in Primary Care.

Reduced variation across the

S.E sector.

Improved outcomes.

IOG compliance.

Integrated/compatible IT.

Tele diagnostics.

Undergrad/ postgrad education in all areas.

Inter-practice referrals.

Principles & Drivers

Extra Care

Housing

How It Will Look and Feel

55

Our Local Performance At the University Hospital of South Manchester (UHSM) seasonal pressures particularly

during winter have presented local challenges to the urgent care system. We have seen a

1.9 per cent growth in Emergency Department (ED) attendances between 2012-13 and

2013-14, but an 8 per cent increase in emergency admissions over the winter period (winter

analysis 2013-14, North West Utilisation Management Unit, Greater Manchester

Commissioning Support Unit).

The number of non-elective admissions is higher than seen nationally, particularly for our

priority population, frail older people. The national standardised rate for non-elective

admissions rate for people aged 65 years and over is 238 per 1,000 population for south

Manchester it is 317 per 1,000 population. The conversion rate from Emergency

Department to non-elective admissions at UHSM is around 30% compared with 25 per cent

nationally. This has informed our local priority setting and commissioning plans.

In addition our bed days lost to delayed transfers of care (DTOCs) are higher for south

Manchester residents at USHM and other providers. The national average of bed days lost

to DTOCs per 10,000 total bed days for 2011-12 was 95 compared with 106 for UHSM and

50 for the national top quartile.

During winter 2013-14 key messages observed in the system included:

Increase in emergency admissions, partially as a result of increase ambulance arrivals

Increase number of people aged over 75 years attending UHSM

4 hour breaches and 4-12 hours waits were lower than in 2012-13

Delayed transfers of care DTOCs were lower than in 2012-13

Source: GMCSU South Manchester Winter 2013-14

Figure 11: Winter Performance at UHSM

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Performance against the 4 hour Emergency target has been challenging over the few years

at UHSM, however there has been some improvement in the 4 hour target and a reduced

number of delayed transfers of care (DTOCs) during winter 2013-14, see tables below.

Figure 12: Delayed Transfers of Care at UHSM

Due to the pressures observed diagnostic reviews of the urgent care system have been

carried out including the impact of the Trafford New Deal and an external review by the

Emergency Care Intensive Support (ECIST) team. These diagnostics have informed our

strategic commissioning plans and led to the adoption of the 4 hour target a system wide

key objective across South Manchester and Trafford CCGs. To support delivery of the plans

and performance trajectory the governance structure for urgent care has been revised to

ensure executive level engagement across partner organisations.

Trafford New Deal Trafford CCG has been working with stakeholders to manage the transition of the changes in

the urgent care system within Trafford, based on planning assumptions of the impact of

neighbouring trusts including UHSM. Whilst activity trends have not changed significantly,

the flow of patients to neighbouring trusts has been different to expectations. This has

impacted on UHSM during winter 2013-14, with considerable work across the system to

manage these patient flows.

South Manchester CCG and Trafford CCG are working closely with USHM and partner

organisations to understand the impact of the system change and manage this. We are now

working to develop system wide pathways across community and social care provision to

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ensure that there is a common standard and response to support admission avoidance and

facilitated discharge for example for intermediate care and social care.

Capacity and Demand Local performance reporting currently provides good quality data to support service

planning and commissioning. This will be refined further to support a better understanding

of capacity and demand across the health and social care economy and subsequently

patient flow by CCGs. This will include a better understanding of planning for urgent care

provision to ensure commissioned services and workforce capacity is in place to support

timely delivery of care including:

Accident and Emergency

Planned emergency pathways of care including ambulatory care

Pathways for frail older people including: demand for intermediate care (home and

bed based), reablement, nursing and residential placements, community services

especially rapid response, 7 day GP model and assessment facilities including

community geriatricians

Extended lengths of stay in addition to delayed transfers of care including reducing

bed days lost to delayed transfers of care

Bed day rates for our population

Planned care referral to treatment (RTT) requirements and acute bed capacity

modelling

A deep dive into ambulance activity and performance will also be undertaken during 2014-

15 as part of the work across Greater Manchester with NWAS and NHS Blackpool. This will

focus on ambulance transfers to UHSM and the impact of the Trafford New Deal to support

developing strategic plans for improving performance and patient pathways.

Achievement of 4 hour target, national priorities and Better Care Fund Criteria It is recognised that the integration agenda and targets around meeting the Better Care

Fund criteria presents challenges for the urgent care system. Our forecast planning for the

strategic plan is based on the outcomes of the initial findings of the Neighbourhood Teams

pilot. The enhanced model is being implemented during 2014-15 which supports vertical

integration with UHSM, alongside our intention to work with Trafford CCG to develop

common standards and a core offer to support admission avoidance and supported

discharge.

The impact of these schemes will be monitored to inform and support acute bed capacity

modelling and delivery of the 4 hour A&E target. The ECIST length of stay (LOS) review

suggests there is considerable scope for efficiency through reducing length of stay,

particularly for older people. For example from the ECIST length of stay (LOS) review audited

366 in-patients with a LOS over 7 days, 175 of whom were identified as potentially fit for

transfer.

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In addition to understanding the impact of commissioned schemes on demand and capacity

and acute bed requirements, we will also be reviewing the impact of waiting list initiatives

on delivery of the 4 hour target especially over the winter and at periods of escalation. This

will inform working with UHSM to smooth out peaks in activity at times of escalation but

also provide us with more assurance around the delivery of 4 hour, referral to treatment

and ambulance targets and reducing DTOCs and NEL admissions so that we are more in line

with the national average. See also the section on planned care.

For further details of risks aligned to demand and capacity see section 4, page 86.

Supporting the system to improve the urgent and emergency pathways As identified above the urgent care system has been under pressure in south Manchester

and achievement of the 4 hour Accident and Emergency target has been challenging over

the last three years particularly during times of escalation such as winter. Although there

has been some improvement on performance during winter 2013-14, this is thought to be

due to the introduction of a number of initiatives including the Acute Medical Model at

UHSM and improved primary care access. However, the reviews have identified a complex

range of issues which require system wide transformation, and we have identified some

core components of the commissioning plans that will need to be in place before winter

2014-15.

Understanding the problem To inform improving the quality and experience of urgent and emergency care for south

Manchester residents a review of the urgent care system has been undertaken by the

Emergency Care Intensive Support Team (ECIST) during Spring 2014. Alongside other

internal diagnostics, this has identified a high level of consensus across the diagnostic

information, which has informed our plans to turnaround performance with key

stakeholders including:

UHSM including community services

Trafford CCG including commissioned community and acute services

Manchester City Council

Trafford Metropolitan Borough Council

South Manchester GP Federation, primary care and GP out of hours

NWAS

Mental health service providers

The review focused on acute and economy wide issues based on analysis of current

pressures in the system and including:

Length of stay (LOS)

*Acute pathways of care for frail older people

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*These compliment the work that South Manchester CCG has undertaken on frail older

people (see Strategic Priority 1).

Key issues identified include:

Systems need to be improved to support early decision making and patient flow

within UHSM

Development of planned pathways for emergency care including ambulatory care

and specialist in-reach to the front of hospital

Implementing an acute frailty pathway and integrated with community services and

primary care including community geriatrician and rapid response

Patient flow issues including internal system process within acute services and

external organisations to support discharge

Adopting best practice seen in some acute areas at UHSM to support discharge

Addressing workforce issues

Whilst the reviews were undertaken at UHSM, they identified system wide issues across

partner organisations in south Manchester and Trafford, which will require system wide

ownership and partnership working to resolve. Therefore the CCG is working with partners

to ensure operational and strategic plans are in place which will be managed by the Urgent

Care Board with appropriate governance and escalation processes across the system

including daily management of delayed transfers of care above 10 and developing

monitoring of the number of patients with a length of stay greater than 7 days to

understand and manage system delays and capacity issues.

System wide strategic plans A system wide strategy and programme of work has been developed with partner

organisations which builds on the CCGs strategic plans for integrated health and social care

and supports turnaround and delivery of the 4 hour Accident and Emergency target. These

triangulate with UHSM plans submitted to Monitor and have been agreed to ensure

consistency of deliver and communications across organisations. UHSM have experienced a

significant period of change within its management structures recently, and it is felt

important to retain consistency re the local direction of travel particularly for our workforce.

Within the programme plan four key areas are being addressed:

1. Re-design of Accident & Emergency provision – front of hospital Capital investment as a result of the Trafford New Deal will enable the redesign of the front

end of Accident and Emergency at UHSM. This provides the opportunity to develop a more

primary care facing service and ambulatory care provision, enabling patients to be managed

in the most appropriate area for their clinical need. This model will link closely with

integrated models of care identified in diagram above, enabling a more sustainable

approach to urgent care provision and improving the quality of patient experience.

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Alongside re-designing the physical design of the Accident and Emergency service delivery at

USHM will be re-designed including:

Front door provision:

Acute Frailty Pathway

Bed capacity and flow

Acute care and speciality pathways

Enablers including smartboards, flagging high risk patients known to integrated

enhanced neighbourhood teams

Ambulatory care with GPs as senior decision making and linking closely with

community and primary care services, including the seven day GP model for high risk

patients, (see Strategic Priority 2 – Primary Care)

Enablers including: workforce, IM&T systems, alerts of high risk cohorts

Flagging of high risk patients on secondary care and Emergency Department systems

2. Developing Discharge to Assess model Back door provision introducing:

Systems to support improved patient flow: daily consultant board rounds, best

practice (SHOP model) to deliver a consistent senior decision making process

Move to a discharge to assess model and ‘pull model’ for managing patient flow and

ensuring appropriate resources in place

Simplify pathways out of hospital, standardised discharge processes

Expected dates of transfer, passport home and home of choice policy

Ward audit tool to support reducing long lengths of stay

Greater Manchester social care discharge pilot at UHSM & piloting social care

discharge model

Increase efficiency and capacity within intermediate care including home and bed

based provision and developing a supported extra care housing model. This will

support increased step up provision, respite provision for palliative care and also the

discharge to assess model.

3. Developing service capability and capacity to manage people in the community to support admission avoidance

Out of hospital care including:

Develop integrated health and social care community services

Implement enhanced neighbourhood teams and virtual ward (including rapid

response, palliative care, frailty tool and IM&T to support mobile working)

Access to shared electronic records

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Implement core standards for community services across populations served by

UHSM, these will align with the Healthier Together standards focusing on services for

frail older people in the first instance

Single point of access to community services

Community specialist assessment including community geriatricians

Seven day GP model – working with high risk cohorts

Out of hospital provision will support people to remain in the community and provide care

closer to home where appropriate to support avoidable admissions. The local model has

been informed by local intelligence including service reviews, clinical audit, mock Keogh and

escalation walkabouts and includes improving provision in the community to manage carer

breakdown, falls, urinary tract infections, cellulitis, acute confusion with rapid assessment

and escalation in care provided including social care and reablement.

The Perfect Week During 2014-15 the health economy will be implementing the Perfect Week. The aim is to

improve patient flow to produce a step-change in performance, safety and patient

experience. The initiative is run over one week during which the whole system focuses on

improving the emergency care pathway. The initial the focus will be on UHSM internal

systems and processes for example implementing best practice and pathways including

discharge, fracture neck of femur and undertaking a few key initiatives in the week to show

what can be done. This will provide an opportunity to raise the profile of new services for

example:

Ambulatory care with GPs as senior decision makers

Enhanced Neighbourhood Teams and seven day GP working model working closely

with the front of the hospital and the acute frailty pathway

Practices implementing national unplanned admissions enhanced service ahead of

national timescales for example using by-pass numbers and same day access for

older people

Discharge to assess model

Care plans on NWAS systems for high risk patients

Single point of access for community services

The intention is to kick start the system and opportunities for the system to work differently

and also to act as an enabler for implementing best practice and new models of working.

System wide working An important component of effective urgent care systems is effective working across health

and social care and primary and secondary care. Therefore, our strategic plans for primary

care, community services and integration are core to supporting the delivery of urgent care

provision. Our strategic plan identifies our model for frail older people, people with

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dementia and end of life care, developing more infrastructure in the community to deliver

sustainable high quality care (see Strategic Priority 1 and Cross Cutting Priority 1).

A key component of our strategy for supporting frail older people is to develop a consistent

integrated rapid response and a virtual ward concept within the community. This model will

be tested during 2014-15.

Rapid response and virtual ward Rapid response will support the management of people who become unwell in the

community through providing a virtual ward concept. Rapid response will be a core

component of the Enhanced Neighbourhood Teams (ENT) ensuring that integrated health

and social care teams including GPs is an integral part of proactive care planning, wrapping

care around patients when they deteriorate. Using Hilda as our vision, this enables the team

to make best use of the wealth of information they will have access to on the person and

their carer and respecting their plans on how best to support them.

For patients requiring rapid-response, the ENT will deliver a 1-hour response, providing care

for up to 72 hours which will then be taken up by core community services (health and

social care). This additional and rapid response will include palliative care, specialist nursing,

allied health professional and social care support and will provide:

Rapid response to support the avoidance of an admission

Rapid multi-disciplinary team assessment and care planning to define interventions

required

Facilitated discharge and post-discharge support within the community to support

step-down from acute care

Social care support, i.e. community alarm, care packages and reablement

Respite and palliative care at end-of-life

Step-up and step-down beds and the clinical support associated with these beds and

home based interventions

Timely information to practices, including key clinical information, from a named

clinician

Single point of access

The rapid response within the ENT will manage people differently when they deteriorate

which require a sub-acute response for example a nursing, therapy, allied health

professional or social care intervention i.e. a medication review, IV therapy, rehabilitation,

reablement, respite care.

The sorts of scenarios that will be managed include the following:

Exacerbation of a long term condition

Acute episode of confusion in dementia

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Acute infection and deterioration in baseline status often referred to as “off their

feet”

Falls

Palliative care crisis

Catheter problems, e.g. a blocked catheter

Impacted constipation

PEG feeds

Carer breakdown

Breakdown of care package in a care home/nursing home, which results in an

inability to manage a patient further

Community Geriatrician A named Geriatrician will be provided for each patch, as an integral part of the ENT,

providing specialist advice, support and guidance in the management of the most complex

frail, older people. This will be through various mechanisms including: attendance at multi-

disciplinary meetings, telephone advice and providing specialist interventions where

applicable. Community geriatricians alongside the development of an Acute Frailty Unit at

the front end of UHSM and the presence of the seven day GP model (targeted to align with

peak times of attendance at the Emergency Department) and IM&T systems, which will

enable the flow of information and expertise to support admission avoidance and early

supported discharge through the ENTs and rapid response. See the diagram on urgent care

model including vertical integration, see diagram below. This will enable our most

vulnerable groups to be prioritised within service provision and improve access to and the

quality of services and outcomes for patients.

Patch working Our integrated ENT and model for managing frail older people in the community will be

provided on a patch basis (see Strategic Priority 2), which is being tested and refined during

2014-15. This will inform the development of our strategy for delivery of care on a patch

basis including the infrastructure that is required to support people in the community.

Intermediate care Some of the pressures experienced across the urgent care system relate to discharge

pathways and access to intermediate care. Therefore we will be working with UHSM,

Trafford CCG, Manchester City Council and partners to develop a system wide intermediate

care provision. Currently there are a number of different providers and pathways across

CCG populations using USHM; this presents complexity for staff and patients when accessing

services. We will work over the next two years to streamline provision enabling us to move

to a discharge to assess model and more innovative models of intermediate care provision.

