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Strategic Plan Refresh 2015/16

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Foreword Welcome to our Strategic Plan Refresh 2015/16 Over the past twelve months we have continued to talk and listen to patients and members of the public. We have made significant progress in delivering our plans to improve care locally. This new chapter of our Strategic Plan demonstrates our progress to date and the achievements we have made against our strategic priorities. It sets out our objectives for the next year and explains a number of new initiatives that we are involved in, along with our health, local authority and voluntary sector partners. We remain committed to commissioning high quality services for everyone in Harrogate and Rural District. Amanda Bloor Dr Alistair Ingram Chief Officer Clinical Chair

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Overview 4

Plan on a page 9

Road map 10

Outcome measures 11

Enablers

Quality 16

Participation 19

Technology 21

Finance 22

Workforce 23

Strategic Priorities 25

Urgent Care 26

Long Term Conditions 28

Vulnerable People and Mental Health 31

Elective Care 36

Health and Wellbeing 38

Primary Care 42

Summary 44

Contact us 45

Contents

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Overview 2014/15 has been an exciting and successful year for NHS Harrogate and Rural District Clinical Commissioning Group (CCG). Through consultation with our public, strong clinical leadership and collaboration with our key partner organisations, we have taken great strides towards improving outcomes for our population within our 6 key strategic priorities. At our Annual General Meeting in September 2014, we were able to update our public and partners regarding our progress. This included: • Improvements in quality such as performance in stroke services and reduced waiting times to access mental health services. • A strong programme of public and partnership engagement throughout the year. • Significant investment in 2014/15 especially in mental health services . • A robust financial position which included the repayment of our inherited deficit and achieving the required surplus . Our Vision : “We will secure high quality services, in the most appropriate setting, making maximum use of available resources. Through clinical leadership and collaborative working we will achieve the best possible outcomes for all our local population” is evidenced through the improvements made in 2014/15 and our plans going forward into the coming year. This refresh of our Five Year Strategic Plan (2014-19) and updated “Plan on a Page” demonstrates these improvements and shows our key priorities and work streams for 2015/16. Our plans for 2015/16 have built upon the NHS Five Year Forward View and associated planning guidance to further develop our operational plans.

The key work streams linked to this include: •Empowerment of patients – In 2015/16 we will expand upon the offer and delivery of personal health budgets. This will involve robust partnership working with our local authority and will be delivered through our local leadership forums. Whilst we were not initially successful in our application to become an Integrated Personalised Commissioning demonstrator site, we are committed to moving this agenda into reality to ensure our population can exercise more choice and influence over their own care and support. •Parity of esteem – In 2015/16 we will implement standards for access to and waiting times for mental health services. We will continue with our innovative approach to identifying and caring for people with dementia. We are working with partners regarding implementation of the Crisis Care Concordat and ensuring system resilience for urgent mental health patients. •Primary care – We have been successful in our submission to take forward new arrangements for Primary Care Co-Commissioning. We will take on full delegated responsibility for general medical care commissioning functions from 1st April 2015. This will allow us to work with GP practices across our area to develop a more integrated approach to improving the quality of healthcare for our population. This is strongly supported by our member practices.

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•Urgent and emergency care – We have implemented a series of schemes through the Better Care Fund (BCF) , to work with partners to redesign the traditional pathways for patients admitted into secondary care. This includes work across the local authority, voluntary sector , hospital and mental health providers to ensure patients are cared for in quality environments away from hospital inpatient beds. These schemes will continue in 2015/16 as part of our plans to reduce avoidable admissions to hospital. •Prevention and public health – We will continue to prioritise Health and Wellbeing as one of its key strategic programmes. We will work with the local authority on a series of preventative schemes such as smoking cessation and alcohol reduction strategies. We are working in partnership with North Yorkshire County Council (NYCC) to implement and extend the prevention officer role. We will continue to work on our carer pathways and social prescribing through BCF Schemes. As an employer we are actively promoting public health. Our staff engagement group has already started a running club and increasing the use of cycling, whilst our Dragons’ Den* style project engaged, encouraged and supported staff to develop innovative ideas for change. *Copyright: Dragons’ Den BBC 2014

•New models of care - Harrogate and District have been chosen to take a national lead on transforming health and social care. Harrogate’s Vanguard site is one of only 29 in the country to be chosen to lead the way in transforming care for local people. It is a partnership between, our CCG, made up of the following organisations: Harrogate and Rural District CCG, Harrogate and District NHS Foundation Trust (HDFT), North Yorkshire County Council (NYCC), Tees Esk and Wear Valleys NHS Foundation Trust (TEWV), Harrogate Borough Council (HBC) and Yorkshire Health Network (YHN). Woking together we will deliver access to prevention, advice and information for individuals who find themselves needing support 24/7. The aim will be to provide support to people to remain independent, safe and well at home with care provided by a team that the person knows and they can trust, set out in a universal care plan. This service will be provided by an integrated care team from community based hubs which include GPs, community nursing, adult social care, occupational therapy, physiotherapy, mental health and the voluntary sector. Boundaries between primary, community, acute, mental health and social care will be removed and acute hospital beds will be used only when they are truly needed.

Overview continued

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Leadership: Local Vision Programme As described in the Five Year Forward View, local leadership across all partners and public sectors is essential in delivering the improved outcomes for our population. In 2015/16 we will continue to strategically plan and implement improvements using the Public Sector Leadership Board. We will also work closely with the North Yorkshire Health and Well Being Board (HWB) and the Delivery Board partners on refreshing the Joint Strategic Needs Assessment and the Health and Well Being Strategy, which informs and underpins our strategy. We are working with other commissioners across West Yorkshire to deliver the “Healthy Futures Collaborative”, particularly regarding improving pathways for cancer, stroke, urgent care and paediatric care. The ‘System Leadership - Local Vision Programme ‘is a ground-breaking collaboration between the Association of Directors of Adult Social Services, Association of Directors of Public Health, Department of Health, Local Government Association, NHS Confederation, NHS England, NHS Leadership Academy, Public Health England, Social Care Institute for Excellence, The National Skills Academy for Social Care, Think Local Act Personal, Virtual Staff College, the Leadership Centre and local public services in places. The programme aims to learn and develop what it takes to become a systems leader by using a local knotty issue where solutions are not in the gift of individual organisations.

The programme has three overall aims: • To assist in the development of a solution to a local ‘wicked’ / intractable issue through leadership development. • To ensure that the leadership learning is left in place to allow it to be used for other issues. • By looking across the local projects, draw together lessons and learning about leadership behaviours and development that will help resolve future wicked issues. Our system issue is around improving outcomes for local people with long term conditions including dementia. Our local pilot aims to distill the initial learning from working with wider partners to develop Harrogate as a dementia friendly town. This is a multi-agency group of local statutory organisations working together to lead the delivery of a local plan to support a ‘public sector pound’, one commissioning framework with the voluntary community sector and working more seamlessly together for the local population.

