Wandsworth CCG Developing the Wandsworth Operating Plan 2017-19

1. Wandsworth CCGDeveloping the Wandsworth Operating Plan 2017-19 A response to NHS Operational Planning and Contracting Guidance 2017 -2019

2. 2017-19 Planning Process • NHS Planning Guidance requires us to produce two separate but connected plans: • 1. A Sustainability and Transformation Plan (STP) through to 2020/21 • This is an ambitious blueprint for the South West London local health system covering all areas of CCG and NHS England commissioned activity, better integration with local authority services, including, but not limited to, prevention and social care. 2. A two year Operational Plan for 2017-19 • Developed by Wandsworth CCG as an organisation-based plan but consistent with the STP. The requirement is for a shared and open-book operational planning process covering activity, capacity, finance and deliverables from the STP.

3. The Five Year Forward View Planning ProcessNHS Planning Guidance requires us to produce two separate but connected plans: Planning Levels for SWL • a five year Sustainability Transformation Plan, which is placed based and drives the Five Year Forward View • a two year Operational Plan, organisation based demonstrating how the STP will be implemented in the first two years STP Level SWL Croydon Kingston & Richmond Wandsworth & Merton Sutton Sub STP Level (SRG Level Croydon Merton Kingston Richmond Sutton Wandsworth CCG Level Locality Level CCG Localities and GP Practices

4. CCGs Working Collaboratively Across South West London • Wandsworth has agreed with other CCGs in South West London to introduce a new operating model to strengthen collaborative commissioning arrangements amongst the CCGs: • The primary focus of the operating model is on consolidation of accountability and senior leadership roles, with four CCGs including Wandsworth appointing a single Accountable Officer and Chief Financial Officer (joined by Sutton CCG in April 2018) • Wandsworth and Merton CCGs will have a shared local leadership team • The CCG remains a separate statutory body with its Membership of Wandsworth’s GP Practices and its Governing Body, and will continue to work with the other CCGs in South West London to exploit the benefits and opportunities of working at scale when appropriate

5. The Wandsworth Operating Plan • This plan describes in broad terms: • our approach to delivering the NHS Constitution targets and the national must-do priorities • our approach to delegated responsibility for commissioning Primary Care Services • our Commissioning Programmes to take forward implementation of the STP in line with the three themes of proactive, planned and urgent care. • continued work, as host commissioner, to align our plan with St. George’s including the Trust’s financial recovery

6. Key Changes to the way we Commission General Practice • Wandsworth CCG has Delegated Commissioning responsibility for general practice services and the functions associated with this. These functions include: • GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing branch/remedial notices, and removing a contract) • Newly designed enhanced services and designing local incentive schemes as an alternative to QoF • Ability to establish new GP practices in an area • Approving practice mergers • Making decisions on discretionary payments

7. Wandsworth Strategic Priorities • Doing core business well – delivering better care and a healthier future for Wandsworth through our clinical leadership, robust commissioning processes and excellent staff, focussed on delivering quality services and improved outcomes for patients. • Transforming primary care – optimising impact and outcomes for patients through delivery of excellent primary care to all people registered with a Wandsworth GP. • Commissioning prevention and social care services– where it will generate an increased health benefit for our population. • Reducing health inequalities – the CCG will commission differentially to address specific population need where it will reduce health inequalities.

8. Operating Plans The Planning guidance sets out the must do priorities for 2017-19 Operational Plans

9. Operating Plans - nine key ‘must do’s’ (1/2)

10. Nine key ‘must do’s’ (2/2)

11. Delivering through Commissioning Programmes • Our commissioning priorities are delivered through eight programmes of work, focusing on delivering proactive, planned and urgent care in line with the STP.  This programme approach enables us to define clear outcomes and track progress for each programme.  • We have agreed joint commissioning programmes with Wandsworth Borough Council where we have a shared interest in delivering integrated care to people with long term or complex health needs or working together to deliver preventative care. • Our approach incorporates into every commissioning programme the key principles of: • Transformation • Integration • Personalisation • Ensuring value for money from the services we commission • Engaging with our patients; placing their experience of care at the heart of our decision making • We work through the commissioning programmes to commission differentially; addressing specific population need where there is evidence it will reduce health inequalities.  This is a reflection of our strategic priorities and a key priority in the Joint Health and Wellbeing Strategy.

12. WCCG Commissioning Programmes Executive Summary CCG/Local Authority Joint Programme CCG Programmes Older People Urgent Care Planned Care Mental Health Primary Care Children Promoting Good Health Learning Disabilities Diabetes CMHT Primary Care Quality Complex Disability OOH/111 Complex Disabilities/CHC Voluntary Sector Reablement COPD CAMHs Perinatal Mental Health Non elective pathways Primary Care Strategy Dementia Community Empowerment Adolescent Transition CVD Prevention initiatives IAPT Care Homes Access & Equity Carers Admission avoidance Primary Care Delivery MSK Complex family therapies Community therapies Frailty pathway SocialCare Prevention Initiatives Trauma Individual Placements Diagnostics Prevention initiatives Acute Paediatrics EOLC Reducing Inequalities Complex Community Placements Ophthalmology /Dermatology Acute inpatient EHCP Intermediate Care Cancer Education & Care Planning to 25+ IT, Capital Planning, Estates & Medicines Management Commissioning Levers & Financing These key enablers support all of the programmes Stakeholder Engagement and Communications Aligning with the Strategic Transformation Plan Delivering the London Health Commission recommendations