In order to address immediate pressures in the system we are procuring five additional

intermediate care beds to be operational before winter 2014-15, with the option to flex this

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capacity if required. These will provide step up provision to support the ENT model. We

have also developed an action plan with UHSM to improve efficiency (delivery model,

readmissions and lengths of stay) within the current bed provision. A key component of this

is the work we are doing with community services to develop an integrated rehabilitation

service, bringing together a number of disparate services to provide a more integrated and

efficient service.

During 2014-15 we will monitor the impacts of more care provided in the community and

the changes to rehabilitation services locally to inform the capacity and procurement of

intermediate care. Working with Trafford CCG we will then enter into a procurement

process to secure the model required across populations access UHSM.

Future model of intermediate care We are currently developing our model for intermediate care with partner organisations. However, the principles of our future model include:

Simplify pathways to access intermediate care for step up or step down from UHMS

no matter where a patient is resident

Discharge to assess

Increase capacity for home based intermediate care closely aligned with other

models of care i.e. integration and patch provision, urgent care

Utilise assistive technology to support assessment models and independence

Develop provision in retirement village/extra care housing facilities and explore how

best to link with other housing facilities for example retirement or sheltered housing

Build in the ability to flex capacity

Exploit opportunities for economies of scale

Self-care Developing models of self-care is a key component of Living Longer, Living Better (LLLB)

which is encompassed in the delivery of integrated provision in South Manchester CCG

through our ENT model. Our strategic plans for the delivery of LLLB identifies the timescales

for delivery of the care models (see section 2, page 24), this will include developing self-care

for all the priority groups. We are working with Manchester City Council to develop

evidence based health and wellbeing services that are able to deliver and support self-care

for these priority groups, alongside using technology to aid self-care and management. We

will embed this culture and approach through our organisational development plans (Cross

Cutting Priority 4).

In addition we will continue to develop 'Choose Well' resources to support people to access

urgent care services appropriately and are embedding the Minor Ailments scheme with local

pharmacies into our primary care engagement scheme.

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Social care discharge pilot UHSM has been identified as a site for the Greater Manchester social care discharge pilot.

The new model will reorganise existing resources to align social care staff from different

authorities in the majority of hospital sites across the area. Staff will support all Greater

Manchester residents attending / admitted to the hospital that they work in, regardless of

the authority in which they are resident. They will input into / co-ordinate:

Admission avoidance

Assessments for discharge

Arrangements for step-down care (in accordance with the policies and procedures

of the borough in which the patient is resident)

Social care assessment processes have been under pressure within the current system and it

is anticipated that the pilot will help to improve patient flow and support better use of

resources.

Developing primary care Primary care provides a key part in managing the urgent care system differently, (see

Strategic Priority 2).

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*Patches

1 Wythenshawe

2 Withington and Fallowfiled

3 Didsbury and Chorlton

4 Wythenshawe and Northenden

ED re-design not included in this model

note: Over 65 multi-disciplinary Out of Hours service

Urgent Care Model (vertical integration)

UHSM Urgent System

Ambulatory Care (assessment, diagnostics,

treatment)

ED Acute Medical Unit

Urgent Care

Centre

Rapid response

(7 day working) :GPSI, community

geriatricianEnhanced &

specialist

Community Service/

Self Referral/Bed and home

based

Intermediate

PATCHES*

Neighbourhood

Teams

MDT Care

Planning

GP practice & GP Fed (7 day

working) proactive Follow-

up of over 65s

moderate risk./ optimisation and

review of medical management of

LTCs

Walk In

GP &

community referral

DISCHARGE

Discharge Liaison Team : early facilitated discharge to community services with rapid transfer of core discharge information and treamtment plan

High risk and frail older people and adults with dementia: Enhanced Community Team. Moderate risk patients to primary care for proactive follow up. GP named clinician

T

RI

AGE

Risk stratified patients flagged and identified in secondary care, access to shared care

plans across primary and scecondary care.Focus on respiratory patients in 2015-16.

Withington Community Hospital will support delivery of some proactive management.Impact: improving proactive management of LTC in primary care, reducing ED attends,

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Vision

• To deliver high quality, value for money and effective services, safely

in the right setting with the right professional

Interventions

14-16

• Develop consultant to consultant referral protocol

• Deliver agreed provider efficiencies

• Implement recommendations on respiratory and cardio-vascular

disease from GEM deep dive review

• Community Dermatology, Endoscopy and Deep Vein Thrombosis

services

Goals and Targets

• Reduced number of consultant to consultant referrals

• Delivery targets for 2014-16 provider efficiencies

• Improve quality and reduce cost of the high usage planned care

pathways

• Deliver targeted QIPP savings from planned care

• Increase number of patients accessing planned care services in a

community setting

Strategic Impact

• Management of planned care expenditure

• Fewer emergency admissions, fewer Emergency Department

attendances and fewer excess bed days

• A simplified and integrated care model between primary, community

and secondary care

• Improved level of patient experience

Strategic Priority 4: Improve and Reform Planned Care

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3.5 Improve and Reform Planned Care

We know that people in south Manchester want to access local services closer to home and

within the community setting where possible. Whilst we aim to achieve this aspiration, the

CCG will take into account the quality of service provided as well as those which deliver

value for money. We will need to work with acute providers, private providers and primary

care clinicians to make sure that planned care is always delivered effectively and safely.

The CCG’s Planned Care Work Programme above has taken into account elective plans that

consider reductions and growth in line with 13/14 activity levels, and increased demand and

18 week referral to treatment requirements. In order to pro-actively manage the contract

and be assured on financial stability, the CCG propose that quarterly, in the Finance and

Performance meeting the Provider informs CCGs on any areas where plans for outpatients,

in-patients and day-cases are considered at risk of over performing. The CCG needs to

understand non-urgent requirements prior to additional activity being undertaken.

A Planned Care Steering Group has been set up with membership from the CCG and Acute

Trust clinicians and through 2014/15 this group will monitor activity pressures in various

specialties and work to redesign and commission services that provide choice, access and

patient satisfaction.

Consultant to Consultant (C2C) Framework Protocol A meeting between colleagues from South Manchester CCG, Central Manchester CCG,

Central Manchester Hospitals Trust and Trafford CCG was held to discuss a proposed

revision of the current consultant to consultant framework. The rationale for the review was

the need to:

Ensure patients are offered choice

Improve patient experience

Make the system more efficient

Review the framework as a result of learning from the C2C audits

Have a more consistent approach across Manchester and Trafford

Many contributing factors result in the volume of C2C referrals:

The increased sub specialisation of Consultants in some specialities

Patients being incorrectly booked into clinics via Choose and Book

The undertaking of a lot of Tertiary work

Two distinct pieces of work were identified as a result of the meeting:

The need to increase the inclusion criteria for each Speciality

The need to undertake a piece of work to ensure patients are seen by the correct

Consultant the first time

It was agreed that this work would continue to be led by the Planned Care and LTC’s Board.

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Figure 13 : Summary of Outlying Specialities at UHSM

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Provider Efficiencies The CCG and Trust have agreed that there is much to be gained by a joint approach to

improving efficiencies across a range of performance metrics including:

Agreement on a clinically developed consultant to consultant protocol

Length of stay

“ Did Not Attend” rates

Follow-up to new ratios

Accident and Emergency attendance to admission levels

0 day length of stay

It is proposed that during Quarter 1 of 2014/15, work is undertaken to benchmark UHSM

against appropriate peers for the relevant service. Reasons for the deviation from peers will

be investigated and where improvements can be made, trajectories will be set to be

delivered from Quarter 2 2014/15 and beyond. This work will be clinically driven and

agreed (See figure 13)

QIPP Schemes Delivered Through Planned Care

Scheme Savings Plan 2014/15

Telederm 212

Dermatology - Community 24

DVT - Pilot 280

Endoscopy 49

Total 565

Disease Specific Improvements to Planned Care

Respiratory & CVD As mentioned previously, we have engaged with the CfV collaboration between NHS Right

Care, NHS England and Public Health England. Through a review of existing, local, health

data the CfV Focus Packs identified the two priority areas for the CCG as respiratory and

cardio-vascular disease (CVD). As these programmes are to be mainly delivered through

primary care the work has been articulated in Strategic Priority 2.

Cancer NHS North, Central and South Manchester CCGs have partnered with Macmillan Cancer

Support, local acute trusts, St Ann’s Hospice and Manchester City Council to deliver a

programme of work to improve cancer care and redesign breast and lung cancer pathways

in Manchester, supported by the development of service specifications for these tumour

groups. Funded by Macmillan, this £3.45m three year programme commenced last

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year. The vision is that everyone in Manchester who is affected by cancer will be able to

say, "I had the best support and treatment from an expert team who made me feel cared

for and in control.”

The background work has already taken place and several exciting projects are due to

commence. There is a focus on cancer care reviews, identifying and managing patients on

the palliative care register and implementing Macmillan information points in all

practices. In addition a practice Cancer Champion role will be developed and a quality

standard recognition mark designed with input from patients and practices. Phase 2 of the

programme focuses on breast and lung cancer specifically.

The programme will be supported with an education strategy for non-cancer specialists

both clinical and non-clinical staff. A Macmillan Cancer Improvement Partnership (MCIP)

Locally Commissioned Service (LCS) will be developed for practices across Manchester to

support delivery of the key areas. A facilitator role will be used to support practices in the

programme work streams.

Manchester has one of the lowest uptake rates for the 3 cancer screening programmes.

Improving uptake has been addressed as one of the key priorities for the Manchester

Cancer Commissioning Board. The CCG is working with the Public Health England screening

team and health improvement teams to monitor uptake at practice level to identify areas

where more support may be required.

Deep Vein Thrombosis (DVT) A DVT Community Pathway has been developed which aims to improve the quality of care

and experience for patients who present to GPs with a suspected DVT. Historically, patients

with a suspected DVT have been referred to secondary care for assessment and

management which often leads to long waits, repeat visits for anticoagulant medication and

unnecessary hospital admissions. However, in the majority of cases much of this pathway

can be managed in an ‘ambulatory’ manner without requiring admission to hospital. The

community pathway will enable the initial assessment of patients to be undertaken in the

community.

Venous duplex scans will also be carried out in community-based locations by trained

vascular scientists/ sonographers. If the scan confirms that a DVT is present, the patient will

be referred back to their GP for assessment and further treatment. Ongoing treatment of

proven DVTs will be managed within primary care, unless there are additional complicating

factors which require secondary care management.

The service meets with the CCGs Strategic Commissioning Plan priorities to implement

ambulatory care pathways and is also in line with the strategic vision for Manchester to shift

care away from secondary care, managing and treating patients in community based

settings.

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Dermatology Following the termination (in March 2012) of the contract with Manchester Skincare for

community dermatology services, waiting times for dermatology referrals at UHSM have

increased significantly. The service is currently at peak capacity, with a number of patients

hitting a 12 to 17 week wait, which is threatening the 18-week referral to treatment

target. The majority of referrals are from GPs. The current waiting list (as at June 2014)

stands at 540+ patients. A clinical review of the waiting list in September 2013 highlighted

that a number of referrals could/should have been managed in primary care or referred to a

community clinic.

South Manchester CCG, in collaboration with Central Manchester and Trafford CCGs, intend

to commission a Community Dermatology Service to deliver community based assessment

and management of dermatological conditions that don’t require specialist intervention at

secondary care level. This will enable improved patient flow through dermatology services,

and support a reduction in the increasing demand for secondary care services. Referral to

secondary care is appropriate for a small cohort of patients with more complex conditions,

e.g. suspected malignancy, multiple pathologies or where there is diagnostic uncertainty or

the need for specialist intervention. However, there are a number of conditions that don’t

require this level of specialist intervention and should be managed outside of an acute

setting.

The overarching aims of the service are to:

Improve access for the assessment, diagnosis and treatment of dermatological

conditions

Deliver timely, appropriate and increased interventions in the community. Only

those patients that really need it will be treated/ managed in secondary care

Create a system to support managing demand for secondary care services and the

delivery of referral to treatment targets

Develop common pathways of care ensuring there is no unnecessary duplication,

and promote the integration and coordination of services

Ensure patients are seen and treated in the right place at the right time and by the

most appropriate clinician

Deliver improved patient experience

Improve the knowledge of primary care clinicians in the management of skin disease

through the development and implementation of a structured educational

programme

In the interim, we are currently exploring options around tele-dermatology to deliver an

innovative model of assessment and diagnosis for patients with routine dermatological

conditions. The model will be implemented as a short, six-month pilot during summer 2014.

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Endoscopy The NHS supports the need to develop improved access to diagnostic tests as part of the

drive to reduce waiting times and improve choice for patients. This is part of an overall

strategy to ensure that diagnostic tests are undertaken at the right stage of a patient

pathway and in the clinically most appropriate setting. The provision of a direct access

endoscopy service enables GPs to refer routine patients for diagnostic investigation without

the need to go into hospital and within a shorter timeframe.

We have recently procured a Community Endoscopy Service (upper and lower) which will

contribute to the delivery of our strategic priorities of Integration and Primary Care.

The Community Endoscopy Service will provide local access for symptomatic patients who

are referred by their GP or healthcare professional.

The community service will provide:

Direct access (one stop diagnostic service)

Facilitate early diagnosis and treatment of gastroenterological conditions

Support primary care clinicians to diagnose and manage common conditions in

primary care

A surveillance service for a cohort of patients

Reduced waiting time for patients

Care closer to home (delivered from two locations across the South Manchester CCG

footprint and outside of the traditional Monday to Friday 9.00 am – 5.00 pm service)

A shift in activity from secondary care to community based care

Reduction in health inequalities through improved access

The service will contribute to the education, training and development of the

primary care workforce through the provision of advice and guidance on the

appropriateness of referrals etc.

Each patient contact is to be used as an opportunity to promote a healthy and active

lifestyle (specifically for the endoscopy service to include dietary management of

conditions)

The community service has been procured and will go live in the summer of 2014.

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3.6 Delivery of the Healthier Together Programme

The Healthier Together programme is part of the Greater Manchester Programme for

Health and Social Care Reform, which aims to provide the best health and care for Greater

Manchester. It is the largest and most ambitious health and care reconfiguration

programme in the country.

The programme is responsible to the 12 Clinical Commissioning Groups across Greater

Manchester, with the CCGs exercising our statutory responsibility for commissioning

through a shared decision-making body, the Healthier Together Committees in Common

(formally a sub-committee of each CCG).

It is widely recognised that the different parts of the health and social care system are inter-

dependent, and that major changes to services in the community are required before

significant hospital changes can take place. The wider Healthier Together programme brings

together the locality programmes developing Community-based Care (Integrated Care and

Primary care) with the reform of “In Hospital” care across Greater Manchester for the “in-

scope” services (these are: Urgent, Acute and Emergency Medicine; General Surgery; and

Women and Children’s services).

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This has led to variations in the range and quality of services available in different areas,

resulting in inequality of access to services in different areas. For example, the mortality of

patients who undergo Emergency General Surgery varies from 23.1 to 51.7 per 1,000 spells

across Greater Manchester, depending on where people are treated. This needs to change,

with everyone entitled to the best outcome wherever they live, and yet we have a limited

number of specialist clinicians, rising demand and serious financial pressures.