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Harrogate District Public Sector Leadership Board

“Plan on a Page”

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Delivery and governance In November 2014, in partnership with NYCC and HDFT, we commissioned a full clinical audit of inpatients at Harrogate District Hospital, Ripon Hospital and Station View. The final report made numerous short term and strategic recommendations for redesigning the pathways of care for patients outside of hospital inpatient beds. These quality and efficiency recommendations will be driven through our local leadership groups. This robust partnership and governance approach will help us further deliver our ambitions within our Five Year Strategic Plan. In 2014/15 HaRD CCG ensured delivery of the key NHS constitutional standards for patients, included waiting times targets for cancer and elective care, reduction in infection, and achievement of access to mental health services. We sustained full assurance with NHS England through the year. In 2015/16 we will continue to ensure this excellent level of performance in line with NHS England ‘s success regime, including the achievement of the new mental health waiting time standards. The 2015/16 Strategic Plan refresh now describes: • Updated Plan on a Page 2015/16 work programme • Review and refresh of Outcomes prioritised for

improvement . • An update on our enablers to improve these

outcomes and those within our Strategic Plan. • A review of our strategic programmes and work plan

updates for 2015/16.

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Updated Plan on a Page 2015/16

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Updated Roadmap 2015/16

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Complete reviews of urgent care

Develop plans for urgent care centre

Implement DVT pathway

Implement care planning

Complete community services review

Implement referral management system

Commission alternative ENT and community dermatology pathwaysReview cardiology and diagnostics

Implement Stop Before your op pathway

Review the social prescribing project

Develop our primary care strategy

Medicines optimisation

2014/15 2015/16 2016-19

Urgent care

Long term conditions –new models of care

Planned care

Vulnerable and Mental Health

Health and Wellbeing

Primary care

Seven Day CAT service

Seven day diagnostics services

Expansion of the community stroke team

Extend care planning Risk stratification increased in

primary care Start to implement new model of integrated care

Implement findings of mental health review

Increase the capacity to diagnose and treat dementia

Implement new access targets for mental health

Implement the carers pathway

Embed preventative lifestyle pathways

GP practices working together as a federation

Implement co-commissioning of primary care

Review QOF and DES activity

Have fully functional 7 day urgent care centre

Data underpins and informs new pathways of

elective care

The inequity in health for people with mental

health is reduced

The Community is more engaged in its health

Health professionals have more access to

preventative services

Move towards a more sustainable and resilient model of primary care

Implement RAIDImplement One GP per Care Home

IAPT expansionSection 136 pathwaysMental health review

Continued implementation ofintegrated care model

Integrated teams to support more people to be at home

Implementcardiology and diagnostics reviews findingsReduce inappropriate outpatient follow upsUse intelligence through RSS to design new

pathways

Outcome measures

There are five outcomes which NHS England have prioritised for improvement. These are: • Preventing people from dying prematurely. • Ensuring that those people with long-term conditions, including those

with mental illnesses, get the best possible quality of life . • Ensuring patients are able to recover quickly and successfully from

episodes of ill-health or following an injury. • Ensuring patients have a great experience of all their care . • Ensuring that patients in our care are kept safe and protected from all

avoidable harm . Against the outcome measures, we have compared our performance against England and also our peer CCGs (highlighted in orange and based on the peers identified through the commissioning for value packs).

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Potential Years of Life Lost (PYLL) from causes amenable to healthcare: • For everyone, 2013 has seen a 25% drop in PYLL which has far exceeded the projected ambition. • PYLL for males has dropped from 2,018 to 1,718 and females from 2,052 to 1,355. • Relative position against comparators has improved from the 11th to 2nd best performer in the group. • Current performance is excellent so whilst an improvement is sought, based on comparison to other CCGs nationally, there isn’t realistic potential

for substantial performance gain.

Ways to improve: through our long term conditions, elective care and prevention work streams

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Health-related quality of life for people with long-term conditions:

• The total EQ-5D score (quality of life measure) has reduced since the baseline performance from 78 to 75.6 but we remain in the upper quintile.

• Relative position against comparators has changed from 1st to 5th.

• The maximum score in 2013/14 is 79 therefore ambition for performance improvement should reflect a slight increase to levels of performance seen in the previous 2 years.

Ways to improve: through our long term conditions, vulnerable people and health and wellbeing work streams

Reducing the amount of time people unnecessarily spend in hospital - combined emergency admissions: • There was an increase in emergency admissions between 2012/13 and 2013/14 but performance remains better than the English average. • We have moved from 4th out of the comparator group to 5th. • A return to 2012/13 performance would be an acceptable level of ambition with future years continuing a downward trend similar to that projected in

the original ambition.

Ways to improve: through our urgent care, long term conditions and primary care work streams

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Patient experience of inpatient care: • We perform very well on this indicator which is based largely on scores from HDFT‘s inpatient patient survey. There is little headroom for

improvement against the current national best scores. • Patient experience of hospital care has improved since the baseline performance and has exceeded the projected ambition. • Current performance is excellent compared to other CCGs and we achieved the best performance in the comparator group.

Ways to improve: continued work through our quality agenda

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Enablers

Our response to the Francis and Berwick Reports and Winterbourne View In responding to the Francis Report, we have has assessed our own preparedness for early warning and developed a system of ‘soft intelligence’ reporting, triangulating data with other sources including patient experience, serious incidents, safeguarding data and benchmarking data where it exists. The reporting requirements from our main providers have grown over the last year and continue to progress through contract arrangements, helping us to achieve more transparency and fulfilling our duty of candor. The Berwick Report places patient safety high on the agenda and our work with providers over the last year has helped establish a learning culture and one of continuous improvement. This year, HDFT has agreed a number of improvements with us, as Commissioning for Quality and Innovation (CQUINs) which originated in reviewing patient safety and are designed through the ‘sign up to safety’ programme. From HDFT, year to date we have seen an improvement from 0% of serious incident reporting being completed to 78% success of reporting and action plans completed within the 9 and 12 weeks within the guidance. This demonstrates significant progress towards a culture of learning from incidents and timely implementation of lessons learned.

The Winterbourne review has led to the ongoing development of a joint strategy for learning disabilities in partnership with NYCC to plan the future developments of local service provision. In the longer term this will improve the availability of community services and reduce the number of people with learning disabilities and complex care needs who currently require inpatient hospital care. The recent community services review has also highlighted areas of service model improvement needed, especially around improving access.

Quality - “commission for quality and improve quality management information”

In our Five Year Strategic Plan we identified 5 key enablers for delivery of our vision within Harrogate and Rural District.

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Safeguarding children The Safeguarding Children Team has been awarded significant assurance from internal audit this year and will continue to work through the action plan associated with the recommendations from that report. As part of the wider agenda, the team is participating in the Child Death Overview Panel (CDOP) as described in “Working Together to Safeguard Children 2013”. Two of the main functions of the CDOP are to; • determine whether there were modifiable factors and establish what, if any, actions could be taken to prevent future such deaths (recognising and taking into account recommendations and directions may result from involvement of other lawful bodies, such as Criminal and Coroner Courts) • identify patterns or trends in local data and report these to the appropriate Local Safeguarding Children Board subgroup. Other key developments include the redesign of the looked after children specification and working alongside other colleagues to ensure that robust standards are in place through ensuring these are contained within the contracts. In 2014/15 we delivered: • Significant gaps in terms of commissioning services for looked after young people aged between 16 and 18 years of age have now been addressed. • Action plans developed in conjunction with the local authority have resulted in improvements for looked after children accessing their statutory initial health assessments. • Commitment from all North Yorkshire CCGs to support the award-winning project by NYCC (“No Wrong Door”) looking at needs and management of young people on the edge of care and who repeatedly break down placements. • Safeguarding children ‘app’ has been developed and publicised at local, regional and national levels.

• Work between designated professionals, York Teaching Hospital NHS Foundation Trust and NHS England has secured agreement for a Paediatric Sexual Abuse Referral Centre to be based at York Hospital.