13. Proposed Governance for the Wandsworth and Merton Transformation Programme SWL STP Programme Board Organisational Boards (CCG, Provider) Local Transformation Board (LTB) Emergency Care Delivery Board Planned Care Delivery Board SWL Planned Care SRO • Priority programmes • STP trajectories • Combined CIP and QIPP Right Care, Best Setting SW London Collaborative Right Care, Best Setting Leadership Group Flow Programme Outpatient Transformation Programme • Discharge to assess • Integrated discharge • Intermediate care • Locality Teams (ECP) • ED streaming • Demand management Key – SWL STP governance Key – individual governance Key – SGH&CCGs governance Key – LHE governance

14. PROMOTING GOOD HEALTH Prevention is the golden thread that runs throughout all our commissioning programmes. We will commission preventative and self-care services to help us deliver better care and a healthier future for Wandsworth • Planning guidance : • The Five Year Forward View and STP outline a vision for a sustainable NHS placing a clear emphasis on increasing the focus on prevention; moving from acute episodic care towards prevention, self-care, self-management and integrated and well-co-ordinated care to cope with an aging population and the increased prevalence of chronic diseases. There is also a clearer and greater focus on better utilisation of Social Prescribing programmes and making self-management initiatives more wide scale. • Work Programme • Working with Wandsworth Council and our partners we are developing a joint programme that is informed by the development of the five year Joint Health and Well-Being Strategy for a Wandsworth focus on: • Directing resources to people with greatest need • Reducing lifestyle associated risks to include targeting high-risk groups • Systematic primary, secondary and tertiary prevention to include targeting areas of health inequalities • Engaging with people who are not reached by mainstream services by working with communities, community leaders and the charity and voluntary sector ensuring they are visible and easier to reach. • Empowering patients through our Self-Management Programmes and access to the Wandsworth Well-being Hub • Working harder to ensure seldom heard and hard to reach groups have equity of access to services as well as having a voice which would allow them to input and shape services. • Creating more resilient individuals, communities and populations through lifestyle schemes and early intervention programmes

15. Promoting Good Health Delivering in 2017-19 • Key Initiatives: • The Promoting Good Health Programme is made up of a series of smaller projects that all have the primary aim of promoting good health, creating a resilient community, promoting the Voluntary and Charitable sector and reducing healthcare usage through the promotion and increased utilisation of self-management for those living with one or more long term conditions. The Programme consists of the following key initiatives that all focus of promoting good health in a wider sense but also have a particular focus: • The Wandsworth Self-Management Service – The service promotes self-management amongst participants and healthcare professionals. It delivers this through a series of courses with internationally recognised Expert Patients Programme being used to underpin the work. • The Wandsworth Wellbeing Hub – The Hub is an impartial service that is designed to enable healthcare professionals to socially prescribe as well as promote the Third Sector by creating a single portal for which an individual can access nearly all Third Sector services. • Developing Community Resilience – The project is being carried out in conjunction with a group of Third Sector partners and focuses on supporting the local population of Roehampton. (The Furzedown Project, Katherine Low Settlement, Tooting Graveney, Balham Autumn Rose Club) have been supported to develop and implement a range of activities that are orientated toward maintaining and improving health. The activities are targeted toward the needs of the local population served by the Wellbeing Centre. A thorough evaluation of outcomes is currently being developed in conjunction with Kingston University. • The Voluntary Sector Coordinator – The CCG are working with the Wandsworth Care Alliance to develop a model where there is a coordinator that can help act as a conduit between the CCG and the Third Sector. This will allow the CCG to commission services more appropriately based on the needs of the population but will also help the CCG grow and build the Third Sector helping the prevention and early intervention agenda. The project has also created a more trusting and transparent relationship between the sector and CCG, as well helping align priorities of the Local Authority and CCG. • Outcomes: • Reduce health inequalities and increased health literacy • Reduce the dependence people with multiple, complex and long term conditions have on their healthcare professional by helping them develop the skills to self-manage and self-care • Ensure that people are able to select/access their services appropriately by making positive and informed choices • Encourage healthcare professionals to better utilise self-management by training them in the basics and showing them the benefits that can be achieved to both the individual and the health economy. • Develop a culture of shared decision making and supporting self management • Increase early intervention and prevention through the use of the Wellbeing Hub, • Develop supported individuals, especially the vulnerable, to make lifestyle changes through schemes such as weight management and smoking cessation. • Promote the Third Sector by making them more visible and easier to access through the portal on the Wandsworth Wellbeing Hub. • Identify, through an evaluation, how running local initiatives can positively impact the local population as well as support organisations local to the area. • Create a voice for the Third sector allowing more effective working with the CCG, ensuring that schemes are tailored to the population and are value for money. • Helping individuals access services and initiatives run by their local charities and organisations in order to reduce isolation and increase independence of those of our population who are; elderly and frail, living with one or more long term conditions and those who need other long term support.