An analysis by Mott McDonald has forecast the financial gap between expected activity in

acute trusts and available funding across Greater Manchester over the next 5 years at £742

million, with a further £333 million gap in social care funding – a total system-wide pressure

of over £1 billion. Doing nothing is not an option. Work on determining the figures for each

locality will be completed in February 2014.

As more people receive appropriate treatment at home or in the community, those patients

that do need to be admitted into hospital, especially in an emergency, are likely to have

more complex needs. They are most in need of very specialist care and being assessed by a

senior doctor will improve their chances of recovery. Senior doctors are not available in all

specialities on site 24 hours a day, 7 days a week due to the large spread of services across

Greater Manchester. This means that Greater Manchester has an inequity of provision out

of hours and at weekends often leading to poorer outcomes for patients.

Over the last 24 months, over twenty clinical congresses involving hundreds of clinicians

have considered the issues facing our health system. They have explored the potential

solutions to ensure services remain high quality, safe and cost effective for future

generations. This work, which has been based on evidence and best practice from around

the world has developed and contributed to this case for change.

The proposals arising from these congresses are for services to be shared across a number

of defined hospital sites, with clinicians working across those sites to provide seamless care,

with the teams delivering the “once-in-a-lifetime” specialist care on a designated site. These

“single services” are shared across the geographical footprint, and the clinical teams benefit

from being part of a wider, sustainable and better supervised team, raising standards in the

“routine” work in the District General Hospital as well as meeting the clinical standards at

the specialist site, a “win-win” for patients. This should also significantly improve efficiency

at all the sites (as routine activity would no longer be interrupted by emergencies), and it is

expected that that the Trusts would share the financial risk to avoid the perception of

“winners and losers”.

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The proposals to change hospital services will be subject to statutory public consultation,

and must pass the requirements of the NHS Assurance process. Clinical assurance has

already been secured for the model via the National Clinical Advisory Team - “We

unanimously support the Programme to proceed to Consultation. This is the most ambitious

and well thought out work we have come across. We are highly impressed”

The determination of the viable options for consultation is subject to a rigorous 9 stage

process:

Combined medical and senior nursing

workforce

Locally developed services to meet

Standards

A single performance management

framework

Local enhanced provision based upon

JSNA

Single clinical leadership and

governance

Building upon existing pathways (PPCI/

Stroke/ Major Trauma)

Combined training and education

arrangements

Greater flexibility of existing staff

2. Project baseline forwards for 5 years (activity, capacity, workforce and finance) and overlay QIPP plans

3. Apply assumed changes in secondary care activity due to interventions in Primary & Integrated Care

4. Apply assumptions about changes in activity under the new model of care

5. Develop site configuration options (using projected activity levels, workforce and patient flows)

6. Determine the level / range of projected activity at each site for each option

7a. Assess if sufficient estate capacity

8. Assess financial impact of options

7b. Assess if sufficient workforce capacity

9. Evaluate options to identify preferred options for consultation

1. Baseline activity, capacity, workforce and finance

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Following extensive pre-consultation engagement, including with key partners such as the

Association of Greater Manchester Authorities, the Committees in Common of the CCGs will

decide to proceed to consultation in April 2014. Subject to NHS Assurance, it is planned that

formal consultation will take place in the summer of 2014, with a final decision at the end of

2014. There are considerable risks in a programme of this size and complexity, and given the

proximity of a general election there is a possibility that the formal consultation and

decision will need to be postponed until 2015 – this would clearly delay the programme and

the delivery of the benefits expected to be realised.

Pre-consultation

engagement

Complete

modelling and

Options

Appraisal

CiC decision to

proceed

NHS Assurance

Formal public

consultation

CiC Decision on

hospital

reconfiguration

Jan - April 14 April 14 Apr – Ma June – Sept14 Dec 2014

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Section 4: Financial Sustainability

4.1 Economic Outlook for the NHS The planning document ‘The NHS belongs to the people: a call to action’ says the NHS could

face a funding gap of £30 billion by 2020-21, as a result of the growing gulf between flat

funding and rising demand, driven by an ageing population living with a growing burden of

chronic disease.

In a statement on its website, NHS England states that this gap “cannot be solved from the

public purse, and that the NHS and the public will instead have to accept radical changes,

freeing up NHS services and staff from old style practices and buildings.”

Over the course of the 2010 Spending Review, local government funding will have reduced

by 33 per cent in real terms. A further real term cut of 10 per cent is confirmed for most

local government services for 2015/16, and a similar trajectory is projected for the period

beyond.

In June 2013, the Institute for Fiscal Studies expressed the view that government spending

cuts will continue until 2020. For local authorities the updated funding outlook model

reveals that the financial black hole facing local government is widening by £2.1 billion a

year and will reach £14.4 billion by 2020. It is in this financial context, that both national and

local policy drivers are determinedly focussed upon making the most effective use of

resources across health and social care services, by integrating services wherever possible to

enable local commissioners and providers to work collaboratively to resolve the financial

pressures in their local systems.

A key enabler of the national policy is the creation of local ‘Better Care Funds’ from 1 April

2015. In the city of Manchester (encompassing the City Council and three Manchester

CCGs) the Better Care Fund, through a formal pooled budget arrangement, will see a

combined transfer of £25.4m of CCG resources to this pooled fund. This funding will support

the continued implementation of the Manchester wide integration programme, ‘Living

Longer, Living Better’, as well as a range of key local and national conditions.

For South Manchester CCG, the transfer to the Better Care Fund will mean that although

combined two year growth of £7.8m has been announced for 2014/15 and 2015/16 (2.14

per cent and 1.7 per cent respectively), only £0.2m of this (or 0.1 per cent growth on

2013/14 baseline) will be retained directly by the CCG in 2015/16, representing a reduction

in funding in real terms of 1.5 per cent.

This explicit efficiency challenge will require strong, cross organisational leadership to drive

through better returns for each pound of investment – not only by releasing cashable

savings but also, ensuring that efficiency savings are generated through improved

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productivity and that these are reinvested in better quality, more effective and more

efficient services for patients.

Economy Efficiency Challenge The efficiency challenge across the health and social care commissioners in Manchester,

together with the three main acute providers, is in the region of £250m for the five year

planning period:

£70m local authority (to 2016/17);

£20m for the Manchester CCGs (2014/15 to 2018/19); and

£160m for the three main acute providers (2013/14 to 2017/18 – source: Healthier Together).

The significant task of reducing and managing the city’s financial pressures is being

addressed through the three overlapping and inter-dependent programmes of work at a

Greater Manchester level, as shown pictorially below, namely:

Healthier Together

Integration (Living Longer, Living Better (LLLB))

Primary Care Strategy

Other ‘Quality, Innovation, Prevention and Productivity’ (QIPP) schemes

It is clear that the LLLB programme in isolation will not entirely address this significant

challenge. Efficiencies must also be delivered through all of the programmes, as well as

other cost improvement plans across all partners.

Living Longer, Living Better Contribution Recognising the range of programmes running in parallel and the on-going modelling work

for each, the precise implications for the acute (and other) sectors are not fully quantified at

this stage.

Joint Committee of Association of

GM CCGs

Joint Committee of Association of

GM CCGsNHS EnglandNHS England

10 local models of integrated care with some commonality10 local models of integrated care with some commonality

Clinically led In hospital redesign across GMUrgent, Emergency and Acute MedicineAcute SurgeryWomen’s and Children’s

Clinically led In hospital redesign across GMUrgent, Emergency and Acute MedicineAcute SurgeryWomen’s and Children’s

Primary Care Commissioning Strategy developed by NHS England working with CCGs, AGMA and others

Primary Care Commissioning Strategy developed by NHS England working with CCGs, AGMA and others

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However, a series of strategic financial planning assumptions have been shared and agreed

with key partners, including provider Trust Directors of Finance and local authority, to guide

the range of affordability during development of the new delivery models.

These reflect the activity shift assumptions expected to be delivered through the above

programmes over the planning period, as well as acknowledgement that reinvestment will

be required in community and other services to secure reductions in hospital capacity.

STRATEGIC TARGETS

Manchester CCGs (Gross % shift based on 2013/14 M8 Forecast SLAM outturn)

TARGET REDUCTIONS - 5 YEAR PERIOD

POD

Agreed target shift %*

Indicative average prices

Target shift required

2014/15 to 2018/19

Indicative tariff cost of activity shift

North

(All Trusts)

Central

(All Trusts)

South

(All Trusts)

£ Activity Indicative

cost £ Activity Activity Activity

A & E -10.0 £97 26,998 £2,606,679 8,927 11,415 6,655

EL -8.0 £1,043 4,001 £4,172,506 1,501 1,243 1,257

NEL -20.0 £1,733 11,098 £19,231,730 4,228 3,546 3,325

OP -16.0 £101 78,998 £7,964,718 25,481 25,957 27,560

TOTAL - ALL CCGs 121,095 £33,975,633 40,137 42,161 38,797

* The targets are based on review of NHS Comparators information for NHS Manchester in

2012/13

Work has been undertaken to ensure that assumptions remain consistent between the

various aspects of planning wherever the scope of modelling is similar.

At this stage, the planned efficiencies are based upon acute hospital based activity, valued

at circa £34 million. An assumption has been made that up to 50 per cent of this will need to

be reinvested in community services in order to sustain the acute activity shifts.

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Table 1 - CCG BCF Transfers (Estimated Impact)

Better Care Fund (BCF) Allocation 2015/16 North Central South Total

£k £k £k £k

CCG contributions

Carers breaks and reablement 1,815 1,735 1,450 5,000

NHS funding transfer/integrated care 7,576 6,886 5,922 20,384

9,391 8,621 7,372 25,384

New social care transfer (from NHS England - formerly

PCTs) 4,160 3,943 4,116 12,219

Total transfer to the Better Care Fund 13,551 12,564 11,488 37,603

Effect of BCF on CCG growth monies:

Growth 2014/15 5,318 4,943 4,312 14,573

Growth 2015/16 4,315 4,010 3,499 11,824

Total two year growth 9,633 8,953 7,811 26,397

CCG transfer (excluding NHS England additional) 9,391 8,621 7,372 25,384

Net CCG growth remaining after BCF 242 332 439 1,013

Finance We have undertaken a process to develop a financial plan for the next five years in line with

the national planning guidance. As outlined above, the position for the next two years will

be extremely challenging, as the requirement to develop at a locality level the Better Care

Fund effectively transfers most of the CCG’s growth.

Allocations Allocations for 2014/15 and 2015/16 were published on the 19th December 2013 following

agreement on the methodology to be used by the NHS commissioning Board at its meeting

in December.

In summary the Commissioning Board agreed the following:

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That in moving to the revised allocation formula all CCGs would receive a minimum

uplift of 2.14 per cent in 2014/15 and 1.7 per cent in 2015/16, with those CCGs most

under target receiving additional increases above this level.

This is in line with previous guidance; funds would transfer in 2015/16 to form a

“Better Care Fund” (BCF).

The table below summarises the allocations for South Manchester CCG:

South Manchester CCG

Distance from

target

Per cent

% £000's

13/14 recurrent allocation 201,201

Distance from target -1.26

Growth 2.14 4,306

14/15 allocation 205,507

Growth 1.70 3,494

Transfer in BCF 4,116

Revised allocation -2.31 213,117

Transfer out BCF 11,683

Revised allocation 15/16 201,434

Per cent increase in allocations 13/14 to 15/16 0.1 233

15/16 allocation per head 1.213

In addition to the above, the running cost allocation will be £3,909k in 2014/15 and £3,510k in 2015/16, a 10 per cent reduction. Planning Assumptions The planning guidance establishes that the CCG must plan for the following:

2014/15 2015/16

Non recurrent reserve 1.5% 1.0% Call to action 1.0%

0.5 per cent contingency 0.5% 0.5%

Total non-recurrent funds 3.0% 1.5%

Surplus 1.0% 1.0%

Tariff -1.5% -1.6%

This table indicates the significant level of non-recurrent resource required in plans in 2014/15, which amount to £6.3 million. This is prudent taking into account the overall two year settlement referred to above, but also needs to be used to ensure plans are in place to deliver efficiency requirements in future years. The tariff deflator which is anticipated to continue at a similar level beyond 2015/16 will create a significant financial challenge to hospital service providers.

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Growth Assumptions The CCG has incorporated the following growth assumptions into its financial plans for

2014/15 planning period.

POD Total

Growth

Non-elective admissions 2.00%

Electives 2.00%

Accident and Emergency 2.40%

Outpatients 1.50%

This effectively works out as a net overall growth on acute expenditure of 1.3 per cent for

2014/15.

These growth rates have been agreed with our main provider UHSM. Other key growth

assumptions factored into our financial plans are:

Prescribing 2%

Primary Care 2%

Continuing Care and Mental Health 2%

Investments The CCG has set aside a resource of £4.0 million for investments in 2014/15 to enable the

reductions in secondary care activity. There are three key initiatives the CCG will invest in:

Neighbourhood Teams – this is phase one of the integration programme.

Enhanced Neighbourhood Teams – this is phase two of the integration programme.

Seven Day Primary Care Access (Frail and Elderly) – this initiative builds on the

integration programme of work in providing improved primary care access for the

frail and elderly population.

Additional initiatives have been identified and developed, which will be implemented once

resources become available.

As outlined above the CCG has set five year targets to shift activity levels in acute trusts, to

the England average. The table below shows the impact upon these targets from the current

set of investments. The CCG has focussed upon reducing Accident and Emergency and Non-

Elective activity through its investments.

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Accident and

Emergency

Non Elective Outpatients Elective

Baseline 66,550 16,625 172,250 15,712

Target % Reduction 10% 20% 16% 8%

Target -6,655 -3,325 -27,560 -1,257

Investment Impact -2836 -1766 -329 0

% Shift on Baseline 4% 11% 0% 0%

% Shift on Target 43% 53% 1% 0%

% Balance

Outstanding

6% 9% 16% 8%

The deflections are based on the Neighbourhood Team initiative results, these deflections have been built into the UHSM 2014/15 plan. Also included in the above table is the estimated number of deflections from other initiatives waiting to be implemented. Reductions in activity in relation to outpatients and elective activity will be achieved through the Healthier Together programme and working with providers to look at improving efficiency ratios. We have factored into our financial plans investment in Primary Care to the value £2 million in each of the three financial years from 2016/17 to 2018/19. This funding will be used to improve quality, reduce variation and respond to delivering community based care. Better Care Fund We have assumed that any investments that are made in 2014/15 which meet the requirements of the Better Care Fund will continue to be supported by the Health and Wellbeing Board and be funded from the Better Care Fund in 2015/16. There is triangulation between the Better Care Fund, Healthier Together and the Southern Sector programmes of work. The impact of schemes in 2014/15 has been modelled in terms of impact on the Southern Sector and projections have been shared with McKinsey’s illustrating this. Southern Sector Challenged Health Economy (SSCHE) South Manchester CCG is part of the SSCHE, and is working in conjunction with providers

and commissioners who are part of the Southern Sector to develop plans that will make the

sector financially sustainable and deliver better health outcomes. These plans are being

developed in light of the Healthier Together and the Living Longer, Living Better

programmes of work.

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Contracts and Activity Planning The CCG has negotiated with all its key providers activity plans based on 2013/14 forecast outturn, less the tariff deflator, and taking into account where appropriate deflections from key initiatives. All secondary care contracts have been agreed on a cost per case basis to ensure full advantage is taken of the key initiatives when the deflections crystallise. Agreeing contracts on a cost per case also increases the risk posed to the CCG in the eventuality that the activity is higher than expected.