Safeguarding adults Our plans will meet the requirements of the accountability and assurance framework for protecting vulnerable people. We are preparing service specifications for HDFT safeguarding to be signed off in 2015. Our Designated Professional for adult safeguarding is working with main partners in a task and finish group to adjust the North Yorkshire Policy and Procedure to reflect the new safeguarding terminology and structure as defined in the Care Act. Our Safeguarding Adults Team will be working with partner agencies and the two local Safeguarding Adults Boards to ensure the choices of the adults at risk are fully taken into consideration in line with the “Making Safeguarding Personal” framework. In 2014/15 we developed awareness and understanding amongst senior NHS managers and consultants by delivering a series of training events for the application of the Mental Capacity Act. The plan for 2015/16 is to cascade this approach to frontline clinical staff and equip with tools and guidance to avoid Deprivation of Liberty (DOLs) breaches. We continue to encourage provider organisations to assess their policies and procedures and ensure that their corporate governance supports the patient and the workforce in terms of safeguarding individuals.

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Patient safety We continue to understand and measure the harm that can occur in healthcare services, via our quality and performance meetings with providers. We have worked with our acute provider on increasing reporting and including the number of Serious Incidents Requiring Investigation (SIRI) disclosed. We have set local quality requirements based on the reductions to pressure ulcers. The monitoring we undertake with HDFT includes infection prevention control and is detailed to ward level for some indicators. HDFT has implemented a new electronic system to assist with early warning scores. The plans developed through this monitoring include the requirements to tackle sepsis and acute kidney injury. On a more global level, we need to review the IPC team specification this year. We will improve antibiotic prescribing in primary and secondary care linked to the review of the Infection Prevention Control Team, we already hold lessons learned reviews for route cause analysis where prescribing has been associated with any C-Difficile infections. We use our protected learning time out events to help educate prescribers in primary care; in addition, this year we have commissioned a new software package to prompt GPs at the point of prescribing. The secondary care monitoring of prescribing antibiotics is subject to continuous review via the medicines management team.

Compassion in practice We continue to ensure that HDFT and TEWV plans are delivering against the six action areas of the Compassion in Practice implementation plans are monitored against the Quality Account and action plans. These are monitored via quality meetings. We routinely receive the reports from both Trusts on Safer Staffing and we monitor monthly the proportion of people who would recommend/ not recommend as part of the friends and family test.

Each quarter, we are reviewing with the Trusts the complaints data and we expect to see further work on improving the quality of experience for patients through a number of initiatives in this years Quality Account.

Research and innovation Practices within our area continue to actively participate in the Northern and Yorkshire Primary Care Research Network (PCRN). We have 14 practices involved in 11 trials involving 410 patients. We are actively involved in working with partners and the Academic Health Science Network to develop a better understanding of what data from different organisations and different sectors is telling us about patients’ use of urgent care services. We are also working the Academic Health Science Network to understand and utilise the evidence to inform our plans regarding falls prevention. We are supporting a social prescribing project for young people with mental health problems at Orb Arts in Knaresborough to help them reduce medication, become more self-reliant and be able to get back to work. This is a one year project ending in March 2015 when it will be evaluated. As a Governing Body, we are also participating in a research project to develop tools for 360o reviews of CCGs. In addition, our joint approach to improving dementia awareness, diagnosis and treatment pathways has been put forward for an Innovation Award. The Local Vision Programme we are involved in is also a national learning and research programme to develop thinking and learning around systems leadership in public sector services.

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Participation – “improving individual and public engagement arrangements” – actively engaging and listening

Annual General Meeting (AGM) and Patient and Public Involvement (PPI) forum Our AGM and PPI forum was held on Tuesday 9 September 2014. It proved to be very successful with over 60 members of our local community attending. We are fully committed to involving local people and our partners in developing local health services and the focus of the event was to: • Share with local people and stakeholders the progress and we have

achievements made so far. • Present the 2013/14 annual accounts. • Find out local people’s views on two of our key priorities, vulnerable

people and mental health, and community services. • Enable the public to meet the CCG team and take part in ’HaRD

Decisions’ commissioning quiz. As well as publicising in the local media invitations were sent to key stakeholders, which included local NHS partners, GP Practices, voluntary and independent groups and local councillors within the locality and all members of the public who are already registered with HaRD Net, our engagement network. We introduced the use of an audience response voting system as a method of gaining feedback. Through interactive presentations the audience were actively involved and invited to provide feedback to questions asked. This method of gathering feedback proved very successful and will be used at future events where appropriate.

Respondents comments included : “ HaRD CCG has certainly made themselves available to the public” “I was really impressed with the event. It was a very friendly and a relaxed atmosphere” “There was a positive and friendly feel about it all” “Good work – thank you!”

HaRD Net We continue to ensure members of our engagement network are actively involved and receive regular news updates and briefs. The membership now stands at 265 members. As part of our ‘Hot Topics’ projects in 2014/15 members of HaRD Net have been able to take part in surveys and gives their views on healthcare services including primary care services, secondary care communication with patients and services for people with Dementia.

Communications and Engagement Strategy refresh A review of the CCG’s current communications and engagement strategy is now underway and as part of that review we will be asking for feedback from the Governing Body, CCG staff and HaRD Net members. The draft refreshed strategy was shared at our patient and public involvement event on 10 March 2015. The final version will be agreed by the Governing Body in April 2015.

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Social media Social media is a powerful tool in enabling us to share and receive information with local people and partners. We now have over 2,300 followers on Twitter and we tweet regularly to communicate key messages such as campaign launches, good news stories and important information on local services. Twitter has been particularly helpful for communicating our winter health messages and encouraging people to Choose Well. Throughout December and January for example, though direct tweets and retweets from our followers, we reached a total of 69,000 social media users for our winter campaign.

Seldom heard groups We are committed to working with our communities and partners to improve the health outcomes for everyone. To ensure that everyone is given the same opportunity to share their views and influence how local health services are provided, we have written to a number of networks and groups, and offered to attend their meetings. This allows us to make direct contact with a diverse range of people to discuss their experiences of NHS services. We are particularly interested in encouraging people with protected characteristics (age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, religion or belief, race, including ethnic or national origin, colour or nationality, sex, sexual orientation) to get involved and share their experiences of NHS services. We are able to analyse the demographic makeup of those that attend engagement events. For example, the evaluation form at the Annual General Meeting (AGM) asked people to record equality information about themselves. This has helped us to identify that younger and Black

Minority Ethic (BME) people were underrepresented at the AGM, and we need to do more outreach to engage with people with these protected characteristics. We will include this in our revised equality implementation plan which also links in to the Communications and Engagement Strategy and Action Plan.

Mapping the future – delivering seamless care for everyone event We held our “Mapping the future – delivering seamless care for everyone” event on Tuesday 16 December 2014. Partners from provider trusts, the local authority, voluntary sector and primary care met to work through a future model for out of hospital services. Health Watch attended too representing the public. There was broad agreement regarding a model of care that provides 24/7 services for people requiring care, especially the frail elderly and those with long term conditions. We are now working on plans to further engage with patients, carers and members of the public on the future model. Patient and public involvement event – 10 March 2015 W held our latest public event titled “Continuing the Conversation” on Tuesday 10 March 2015 at Pavilions of Harrogate. The event took place in partnership with our key stakeholders within the health and social care system. Over 100 people attended and it was a great opportunity for us to hear from our local communities and as the title of the event suggests, we updating our public on our progress and heard views and feedback on our future plans. The feedback reflects the information we have collected through our previous patient and public engagement sessions.