16. MULTISPECIALTY COMMUNITY PROVIDER (MCP) The MCP care model will evolve from the learning from the 14 MCP vanguards about what does and doesn’t work. We want to integrate primary care and community acute services, dissolving the boundaries that prevent joined-up care that is preventative, high-quality and efficient. The MCP allows us to create a new system of care delivery that is designed around the health of the population. Planning guidance : The Five Year Forward View outlined a need to create new models of accountable care provision such as a MCP, as included in the development of almost all STPs.By focusing on prevention and re-designing care, the MCP contract can improve health, achieve better quality, reduce unavoidable hospital admissions and elective activity, and unlock more efficient ways of delivering care. Work ProgrammeWorking with Wandsworth GP Federation as the Lead Provider for the MCP contract, we are delivering a MCP model of care from 1st April 2017 which will involve: • Transformation of Primary Care and Out of Hospital Care across Wandsworth • Combining primary care and community-based health and care services to be delivered by the GP Federation • Incorporating a wide range of services and specialists wherever there is a patient need to do so • Allowing health and care professionals to work together with and for patients • Ensuring agencies across health and social care are connected and co-ordinated to deliver multidisciplinary care for patients at home and in the community

17. Multispecialty Community Provider (MCP) in 2017-19 Key Initiatives and outcomes in 2017/18: The Federation will deliver the MCP specification for a seven year period from 1st April 2017 using a phased approach; the specification will evolve over time as learning is captured and evaluated • Phase 1 services to commence from 1st April 2017Primary Care Enhanced Services – Planning all Care Together (PACT)The PACT enhanced service identifies patients at risk of hospital admission and incentivises GPs to pro-actively manage their care.Primary Care Enhanced Services – DiagnosticsFour diagnostics services have been bundled into an overarching specification to ensure a standardised, efficient service, which all patients across Wandsworth can access: 24hr Ambulatory Blood Pressure Monitoring, 12-lead Electrocardiogram, Phlebotomy, Spirometry.Enhanced Care Pathway (ECP)The ECP will support the 3000 frail older patients on the Community Adults Health Services caseload, initially focusing on 500 of the most complex patients at highest risk of deterioration.Primary Care Quality ContractThis borough wide contract operates at individual practice level to identify and resolve gaps in quality, supporting GP practices to deliver high quality patient care.Learning Disability Primary Case ManagementThis service will reduce health inequalities by improving access to fully integrated Primary Care for people with learning disability. • Phase 2 services to commence from 1st October 2017Community Adult Health Services (CAHS)The CAHS model will link systems and health professionals to work together to improve the delivery of care for people in the community.Better at Home ServiceThis new support service will enable individuals to remain independent in the community and will assist in helping patients to adjust at home following hospital admission, requiring collaboration with Community Services and the voluntary sector.Key Initiatives and outcomes in Future Years (2018/19 and beyond):Phase 3 servicesEnd of Life Care Co-ordination Centre (EOLC)The EOLC Centre will improve the coordination and utilisation of EOLC services, providing more joined-up care for patients, families and carers, and freeing up clinical time for health and social care professionals.Community Based Care Models for Long Term Conditions (LTCs)The current redesign of diabetes services being undertaken by the CCG will be continued under this service, moving the focus of diabetes services out of hospitals to be led by primary care, with support from diabetes consultants and diabetes specialist nurses, creating a streamlined, smooth care pathway.

18. PRIMARY CARE Primary Care transformation is a strategic priority to achieve a sustainable, high-quality health system. At the heart of this transformation is the need to support General Practice to achieve a series of specifications set out in the London Strategic Commissioning Framework for Primary Care. The vision for primary care in South West London, through the STP, is to deliver these specifications, which are structured around three themes of co-ordinated care, accessible care and pro-active care; delivery across London is expected within the next five years. Primary Care will also prioritise in delivering the areas set out in the General Practice Forward view, including 10 High Impact Actions for General Practice. • Planning guidanceAs set out in the NHS Operational Planning and Contracting Guidance, the General Practice Forward View states that CCGs should plan to spend approximately £3 per head in 2017/18 and 2018/19 for practice transformational support; this funding will be used to deliver on work programmes to transform primary care. Alongside this, Primary Care will also deliver on the priority areas set out in the General Practice Forward View; Investment, Workforce, Workload, Practice Infrastructure and Care Redesign, alongside supporting General Practice in delivering the 10 High Impact Actions. Work Programme • The CCG’s work in Primary Care for ‘17/18 and ‘18/19 will be focussed on delivering the Strategic Commissioning Framework for transforming Primary Care in London. The framework sets out specifications to be delivered, structured around themes of co-ordinated, accessible and pro-active care. • The General Practice Forward View Primary Care Plan covers a number of key areas to develop resilience, sustainability and transformation in primary care, with key enablers being: • Extended access • Online Consultations • Provider Development • Training care navigators and medical assistants • PMS Plan • Workforce • A set of Primary Care Commissioning Intentions, for the next two years, was published in September 2016, framed within three main areas: • Deliver the specifications in the London Strategic Commissioning Framework for Primary Care (line for each theme co-ordinated, accessible, pro-active) • Development of a Multispecialty Community Provider Model • Ensuring delivery of high quality Primary Care

19. Primary Care Delivering in 2017-19 Key Initiatives for Primary Care: • Extended access – Wandsworth GP Federation are working to develop 8-8, 7 day access to general practice, ensuring patients can access routine and same day appointments. • Online Consultations – this will enable patients to interact remotely with their practice, offering the opportunity to contact a GP for new and follow-up consultations, provide updates on their condition and receive advice or signposting to additional support. • Provider Development – the General Practice Resilience Programme supports practices in becoming more sustainable and resilient. A Resilience Plan is being developed to ensure practices which are in most need of this support receive it. • Training care navigators and medical assistants – reception and clerical staff will be trained to take on enhanced roles, developing skills in active signposting and letter processing to deliver efficiencies and free up GP time. • PMS Plan – the PMS review will be linked to the GP Forward View priorities, including routine and same-day access. • Workforce – Wandsworth GP Federation have become a CEPN to deliver training and education to primary care staff. A Workforce Strategy was developed with the CCG, setting out education and training needs to support clinical and non-clinical staff through the transformation of primary care. Outcomes: • Delivery of the specifications from the Strategic Commissioning Framework for transforming Primary Care in London to provide proactive, accessible and coordinated care for patients, improving patient experience. • Deliver on the set of Primary Care Commissioning Intentions over the next two years. • Reducing emergency admissions to secondary care and excess bed days by providing proactive primary care. • Providing equal access to services in the community for all patients. • Delivering priorities in General Practice Forward View, with a view to invest and commit to strengthening general practice in the short term and delivering a sustainable transformation of primary care for the future, as well as delivering the 10 High Impact Actions.