One of the key risks around secondary care expenditure is the potential increase in costs that will be incurred for activity delivered by UHSM. This is due to the fact that UHSM have highlighted that historically the Trust had been under charging for certain clinical procedures. The full impact of this could be in the region of £2.5 million for South Manchester CCG. We have agreed to cap this potential impact at 50% in 2014/15. This impact will be monitored on a bi-monthly basis both by the Trust and the CCG.

QIPP The CCG has a QIPP target of £4,761k (2.25 per cent) in 2014/15 and £3,898k (1.78 per cent) in 2015/16. The CCG has developed QIPP plans to address the required savings in 2014/15. The full year effect of the investment initiatives will assist in delivering the savings to meet the QIPP target for 2015/16.

Main Schemes

Scheme Savings Plan 2014/15

£000

Seven Day GP Model 1,458

Enhanced Neighbourhood Teams 731

Total 2,189

Other Schemes Scheme Savings Plan

2014/15

£000

2013/14 Roll Over 495

Telederm 212

Dermatology - Community 24

DVT - Pilot 280

Endoscopy 49

Prescribing 680

Prescribing 400

Prescribing 60

Minor Ailments 80

Service Review 198

Out of Hours and Accident and Emergency Diversion 66

GP referral - Engagement Scheme 116

Total 2,660

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There are robust systems in place to monitor and report the progress of QIPP plans within

the CCG. However, as the majority of the schemes are predominantly focused on secondary

care and prescribing there will be a time lag in evaluating the schemes, as the information is

often two or three months in arrears.

4.2 Risk Management In order to manage any potential financial risk we have in place the following:

0.5 per cent contingency in line with planning guidance

Developing additional QIPP schemes

Manchester citywide risk share

Review investments

The table below outlines the key risk in the delivery of this strategy.

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Section 5: Cross Cutting Priorities

Vision

• Ensure community and voluntary sector services are aligned to the delivery of our Living Longer, Living Better care models to maxmise the potential for out of hosptial care.

Interventions

• Review of community services

• Development of Community Nursing & Community Rehabiliation services

• Development of VCS commissioning strategy

• Delivery of VCS Social Isolation Programme

• Reconfiguration of Public Health Wellbeing and Lifestyle services

Goals and Targets

• Alignment of community services to Neighbourhood team model

• 23 Community Services to be reviewed

• Older people supported through social isolation programme

• Increase in the number of VCS organisations commissioned by CCG

Strategic Impact

• Improved level of patient experience

• Early identification and management of long term conditions

• Increase in the number people supported to self-care

• Fewer emergency admissions, fewer Emergency Department attendances, and fewer excess bed days

• A simplified and integrated care model between primary, community and secondary care

Cross Cutting 1: Community Services & VCS

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5.1 Community Services & Voluntary Sector Community Services Nationally, community services are a large part of NHS activity. Around 100 million community contacts take place each year, ranging from universal public health functions such as health visiting and school nursing to targeted specialist interventions in musculo-skeletal services, chronic disease management and intensive rehabilitation. The scale of these interventions is poorly understood and not well served by the way the debate on health services often defaults to ‘GPs and hospitals’ or ‘primary and secondary care’ (The Kings Fund, 2014). Nevertheless, there has been a longstanding ambition to shift more health care from hospitals to settings closer to people’s homes, and from reactive care to prevention and proactive models based on early intervention all of which community services are suggested to be able to do.

For South Manchester CCG, community services are a lynchpin to an integrated health and

social care economy, bringing care closer to home. In April 11, Community Services

transferred to UHSM as part of the Government’s Transforming Community Services

Programme. In total, 32 services transferred, with circa 380 community health service staff.

The services ranged from district nurses to those working in podiatry and continence care; a

total contract value for South Manchester Community Services accounting for

approximately to 10 per cent of the CCG annual budget. In September 2013, the CCG

recognised the need to better understand the delivery and effectiveness of community

services in South Manchester, and how these services could support the delivery of the

following goals:

To increase value for money in the delivery of healthcare services

To support the shift of provision of care from hospitals and into the community,

Improving the health and wellbeing of patients

Greater patient satisfaction

In March 2014, we completed our review of community services. We are now looking to

redesign and investment in those community services to support the implementation of our

integrated care models and deliver the activity shifts needed; moving care from hospitals to

the community. There is an emerging consensus (Kings Fund 2014; Department of Health

2009, 2013a, 2013b) about the impact that community services can have and what is

needed to improve their effectiveness. In February 2014, the King Funds identified a number

of main steps to improving effectiveness of community services and these findings resonate

soundly with our own:

To reduce complexity of services

To wrap services around primary care, patients and populations

To build multidisciplinary teams for people with complex needs, including social

care, mental health and other services

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To support these teams with specialist medical input and redesigned approaches to

consultant services – particularly for older people and those with chronic

conditions

To create services that offer an alternative to hospital stay and support people to

leave hospital sooner

Develop the capability to harness the power of the wider community - in terms of

patient experience, careers, prevention and self-care

Services that provide value for money and meet national benchmarks in terms of

efficiency, productivity and quality of care

Voluntary Sector Resent voluntary and community sector (VCS) research indicates that Manchester has

around 3000 VCS organisations within the city, 65 per cent micro in size, 17 per cent small,

13 per cent medium and 5 per cent large which provides a rich mix and blend of service to a

wide range of the population. Through closer partnership working with the Commissioners,

the VCS and the including the above proposed activity it is intended to align provision to

meet a number of priorities including support for universal provision, self-determined

support and care, prevention and early intervention and reducing the demand for statutory

services

We are working in collaboration with Manchester City Council (including Public Health

Manchester) to review how it can better align and engage with existing services

commissioned from the VCS and to support a broad range of health, Public Health and social

care commissioning outcomes. These proposals include:

An improved and upgraded database of organisations, services and opportunities linked

to a web-based directory to increase access to significant existing VCS provision in the

city

Partnership working between the above agencies to review health and social care

priorities and the development of a joint VCS strategy

As part of a planned longer term city wide solution a reconfiguration of Public Health

Wellbeing and Lifestyle services including integration with the VCS via network

membership, enhancing the breadth of the offer

As a short term approach and within current commissioning systems work with

Manchester’s VCS infrastructure provider to support education and awareness raising of

the VCS offer in Manchester linking into and supporting primary and secondary care

services

Voluntary Sector Commissioning: Reducing Social Isolation and Loneliness South Manchester CCG, in conjunction with its neighbouring Manchester CCGs have put

together a £650k fund to commission the VCS to help identify the factors that contribute to

and cause people in Manchester to be socially isolated and/or lonely.

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The fund is being administered by Manchester Alliance for Community Care (Macc) and has

successfully awarded 29 VCS groups grants to conduct this work on behalf of the CCGs.

Macc will be working with the Charity Service and the Office for Public Management to

evaluate the activities of the VCS groups and each CCG will be working with the VCS groups

in order to ensure that the CCGs can learn as much as possible about how the VCS operates

in Greater Manchester.

Towards the end of 2015, the CCGs hope by working with the VCS, we will have vital

intelligence about the causes of social isolation and loneliness and ideally, a series of

transferable actions that could be embedded into existing services to reduce it

systematically.

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Vision

• Prevention is better than cure. By systematically considering prevention in all of our commissioning, we will reduce premature death and prevent chronic disability or reduce its impact on people’s wellbeing. We will build a health system that takes prevention seriously.

Interventions

•Continue to work with Public Health to develop a deep understanding of our local populations

•NHS contact count and ensure that staff are trained in brief intervention

•Co-commission cost-effective preventative services - smoking cessation, reducing obesity and reducing alcohol consumption

•systematically detect disease early, through active case finding and promoting early presentation of symptoms; focusing on our major killers - cancer, heart disease, stroke, respiratory disease and liver disease

•ensure that prevention is systematically built into to key pathways

Goals and Targets

• Redesign of Health and Wellbeing / lifestyle services in 2014/15 to meet local need

• Implementation and evaluation of impact of AF work programme in all member practices

• 66% uptake of NHS Health Check Programme

Strategic Impact

• Reductions in the number of years of life lost from treatable conditions

• Reduction in preventable acute episodes

• Reduction in AF related stroke

Cross Cutting 2: Prevention

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5.2 Delivering a system focused on prevention

Preventative services will be most effective if we adopt an integrated approach to delivering

services that provide early help and support to avoid the progression of disease and

resulting demand. Investing in prevention now will avoid having to pay for more costly

treatment later on. As well, good health in itself will generate economic growth, such that,

in avoiding illness and injury, people have more opportunities in life to maximise their

educational, employment and human potentials.

Prevention is thought in many instances to be cost-effective. In some cases, prevention

might even be “cost-saving” to the health care system. However, whether a particular

intervention is cost-effective and/or cost-saving depends on key contextual variables

involving place and time and is not always simple.

All else being equal, health interventions that are cost-saving are clearly preferable. A

number of preventive health interventions offer particularly high economic value when seen

from the health service payers’ perspective, in that the value of health system resources

avoided through prevented illness or injury (and thus freed up for other use) exceeds the

value of resources required to implement the intervention. It is important to note that this

limited perspective considers only those direct costs associated with the delivery of health-

related services in relation to the prevention, diagnosis, and treatment of disease (e.g.,

community preventive health services, medications, ambulances, inpatient or outpatient

care, rehabilitation, etc). Excluded from consideration are the often substantial public and

private costs borne by individuals and institutions outside of the formal health sector.

Identifying benefits to the integrated health and care system is a preferable method of

supporting prioritisation for investment.

Health Inequalities in Manchester

Manchester residents have some of the poorest health in England and this has a significant

impact on their ability to live a long and enjoyable life, maintain employment and

participate in social activities. It also has a substantial impact on the economic and social

success of the city and on the demand for health and social care services.

Health inequalities are unjust differences in health, illness and life expectancy experienced

by people in different groups of society. In 2013, Public Health England analysed premature

deaths from the four most common causes – cancer, heart disease and stroke, lung disease

and liver disease. Manchester is ranked 150th out of 150 in terms of early death.

The pressures of an ageing population, increasing prevalence of heart disease, diabetes and

hypertension, prevalence of lifestyle risk factors and greater public expectations are all

threats to the financial stability and sustainability of the NHS. The NHS Mandate sets out the

93

strategic direction of the NHS. Tackling health inequalities and thereby preventing people

from dying prematurely is a key component of the mandate

South Manchester CCG cannot address all health inequalities in isolation. It is estimated that

only 15-20 per cent of inequalities in mortality are directly influenced by health

interventions. Population level shift in health inequality will only be achieved through

partnership working where the priorities of key organisations and stakeholders are aligned

to a common goal, local health inequalities are complex and there is no single, simple

solution. However, there is strong evidence of areas where CCGs can have a demonstrable

impact. Only a small percentage of the current NHS budget is spent on prevention. With

pressure on budgets and fundamental changes in NHS and public health structures, it is

essential that the CCG and partners work together at a strategic level to maximise impact.

We have a good understanding of the distribution and impact of premature mortality, ill

health and disability in south Manchester. Around 80 per cent of deaths from the major

diseases that contribute to low life expectancy and ill health are attributable to lifestyle risk

factors – alcohol, smoking, physical activity and diet.

Primary care data provides good information on the local prevalence of risk factors,

identifies where there is unexpected variation and provides priority areas for action.

Economic studies have identified public health interventions that are proven to be cost

effective and, in 30 cases were found to be cost saving. Investment in evidence-based

programmes that tackle key risk factors will be our focus for prioritisation.

Taking action on the five major killers (cancer, IHD, stroke, respiratory disease and liver disease) and mental health will bring benefits across the spectrum of ill-health. The actions we need to take to prevent premature mortality are the same actions we should

be taking to increase healthy life expectancy at all ages. The health challenges outlined

above are significant and it is clear within the first two years of our five year strategy there

has to be a focus on the key areas that we feel will have the biggest impact on our

population health. The impact of prevention as a cross cutting theme for us is measured in

the context premature death and disease.

There are proven internal and external inequalities in life expectancy and healthy life

expectancy in south Manchester. The CCG has a specific legal duty in relation to tackling

these health inequalities. It is clear that action is required at all levels to impact on

premature mortality and morbidity. Prevention is one of the “golden threads” that run

throughout our plans to successfully tackle inequalities in health outcomes. In addition to

the use of the CCG Outcomes Tool and Commissioning for Value packs to inform

commissioning, we aim to embed the principles set out within “Commissioning for

Prevention” into all of our commissioning and service redesigns.

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South Manchester CCG via its partnership in the development of the JSNA, bases its

priorities for action on clear analysis of epidemiology and outcomes. Via membership of the

Manchester Health and Wellbeing Board, we ensure that these priorities are shared with

key strategic partners.

The national measure of a CCG’s ability to prevent people from dying prematurely is the

indicator ‘Potential Years of Life Lost from causes considered amenable to health care’

(PYLL-AH). This indicator reviews deaths considered premature (generally under 75 years of

age) where the cause of death should be avoided through the delivery of timely and

effective healthcare.

In order to identify evidence-based prevention actions, Public Health conducted a health

needs assessment of PYLL-AH in south Manchester; reviewing the epidemiology and

highlighting areas where there is potential to improve performance in prevention. This

health needs assessment adds a layer of intelligence to that already identified within the

JSNA.

In 2012 it is estimated that in South Manchester CCG area there were 3531 potential years

of life lost to causes considered amenable to healthcare. Although our performance is

approximately in line with the performance for the whole of the Greater Manchester area,

when compared to CCGs with similar populations, over a four year period, we have a

statistically significant higher PYLL-AH.

The data also highlight gender inequality. During 2012 in South Manchester there was 2001

PYLL-AH for males, but only 1529 years for females. This gender inequality is replicated at

both Greater Manchester and national level.

Detailed analysis of the data suggests that the key disease areas where there is most

potential to improve health outcomes are; cardiovascular disease (CVD – particularly

ischemic heart disease and stroke), cancer and respiratory disease.

A review of current evidence and guidance has identified interventions which are most likely

to reduce the risk of developing conditions belonging to the disease groups identified above

and their corresponding preventable risk factors.

These key areas are:

Screening for preventable risk factors during routine assessments

Brief advice intervention; reviewing the training needs of primary care and

commissioned providers and developing a programme that covers a wide range

of lifestyle risk factors

Extended behaviour change intervention; integrating brief advice and extended

behaviour change interventions into clinical pathways

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Self-care; supporting the development of a self-care approach. As a minimum a

universal approach should cover; training and education for practitioners;

awareness raising; and streamlining of referral pathways.

Smoking cessation and harm limitation; incorporating the review of the

Manchester Health and Wellbeing Service and understanding how this can be

promoted and supported in primary care

Vaccination (particularly HPV and influenza); reviewing invitation and reminder

systems for seasonal influenza vaccination against processes developed for child

vaccination programmes

Access to specialist services

Maximising uptake of the NHS Health checks programme; including a survey of

primary care attitudes and experiences to understand how primary care can be

better engaged in delivering and following up health checks with their patient

populations

Addressing the wider determinants: Work as a Health Outcome There is a strong evidence base which tells us that people live longer, healthier lives when

they are in work. Being out of work is associated with higher rates of cardio-vascular disease

and overall mortality, smoking and alcohol consumption and significantly higher rates of

mental health disorders. A health and care system which incorporates a focus on moving

into, and remaining in work as a routine element of service delivery will achieve better

health outcomes for the Manchester population.