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In 2014/15 we have implemented the use of the healthcare intelligence tool RAIDR within our care planning enhanced service, using it to identify our top 4% of at risk patients. We are expanding the use of RAIDR to help with additional health care planning. We have also agreed to roll out the medicines optimisation tool OPTIMISE Rx which will enable GP practices to make real time switches of medication to be more cost effective based on national guidance. Our practices within the CCG had the highest roll out of using the NHS England Dementia Prevalence tool locally, resulting in one of the highest expected to observed ratios of dementia prevalence. Practices have also taken up the offer through working with the West Yorkshire 10CC network to roll out the Apodi software support to identify patients with atrial fibrillation who are not adequately anticoagulated. We have also completed a pilot on using near patient testing for Deep Vein Thrombosis, resulting in better pathways and care closer to home with fewer A/E admissions. This is now being rolled out across the CCG.

In 2015/16 we will be setting out an IM&T strategy that outlines our vision to integrate the locality’s IT systems to support our objective for integrated health and social care services. We are committed to making progress in 2015-16 towards one NHS number in all settings so that we can progress plans to pilot data sharing between providers. We have agreed with health, social care and voluntary providers that a new group will be established to progress care record sharing between providers as part of our Better Care Fund. In the future open Application Programming Interfaces (APIs) between different computerised data systems will have an important part to play in achieving this ,by making application functionality easily available, allowing the best system for the job to be chosen, promoting and accelerating innovation. Open APIs will become a condition of our contracting with providers.

Technology – “increase capability and capacity to produce and share information and integrated systems to support better patient care.”

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Better Care Fund (BCF) Our plans support previous BCF submissions regarding the minimum CCG contribution into pooled budgets arrangements (£9.557M in 2015/16.) Together with the other CCG partners involved in the pooled budget arrangements within NYCC, we are in the process of agreeing clear risk sharing arrangements, with a view to minimising the financial risk of delivery of plans for all organisations. The ambition for reducing non elective admissions is reflected in activity and finance plans to support transformation within the overall health and social care community.

Contract We currently have a 2 year signed contract with our main acute provider, HDFT. This contract will be refreshed to ensure we commission sufficient capacity to meet the activity required to deliver constitutional standards (including elective waiting times), support BCF plans and ensure financial sustainability for both organisations. We also use our contracting process to ensure we are driving the redesign and integration of services described within our strategic priorities. This will ensure an improved quality care pathway for our population whilst driving efficiency across the health and social care community.

Quality, Innovation, Productivity and Prevention (QIPP) programme We have an ambitious Commissioning for Quality, Innovation, Productivity and Prevention (QIPP) programme for 2015/16. To develop this plan we have worked with clinicians, finance and business intelligence to ensure the schemes are realistic and improve quality for patients. This has included: • Prioritisation workshop with GPs. • Interrogation of benchmarking and Commissioning for Value data. • Evaluation and development of current schemes. • QIPP ideas generation from CCG staff and peer CCGs. Our QIPP programme for 2015/16 includes plans associated with: • Referral Support Service (RSS). • Outpatient follow up reduction. • Medicines management. • Falls prevention. • BCF funded programmes associated with urgent care admission

avoidance.

Finance – to create, with our partners, affordable and sustainable health services using financial enablers such as the contract , quality premium, CQUIN and non recurrent funds

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We recognise how important the changing workforce is to all aspects of the successful implementation of our strategy and to sustaining high quality services to meet the vision of NHS England’s Five Year Forward View. We know there are some challenges in parts of Yorkshire and the Humber in recruiting GPs, and as they play such a critical role in the workforce, it is a growing concern amongst Doctors that there is likely to be a shortage of GPs in future years.

Other workforce planning issues include the numbers of nurses needed to take up practice nurse roles, and of local significance, the number of qualified nurses working in the care home sector where recruitment and retention is difficult. Our work is summarised below, but features close working relationship with NHS Health Education England and the Commissioning Nurse Leaders Network.

A number of key initiatives will have implications for our workforce:

• We have been successful in our application to become a Vanguard site through NHS England’s New Model of Care Programme. This will focus on the acceleration of the design and implementation of new models of care in the NHS. Our system vision will need a shift to more highly skilled workforce with more capacity in the community.

• We are working with partners to implement the BCF. The workforce is at the heart of these changes and needs better information sharing, co-location of professionals, single assessment, strengthened clinical leadership and an assessment of skills across the health, social care and voluntary sector workforce.

• Our GP practices have already formed one federation and are working on sharing skills, capacity and knowledge across our area working towards a resilient future model of primary care.

• We will engage with Health Education England, the Local Education and Training Board (LETB) and NHS England to work through the implications of the Investing in People Plan (2015/16), and develop a better understanding of the demand line for the primary care workforce, based upon the needs of patients in a primary care setting.

• We are working closely with Health Education England Yorkshire and Humber to better understand workforce supply and demand across the region for both current and new staff into the NHS, and develop a good understanding of who we have working in the primary workforce by adopting the GP workforce tool across all our practices. The CCG has been approved by Bradford University as a suitable placement for student nurses. This provides the opportunity for the CCG to make a contribution to the profession and influence the future workforce requirements.

• We will look to roll out locally the learning from the Academy Health Science Network (AHSN) work on emotional and physical health and wellbeing for NHS staff. We are already signed up to the Mindful Employer programme.

Workforce – “to ensure that our workforce(primary, community and secondary care) is competent and in the right place to enable seamless care”

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Staff satisfaction

We recognise that our staff are our greatest asset. In 2014/15 we continued our comprehensive staff development programme and many of our staff are undertaking further learning and development through the NHS Leadership Academy, Mary Seacole Programme, the Finance Staff Development Programme (FSD) and the Chartered Institute of Management Accountants (CIMA). Our new commissioning team has been set up with quality at the heart of commissioning activity. Every contact with patients count and as a commissioner, we want every experience for patients to be a good one. We monitor our main provider hospitals on any incidents that relate to staffing levels, and closely assess provider staff survey results. This programme will continue in 2015/16.

We have a bi-monthly Staff Engagement Group meeting; our workplace approach is designed to ensure that our employees are aware of and are committed to the CCG’s vision and values, are motivated to contribute to the CCG’s success, and are able to enhance their own sense of well-being. We are currently developing an Organisational Development plan with input from Staff Engagement Group and colleagues from human resources. An all-inclusive plan will include a CCG-wide skills audit to identify learning areas and opportunities, and to utilise current staff strengths in order to continue individual learning. We have recently developed CCG staff appraisal documentation to reference how staff feel they live the CCG’s vision, values and behaviours, as well as how staff feel they help meet the CCG’s Equality and Diversity objectives.

We have applied to be a ‘Two Ticks Employer’ which is for “employers who have made commitments to employ, keep and develop the abilities of disabled staff.” Having this status means we can apply for grants for specialist equipment / adaptations should they be required.

We have registered with the Mindful Employer® which is an NHS initiative run by Workways, a service of Devon Partnership NHS Trust which supports people with a mental health condition to find or remain in employment.