20. URGENT CARE • Increasing pressure on urgent care services leads to poorer access and longer waits for patients. This in turn results in longer waits in A&E departments and also has a knock on effect for planned surgery. This is not the experience that we want for patients in Wandsworth • Planning Guidance: • Deliver the four hour A&E standard, and standards for ambulance response times including through implementing the five elements of the A&E Improvement Plan. Implement the Urgent and Emergency Care Review, ensuring a 24/7 integrated care service for physical and mental health is implemented by March 2020, including a clinical hub that supports NHS111, 999 and out-of-hours calls. Deliver a reduction in the proportion of ambulance 999 calls that result in avoidable transportation to an A&E department. • Work Programme • The CCG’s urgent care programme will focus on: • Working with colleagues across SWL to move towards delivering urgent care services which are available consistently and achieve effective outcomes for all patients. • Ensuring the London facilities standards for urgent care centres are fully implemented so as to ensure there is a consistent urgent care walk-in offering for the public, reducing confusion and ensuring patients receive the right care, the first time. • Work with London Ambulance Service (LAS) to make sure that patients only need to be taken to hospital when that is clinically appropriate and that handover into community based services is consistent and effective. • Ensure primary care is the first point of contact for patients requiring urgent care. Increasing urgent care access and access routes into general practice. • Increasing the number of patients at St George’s Hospital that are identified and managed ambulatory. This means more patients will be assessed, diagnosed, treated and able to go home the same day, without being admitted overnight, thereby reducing unnecessary hospital admissions

21. Urgent Care Delivering in 2017-19 Ambulatory Emergency Care (AEC) - Working with St George’s Hospital to implement the SWL AEC specification (12 hours a day, seven days a week service), building on and sustaining the work delivered as part of the 2016/17 AEC CQUIN. The specification aims to increase the number of patients that are identified and managed ambulatory, resulting in the reduction of emergency admissions at the hospital. A&E Streaming - We will be working with St George’s Hospital to improve the streaming pathways at triage. This will include identifying and navigating more patients back to their local GP (when appropriate), and fast tracking patients into any appropriate urgent specialist assessment units (e.g. ambulatory care, SAU, frailty) Ambulance demand management – we will be working with LAS to manage demand through a number of the conveyance reduction initiatives. This will be achieved by improving the skill mix of paramedic staff to facilitate ‘see and treat’ and ‘hear and treat’, the identification of frequent callers and the development of care/escalation plans to reduce avoidable call outs for this cohort of patients, and streamlining the number ambulance alternative care pathways to make sure they are effective and relevant • Outcomes: • Reducing non-elective admissions • Increase navigation of patients who can be treated in primary care back to local practices, reducing A&E attendances • Reducing ambulance conveyances into hospital and ambulance call-outs

22. Urgent Care Delivering in 2017-19 (continued) • Integrated Urgent Care - Direct booking from integrated Urgent care (IUC) service into general practice. The IUS service looks to bring NHS 111 and Out of Hours GP services closer together to provide patients with a “new front door” to urgent health care services. The service was recently commissioned across south west London (September 2016). A key clinical standard of the service is the ability to directly book into GP and GP Out-of hours appointments. The CCG plans to work with the provider and local practices to pilot and evaluate this function of the service • Urgent Care Centre - The CCG will work with local providers to deliver the new London facilities standards. The standards recommend for current walk-in centres, minor injury units, and GP led health centres to be transformed into Urgent Care Centres (UCC) where possible, with sites providing walk-in urgent care 16hrs a day, offering access to diagnostics (e.g. x-ray, bloods). We will work with SWL colleagues to undertake a facilities stocktake that considers the current urgent care service offer, and the potential changes to this provision in response to the London facilities specifications. Resulting in a coordinated SWL plan for the designation of U&EC facilities, ensuring patients have equitable access to such centres across SWL. • Transforming Primary Care - to enhance primary care services; providing patients with increased access to a GP, 12 hours a day, 7 days a week. We will be working closely with our primary care colleagues to deliver key access specifications which could have a more direct impact on attendance at A&E, these include: Same day access, Extended opening time, deliver more urgent care in local practice • Outcomes • Provide improved access to a well-connected and clearly defined integrated urgent and emergency care system in Wandsworth • Delivering new clinical models of care that supports patients to be proactively managed in the community and at their local practice, reducing urgent and emergency care demand • Provide a consistent urgent care centre walk-in offer, which is equitable for all our patients • Increasing urgent care and general access to a local GP, subsequently reducing A&E attendances

23. Planned Care Programme aim: To reduce outpatient activity at acute trusts by better treatment and management of patients Work Programme Working with Merton CCG, St. George’s and other local providers on a joint programme of work including: • Diabetes • Podiatry • ENT • Gynaecology • Musculoskeletal services • Anticoagulation service provision • Ophthalmology • Procedures of Limited Clinical Effectiveness