Manchester has an unemployment rate of 16.7 per cent, twice the national average, and the

majority of those of working age who claim out of work benefits do so as a consequence of

a health condition. In south Manchester, Brooklands, Sharston, Baguley and Woodhouse

Park the claimant rates are particularly high.

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The Health and Wellbeing Board has adopted work and health one of its eight strategic

priorities and we are working with our partners across the city to drive work and health

priorities forward relating to:

priority service redesigns,

primary and secondary care education programmes

increasing referrals to ‘Fit for Work’ Services

Developing our potential to offer employment and skills opportunities and increase social value as an employer and commissioner

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Vision

• Quality is at the heart of everything we do as a Clinical Commissioning Group (CCG). Strong clinical leadership and engagement is critical in improving quality and improving outcomes for patients. As a CCG we also recognise that we need to think, plan and act differently to improve quality.

Interventions

• Implementation of new quality strategy

• Promote the usage of NHS Change Model

• Development of CQUINs that help deliver CCG objectives

• Implement patient safety dashboards

• Partnership working with CQC, Monitor, TDA, Health Watch

Goals and Targets

• Quality Strategy embedded and delivered

• CQUINs managed effectively

• Improved reporting on patient safety and experience

Strategic Impact

• Improved level of patient experience

• Improved patient safety

• Increase in the number people supported to self-care

• fewer excess bed days

• A simplified and integrated care model between primary, community and secondary care

Cross Cutting 3: Quality

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5.3 Quality and Outcome focused, Patient Voice, CQUINS Improving quality and outcomes Quality is at the heart of everything we do as a Clinical Commissioning Group (CCG). It is the golden thread that runs through everything we do. We recognise that strong clinical leadership and engagement is critical in improving quality and improving outcomes for patients. As a CCG we also recognise that we need to think, plan and act differently to improve quality.

With reduced resources and unprecedented financial savings to be made, the CCG needs to

be more innovative utilising evidence based models to ensure sustained quality

improvements for the population it serves. We have adopted and embedded the principles

in the NHS Change Model to better support the achievement of high quality care for all, now

and for future generations.

The NHS Change Model

There have been numerous reports released in the last year some of which have shaken the

NHS to its core. Scrutiny of the quality of care for our patients has never been greater and

reports such as Winterbourne, Francis, Berwick and Keogh have highlighted failings in care

provided to our most vulnerable patients and failings in those responsible for the regulation

and commissioning of those providers. Although the reviews in the main have been focused

Cross Cutting 3: Quality

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on the acute providers the learning from these reviews are equally applicable to all NHS

funded services.

As a CCG we have developed and implemented action plans in response to these national

reviews of quality, however with the release of “Hard Truths: the journey to putting patients

first”, DH January 2014, a different approach is needed.

The findings from the national reviews have informed the development of our

organisational strategic aims and the work plans falling from these and they have changed

and strengthened the way we commission providers through all aspects of the

commissioning cycle.

To ensure that this continues we will be refreshing our quality strategy.

We are committed to quality and improving this for our citizens. We have an ambitious

quality strategy in place that has taken the first steps to address the issues and concerns

outlined in these national reports. This now needs to go further and encompass all the

learning from these national reviews, as outlined in “Hard Truths”, into one overarching

strategy for quality with a robust implementation plan behind this incorporating strong

metrics to enable us to monitor and measure success.

As part of this refreshed quality strategy we intend to:

Work with the local authority to develop a shared quality strategy, with shared values and shared aims. This would replace the CCG Quality Strategy

Further promote the use of the NHS Change Model and evidence based improvement tools within all our providers through NHS contract levers such as CQUINs and information requirements.

Further develop the quality standards in place presently with providers, such as exploring how to measure the culture of a provider in a tangible way and how to identify and assess effective leadership.

Develop and strengthen our provider quality dashboard, including data published by providers in relation to complaints, staffing, and safety.

Continue to develop quality dashboards for community providers and small providers.

Further develop commissioner walk-rounds in providers extending these further to small providers and community providers.

Build stronger relationships with the Care Quality Commission, Monitor, Trust Development Agency, HealthWatch and other partners who hold vital information about our providers in order to identify quality concerns earlier and work collaboratively to resolve these.

With the release of a lot more information in the public domain strengthen processes for collating and triangulating all available data to better identify quality concerns in a timely manner and enable clinical leads to take prompt action to address these.

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Patient safety We have an ambition in the current quality strategy in relation to the development of an early warning system. This objective outlines the approach that the CCG takes in relation to being able to understand and measure the harm that can occur in healthcare services. This involves the gathering of data from all available sources, analysis of this information to identify trends and themes through a CCG Quality Surveillance Group which results in actions for the CCG to take to inform, assure and improve quality and patient safety. This is represented pictorially below.

Quality Dashboards for CCG

Committees and Board

Queries to raise with providers that inform contract monitoring

meetings

Identification of trends across

specialities

Identification of issues that need

escalation

NPSAProvider

informationMortality indicators

CQCNational

audit

Complaints and PALS

MonitorInformation

from GP members

Serious incidents

National Inquiries

Serious case reviews

Information from PPAG

Information from

Healthwatch

Supported by data from the quality

and performance compendium Supported by data from datix

CCG Quality Surveillance

Group

The CCG Quality Surveillance Group has been developed across four CCGs (Central

Manchester CCG, South Manchester CCG, North Manchester CCG and Trafford CCG) and

attended by the Clinical Directors of Quality. The role of this group is to review this

information and identify any actions needed to improve quality. The group then determines

where and when this information needs to feed into the commissioning cycle. This area is

still in development in the CCG. The work in this year has focused mainly on the large acute

and community provider. Work is to continue to further roll out this approach to all

providers.

With the introduction of more real time data available in relation to quality such as

published complaints reports, information on safe staffing, and information published under

the transparency agenda this process will be developed further to ensure this information is

captured and fed into the early warning system process.

The CCG has also purchased and is rolling out a system to allow us to capture real time concerns about other providers as identified by our GP members, members of the CCG

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Patient and Public Advisory Groups and HealthWatch. The implementation of this system across all GP practices will allow a further level of detail in relation patient safety. Patient experience Measuring improvement in patient experience is a difficult task. Patient experience is subjective and involves multiple factors. The development of the Friends and Family Test has helped us gain a tangible feel for how patients experience care in the acute sector. The real benefit of this has been the additional questions providers have included in this test allowing them to identify the areas of the patient experience that were not optimal and more importantly put plans in place to address these. The information from the Friends and Family Test gathered this year gives us an indication of patient experience in the acute provider. We will use this as a baseline to measure, monitor and improve patient experience in this setting. This measure gives us the ability to measure improvement in patient experience but will not be looked at in isolation. All providers are required to work to address patient concerns and complaints and improve patient experience. To fully understand and improve patient experience all of this data needs to be looked at and analysed. This will be done as outlined in the CCG early warning system and Quality Surveillance Group and actions identified within this forum, these actions will then be scrutinised and agreed through the CCG Quality Committee and taken forward with our providers from there. All providers are required to gather data about their patients in relation to the protected characteristics. As a CCG we have requested that this data be included in any report about patient safety, complaints or patient experience. This needs to be strengthened moving forward but is hampered by national electronic systems for capturing patient data which does not allow for data collection against all the protected characteristics. Providers have plans in place to improve the collection of this data against the nine protected characteristics and this will be monitored and built on. This information will be analysed by the CCG Quality Surveillance Group and actions identified within this forum, these actions will then be scrutinised and agreed through the CCG Quality Committee and taken forward with our providers from there. The Provider Quality Dashboard that the CCG currently has in place is reported on quarterly at the CCG Board. Included on this dashboard are the results from the Friends and Family Test and narrative in relation to what the provider has done based on the feedback from patients. Performance against this will continue to be monitored and reported against. These papers are in the public domain. On the 28 January 2014 South Manchester Patient and Public Advisory Group met to discuss the systems plans for 2014-19. The members of the group have provided detailed feedback and suggestions about the priorities identified. The PPAG members in south Manchester are an invaluable advisory group, and have been proactively involved in a range of activities during 2013/14. We are fully committed to having our patient’s voice at the centre of everything we do in South Manchester, and will continue to work with the PPAG as we implement our challenging and ambitious plans.

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Compassion in practice South Manchester CCG has quality standards in all our provider contracts. These cover areas such as safe staffing, culture, leadership, mortality etc. These are monitored on a quarterly basis with the providers and evidence on compliance against these is gathered in various ways such as the CCGs attendance at internal governance meetings, commissioner led walk rounds and formal reports. With the release of every new national review on quality or national strategy relating to quality the CCG requests providers to share their plan/ strategy to address these. This has included this year how trusts are going to implement Compassion in Practice. The CCG will be monitoring the implementation of Compassion in Practice in the large acute and community sector through the quarterly quality assurance monitoring meetings led by the CCG Clinical Director for Quality. This area needs to be further strengthened in relation to our smaller providers and will form part of the quality monitoring cycle. Staff satisfaction We are able to benchmark staff satisfaction in some areas currently through the NHS staff survey. The weakness in this is that this is an annual survey, there is a significant lapse in relation to the time the survey is done and when the information is released and it does not cover all of our providers. We have and will continue to request assurance from providers in relation what steps they have put in place to address concerns identified through this survey. Through the Friends and Family CQUIN in 2014/15 a Staff Friends and Family Test has been developed and will be implemented in the next year across acute, community, care homes, ambulance and mental health providers. This will allow the CCG to truly benchmark staff satisfaction in a timely manner and identify what providers are doing to improve this. The score will be indicative of how staff are feeling, however the narrative will provide richer data to identify why and what factors have affected this. As a CCG we will not look at this data in isolation but will also look at other available data sources such as published staffing levels within the provider, sickness rates, deanery reports and whistleblowing alerts. This will allow us to look in more detail at the factors affecting staff satisfaction and work with our providers to address these. With the publication of staffing levels by each provider, the implementation by providers of the Staff Friends and Family Test and triangulating all other relevant sources of information we will have the metrics to measure staff experience and be able to identify the factors that affect these. This information will be analysed by the CCG Quality Surveillance Group and actions identified within this forum, these actions will then be scrutinised and agreed through the CCG Quality Committee and taken forward with our providers from there.

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Improving Quality for our Frail Older Adults and Adults with Dementia For South Manchester this will mean working towards shifting the balance between hospital and community care and rethinking how and where care is delivered whilst addressing quality and continuity of care across all the different sectors. We will ensure that any large scale changes reflect the need to provide integrated, equitable, accessible and financially sustainable pathways of care for frail older people and people with dementia. To achieve this we will ensure systems are integrated between primary and secondary care, mental health and social care and that resources are appropriately targeted towards the specific needs of the frail older person and the person with dementia. We will continue to work within the agreed city wide outcomes measurement (Living Longer Living Better Framework for Integrated Care) recognising the role we have in ensuring equitable provision for all older people in Manchester. This will include:

Quality, safety and patient/user experience

Cost, volume and flow of services

Outcomes, clinical effectiveness/performance

System wide operational efficiency including organisational and human resource effectiveness

The diagram below provides a visual illustration of this approach:

Improving Quality in Primary Care There is wide variation in the quality of care across General Practice and outcomes for patients in south Manchester are among some of the poorest in the country. The CCG will address this variation and enable easy access to high quality responsive primary care services as the first port of call for patients, providing a consistent offer irrespective of where they are registered and supporting people to stay healthy.

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Over the next two years we will focus primarily on reducing this variation for the frail / elderly, adults with long term conditions and those nearing the end of life. We will measure quality of primary care through a range of indicators including:

Quality and Outcomes Framework

National patient surveys and local patient experience surveys

NHS England GP High Level Indicators and Outcomes Standards

Public Health Observatory practice profiles

Quality and performance scorecards

Evidence Base

Benchmarking We will commission extended services for all patients in south Manchester and develop clear quality and performance indicators to measure and monitor quality of these services. Previous arrangements for contracting extended services will be replaced with the standard NHS contract framework and a clear process for monitoring performance

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Vision

• Our organisational development approach to shaping and delivering our strategy is essential for our success. It is predicated on embracing and managing change in response to our strategic priorities. We are building on the significant progress made to date and strengthening the capacity and capability of our workforce, at the same time enhancing our culture and capabilities.

Interventions

• Implementation of our organisation development plan

• Delivery of our community of connected individuals

• 360 Stakeholder Suvery and ongoing engagement

• Leadership development programme

• Update our Constitution

Goals and Targets

• Self-care and management of long term conditions

• Promotion of health and wellbeing

• Person centered care co-ordination

• Outcome based care planning

• Working with individuals and their families

• Working across different organisational boundaries

Strategic Impact

• Improved level of patient experience

• Improved patient safety

• Improved level of stakeholder engagement

• Increase in the number people supported to self-care

• A simplified and integrated care model between primary, community and secondary care

Cross Cutting 4: Organisational Development

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5.4 Organisational Development & Communities Our Organisational Development approach to shaping and delivering our strategy is essential for our success. It is predicated on embracing and managing change in response to our strategic priorities. We are building on the significant progress made to date and strengthening the capacity and capability of our workforce, at the same time enhancing our culture and capabilities. Our approach is one of inclusivity, and is a journey of development and involvement of partners, patients, carers and all practices in south Manchester. We value the skills knowledge and expertise of our entire workforce; they are our enablers to support the changes and we aspire to:

Align local activities with our Strategic Plan and health system using our culture and values to support this

Review and re-shape structures and business processes to support integrated care, the CCG and commissioning partnerships

Capitalise on the commitment, skills and capabilities of our clinical and managerial leaders and enhance these to deliver our Strategic Plan

Fulfil our role as local leaders in respect of talent management, workforce planning and workforce development

Positive patient experience We will achieve this by:

Developing the skills of our GPs, practice nurses, support staff

Clinical leadership and succession planning

Board development reflecting our constitution

Developing our wider primary care teams and skill mix across a variety of disciplines

Delivering our equality and diversity plans Our strategic plan and ultimately the delivery of our vision will be supported by a robust structure that respects all parties in the delivery of health care to our patients. Whilst we must look for opportunities we will be mindful of sharing risk, we must support and not destabilise but we must be innovative and efficient.

System Change The concept and development of an Integrated Care approach has been driven as a response by the collective providers and commissioners across health and social care in Manchester. The partner organisations are testing and developing new delivery models of community based care in Manchester as part of Living Longer Living Better; the citywide programme for Integrated Care.

The current delivery plans across the three localities are supporting the agreed population groups that each locality has prioritised for implementation during 2014/15:

Frail Older Adults/Adults with Dementia

Adults End of Life Care.

Adults with a long term condition

Adults with complex needs

Cross Cutting 4: Organisational Development

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One of the primary purposes of this approach is to assist in the empowerment of our workforce to dismantle organisational barriers to change and integration. Delivering an OD plan in a staged co-ordination across the conurbation will assist and drive this objective. Our Objectives The aim of the organisational plan is to effect behaviour changes associated with:

Self-care and management of long term conditions

Promotion of health and wellbeing

Person centered care co-ordination

Outcome based care planning

Working with individuals and their families

Working across different organisational boundaries

Connecting systems and people with up to date information and supporting co-ordinated care for people to enable them to live longer and live better

Creating the necessary changes within the wider workforce that includes individuals, their carers, families and the community as a whole, to focus the population on how its health is improved

In order to execute the plan over a three year cycle, the workforce will be exposed to development in the six domains. Their level of knowledge will be assessed on a hexagonal plot within these domains and the delivery of the organisational plan will be in part judged on the individual development of these domains within the workforce.