We are delighted to have been accepted to become a member of Dementia Forward, a local organisation supporting people living with dementia and those who care for them. Membership was granted based on a Members Action Plan, which the CCG submitted and commits us to The National Dementia Declaration and delivering those seven outcomes through the following actions:

We aim to achieve this by commissioning, and monitoring the quality of services to diagnose dementia at the earliest time appropriate for the individual person, ensuring the optimal physical and mental health of people with dementia and their carers, including appropriate use and monitoring of medication, working in a co-ordinated way with our partners in social care and the third sector to provide long term monitoring and support for people with dementia and their family. This includes working closely with care homes, ensuring that high quality end of life care is available.

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Strategic priorities

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Urgent care – ensuring safe, effective and timely unplanned care where clinically appropriate

Long term conditions – ensuring people with long term conditions are supported to maintain their independence for as long as possible

Primary care – ensuring primary care is sustainable for the future and scaled up to provide care out of the hospital

Vulnerable people and mental health - improving mental wellbeing and moving towards parity of esteem

Elective care – ensuring that planned care is safe, cost effective and provided in the right location

Health and Wellbeing – working with our partners to prevent ill health

In our Strategic Plan 2014/15 to 2018/19 we identified 6 Strategic Programmes that would be our priority areas for improvement. We have updated on own work last year against our initial milestones and demonstrated our work plan for 2015/16 , linked to the direction of the NHS England 5 Year Forward Plan.

Redesign urgent care

Urgent care – “ensuring safe, effective and timely unplanned care where clinically appropriate” What did we say we would do by the end of 2014/15? • Complete review of urgent care • Develop plans for urgent care centre • Implement Deep Vein Thrombosis (DVT) pathway What have we delivered against our milestones? We have reviewed the effectiveness of urgent care service provision for our frail elderly population. At our Mapping the Future event in December 2014, there was particular emphasis placed upon coordinating services across our range of care providers to improve access and quality of experience for our local population. A number of work streams have been developed that will be implemented throughout 2015/16. We continue to develop our plans for an Urgent Care Centre in Harrogate and Rural District. Our Urgent Care Working Group is using primary and secondary clinicians to develop appropriate pathways of care prior to a decision on the development of appropriate area for the centre. We are currently piloting GP sessions within the hospital emergency department.

The GPs have added capacity to the busy department , whilst ensuring coordination of care between primary and secondary care clinicians. We will evaluate the learning from this pilot , and make decisions regarding long term sustainability. All GP practices have implemented the DVT pathway pilot. This has evaluated well. A revised pathway will be rolled forward so that patients benefit from near patient testing and avoid needing to attend the accident and emergency department. Our Urgent Care Working Group ensures the vision and plans for urgent and emergency care in Harrogate and Rural District incorporate the aims of the national Urgent and Emergency Care Review. We also participate in the West Yorkshire Collaborative Urgent Care Working Group where discussions are under way to agree how to develop an Urgent and Emergency Care network for the area.

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What are we going to do? Our commissioning plans for 2015/16 will be centred around the robust delivery of our Better Care Fund schemes with our key partners across primary care, acute providers and the voluntary sector. These schemes include: • Expansion of the Community Stroke Team . • 7 day implementation of the Clinical Assessment Team at HDFT. • GP and Fast response team support to residents within care

homes. • Voluntary carers support embedded in community teams. Our plans for 2015-16 incorporate commitments set out in the October 2014 redraft of NYCC-wide Better Care Fund plan. The HWB is committed to achieving a reduction of 8.5% non-elective admissions. In the event of changes being proposed to targets, these would be discussed at the HWB, and supported by evidence that the plan can still be delivered and funded. BCF plans for non-elective admissions can be translated into deliverable plans reflected in contracts agreed with acute providers. Operational resilience Like many areas of the country Harrogate and Rural District experienced a surge in urgent activity over the winter period. We worked well with partner organisations to manage the flow of patients effectively and safely through a local bronze command structure and if required silver command. HDFT was the best performer in the region regarding waiting times in the Accident and Emergency department and through our work

with adult social services, there were relatively few patients delayed for their care outside of hospital. In 2014/15 we funded a number of initiatives through our winter funding allocations. These included: • Additional bed capacity at Harrogate District Hospital • Additional GP and nurse sessions within practices • Expanded hours from our Psychiatric Liaison Teams • Additional capacity from Patient Transport Discharge Vehicles Through our multi partnership Systems Resilience Group (SRG) , we will evaluate all these schemes, and prioritise funding in 2015/16. The emphasis will be placed upon quality experience of care for patients outside of the main acute hospital. We will also assess our current GP Out of Hours service and align this capacity to the redesign work within the new models of care framework. Seven day services We are working with our main provider towards implementation of the “Everyone Counts, Planning for patients” guidance for 7 day services. In 2015/16 this will mean using our Service Development and Improvement contract to improve timely access to senior clinical opinion and 7 day access to diagnostic tests and results. We are working in partnership with NHS Improving Quality to drive through this work, and learn from other healthcare providers.

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Long term conditions and integration of community teams – “ensuring people with long term conditions are supported to maintain their independence for as long as possible”

What did we say we would do by the end of 2014/15? • Implement care planning • Complete community services review What have we delivered against our milestones? Since last year, all patients who have been identified as being in the top 4% of at risk of unplanned hospital admission have an Enhanced Care Plan developed with their GP. This Care Plan expanded upon the national Avoiding Unplanned Admissions Directive Enhanced Service (DES), including additional elements to allow greater patient ownership and engagement, such as personal goal setting. Furthermore GPs were tasked with delivering these plans via the Royal College of General Practitioners (RCGP) two visit model, as described in “Care Planning – Improving the Lives of People with Long Term Conditions”. Clearly expanding the population receiving care plans from 2 to 4% of the population doubles the reach initially proposed in the National DES, whilst the more involved approach aims to increase its impact, with respect to unplanned admissions and patient satisfaction, ownership and independence.

The Community Services Review is now completed. This identified a number of immediate actions for our provider trust, and was shared with the public through our AGM in September. The outcomes from this event, as well as the review itself, have fed into our work to develop an integrated care model across health and social care, taking on board recommendations from the Five Year Forward View. A joint vision for this model was proposed following the “Mapping the future” event in December 2014, in partnership with NYCC, provider trusts and the voluntary sector.

And this is our response:

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Harrogate vision for care out of hospital by 2020

And this is our response:

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What are we going to do? Following the “Mapping the Future” event, we are moving forward with delivering the agreed model of delivery across health and social care. In 2015/16 we will implement the work streams which start to move toward this vision. These work streams include; • Reviewing intermediate care provision and access/ discharge

protocols. • Shared core care records between providers, through IT

interoperability or interfaces. • Create a Single point of access for information about, and

referral to, community health, social care and voluntary services.

The model has formed the basis of our Vanguard Bid for new models of care, and is a key part of our collaborative working with partners. Care planning We plan to continue with care planning through 2015. As this is a new and innovative approach, we are evaluating the effectiveness of care planning. Such evaluations will influence the decision with respect to continuing the process or even rolling it out further . Evaluation measures the quantitative impact upon unplanned admissions and hospital activity, as well as more qualitative elements, in accordance with the nationally recognised Long Term Conditions 6 (LTC6) questionnaire. From our initial evaluation, over 8 out of 10 people with care plans strongly agreed or agreed that they had the opportunity to discuss. Over 6 out of 10 people strongly agreed or agreed that they felt confident to manage their own health.