24. Planned Care Programme Delivering in 2017-18 Key Expectations in 2017/18: •  The programme will deliver various outputs in order to reduce reliance on hospital based outpatient care. Some of the work programmes are whole system changes, others rely upon increased work up of patients in primary care prior to referral: • Diabetes – a whole system service redesign moving services into the community with the patient's case load being managed by the GP rather than community services or consultants. Including a service redesign of Podiatry to deliver community services integrated with acute services across South West London with a view to establishing a 7/7 virtual service. • Gynaecology - increased work up of patients in primary care prior to referral including undertaking diagnostics. Patient pathways established for Heavy Menstrual Bleeding, chronic pelvic pain, infertility and urinary incontinence. Redesign of the uro-gynaecology service with significantly reduced steps in the patients pathway with a simple service delivery model. • MSK - redesigned patient pathways for lower back/spine, knees, wrists/hands to support GPs referring to the right place at the right time and making good use of community contracts. • Ophthalmology - Introducing a community ophthalmology service as a satellite service to that at the acute trust at a preferential tariff. • Anticoagulation - Providing anticoagulation services in the community including initiating DOACs in primary care. Repatriation of patients from secondary care to primary care for anticoagulation management • ENT - reduce unnecessary procedures of limited clinical value initially for tonsils by empowering consultants to refer back referrals that do not adhere to the agreed policy. Reduce the number of patients having ear wax removed in secondary care. • POLCVE - educating primary care in the thresholds and processes of procedures considered of limited clinical value to maximise the South West London Effective Commissioning Initiative; providing pathways and guidance and working with the main acute provider to empower consultants to understand referral requirements.

25. Planned Care Programme Outcomes Expected Outcomes: • Reduced outpatient appointments at acute trusts • Reduced amputations • Reduced admissions for complications of diabetes • Reduced procedures considered of limited clinical value • Increased initiation of anticoagulants in primary care • Improved patient outcomes Planned Care Long Term Plans Long Term Plans • Improve primary care identification of cancer • Neurology service redesign  • Improved respiratory services • Improved dermatology services

26. LEARNING DISABILITY • We want to improve the lives of people with a learning disability. We will do this using our commissioning levers to support people to be more independent, have healthier lives and have more choice and control: and most importantly by listening to our patients and carers tell us about what works for them. • Planning Guidance • Deliver actions set out in local plans to transform care for people with Learning Disabilities, including implementing enhanced community provision, reducing inpatient capacity and rolling out care treatment reviews in line with published policy. • Work Programme • Implement Personal Health Budgets for people with learning disability • Commission primary care services that will improve physical health of people with learning disabilities to optimise impact and outcomes for patients through delivery of excellent primary care to all people registered with a Wandsworth GP • Ensure that all commissioned services have service specifications that reflect the nature and cost of what they are delivering, ensuring providers are held to account for delivery of high quality services. • Develop local processes that will strengthen delivery of the Care Treatment Review process, bring families, professionals and advocates together to agree care plans for complex patients • In partnership with South West London Commissioners ensure that the needs of Wandsworth patients are reflected in the priorities of the five year Sustainability and Transformation Plan (STP) • Explore commissioning opportunities for developing community based service models that supports re-provision of care for service users from inpatient hospitals to the community and provides an intensive support service in the community to meet people’s needs in times of crisis and enable people to remain in their home or usual place of residence and avoid hospital admissions

27. Learning Disability Delivery in 2017-19 • Wandsworth CCG has a focus on improving services for people with Learning Disability (LD) as a key commissioning programme. • Working with patients and carers, and recognising the national priority of the Transforming Care programme, the CCG will continue to build on the work from 2016/17 to: • Enhanced community provision to deliver integrated provision around the needs of patients; identifying patients with the most complex needs and ensuring patients can be supported in the community wherever possible • Community Treatment Reviews: continue the rolling programme of CTRs , ensuring that patients are cared for by enhanced community services wherever possible and admitted to hospital type settings of care on an exceptional basis. The CTR process maintains a focus on getting patients back into the community, with family and support networks, as soon as possible after any hospital admission. • Roll out of personal health budgets to deliver our commitment to offering Personal Health Budgets (PHBs) to people with LD as a way of increasing the personalisation of services, offering patients and families choice and driving improved outcomes and quality of life for people with a learning disability. • Market management: The CCG intends to develop partnerships with a smaller number of providers to ensure patients get optimal care wherever and whenever required. • Improved outcomes include: • More integrated, rapid response community services that reduce the number of people with a learning disability who need a hospital type placement, and reduces the length of stay for those who do require a hospital placement • Improved control and quality of life for those patients accessing a personal health budget • Improve transition for those moving through adolescence to adulthood to ensure that seamless, integrated care is available throughout to patients and carers

28. MENTAL HEALTH We know that mental ill health is the single largest cause of disability and one of the greatest areas of health inequality. People with severe and prolonged mental illness currently die on average 15 to 20 years earlier than the wider population. • Planning Guidance: • Achieve and maintain the two new mental health access standards: more than 50% of people experiencing a first episode of psychosis will commence treatment with a NICE approved care package within two weeks of referral; 75% of people with common mental health conditions referred to the Improving Access to Psychological Therapies (IAPT) programme will be treated within six weeks of referral, with 95% treated within 18 weeks. Continue to meet a dementia diagnosis rate of at least two-thirds of the estimated number of people with dementia. • Work Programme • We continue to develop the Primary Care optimum model which was linked to the reconfiguration of the Community Mental Health Teams and the development of a Single Point of Access for mental health services. • The Primary Care Plus service development (primary care liaison) commenced it’s first phase of development in 2016/17 and will roll out to its second phase in 2017. • Talking therapies – a re-modelling and procurement of IAPT and digital MH services has been completed and implementation of the new Talk Wandsworth service will commence in April 2017. • Continue to develop services to address health inequalities, particularly amongst BME and LGBT communities within Mental Health services.