What will success look like? “Our Community of Connected Individuals”

A community of individuals (including individuals, their carers, families, and voluntary sector organisation) supported and developed through the organisational plan. (Known as the community of connected individuals (CCI)

A workforce that is sufficiently empowered to understand and promote the principles and behaviours associated with the delivery of community based care delivery

A workforce trained to have sufficient flexibility, to work across traditional boundaries, becoming more efficient and effective in the delivery of community based care

Patient identification 1. 2. Models of Care

3. Workforce skills

4. Connecting systems

Aligning resources 6.

Social Change 5.

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A workforce motivated to build and generate “bottom up” developments for the delivery of efficient and effective community based care

A workforce empowering and developing the range of “change champions” that already exist within our communities and our collective workforce

The organisational development plan will include supporting behaviour changes through a variety of methods and approaches within a mixed delivery educational delivery model including:

Working with communities and voluntary sector organisation delivering community based programs for individuals, their carers and families

On line modules developed by the stakeholders to address each of the 6 domains

Peer led problem based learning groups

Lectures and face to face courses

Patient identification

The CCI knowing the Frail Older Adults/Adults with Dementia population in Manchester. This will lead to a genuinely shared care approach to care delivery

Enabling the CCI to promote and disseminate the use of the social capture of frailty tools and applications

Educating the CCI about the relevance and data collection issues surrounding risk stratification and frailty scoring

Models of care

The new delivery models (NDMs) will initially co-exist with multiple care pathways and vertical services delivered by our local community of providers. These services over time will be fully co-ordinated and delivering model/s of care that support this population group

This can most effectively be done by developing programs for the staff in leadership, relationship management, process analysis and other key areas of personal development

It is only by facilitating the personal development of the workforce that sustainable integration and development of services will be effected

Skilling the workforce to deliver co-ordinated care

Cascading of end of life delivery skills from specialist palliative care nursing teams to more generalist Neighbourhood Teams (Enhanced)

Cascading of pain management delivery skills from specialist chronic pain teams to more generalist Neighbourhood Teams (Enhanced)

Training voluntary sector and volunteers to visit isolated elderly and assist with bereavement planning and sitter services

Training healthcare assistants to run frail elderly exercise classes.

Promoting improved dialogue and effective care planning between secondary care teams and Neighbourhood Teams (Enhanced)

Connecting Systems

Up skilling the workforce to use mobile devices and make maximal use of new IT platforms

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Empowering the workforce to address the failures of IT implementation and drive better implementation of IT solutions

Resource utilisation

Raising Awareness of the CCI about what is available

Empowering the CCI to expect the most effective care and to make efficient use of the resources provided

Encouraging the CCI to hold all stakeholders to account for the services they are meant to provide

Social change

The clear implication of shifting resource into the community is that the CCI needs to respond to this opportunity and challenge by supporting the resources directed towards them, not squandering them and using new resources appropriately

Examples of this will include:

Using existing community assets, community /social groups, churches, mosques, synagogues and other religious communities

Decreased use of Accident and Emergency as a first stop for healthcare advice

These changes will be the hardest to achieve and require societal embracement of the LLLB plans. This will only be achieved slowly through public engagement and confidence once local services developed by local delivery of the LLLB plan are sustained, trusted and perceive to be effective

Interventions:

Equality, Diversity, and Human Rights As a public sector body, the CCG has a statutory requirement to meet the legal duties set out in the Equality Act 2010. The specific duty requires the CCG to:

Publish information on an annual basis to prove its compliance with the general equality duty

Determine and publish Equality Objectives every four years, with annual updates on progress towards achieving them

Our Equality, Diversity and Human Rights Strategy aims to:

Eliminate unlawful discrimination in all our functions as a Commissioner and employer

Reduce inequalities in health amongst different groups of people living in the city

Develop a holistic awareness and understanding of communities and their health needs

Commission services from providers who are able to responsive to the diverse needs of individuals and their families

Promote equality of opportunity and inclusion so that our staff and patients can achieve their potential and have the best life chances possible

Become a strong community leader, championing equality in all aspects of our work with other local partner agencies

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As the local lead health commissioners across Manchester, we have a duty to ensure that all of our local healthcare service providers are meeting these statutory duties. As well as regular monitoring of performance, patient experience and service access, we will work with our service providers to analyse their annual publications and progress on equality objectives. South Manchester has used the Equality Delivery System (EDS) to assess their performance in responding to and meeting the equalities duties. This is an annual audit, which is assessed jointly with local communities, and has encouraged the active engagement of local people and communities, local voluntary and community sectors, and local NHS workforces in the review of services and workforce practices. The second stage, EDS2, will be implemented in 2014/15 and is a refreshed and streamlined EDS which focusses on genuine local engagement with patients, the public and other local stakeholders.

Inclusive Leadership The ultimate purpose of leadership in the NHS is to focus on the patient, carers, families and other service users. The Francis report called for a whole service, patient centred focus and a re-emphasis on what’s important, including the following themes:

Commitment to common values throughout the system by all within it

Openness, transparency and candour in all the system’s business

Strong leadership in professional disciplines

Empowering and engaging staff Our challenge is to ensure these themes (and others) are embedded and embodied in practices and behaviours, within the complexity and diversity of organisational cultures and realities. Developing and understanding of and competency in inclusive leadership is one means of achieving this. We will strive to support our leaders to create an environment where everyone is able to give their best, for the best of the CCG Motivating the Workforce

Staff survey and 360 stakeholder surveys, offering the opportunity for feedback

Development ‘away’ days for as part of culture continuous improvement

Succession planning and talent management for all level

Succession planning amongst primary care

Development of the Workforce - Skills The CCG aims to support a culture of life-long learning for our entire workforce. Individual personal development plans resulting from annual appraisals will identify any gaps in current knowledge as well as the skills and competencies required to fulfil emerging roles in the organisation. A training and development plan, refreshed annually, will combine individual personal development with those that will support the CCG to deliver its organisational responsibilities. Leadership Development The CCG will use bespoke frameworks to develop its leadership competencies at all levels within the organisation, with the aim of:

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Assessing the current behaviours and practice of individuals and immediate teams, building on current strengths and establishing support and development programmes that will enable the workforce to see where their roles, and responsibilities to achieve the wider CCG objectives

Strengthening the relationships between clinical, non-clinical and managerial staff across the CCG and practice teams

Develop customer/client relationships

Understanding and building partnerships across health and social, that will drive forward the integration agenda in South Manchester

Constitution The NHS is founded on a common set of principles and values that bind together the communities and people it serves patients and public, and the staff who work for it. The NHS Constitution establishes the principles and values of the NHS in England. It sets out rights to which patients, public and staff are entitled, and pledges which the NHS is committed to achieve, together with responsibilities, which the public, patients and staff owe to one another to ensure that the NHS operates fairly and effectively. South Manchester CCG is committed to serving its population and has full sign up to its constitution from member practices. Our constitution describes how the CCG will operate and ensure accountability to patients and the public, member practices and the NHS Commissioning Governing body and other accountable organisations. It has been refreshed since initial publication in April 2013 and clearly set out the functions and duties of the CCG.

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Vision

• Improve the delivery of those services commissioned City-Wide and through specialised commissioning

Interventions

• Delivery of NHS Continuing Healthcare and Funded Nursing Care

• Personal Budget Pilot / EOLC Care Pathway fast track protocol

• Development of integrated discharge pathway

• Implementation of the Early Years New Delivery Model

• Delivery of Mental Health Improvement Programme

Goals and Targets

• Self-care and management of long term conditions

• Improved mental health care

• Increased numbers of residents using personal health budgets

• Working with individuals and their families

• Strengthen safeguarding procedures

Strategic Impact

• Improved level of patient experience

• Improved patient safety

• Improved mental health care

• Increase in the number people supported to self-care

• A simplified and integrated care model between primary, community and secondary care

Cross Cutting 5: Collaborative Commissioning

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5.5 Collaborative Commissioning Collaborative Commissioning Arrangements South Manchester CCG has contributed to developing the NHS Greater Manchester Integrated Plan and remains committed to collaborative commissioning with colleagues across Greater Manchester moving forward. This is evident in the reform of services under development through the Healthier Together work programme. The three Manchester CCG’s have retained a working relationship to manage the services commissioned on a city-wide footprint, which include: Mental health, Child and Adolescent Mental health Services, Learning Disabilities, Voluntary Sector, Children’s, Maternity and Neonatal, Specialist, Cancer, End of Life Care, Carers, Continuing Healthcare. The following outlines our priorities in relation to these services.

NHS Continuing Healthcare (CHC) and NHS Funded Nursing Care (FNC) NHS Continuing Healthcare (NHS CHC) is the name given to a package of care, which is arranged and funded solely by the NHS for individuals outside of hospital who have on-going healthcare needs. To qualify for NHS CHC, an individual must have a ‘primary health need’ which is assessed using the National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care (DH Dec 2012). The National Framework for NHS CHC and NHS FNC (DH December 2012) is a major policy driver and a key CCG priority for delivering a quality health service for Manchester people who have a primary health care need and FNC for people requiring access to a registered nurse on a 24/7 hour basis. The delivery of this nursing care is provided within a registered care home with nursing. Implementation of the National Framework for NHS CHC and NHS FNC (DH December 2012) ensures;

Quality - person-centred care plans assessed based on need and monitored on outcomes

Patient Experience - patients, carers and families contributing to the assessment process and outcomes identified, and

Best Value - patient care is provided in an appropriate setting of choice, within a reasonable offer of care, and is provided by an experienced and expert workforce

We are committed to improving health services for patients eligible for CHC and FNC and forms an integral part of Manchester’s strategy for the delivery of integrated care and shifting care from a hospital to a community setting ‘Living Longer Living Better’ (LLLB). The delivery of the National Framework for NHS CHC and NHS FNC will support a number of the care models described within ‘LLLB’ and are key enablers to delivery model implementation working in partnership with Manchester City Council and other key strategic partners. NHS CHC and NHS FNC services in Manchester have been subject to a high level external review over the last 2 years to access both the internal and external processes. External audit findings have strengthened the decision to commission an in-depth internal review of the NHS CHC and FNC process to ensure the CCG and NHS England of compliance with the

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National Framework. Audit findings have and will continue to inform the basis of the work plan in terms of key work streams and future commissioning intentions ensuring continued improving in the commissioning of NHS CHC and FNC services.

Personal Health Budgets (PHBs) and Personalisation (person-centred care) Manchester was a successful PHB pilot site and contributed to the national evaluation published in November 2012. The national evaluation found that PHBs improved people’s quality of life and this was reflected in the local findings in Manchester. As a result of the national findings the Government announced that from April 2014 ‘all patients (adults and children) eligible for NHS CHC would have the right to ask for a PHB’, this was the start of the wider roll out across clinical areas especially mental health, long term conditions and children. Legislation was passed on the 1st August 2013 that gave the NHS powers to make direct payments for healthcare where deemed appropriate. Manchester has delivered over 100 PHBs to individuals eligible for NHS CHC and a PHB is now delivered as part of the core offer provided within service delivery for NHS CHC. Implementation of PHBs has resulted in the requirement to challenge existing policies and procedures and develop new and robust policies and procedures to ensure clinical and financial governance and accountability working with Manchester City Council and other key stakeholders allowing for a standard approach for individuals and families who receive integrated budgets. Funded nursing care teams, within the three acute hospitals across Manchester are now offering PHBs to patients as part of the standard offer. Everyone who is eligible for NHS CHC will be made aware of their right to a PHB as first offer and offered a PHB and personalised care plan that reflects their preferences and agreed decisions. The population groups will include;

All people with complex care needs

Mental health needs CHC

Learning Disabilities

Chronic disease pathways

Everyone should have the right to tell their story once rather than facing repetition, duplication and confusion identifying and tackling issues at an earlier stage before they escalate to more costly crisis services.

In addition to adults, children also have the right to ask for a PHB as of the 1st April 2014. Manchester CCGs have already been piloting PHBs with children and so far, 6 children with a primary healthcare need are receiving a PHB. These packages are being delivered as an integrated budget with Manchester City Council via a single health, social care and education care plan.

The PHB work plan is also committed to supporting the development of a number of other service areas and innovations required for the successful implementation and integration of PHB. These include;

Peer network support

Brokerage

Training and development (frontline clinical staff)

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Leadership and learning across health, social care, education and other key stakeholders

Market management to include quality and availability of care provision, availability of experienced personal assistants to support people with complex health needs and promoting non-traditional models of service delivery

Finance sustainability requiring measuring cost and outcomes will be a key priority associated with obtaining savings from patient’s original personal health budgets at the budget saving stage

End of Life (EoL) Care Pathway Development Pathway development and implementation to enable early identification and effective communication of entry to the end of life phase to enable the following;

All patients who are identified as being eligible for the NHS CHC Fast Track Protocol will discharge within 24 hours of fast track tool being applied

Effective management of health and social care needs: Completion of a comprehensive single multi-agency plan that can be delivered upon 24/7 365 days a year with the flexibility to meet changing needs

Effective management of mental health, physical health and social care needs: All patients with mental health, depression and learning disability should have equity of outcomes for their physical health at the end of their life

A confident and well skilled work force and supported carers to deliver self-care

Registered Nursing and Care Homes: All staff to receive training to enable them to engage sensitively, respectfully and creatively with dying residents. Also, to ensure supportive relationships between staff and relatives help to ensure a “civilised death”

Carers’ wellbeing is maintained during and after the end of life of the person: Care management, practical and bereavement support to be made available to:

Child

Family / Carer

Siblings

Carer experience and ‘bereaved carers view on the quality of care in the last 12 months of life

Patient experience: Independence, comfort and wellbeing optimised during the end of life period adhering to the patient/family’s wishes. Patient experience of care planning and pain management

NHS Continuing Healthcare (NHS CHC) Redress and Restitution Claims The responsibilities for CCGs are set out in the NHS Continuing Healthcare (Responsibilities) Directions 2007 and 2009 and previously in the Continuing Care Directions 2004. The Directions stipulate that CCGs have a duty to take reasonable steps to ensure that an assessment of eligibility for NHS CHC is carried out in all cases where it appears to the NHS that there may be a need for such care.

The CCGs will deliver the responsibilities of the Directions 2007 and 2009 and has implemented the NHS Continuing Healthcare Redress and Restitutions Claims Process for dealing with requests for legacy claims and new and future claims.

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Additional requirements of the process include the facilitation of The Special Review Panel (SPR) process should the applicant disagree with the decision made by the CCG. If the CCG has exhausted attempts at local resolution, the applicant is advised that they can request a review by an IRP by contacting NHS England (NHSE). The requirement for NHSE to establish independent review procedures is laid down in the NHS Continuing Healthcare (Responsibilities) Directions 2009. The procedures are in place so that individual patients and/or their nominated representatives can challenge a CCG’s decision about their eligibility for NHS Continuing Healthcare. The team will be required to provide and facilitate any IRP commissioned by NHS England in accordance with Directors 2009.

The targets for the CCGs are to ensure that where the CCG has failed to assess the individual and where evidence of a Primary health care need can be demonstrated, that individual is restored to the financial position they would have been had CHC funding been awarded at the appropriate time.