Ticket Home We will prepare a further report exploring the detail of suggested methods of improving discharge procedures including Patient Transport Services, medication, emotional and practical support to return home safely when medically fit. This is linked to the aspiration for the provision of community hubs across the locality that will provide respite/rehabilitation/step up/step down/intermediate care for patients who may otherwise require an acute setting and also to provide specialist clinics, information, advice and guidance to people in the community as a preventative measure. Our long term vision sees the system operating seamlessly between home, hospital and return home, with an automated approach to the order and supply of support services. After ordering, patients will receive details, before they leave hospital, of how their support needs will be fulfilled and, by whom – this is the ‘ticket home’. Whilst a future that provides such a system is several years ahead, as a first enabler to this, we are requiring through one of the local CQUIN schemes, that HDFT ensure that all patients have a clear discharge date and that services are planned in advance to ensure a smooth patient journey and transition from hospital to home as planned. Securing reliable discharge dates that are achievable provides for better service planning, more predictable demand and begins the journey toward our vision for ‘ticket home’.

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Improve mental wellbeing and move towards parity of esteem What did we say we would do by the end of 2014/15? •Implement Mental Health Liaison Service (formerly referred to as RAID - Rapid Assessment Interface Discharge) •Implement one GP per care home •Expand Improving Access to Psychological Therapies (IAPT) •Implement Section 136 pathways •Mental health review What have we delivered against our milestones? An enhanced Mental Health Liaison Service was developed during the early part of 2014 and went live in September 2014 working in the Emergency Department and across the wards. It has been fully staffed since November 2014 and works 7 days a week, 8am to 8pm at Harrogate Hospital and also links to Ripon Community Hospital (Mon-Fri 9am - 5pm). Every care home in our area is now linked to a GP practice and this has been welcomed by the homes. The capacity of the Elderly Mental Health Care Home Liaison Team has been doubled to support people with dementia and delirium. Urgent in-reach from the District Nursing Team has been developed and will be implemented in April 2015 to assist homes to manage acutely unwell residents, as an alternative to admission. We have reviewed the current contractual arrangements for IAPT and a redesigned service model offering better integration between IAPT, mental health and primary care and rapid

access to IAPT services. This has already resulted in a greater uptake, meaning we are on target to deliver our goal of offering 15% of eligible people IAPT by the end of March 2015. We are on track to open a Section 136 suite by June 2015. The required building work and staff recruitment has taken place through TEWV, our mental health provider. We have reviewed the current specification of all mental health services, the resources associated with each part of the service and identified the parts of current pathways where problems occur. This has produced 14 key recommendations from the information gathered from the review that will inform our re-specification of all Mental Health services in 2016/17. In addition we have implemented the sharing of dementia reviews between primary care and the memory clinic, which has moved 800 follow up appointments to primary care and so significantly increased capacity in specialist services for diagnosis and the management of people with complex problems. All of our practices have used the dementia tool and signed up to the new Dementia Enhanced Service to ensure accurate coding of dementia and that people are diagnosed with dementia at the most appropriate time for them. We have also held an educational event about dementia for all CCG GPs and practice nurses. This has built on our past work on improving dementia services and resulted in our CCG having a dementia diagnosis percentage well above the national average, the highest in North Yorkshire, which has attracted National recognition (http://www.england.nhs.uk/2014/12/09/dementia-challenge/)

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What are we going to do? We will continue to provide one GP practice per care home and fully evaluate the effectiveness of this service. Additional resources are planned for the community FAST response team to provide emergency in-reach to care homes in April 2015. We will use the outputs from the mental health review to re-specify the service for 2016/17. We will move the diagnosis of dementia into the community and significantly improve post diagnostic support by attaching a Memory Support Worker to each practice so every patient will have a named Worker who will support them along the pathway from before diagnosis ,through the whole duration of their illness. This will ensure capacity in the system as increasing numbers are diagnosed with dementia, bring services closer to people’s homes, allow closer integration between services and free the specialist services to improve care for people with complex problems and early onset dementia. NYCC and partners have produced a suicide prevention implementation plan in response to the government’s Preventing Suicide in England :a cross-government outcomes to save lives (2012) and the subsequent Preventing Suicide in England: one year on first annual report on the cross-government outcomes strategy to save lives (2014). We will be the joint host for the post of Suicide Prevention Coordinator which will be funded on a multi-agency basis between NYCC, public health and the police. The post holder will be instrumental on delivering on actions within the North Yorkshire Suicide Prevention Implementation Plan.

Parity of Esteem

The priorities we are allocating to mental health to achieve parity of esteem are: • IAPT Expansion – research and scope for further development: eg anxiety/depression in age 65+, young people, long term physical conditions, medically unexplained symptoms. • Personality Disorders – research and scope for further development. • Early Intervention Psychosis – aim is that >50% of patients receive a NICE compliant care package within two weeks after diagnosing a first episode by April 2016. • Community Activity Occupation - support for mental health patients to become more productive, active within their communities to aid wellbeing: paid employment, voluntary work, etc. This requires scoping for further development and a pilot is currently running at Orb Arts in Knaresborough. • Improving access to autism/Attention deficit hyperactivity disorder (ADHD) provision and services. New autism assessment and diagnosis service planned to go live by September 2015. This is part of our significant investment into autism services over the last 2 years. • Improving dementia diagnosis. We are on track to achieve an overall 66.7% diagnosis rate by March 2015, further work is being planned to develop a cognitive impairment pathway with primary care, Dementia Forward and TEWV. This will maintain and enable us to further improve high diagnosis rates.

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We have a number of areas where we recognise the need to further identify and support the needs of young people with mental health problems. We are implementing recommended changes to improve access for diagnosis and signposting to services for children with autism and ADHD. The New Assessment and diagnostic service is in development. We are monitoring our service provider’s compliance with NICE guidance and reviewing diagnostic service quality. There will be a re-provision of the diagnostic service with post-diagnostic pathway workshops being planned. We have co-authored the North Yorkshire County Council All Age Autism strategy. We have held a number of engagement events using appreciate inquiry, including public consultation around improving mental health service provision for children and young people. Our plans to reduce the 20 year gap in life expectancy for people with severe mental illness include: • Joint working with the police, social care and public health to address suicide rates in North Yorkshire. For example, hosting a Suicide Prevention Co-ordinator post. • Ongoing development of the self-harm and poisoning pathway at Harrogate District Hospital through the liaison psychiatry service. • Improving the urgent response to people in crisis. The Crisis Concordat was agreed in 2014 by all key strategic partners including HDFT. By the end of February 2015, the action plan will be agreed by the “Silver Group” at strategic level and a “Bronze Group” established to oversee implementation.

The task for 2015/16 will be to implement the Concordat, including a review of “what works” in reducing the risk of a crisis, and is applicable for everyone including children, young people and over 65’s. The crisis concordat aims to: • Improve access to support before crisis point. • Ensure urgent and emergency access to crisis care. • Quality of treatment and care when in crisis. • Recovery and staying well. These groups will ensure there is robust system resilience plan in place for urgent mental health care. Transforming care for people with learning difficulties

Work is ongoing with local authority colleagues in producing a joint commissioning plan by the end of March 2015 that will assess opportunities to implement whole system change within North Yorkshire and York in the provision of facilities to support people with learning disabilities. We are also implementing a toolkit with GPs to improve access for people with a learning disabilities to general healthcare, and primary care checks. Implementation of Payment By Results (PBR) should also help improve the availability of community services for people with learning disabilities.