29. Mental Health Delivering in 2017-19 • Programme for 2017/18 • Ensuring Parity of Esteem for mental health services; uplift for MH budgets in line with allocation growth, taking into account mental health policy issues in FYFV for mental health. • Achieving access target -  50% of people experiencing a first episode of psychosis to receive treatment within two weeks. To deliver this locally a Service Delivery and Improvement Plan (SDIP) was linked to additional funding in the Mental Health contract. • Within IAPT, 75% of adults to have first treatment session within 6 weeks of referral and 95% within 18 weeks of referral. The newly procured Talk Wandsworth service will include this requirement, alongside the existing national targets for access and recovery. Talk Wandsworth will also include local incentives to improve waiting times further as well as to improve access for priority harder to reach groups. • Roll out Primary Care Plus to all GP localities from Autumn 2017. Continue implementation of CMHT services and Single Point of Access to improve access, assessment and recovery functions. Continue transformation work to re-model Crisis and Home Treatment Team services linking closely to the Mental Health Trust modernisation plans. •  Implement recommendations from the review of Personality Disorder services within SWLSTG, encompassing Service User Network (SUN project) • Urgent and Emergency Care and Crisis Care Concordat which includes the further development of Street Triage services across SWL and continued use of MH CQUIN to fund the Psychiatric Decision Unit pilot, which was implemented in November 2016 and Crisis Café due for implementation in April 2017. • Sustain work to reduce health inequalities and prevent mental ill health/promote wellbeing - expanded wellbeing services in primary schools, community resilience through community champions, network of family care, expansion of BME peer support and developing training for Muslim women, Well family programme, MH and physical exercise pilot programme, LGBT and MH support project and suicide prevention training in primary care. • Work with Local Authority to transform through procurement of the 24 hour rehabilitation and peripatetic hostels. Outcomes IAPT - more people being seen earlier and are recovering from anxiety and depression, including a particular focus on targeted groups within the community. Re-modelling of CMHT, investment in Early Intervention Services and Primary Care Plus development to improve the wait for access into secondary mental health care, meaning that those needing services are seen and treated quicker. With additional plans to streamline access points, improve discharge and develop primary care liaison to further improve this. Improving wellbeing and strengthening prevention in BME communities through impact of extended mental health services in primary schools, development of community networks through champions, MH expert faith leaders and improving experience on inpatient wards. Suicide prevention strategy has improved understanding of key local determinants around suicide and has developed actions to reduce the rates of suicide

30. CHILDREN We are working with our partners in Wandsworth Borough Council and primary and secondary care to ensure equitable services for all young people led by their needs, with a flexible delivery model to improve outcomes and support and empower children, young people and their families to manage their care and lead longer, healthier lives. • Planning Guidance: • Local commissioners to set out how they will put the Children and Young Peoples Mental Health Plan into practice • Work Programme • CAMHS – implementation of the CAMHs Transformation Plan developed in line with the principles of Future in Mind • Transforming Care – Developing community based service models for Children with Learning Difficulties with challenging behaviour to reduce inpatient admissions • Children with Complex Needs – redesigning services to develop an integrated service model delivering personalised care. Redefining the local offer and enhancing joint governance arrangements with the local authority to ensure seamless care. • Roll out the Personal Health Budget pilot for children receiving continuing healthcare • Children’s Therapies – rolling out of the parent training across the borough and all ages. Expanding the redesigned service. • Children Looked After – ensuring a high quality health assessment service to support the health and wellbeing of this vulnerable group

31. Children Programme Delivering in 2017-19 • Key programmes for delivery in 2017-19 • Continues roll out of the CAMHS Transformation Plan- a 5 year programme of investment focusing on key initiatives to enhance Early Intervention / Prevention, Improve access to CAMHS services, Targeting Vulnerable Children and improve access to CAMHS for children with Eating Disorders. • Transforming Care – working with community based providers to enhance community provision to deliver integrated services based around the needs of patients; ensuring treatment within the community wherever possible. • Children with Complex Needs – developing integrated service delivery models; working with Wandsworth Borough Council to develop a shared understanding of the level of complexity of need and designing and commissioning services, with the support and involvement of service users and their families, from a range of providers . • Transition - Improve transition for those moving through adolescence to adulthood to ensure that seamless, integrated care is available throughout to patients and carers. • Personal Health Budgets. Continued roll out of the local offer to all eligible children and families. • Children’s Therapies – rolling out of parent training across the borough and all ages. • Children Looked After – ensuring a high quality health assessment service to support the health and wellbeing of this vulnerable group Outcomes CAMHS - Improving access to services, improving emotional well-being and ensuring early intervention to address emerging mental health issues. Transforming Care – reduction in residential care placements and a more integrated model of service delivery, providing seamless care for the child and their family. Children with Complex Needs – Services designed and delivered with the involvement of service users that meet the assessed needs of the child. Integrated decision making to ensure a seamless service provision. Personal Health Budgets – personalised services that deliver control & choice in the delivery of care packages Children’s Therapies – building on the service redesign learning and empowering parents to have expert skills in therapies. Children Looked After – meeting Ofsted standards and improving health outcomes for CLA