The sheer volume of claims the CCG has received has meant significant resources have had to be applied to support the process.

The timescale for the complete resolution of all claims is difficult to give an accurate date for. There is a general consensus across CCGs in the North West of England that the claims are going to take many years to conclude. Estimates vary from 5-15 years. Primarily because the processes does not end with the CCG’s decision but appeal mechanisms to NHS England and from NHS England to the Parliamentary and Health Service Ombudsman (PHSO) after that.

Joint Working Agreement (JWA) CHC assessments in a hospital environment or immediately following the sub-acute phase of an illness can distort the outcome and increase the costs of continuing health care provision. Screening and application of the Decision Support Tool in an acute environment could also lead to delays in discharge.

NHS North, Central and South Manchester CCGs, Manchester City Council and the three Manchester Acute Trusts agreed to operate a joint working agreement wherein individuals with an assessed need are discharged to a nursing home for a maximum of period of eight weeks. The first four weeks are provided for recuperation following which the CHC checklist and if pertinent the Decision Support Tool are applied.

This agreement has been in operation since April 2012 and has recently been subjected (in North Manchester) to a clinical evaluation undertaken by the Greater Manchester Commissioning Support Unit Utilisation Management Team. The outcome of this review together with a financial evaluation will be used to scope the future development of the scheme.

Future Commissioning Intentions 2014-/16

Early identification and effective communication of entry to the end of life phase with effective management of health and social care needs.

Registered Care Home and Nursing Strategy development and implementation

Development of integrated discharge pathway (JWA , I.C. and Reablement provision)

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Continuing Healthcare personalisation. PHB roll out.

Development of nursing homes and homecare frameworks

Review of community equipment services

Improving Dementia care in nursing homes Children: The Manchester Early Years New Delivery Model (EYNDM) We continue to be committed to improving health, social care and educational outcomes for children and families and the Manchester Early Years New Delivery Model (EYNDM) provides integrated service delivery between Health and Local Authority services for 0-4 year olds.

The EYNDM forms an integral part of Manchester’s strategy ‘Living Longer Living Better’ (LLLB) and is based on an integrated care pathway with five key stages (pre-birth, new birth visit and follow-up, three months, nine month health and development review and the two year health and development review).

In delivering the integrated service, Health Visitors and Early Years Outreach Workers will work together to ensure that children and families are engaged, that assessments take place at the key points and that when children and families are identified for further support, they receive the right evidence based interventions which are delivered as part of an integrated package of public services, that are properly sequenced and bespoke to the needs of the family as a whole. A catalogue of evidence based interventions has been developed for use in Manchester for targeted support for children and families.

A set of agreed outcome measures and performance indicators have been agreed and these include: number of referrals to speech and language therapy, type of referral, numbers referred to parenting courses/completing parenting courses and numbers referred to early years outreach services. Qualitative measures are also being collected including life story examples and the views of larger number of parents and key stakeholders on the new model.

Health colleagues have also identified three areas of the city where outcomes from implementing the new delivery model can be compared to outcomes from the business as usual model. This information will inform commissioning decisions as the model is fully rolled out as well as testing out some of the assumptions behind the model. Longer term outcomes and benefits from the approach are linked to improving outcomes at the end of the Early Years Foundation Stage, reducing neglect and improving speech, language and communication. Specific measures are developed for Manchester which are linked to, for example, improving the percentage of children that achieve a secure level of development in the Early Years Foundation Stage Assessment. There is a requirement to measure the long term impact the model is having on the overall goal of improving school readiness and the benefits provided to services involved. The high level metric is to increase the number of children achieving a secure level of development at the end of the Early Years Foundation Stage 1.

Benefits arising from the collection and analysis of the data will be reviewed in line with the Greater Manchester Early Years Public Sector Reform to ensure the work in Manchester informs the work taking place across Greater Manchester. Agreement has been reach on

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the outcome indicators to be measured and the data to be collected from the early implementation sites. In addition, Manchester has started to track children eligible for targeted support from October 2013 and is monitoring their progress through checks at 36 months and 48 months in the early implementation sites.

Personal Health Budgets (PHBs) NHS North, Central and South Manchester CCGs deliver PHBs to children with a primary healthcare need as a core offer within service delivery of NHS Implementation of the National Framework for NHS CHC (DH December 2012). Manchester currently has six children in receipt of a PHB via a direct payment. These children and families use their PHB to deliver and meet a range of support needs including overnight care, additional respite, specialist non-standard equipment (bespoke) and extra allied health professional therapy. A case study example of a PHB working well for a family is as follows;

PHB: Case Study A three year old girl with complex needs, including uncontrolled seizures, received support from her family and the school, however the family found it increasingly difficult to balance home, work and family life as her seizures became worse. The option of a PHB was discussed with the family and following discussion, the family accepted. They considered the benefits of a PHB to provide more flexibility with regards to the type of support they could access and also the timeliness of the support, challenging previous traditional models of delivering care. Mum uses the direct payment option to engage the services of a Personal Assistant at time when the care is needed most. Mum also uses part of the budget to provide additional therapy sessions and sensory equipment in the home.

PHB: Transition Enabling children in Manchester to obtain a PHB has supported a number of young people who have transferred from children’s services to adult services. Most of the young people transitioning from children’s NHS CHC to adult NHS CHC choose a PHB as opposed to a traditional package of care offer. The young people find the flexibility and choice available to them far better via a PHB as they continue towards their journey to independence and successfully move to independent living with the support of their individually chosen care team.

Special Education Needs The Children and Families Bill and associated regulations take forward wide-ranging reform of the system for identifying, assessing and supporting children and young people with special educational needs and their families. Those reforms make provision for:

Children and young people to be at the heart of the system

Close cooperation between all the services that support children and their families through the joint planning and commissioning of services

Early identification of children and young people with Special Educational Needs (SEN)

A clear and easy to understand ‘local offer’ of education, health and social care services to support children and young people with SEN and their families

For children and young people with more complex needs, a coordinated assessment of needs and a new 0 to 25 Education, Health and Care plan (EHC

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plan), for the first time giving new rights and protections to 16-25 year olds in further education and training comparable to those in school

A clear focus on outcomes for children and young people with Education, Health and Care Plans, anticipating the education, health and care support they will need and planning for a clear pathway through education into adulthood, including finding paid employment, living independently and participating in their community

Increased choice, opportunity and control for parents and young people including a greater range of schools and colleges for which they can express a preference and the offer of a personal budget for those with an EHC plan

The Special Educational Needs and disability reforms (SEND pathfinder) are currently being piloted throughout the UK, with each region having its own pathfinder champion. Within the northwest this is the Greater Manchester consortium of Trafford, Wigan and Manchester.

The 0– 5 coordinated assessment process and Education, Health and Care plan (EHC) plan are core components of the SEND reforms underpinning the vision that all children and young people should receive the support and opportunities they need to enable them to achieve at school and college and to make a successful transition to adulthood. They should not be viewed in isolation but within the wider landscape of proposed changes including the local offer, the option of a personal budget for those with an EHC plan, improved multi-agency working and joint commissioning. The draft regulations and Code of Practice (CoP) have recently been issued and gained royal accent and subject to Parliamentary approval of provisions in the Children and Families Bill, all areas will need to implement the SEND reforms from September 2014.

All work in relation to the SEND agenda is overseen by the integrated SEN reform programme board which has representatives from health education and social care. A programme of work is currently underway across the city concentrating on the following strategic areas of the bill:

Local offer

Early intervention

Transition to Education, Health and care plans

Personal budgets and SEN’D

Identifying CYP with SEN’D

Joint commissioning of services

Meeting the healthcare needs of CYP with identified health needs

Children and Adults Mental Health Service The Executive Nurse and Director of City Wide Commissioning, Quality and Safeguarding at NHS North, Central and South Manchester CCGs and the Director of Children and Commissioned Services, Manchester City Council gave a mandate to undertake a review of Child and Adolescent Mental Health services (CAHMS) in Manchester. Importantly, the timing of the review is also linked to the recent Mental Health Independent Report commissioned by Manchester CCGs and Manchester City Council which looked at the provision of mental health services across Manchester.

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The findings of the Independent Mental Health report identified issues for children transitioning from CAMHS to adult services and out of hours arrangements for CAMHS provision. Given the findings of the Independent report, the CAMHS commissioning review provides a timely opportunity to review and “sense check” existing commissioning arrangements for CAMHS and provide assurance that these services are delivered safely and are fit for purpose while being strategically aligned to achieving the outcomes of the Mental Health Improvement Programme and aligned to the delivery of the Manchester Strategy ‘Living Longer Living Better’. The aim of the CAMHS commissioning review is to implement the nine recommendations identified which will aim to:

1. Increase the opportunity to identify mental health distress and mental ill health in both early years and children of school age

2. Improve the education and awareness rising of Children and Adolescent mental health conditions in professionals who operate within public agencies across Tier 1 services

3. Support mainstream schools to deliver a more robust universal offer by reviewing and redirecting existing resources

4. Improve partnership working across multiple agencies 5. Improve navigation and access to information from CAMHS services. 6. Improve / level consistency in diagnosis 7. Explore the opportunities for a single point of access to CAMHS services and to

defragment existing provision 8. Improve transition arrangements for children transitioning from children’s to Adults

mental health services as part of the Mental Health Improvement Programme 9. Integrate existing work (Early Years New Delivery Model) to support the broader

commissioning intentions

Dementia

Dementia affects 1 per cent of people aged 65-69 and 16 per cent of people over 80. Approximately 3,300 people in Manchester may have dementia at any one time; of these, the majority are aged over 65 years, approximately with 90-100 aged below 65 years.

The Dementia Care Pathway specification is relevant for the treatment and care of people with Alzheimer’s disease, dementia with Lewy bodies, fronto-temporal dementia, vascular dementia, and mixed dementias, based on NICE guideline 42.

Dementia is a progressive illness from which ‘recovery’ is not expected. Health and social care expected outcomes include:

Maintenance of the best possible quality of a patient’s life

Maintenance of independence

Provision of the best possible quality of support to informal carers, during the processes of treatment and care

Provision of the best quality formal care either in the home, wherever possible, or in the care home setting

Reduced need for hospital and/or residential care

Improved mortality and morbidity

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The services provided under the Dementia Care Pathway specification include:

Community-based assessment, treatment and advice, including crisis support

Specialist inpatient-based assessment and treatment, where required

In-reach advice to people with dementia living in nursing homes or residential care within the city of Manchester

Liaison services within acute hospitals within the city of Manchester

Memory clinics

Community-based multidisciplinary psychological and psychosocial interventions

Advice to GPs regarding prescribing

Family interventions

Assessment and support to promote independent living

Psycho-education

Monitoring of relevant physical health risks

Exceptionally, inpatient admission if the individual needs a place of safety

In-reach services to nursing and residential homes in the city of Manchester

Liaison services to acute hospitals within the city of Manchester

People with dementia and their carers do not always receive the health and social care interventions required to support them to live in the community. Often care provided fails to recognise community support as a resource to facilitate resilience and promote independence. Poor quality community services increase the challenges of living with dementia and dependence on hospital and residential care.

The integration of health and social care is provides an opportunity to create a structured,

coordinated and strategic approach to community support for people with dementia and

their carers to enable the person with dementia to remain in the community for as long as

possible.

Mental Health

Mental Health is one of the CCG’s key strategic priorities and improving the health and wellbeing of Manchester people who suffer from mental health conditions is an important component of the five year Strategic Plan.

Mental Health services in Manchester have been subject to a number of high level external and independent reviews and reports over the last ten years and commissioners have concluded the current mental health system is not fit for purpose nor is it in line with current expectations of delivery and improvement. The current system is fragmented, complex and difficult for users and professionals to navigate. Additionally, waiting lists for some services are far too long.

Our main service provider, Manchester Mental Health and Social Care Trust (MMHSCT) is currently facing a number of challenges which we are closely monitoring. These include:

Demand management in urgent and acute care pathways

Excessive use of independent sector beds outside of Greater Manchester

Levels and nature of serious untoward incidents

Embedding learning from incidents

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Assurance of safeguarding processes

Staff engagement issues

Potential financial pressures as a result of re-tendering exercises for services commissioned by other organisations

These issues, alongside our desire to create a mental health system to be proud of, have led us to develop a new vision for mental health services in Manchester: our Mental Health Improvement Programme (MHIP).The MHIP describes our commissioning intentions for the future and the need to:

Reduce the current fragmentation between services, and encourages a more integrated approach to service delivery

Improve the outcomes which services achieve, rather than on the detail of how they are structured

Have clear pathways through services, so that, irrespective of how people access services, there is a shared understanding as to how people will be supported to move through those services and into recovery – without being blocked or delayed by organisational boundaries

Improve access to services, with care and treatment based on assessed needs and good practice guidance

Integrate statutory and third sector organisations aligned to the delivery models emerging from the Living Longer, Living Better programme

Parity of esteem between mental health with physical health

Secure sustainable services for the population of Manchester

Following a period of engagement between November 2013 and February 2014, a full set of service specifications for mental health services in Manchester were developed and approved as the basis for future commissioning. The specifications, intentionally, do not specify in detail the structure of teams and services which providers should offer, we envisage potential providers responding to the specifications by demonstrating how they would intend to offer services, within the constraints of the financial resources available, and look to be creative and innovative in the ideas being proposed.

In its current configuration, the main provider in the city, Manchester Mental Health and Social Care Trust, cannot deliver our vision for the future as its size and structure means it does not have the necessary long term clinical or financial viability. It is not currently a Foundation Trust nor has plans to become one. Only large scale transformational change, with a strong strategic partnership arrangements in areas such as inpatient beds, crisis service management and end to end pathway management (including tertiary service provision), could address the challenges we currently face. To effect the change Manchester needs, we are actively seeking a solution with our commissioning partner, Manchester City Council. During 2014, this will result in either a procurement exercise or the initiation of a managed, strategic partnership approach.

The affordability of the care pathways within the available financial resources has been tested and there is some reasonable assurance. This is based on a successful and deliverable transformation process, the rebalancing of resources and higher quality, more effective services. There is no intention to withdraw funding in order to meet savings targets or invest in other areas of care. However, as with all services, future budgets may be affected by NHS

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and Local Authority funding allocations in coming years. There is also an expectation that future demand will be met within current resources.

Manchester CCGs acknowledge that additional investment is required within psychological therapies in order to achieve the national Improving Access to Psychological Therapies (IAPT) and recovery targets. In order to ensure that the benefit of any additional investment is maximised to achieve the targets and also health outcomes, the national IAPT Team are working with the providers, Manchester Mental Health and Social Care Trust and Self Help Services, and commissioners. This work includes an analysis of current data and advice regarding potential performance improvements so that additional resources can be targeted effectively to achieve maximum benefit.

Manchester CCGs will also continue to contribute towards the funding of the Greater Manchester Veteran’s IAPT service provided by Pennine Care Trust. Safeguarding Children and Vulnerable Adults Accountability Manchester CCGs are statutorily responsible for ensuring that the organisations from which they commission services provide a safe system that safeguards children and vulnerable adults at risk of abuse or neglect. This includes specific responsibilities for Looked After Children (LAC) and for supporting the Child Death Overview process.