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Personal Health Budgets (PHB) have been available since October 2014, with an uptake to date for those individuals eligible for continuing health care funding. We are committed to working with local partners (local authority, mental health provider and people with lived experience/user-led organisations) to develop PHBs in mental health and learning disability. We are submitting an application for the “Getting Started” PHBs in Mental Health Agenda with sign up from all North Yorkshire CCGs. The Getting Started; PHB in Mental Health is part of a wider roll out of PHBs and support offered within Yorkshire and the Humber. The other two themes in the Getting Started programme will be learning disabilities and long term conditions.

Convenient access for everyone We have a number of initiatives that will help us deliver improved access to a full range of services, including general practice and community services, especially mental health services in a way which is timely, convenient and specifically tailored to minority groups. These include: • Review of current NHS provision of autism/ADHD assessment and diagnosis, and the development of a joint All Age Autism Strategy with NYCC. • Expansion of the mental health liaison service. • The community care review highlighted the need to improve access to, and integration of, community services. We will work towards developing a community hub consisting of a range of health (including mental health) and social care services.

• Reviewing urgent care services and access to urgent care for all. • Expanding the ole of Crisis Resolution Team in the Accident and Emergency Department. In line with the Five year Forward Plan, we will work with our mental health provider to ensure the following new mental health access targets are met within 2015/16: • More than 50% of people experiencing a first episode of psychosis must receive treatment within two weeks. • At least 75% of adults referred to IAPT should have had their first treatment session within 6 weeks of referral. • A minimum of 95% of adults referred to IAPT should have had their first treatment session within 18 weeks of referral.

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Children and maternity In 2015/16 we will implement a number of initiatives to enable children and their families to have the best start in life, achieving good health outcomes, and reduce health inequalities. These will include: • Collaborative CCG commissioning arrangement for looked after

children/safeguarding. • Spot purchasing arrangements for Looked After Children aged

16-18 years in partnership with NYCC and HDFT. This enables these vulnerable young people to be invited for a review health assessment.

• A new specification for Child and Adolescent Mental Health Services (CAMHS) for discussion and implementation from April 2015: based on the national CAMHS model specification this covers specialist Tier 2 and Tier 3 services.

• We have agreed proposals for Designated Clinical Officer/Designated Medical Officer role and for the responsibilities of health in the Education Health and Care Plan process. A Local Agreement has been drafted and is now progressing through contracts for all local providers.

• Supported Local Authority colleagues with a series of Autumn Roadshows on Special Educational Needs and Disabilities and the Implications of the Children and Families Act.

• The CCG has financially contributed to a joint speech language and communication needs commissioning project with other local CCGs and Local Authority partners. This was launched in January 2015 and majority of the work will be undertaken in 2015/2016.

In 2015/2016 we will await the Government’s review of maternity services as indicated in the recent Five Year forward plan. This will support the CCG to move forward with our strategic vision of commissioning personalised integrated maternity services for the local population which are safe, effective and of high quality. In collaboration with the North Yorkshire and York Maternity Services Network, consultation on a commissioning strategy for maternity services is scheduled to be undertaken in the summer, and this will inform the CCGs response to the government review expected to be published in the Autumn of 2015.

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Improve elective care to maximise quality, outcomes and value What did we say we would do by the end of 2014/15? • Implement Referral Support Service (RSS) • Commission alternative ear, nose and throat (ENT) and

community dermatology pathways • Review cardiology and diagnostics What have we delivered against our milestones? Since July 2014, we have invested into the RSS. It has been operating so that all referrals to secondary care receive an administrative and clinical triage. This ensures all appropriate information and patient history is passed to secondary care for clinicians to make the best decision of care for patients. This will improve the quality of referrals and reduce the variation in practice across the area. Clinical triage of the referrals started in December 2014 and is starting to have an impact. The service will be evaluated in June 2015 with the aim to show reduced variation in practice. ENT and community dermatology reviews have been incorporated into our work on potential redesign of care pathways identified through the referral support service pilot. Real time activity and referral patterns will underpin the new models. We are participating with HDFT in the review of cardiology services. This was driven by feedback from practices through our soft intelligence tool that pathways of care could be better integrated.

The outcome of the review will lead to service improvements through more streamlined pathways and better patient experiences. The HDFT radiology review is due to report by March 2015. This is expected to lead to improvements in capacity of diagnostics to meet the demands of increasing technological advances in clinical diagnostics. It will also result in improvements in seven day working.

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Improve elective care to maximise quality, outcomes and value

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What are we going to do? Our reviews of elective care referrals and the work developing as part of our initiatives in 2014/15 will lead to a series of changes in year to the patient pathways across a number of specialities. These will include using the evidence from the RSS project to develop new pathways of care where gaps are identified. We are already working with HDFT and the Yorkshire Health Network to review all the dermatology guidelines for referral, which will include complex wound care. Implementing condition specific registers within secondary care to ensure that follow up outpatient appointments are appropriate. This will inform us of current outpatient activity within the hospital and enable the future commissioning of follow up appointments that could be provided in the community rather than in secondary care. A review of physiotherapy and musculoskeletal (MSK) services leading to a re-specification of the services. As a result of the review so far physiotherapy waiting times have reduced dramatically. Funding for assisted conception (including IVF) in line with our policy. This has now been included in our routine commissioning plans.

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Health and Wellbeing – “working with our partners to prevent ill health” What did we say we would do by the end of 2014/15? • Implement ‘Stop Before your op’ pathway • Review the social prescribing project What have we delivered against our milestones? The ‘Stop Before Your Op’ pathway was launched in October 2014 across all GP practices in our area. The objective of the initiative is to signpost patients to the North Yorkshire Stop Smoking Service if they are identified by their GP as requiring elective surgery, for improved health outcomes. As part of our BCF plans, several voluntary sector providers received funds to provide services that connect residents to a broad range of voluntary and community-based services that address issues such as social isolation, limited mobility, and carer support. These sign-posting and referral services are often called “social prescribing” services. Our goal is to complement health and social care services in the community, supporting elderly, vulnerable, and needy residents to remain health and active in their own homes for as long as possible. The voluntary sector organisations involved in these BCF schemes are Age UK North Yorkshire, Age UK Knaresborough, Carers’ Resource, St Michael’s Hospice and the British Red Cross.

We are continuing to evaluate these services. In addition we have: Implemented alcohol prevention work by ensuring Identification and Brief Advice (IBA) is offered to patients when presenting with a condition which is potentially linked to alcohol at hospital. Patients are asked specific questions and are either given brief advice or are referred to a community team for counselling. We have worked with HBC, North Yorkshire County Council Public Health and Public Health England to ensure practice nurses are up to date with Identification and Brief Advice for alcohol, smoking cessation and physical activity. A training event was held in October 2014 to support practices nurses. We are working with Harrogate Borough Council to promote its Health and Active Lifestyle initiatives.

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What are we going to do? We have a number of initiatives that are impacting on prevention. We went through the cycle of the first four steps commissioning for prevention report in developing our strategic plan last year, and we continue to monitor and prioritise projects using the methodology. We aim to further improve ‘Stop Before Your Op’ smoking scheme by working with HDFT to roll it out across outpatient appointments and pre-op assessments. We will be evaluating the project within primary care. We have an ambition to expand this programme into community and mental health services. We continue to support carers as a part of our dementia strategy and as a part of its Parity of Esteem work. We are engaged with NYCC’s plans to implement the 2014 Care Act. In addition to our statutory obligations under The Care Act, we are investing BCF monies into an initiative to embed Carers’ Resource case workers with the community district nursing teams. The aim is to identify hidden carers before a crisis strikes, and provide more integrated, coordinated care across the health, voluntary and social sectors.