32. OLDER PEOPLE PROGRAMME Our focus will be on making sure that the services we have redesigned and commissioned are delivering the outcomes that matter to patients and carers; that partner organisations have agreed ways of working together at a team around the patient and that older people living in care homes have access to high quality effective health services. Planning Guidance: • NHS systems will only become sustainable if they accelerate their work on prevention and redesign. • Developing an MCP that is to commission community adult health services in 17/18 • Develop and agree a high quality STP with critical milestones for accelerating progress in 2017-19 Work Programme Working with Wandsworth Council and our partners we are developing • The STP right care best setting with the focus on aligning reablement between health and social care and integrating discharge processes at St. George’s Hospital. • Continuing to deliver the Enhanced Care Pathway in GP localities in MDT Teams. Emphasis will be on increasing the numbers of patients accessing this service, utilising community networks better and the further development of personalised outcomes in the care plans. • Rolling out the Enhanced Care Pathway into nursing homes with funded support in the care homes for care planning, a dedicated community nursing and therapy team for support and training, and a shared approach to quality monitoring with Wandsworth Borough Council through a quality dashboard. • Developing admission avoidance pathways including GP referral to Rapid Access clinics, rapid response reablement service and introducing step-up beds • Developing senior health outpatient clinics for the over 75s predominantly with shared care arrangements with other specialties starting with Neurology and Cardiology.

33. Continuing Healthcare • NHS continuing healthcare  is a package of care arranged and funded solely by the NHS for patients aged 18 or over to meet physical or mental health needs arising because of a disability, accident or illness. In 2017/18 we will be building on the work in 2016/17 to: • Further strengthen our commissioning and contracting processes • Improved  Fast Track referrals to ensure eligible patients are able to access care quickly, and undertake assessments outside of acute hospitals • Ensure timely reviews of the needs and care for all patients on the caseload • Ensure our governance arrangements and processes are clear, transparent and applied equitably. • Implement closer working with social care and colleagues in the acute trust  • Improve information sharing with patients Use Insert > Header & Footer to amend for all slides

34. Personalisation – Implementing Personal Health Budgets • Personal Health Budgets, as part of the wider personalisation agenda, offer a tool to support self management and care planning in line with the Governments mandate to increase choice and flexibility; giving individuals more control over the services they receive. • In light of the greater emphasis on patients as partners in the identification of care that best meets their needs, there is a commitment to ensure that service user, carer and stakeholder engagement is embedded within the development and delivery of the Personal Health Budget Programme.

35. Engaging & Empowering Patients IAPT Accessibility & waiting times are areas of concern The CCG has a strong record of engaging patients and the public in the development of services; active engagement with patients is a common thread through all of our commissioning programmes. Our aim is to ensure that PPI and the patient voice are at the centre of everything we do as a CCG. This means that we systematically embed PPI and the patient voice at every stage of the commissioning cycle as illustrated by the following examples. Staywell this winter Campaign Feedback was on style and language used. 12,000 leaflets produced in a number of languages: Somali, Arabic, Romanian, Polish, French, Lithuanian, Tamil, Bulgarian, Spanish, Urdu, Portuguese, Bulgarian and English Older People’s Mental Health Carers felt that whilst the memory assessment service and the Behaviour and communication support service had high quality interventions that the Community Mental Health functions could be better in terms of access, expectations and timeliness Children's Therapies Parents expressed that service delivery was inconsistent. The service did not manage parent expectations • Older People • Themes highlighted through discovery interviews: • Treatment and care • Positives and negatives • Prescriptions and medication • Each patient/carer had a different experience of care.

36. Engaging and EmpoweringExamples are shown below how the patient voice is embedded at every stage of the commissioning cycle Patients Wandsworth Clinical Commissioning Group

37. Engagement & Empowering (1/2) Examples of how patient’s views are used to inform and shape our services

38. Engagement & Empowering (2/2)

39. Quality • WCCG first priority is to commission services that offer quality for local people - Services that are clinically effective, safe, well-led, responsive to patient’s needs and offer a positive patient experience • Over the years WCCG has implemented robust quality governance arrangements to ensure the commissioning of high quality services which are responsive to the needs of our population. • A quality strategy was set out as an integral part of the overall CCG’s Integrated Governance and Risk Management Strategy, outlining the structures and process that are in place to support the quality assurance and improvement framework • It is these same robust arrangements that we will continue to implement and improve on as we work on the goals of the Operating Plan and STP. These include; • Setting out a common understanding of Quality with all staff, providers and placing quality at the heart of everything we do • Setting out a Quality Assurance Framework • Use of National quality drivers to inform the way we continuously monitor, measures and improve on quality Use Insert > Header & Footer to amend for all slides

40. Quality • 1. We set out a Common Understanding of Quality • CCG has ensured through our quality strategy we • Established a shared understanding of quality for all staff and with all its commissioned services and key stakeholders; • Placed the established understanding of quality at the heart of everything we do to achieve commissioning high quality services through our mission statement and strategic objectives • Quality is defined as care that is safe, effective and provides as positive an experience as possible. The Care Quality Commission (CQC)’s new inspection approach goes further to build on the three dimensions of quality with two additional dimensions Organisational Culture & Leadership and Responsiveness. (The NHS Outcomes Framework builds on the definition of quality through setting out five overarching outcomes /domains)

41. Quality 2. We set out a Quality Assurance Framework; We developed a quality assurance framework adopted from Sir Bruce Keogh’s four stage methodology. 1 Quality Data Analysis , 2. Triangulation , 3. Multi-disciplinary Clinical Reviews and 4. Support Improvement . We believe this to be transparent, comprehensive and systematic. The next few pages explain how we implement the framework in brief