In response to the guidance set out in Safeguarding Vulnerable People in the Reformed NHS Accountability and Assurance Framework 2013, Manchester takes a cross generational approach to safeguarding children, young people and adults. This is delivered through the integrated Citywide Commissioning, Quality and Safeguarding Team and provides strategic leadership for safeguarding children, Looked After Children and vulnerable adults across the Manchester health economy. The roles provide leadership, quality assurance, training, supervision and specialist clinical advice on safeguarding to the CCG and the provider organisations.

Manchester CCG’s are required to provide assurance that safeguarding activity within all commissioned services meets national safeguarding standards and demonstrates a model of continuous improvement. This is reflected in local policy and procedure and reflected in the CCG governance framework and delivery plan.

Vision Safeguarding Children

We have a strong commitment to working with partner agencies through the Manchester safeguarding children board (MSCB) to implement learning from serious case reviews, to identify and support victims of child sexual exploitation, to ensure equal health involvement in the development of the Multi Agency Safeguarding Hub (MASH) and to ensure the specific responsibilities for LAC are met

Safeguarding Adults:

We have a strong commitment to working with partner agencies through the Manchester Safeguarding Adult Board (MSAB) to implement learning from Domestic Homicide Reviews and will continue to refocus our safeguarding adults work from the reactive to the proactive, to identify areas of concern early and take embed

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proactive action. We will work with healthcare providers to empower patients and carers to make choices. We will provide support for practitioners to help them determine the least restrictive options for planning and providing care for vulnerable adults.

Specialised Services - Commissioning Plan We recognise the challenges faced at a national level across Specialised Commissioning. We will engage with our colleagues in Specialist Commissioning, Cheshire, Warrington and Wirral Area Team in the work that they are focusing on which over the next 2 and 5 years have been described as:

Mental Health: Develop North West CAMHS tier 4 system, review secure mental health

Cancer and Blood: Cancer IOG compliance, HIV commissioning arrangements

Trauma and Head: Adult neuro-rehabilitation services, major trauma

Internal Medicine: Cystic fibrosis capacity, Cardiac services, Vascular services, Respiratory services, Acute kidney injury, Inherited metabolic disorders

Women and Children: Neonatal services, Paediatric neuro-rehabilitation The Armed Forces Commissioning landscape is quite complex services being commissioned by Defence Medical Services, NHS England, Local Authority and CCGs, with CCGs having responsibility for providing health services to veterans, and also specific obligations and expectations under the armed forces covenant. The Armed Forces Commissioning priorities have been shared with the CCG, and we will work with the Area Team to support delivery where needed. The commissioning plans describe a North region CCG leadership model aimed at securing wholesale CCG shared ownership of Armed Forces Networks. We will engage with the North Yorkshire and Humber Area Team to progress these discussions. Figure 14: Specialised Services - Plan on a Page

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Vision

• Move from traditional Medicines Management towards Medicines Optimisation which is focused on improved patient outcomes; ensuring that the right patients get the right choice of medicine, at the right time.

Interventions

• Clinical focus areas are Atrial Fibrillation and Respiratory conditions (Asthma and COPD).

• Review of patients living in Nursing and Residential Homes.

• Integration of Medicines Optimisation support within the neighbourhood teams.

• Increased collaborative working on projects with Community Pharmacy.

• Safe movement of patients receiving drug treatment(s) in secondary care to Homecare.

Goals and Targets

•Identification of patients with AF, together with the safe introduction of anticoagulants including NOACs.

•Review of under and over use of inhalers for patients with asthma/COPDImproved monitoring of patients, systems relating to medicines and training of staff within Care Homes

•Rolling programme of projects increasing the use of Community Pharmacy: New Minor Ailment Scheme, Inhaler technique and Dementia Screening.

•Increase the number of clinical areas where medicines can be given via Homecare.

Strategic Impact

• Improved patient outcomes: reduced number of strokes (AF), reduced respiratory admissions.

• Increased utilisation of Community Pharmacy services to help reduce GP waiting times and A&E admissions.

• Enable care closer to home.

Cross Cutting 6: Medicines Optimisation

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5.6: Medicines Optimisation

Medicines play a crucial role in maintaining health, managing chronic conditions, and curing disease. In the NHS we invest approximately £13 billion on medicines each year. To date medicines have been managed in relative isolation in the various sectors in the NHS. This has resulted in fragmented services and relatively poor outcomes for patients, in relation to their medicines.

Medicines optimisation (making sure people get the right medicines and use them as prescribed) offers a step change in the way that we support patients to take their medicines and will focus on engaging with patients and the public around what services and support are needed to ensure they get optimal benefits form the medicines they take.

In Greater Manchester, medicines expenditure is about 12 per cent (circa £700M) of total healthcare spending (£6 billion). Inflation on medicines costs stands at approximately 3-5 per cent, which currently outstrips general inflation. Medicines are still the most common therapeutic intervention and biggest cost after staff, but significant work is required to optimise usage, for example:

30 to 50 per cent are not taken as intended

Patients have insufficient supporting information

Data suggests 5 to 8 per cent of hospital admissions due to preventable adverse effects of medicines

Medication errors across all sectors and age groups at unacceptable levels

Medicines wastage in primary care: £300 million per year with £150 million per year avoidable

Unexplained variation in medicine prescribing and use

The threat of antimicrobial resistance

Appropriate versus inappropriate poly-pharmacy

There is a need for a strategic joined up approach to manage and optimise resources effectively across the Health economy. Medicines Optimisation is integral to Clinical Quality and a key part of the work of all commissioners and providers within Greater Manchester. South Manchester CCG plays an integral role within the Greater Manchester Medicine Management Group (GMMMG) collaborating with local healthcare professionals in order to deliver the Medicines Optimisation strategy.

The success of the Medicines Optimisation strategy relies on effective clinical engagement across GM. The CCG Medicines Management Team and GMMMG must focus on programmes which deliver long term patient gains and move away from quick financial wins in order to deliver sustainable cost effective, evidence based prescribing.

Medicines Optimisation is about enabling prescribers and patients to make the right treatment choices. Distilling the relevant facts from the available evidence, using local knowledge to inform decision-making, and providing support to continually audit and improve the care. The safe prescribing of medicines reduces harm to patients, supported by well organised systems.

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Medicine Optimisation 1. Long Term Conditions 2. Self- care 3. Quality and Safety 4. IT support for Medicines Optimisation 5. Finance/QIPP 6. Homecare medicines 7. Specialised Commissioning Transfer 8. Primary Care support and development

An effective medicines optimisation strategy

Shared decision-making approach to medicines use; patients have access to support for medicines taking; medicines considered in all care pathways; arrangements for medicines optimisation in all commissioned services; use of CQUINs and quality/Key Performance Indicators; safe use of medicines addressed in all settings and professional collaborative working integral to local systems e.g. supporting the safe use of medicines in care home settings and developing links through Local Authorities to support patients taking medicines in their own home.

Effective formulary systems for ensuring safe, effective and prompt implementation of national guidance (e.g. NICE) or locally agreed policies in relation to medicines

Effective arrangements are in place for local decision making on new medicines in line with commitments and the NHS Constitution e.g. robust processes for managed entry of new medicines; safe and effective systems for considering individual/exceptional funding requests and dealing with appeals in a timely manner; agreeing shared care arrangements; avoiding post-code prescribing.

Enhancing quality of life for people with long-term conditions (Domain 2 NHS Outcomes Framework 2012/13) e.g. targeted medication reviews, empowering patients to manage their condition, preventing unplanned admissions.

Effective systems for ensuring cost-effective use of medicines and budget management (value for money) e.g. mechanisms for reviewing expenditure data; health community wide formularies; commissioning policies; planning future developments; Payment by Result (PbR) exclusions.

Transparent and efficient relationships with the pharmaceutical industry e.g. joint ventures and risk sharing

An effective relationship with community pharmacy - Effective methods of communication with community pharmacy, their representative groups and local professional networks; local enhanced services commissioned; recognising the important and expanding contribution made to public health; existing contract levers/incentives to optimise medicines use in primary care e.g. targeted Medicines Use Reviews and New Medicines Service.

Robust and senior advice on the legal, safe and secure handling of medicines for all services provided or commissioned by the CCG including medicines governance and

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policy; Controlled Drug Accountable Officer; arrangements for effective development, use and monitoring of patient group directions (PGDs); access to medicines out of hours; prompt implementation of safety alerts; effective systems for learning from errors and near misses.

Reducing serious harm caused by medication errors (Domain 5.4 NHS Outcomes Framework 2012/13) e.g. safe repeat prescribing systems and monitoring of high risk drugs.

In addition to the above; patient focused activities to manage an individual’s risk factors, medication reviews and training of care staff, safe transfer of patients between settings and reduction in unnecessary admissions and re-admissions.

Summary of the four principles to make Medicines Optimisation part of routine practice:

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Areas where GMMMG can have a significant impact

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Section 6: Engaging with Stakeholders

6.1 Call to Action Engagement Our system with partners across Manchester (including North and Central CCGs) have for some time been working on a number of programmes of work to address the challenges the NHS face over the next three to five years. These include Healthier Together, Living Longer, Living Better and Primary Care development work. Rather than a separately branded Call to Action engagement programme (which would confuse audiences familiar with our on-going work), we have used engagement within these programmes as an opportunity to discuss challenges and collect feedback to inform the CCG’s strategies going forward. This engagement involved work with patients and the public, the voluntary sector, CCG members and local councillors.

This work is on-going and we are currently in the midst of a stakeholder ‘conversation’ about what the future NHS will look like as a preliminary exercise prior to the Healthier Together formal consultation planned. A full ‘you said, we did’ as well as Question and Answers will be finalised after this process and will support future engagement work which will continue after the Healthier Together consultation as services continue to develop and change. As well as active engagement, we have used existing data we have about local stakeholders’ preferences and needs to inform our work. This latter approach is supported by local people’s feedback that they often feel over consulted and asked similar things. We have, in Manchester been engaging with the local population in numerous ways for a number of years now and use of this data is just as important as gathering new information.

In terms of themes which have emerged, there are many, some general, some specific to areas of care. These include:

A recognition of the challenge facing public sector agencies with demand increasing above resources

General support for integrated care and the development of joined up services in the community.

The importance of supporting people to self-care and look after their own health

The need for access to GP practices to be improved

A need to ensure that resources shift into the community, including primary care, to support the work

The importance of the voluntary sector in supporting communities

6.2 Engagement with member GP practices All 25 member GP practices have signed up to the South Manchester CCG constitution which outlines the ways in which the CCG will work, as a member organisation, to deliver its objectives and statutory duties.

Communication and engagement is essential both for our member GP practices and for the population of south Manchester. Our practices have the experience of working together, driving up quality locally, and agreeing system wide approaches when necessary and we have access to the legacy of information obtained from the last four years of patient and public engagement work carried out by NHS Manchester.

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Engagement and communication with south Manchester GP practices takes place at least on a monthly basis via the link manager practice visits. In addition, each practice has a direct link to a board member.

South Manchester CCG has four ‘patch’ working groups which meet regularly to look at how improvements can be made to patient services in their local area and improve patient pathways and experience of care whilst improving on quality in both primary and secondary care. The patch group meetings are attended by the link managers to the practices in that patch and have at least one board member in the group.

Each south Manchester GP practice has signed up to attend the bi-annual events. These meetings bring all the 25 practices together and are attended by a minimum of one GP and the Practice Manager along with salaried, locum and doctors in training. The meeting is attended by all board members and the commissioning team.

It is agreed that a ‘one size fits all’ method cannot be applied here; communication and engagement methods will need to reach our 25 member practices and cover the diversity of the south Manchester population. A whole range of methods (electronic, web, poster, focus groups, face to face meetings, information stalls, social marketing etc.) will need to be used. It is important that communication is targeted to the appropriate audience and therefore filter communications through a reduced number of channels – getting the right information to the right people at the right time. (For more information on communications and engagement please refer to the CCG Communications and Engagement Strategy which can be found on the website www.smccg.co.uk) 6.3 Patient and Public Engagement South Manchester CCG recognises it has a statutory duty to involve patients and the public in future commissioning arrangements and to promote the involvement of patients in decisions about their individual care and treatment.

We understand that we cannot be effective commissioners unless our patients and public are at the heart of everything we do. Everyone has a stake in the health of their community and an engaged and supportive public can provide a powerful mandate and resource for our CCG as we evolve. We believe that patient and public engagement should be ongoing and sourced from a range of relationships, mechanisms and processes.

We are working to a model of engagement involving four distinct but interrelated activities:

Informing local people about health, health services and CCG activities

Listening to local people’s experiences and needs

Involving local people throughout the CCG’s work

Enabling people to manage their health and make healthy choices

Patient and public views will be reported to a number of committees within our organisation - the CCG Board, Quality and Performance Committee, Communications and Engagement Committee and the Patient and Public Advisory Group.

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The voice of patients and their communities will inform:

Our decision making at all levels of the organisation on an ongoing basis.

Our quality improvement work by contributing towards needs assessments, strategy development and service redesign.

Our quality assurance work by highlighting patient, carer and community experience to inform our monitoring and evaluation of existing services, care pathways, providers and healthcare interventions

South Manchester CCG will ensure that the results and outcomes of patient, public and community engagement, and details of the complaints we receive, are reported publicly on a quarterly basis. Papers will be stored on the Manchester CCGs website and linked to through our regular stakeholder communications. In addition, an annual report will detail all the activity carried out, what was learnt and how it was used to inform decision making. This will be made public and disseminated to local stakeholders using the mechanisms outlined within the strategy. Additionally, outcomes from individual projects will be communicated to those involved to indicate how their feedback and input has influenced the work. 6.4 Partnership Working South Manchester CCG has a number of commissioning partners. In collaboration with North and Central Manchester CCGs we commission citywide services. This includes services such as mental health, continuing health care and children. In addition we will work closely with neighbouring CCGs in Trafford and Stockport to develop an integrated approach to service delivery with the aim of addressing cross boundary issues for patients. We also have strong links with Manchester City Council, both in the commissioning of services and in its Memorandum of Understanding with the Manchester public health team which transferred to the council in 2013.

South Manchester CCG recognises the need to continuing with the established relationships already in place with the voluntary and community sector and the local health services. We will continue to build on these positive relationships with all relevant groups and organisations and will work to develop these further during 2014 and onwards.

There is voluntary and community sector representation on the Health and Wellbeing Board, which is not the case across other parts of the country. However, it is recognised that a strategic relationship is not just a range of meeting structures. Moreover, such structures cannot be the sole means of preserving and developing the relationship nor should they be exclusively concerned with current funding relationships.

We recognise that many voluntary and community sector organisations provide value services and guidance, and support, which have a direct impact on health outcomes for patients. South Manchester CCG recognises that the voluntary and community sector is not simply a market of suppliers: it creates, innovates and is in a prime position to be a partner in the delivery of the CCG strategic priorities. It also provides challenge and criticism which if not always perceived as “friendly” is at least motivated by a shared desire to improve quality of life for people in South Manchester. We will continue to work with local organisations including Manchester Alliance for Community Care (Macc); an 'umbrella' body

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that supports and develops voluntary and community sector groups in the city to develop these opportunities further. 6.5 External Partners South Manchester CCG recognises the structure that it operates is within a broad partnership environment. We will also have a relationship with the Commissioning Support Unit, Local Medical Committee and Health and Well Being Board as all these organisations develop particularly in respect of delivery of our aims and objectives, primary care and specialist commissioning. The CCG will continue to work with NHS Greater Manchester to support the development of the commissioning support service and to identify our support requirements moving forward.