We are working closely with Harrogate Borough Council, HDFT and NYCC to shape and jointly commission services for the people of Harrogate and Rural district, through its Public Services Leadership Board which aims to pool resources particularly for the voluntary sector.

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‘Healthy Ripon’ The “Healthy Ripon” project commenced in March 2012, in part as a response to the North Yorkshire Strategic Review, as well as the growing view that the Ripon Hospital building was increasingly not fit for purpose. This started with a World Café event to engage with local people followed up with a stakeholder event to further shape a vision for the future of health provision in the Ripon Community. This described the development of a “Community hub” with the ambition of addressing wider community needs, including disease prevention and individual wellbeing. The focus was on integration of health and social care. A Wellbeing Collaborative was established with our CCG and partners from NYCC, HDFT, TEWV, Harrogate Borough Council and local GPs. The initial focus was on small scale steps promoting health initiatives and improving access to existing services. In March 2013 the collaborative identified the opportunity for a partnership approach to service co-location and delivery as NYCC planned to use an existing site for the development of Extra Care Housing in Ripon. This led to a further event in which a new aspiration and high level concept design for a Community Hub emerged, pulling together Primary Care, supported accommodation (extra care housing), diagnostic and out-patient facilities, social care, rehabilitation, and leisure services.

Current position A need has been identified to ensure healthcare, adult social care and the voluntary sector are more joined up, specifically to prevent unnecessary admissions to hospital and also to support people who are discharged from hospital to regain their confidence in living independently. There is potential to ensure all these services are more integrated by being co-located. There are likely to be clear economies of scale that could be achieved by bringing together the different providers and stakeholders in Ripon in one (or perhaps two) community hubs. At present GP surgeries, HDFT, NYCC and TEWV and Harrogate Borough Council are all providing facilities which overlap with respect to services delivered and facilities required. Potential outcome A health hub on the site alongside Extra Care Housing to allow transformation of facilities and services. Dependent upon the site that is used for this development this may need to be developed in two phases to enable existing services to remain operational. Next steps The Partnership are seeking external support to undertake an options appraisal. Following this the next steps for the project will be determined. Including public engagement and consultation as required.

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‘Healthy Futures Programme’ – West Yorkshire Commissioners The “Healthy Futures programme” is a group of initiatives where the commissioners of West Yorkshire are working collaboratively to improve specific health services - the priority services being cancer, paediatrics, stroke and urgent/emergency care. A strategy for each of these services has been developed and the initiatives support the delivery of these strategies. We are in the “Design and Delivery” phase of the programme. The current work plans are: 1. Cancer services Improving access to diagnostics Early diagnosis and increasing screening 2. Paediatrics project Strategic review of acute paediatric services CAHMS provision for looked after children (out of area) 3. Stroke project Atrial fibrillation strategy to increase the appropriate anti-coagulation to reduce strokes Review of resilience within the hyper-acute stroke units (HASU) to ensure quality and sustainability 4. Urgent and emergency care Options for future designation of major emergency centres

Health inequalities Health inequalities in our area continue. The latest community health profile shows a 6.2 and 4.4 year gap in life expectancy for men and women respectively. Early deaths in men are reducing in line with England whereas in women it is more static. Early deaths from heart disease, stroke and cancer are reducing and these remain our biggest contributors to preventable deaths. We continue to work with our public health colleagues and GP practices on improving uptake of the NHS Health Check which helps embed high impact interventions on health inequalities. We are working with HDFT and local GPs to understand any gaps in diabetes care and improve outcomes. We are committed to working with NHS England to address racial inequalities through the Workforce Race Equality Standard (WRES). The Standard forms the first stage in a process of addressing workforce equality issues. A report will be submitted annually to the coordinating commissioner and published on our website outlining progress against the standard.

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Primary Care – “ensuring primary care is sustainable for the future and scaled up to provide care out of the hospital” What did we say we would do by the end of 2014/15? • Develop our primary care strategy • Medicines optimisation • Develop a co-commissioning model around primary care What have we delivered against our milestones? In 2014/15 we implemented PSA monitoring within GP practices, this ensured patients were able to access this service at their local practice rather than the hospital. We also co -ordinated our GP practice and memory clinic services for dementia patients to avoid unnecessary duplication and follow up. As part of our winter resilience schemes we ensured additional primary care capacity over busy weekend and bank holidays periods. Through development work with NHS IQ and our member practices, we have already identified in our Five Year Strategy four key themes for primary care development locally. The four key themes are: • Workforce development – ensuring we have the right scale

and shape for primary care in the future to cope with more care out of hospital

• Improving mental health – to collaborate better with secondary care to improve diagnosis and management of people with mental health conditions.

• Reducing avoidable admissions – building on our current care planning programme which already goes further than the national contract, to shift the balance from unplanned care

• Improving access – ensuring patients have access to high quality primary care improving experience and quality of care out of hours.

We have continued to maximise our efficiency in prescribing. We are implementing a medicines optimisation module in our GP practices which will enable near patient switches to more cost effective prescribing.

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What are we going to do? On the 9 January 2015 the CCG applied to implement delegated commissioning arrangements setting out our commitment to improving the quality and capacity of primary care to fulfil our vision of a sustainable health and social care system. Being able to shape primary care medical services through delegated commissioning arrangements will mean integration between all elements of health services becomes a reality in our area. We have established a Primary Care Commissioning Committee and undertaken robust governance and conflicts of interest management processes during 2014/15 to ensure we are ready to take on this role. Delegated commissioning will allow us to progress the themes currently in our plan and in addition this will enable us to take a holistic approach to commissioning end to end pathways which will lead to improved quality of care; integrated of services, reduced duplication, engaged whole system approach including integrated personalised commissioning. Patients will experience a number of benefits including: • More opportunities for shared decision making, meaning

patients are more informed and involved in their care including personal health budgets, allowing choice and flexibility of services.

• A greater focus on prevention through care planning • More care delivered closer to their homes as capacity within

the community increases

• A more flexible integrated community service system to cope

with the demographic changes within our population as it becomes older.

• An even greater emphasis on primary care teams managing long term conditions.

Our early priorities are to: • Determine Personal Medical Services (PMS) premium

reinvestment programme. • Review delivery of all the enhanced services that GP practices

provide so that there is equity across all practices. • Review and evaluate Quality and Outcomes Framework (QOF)

and Directed Enhanced Schemes (DES) activity to ensure effort is targeted appropriately for our population and determine and agree any re-specification.

• Maximise the key role of primary care in our vision for integrated community services.

• Work with our local GP alliance to develop workforce and sustainability plans for primary care.

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Summary Over the last 12 months the CCG has been able to demonstrate delivery of our year 1 milestones within the 5 year Strategic Plan. This has been achieved through engagement with our public, strong clinical leadership and collaboration with our key partners. In 2015/16 this strategic journey will continue at a pace. As a result of our key work streams and priorities this year our public can expect: • A more integrated system of care , including sharing of care

records and single point of access. • More care outside of acute hospital. • An improved quality in the pathways of care for both urgent and

elective patients. • Lower waiting times and parity of esteem for mental health

patients.

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Contact us

Harrogate and Rural District Clinical Commissioning Group 1 Grimbald Crag Court St James Business Park Knaresborough HG5 8QB Tel: 01423 799300 Fax: 01423 799301 Email: hardccg.enquiries@nhs.net Twitter: @HaRD_CCG

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www.harrogateandruraldistrictccg.nhs.uk