42. Quality (2. We set out a Quality Assurance Framework Continued ) Quality Data Analysis; we • Have worked at building a clear understanding of how to identify and measure if care is of a high standard • Have built a common awareness that poor standards of care do not necessarily show up on quality outcome indicators • Use the wealth of intelligence, gathered formally and informally across the CCG and externally, e.g. this includes but is not limited to through the use national contract, London Quality Standards, CQC standards, Quality Alert System (Make a Difference), Serious Incidents etc. The intelligence from these is used as early warning signs to detect if commissioned services are outside the expected range of standards. Triangulation: we • Have built an understanding that Quality cannot be seen in isolation but as a part of a broader picture about cost, performance and contracting. • Continuously monitor, linking the data gathered (from stage 1 ) from our commissioned services against standards and identifying where data links to enable us to dive deeper to identify potential areas for improvement to be delivered. • Ensure any intelligence triangulated with other sources of information ensures a strong evidence base for commissioning decisions and challenges to providers where indicated • Work proactively and routinely to share intelligence to identify good practice and any potential or actual quality failure, whilst respecting formal accountabilities.

43. Quality (2. We set out a Quality Assurance Framework Continued) Support Improvement We are continuously looking for ways to support quality improvement of our services through the commissioning process. CQUINs are used to incentivise commissioned services to deliver high quality care, drawing on NICE Quality Standards and are monitored with commissioned services through CQRMs. Through the various Clinical Reference Groups, WCCG has created forums which lead on and oversee the development and implementation of key innovative actions to support the delivery of the Quality, Innovation, and Prevention and Productivity agenda for the CCG • Multi-disciplinary Clinical Reviews • There are different types of multi-disciplinary reviews used by WCCG to work with commissioned services and other partners to ensure quality is maintained and continuously improved. Quality outcomes obtained from data analysis (stage 1) and triangulated information (stage 2) will be discussed and scrutinised through the multi-disciplinary review meetings such as: • Clinical Quality Review Meetings (CQRM) • Commissioner Quality Inspections/Informal Walkabouts • Day-to-day Conversations with key senior Directors /Officers from providers • Quality Account Process –CCG involvement and comment • Commissioning and Contracting Levers • Stakeholder Oversight Meeting – (Another type of exploratory deep dive meeting to discuss areas of concerns, identify progress and areas for the CCG and the commissioned service to improve on together • Risk Summit: concerns may escalate to the establishment of the risk summit process involving external bodies such CQC, NHSE, NHSI • Quality Control Panel: Jointly with the local Authority. • South London Quality Surveillance Group: collaborative across CCGs in SL

44. Quality • The following diagram provides some practical examples of some of the processes in place for monitoring quality information to ensure the Board and leadership team are able to identify early warning signs of quality concerns

46. Summary of Resource Allocations

47. Draft Financial Plan – 2017/18 and 2018/19

48. BCF - integrated health and social care community model for frail elderly • The Better Care Fund (BCF) outcomes will be delivered through embedding a comprehensive frailty pathway across health and social care providers in Wandsworth. • The integrated health and social care model will reduce delayed transfer of care and deliver joint assessment and care planning through integrated care packages such as reablement • The pathway will focus on delivering the outcomes that make a difference to older frail adults and their carers and care will be co-ordinated around their needs. • At each stage of the pathway mental, physical and social care needs will be managed in an integrated way, to keep patients well and cared for in their own home wherever possible.

49. QIPP • The STP (Sustainability and Transformation Plan) has identified activity that can potentially shift from an acute to a more appropriate setting of care and avoidable emergency activity that we should be working to prevent. • The QIPP plan for the next two years has two aims.  The first is to deliver the transformational change needed to deliver the STP.  Therefore, the QIPP plan for 2017-19 is specific to WCCG but consistent with the STP plan.    The second aim is to generate savings that can be used to transform services. • Alongside this the CCG has developed an approach to the NHSE Right Care initiative which means that  we have embedded Right Care in our planning through which we have identified our opportunities and priorities for the next two years which will improve the quality of healthcare and outcomes for patients.. • We have planned for a QIPP programme of £20m in each of the next two years  (4% of allocation).   This will ensure compliance with all national financial requirements and provide a small sum that can be used to invest in the changes identified in the STP .  • We have a robust QIPP programme in place of £8.7 million, after risk assessment for deliverability and timing, although at this point in time subject to final contract negotiations.  There is a further £6.8 million which has been identified through the transformation programme and is being worked up in partnership with Merton CCG and St George’s Hospital. • We are working up further initiatives to £4.5 million to complete the plan and provide the investment fund.

50. Right Care Approach The Right Care programme helps health economies find where they have opportunities to improve efficient use of resources by targeting areas of spend on sub-optimal pathways.  The primary objective for the programme is to maximise value. • The value the patient derives from their care and treatment • The value the population derives from the investment in their health care (health care availability and usage) • The value in increasing equity and reducing health inequality. The CCG has clinical engagement in the programme and a process by to take the Right Care approach through from data analysis to transformational change of services.  Wandsworth CCG has scrutinised the Right Care information, and in partnership with Merton CCG and St George's Hospital, has identified priority areas where we can achieve better value; the main priorities being trauma and orthopaedics and the muscular skeletal specialties (including rheumatology and pain management) and Neurology.  Other areas where we will develop a combined response to efficiency opportunities and operational pressures will be for Diabetes, ENT and Dermatology.  In addition there are two further work streams, which will improve the quality of healthcare, on  • Older people with multiple long term conditions (complex patients) and • Enablers to other pathways such as diagnostics.