City and Hackney Clinical Commissioning Group

1. City and Hackney Clinical Commissioning Group Draft Commissioning Intentions 2014/15

2. Maternity Programme Board

3. Programme Board Objectives • Ensure our maternity services are affordable, of high quality and improve patient experience • Increase the numbers of women who book early • Improve the quality of the community midwifery • Early identification and provision co-ordinated care for vulnerable and at risk women • Ensuring user views drive the service model and improve quality

4. Commissioning Intentions • Ensure our maternity services are affordable, of high quality and improve patient experience • On-going review and monitoring of Homerton staffing levels; • Roll out of friends and family. • On-going review and monitoring of the levels of care offered to pregnant women • Improving the care of socially vulnerable women: • Improving the services offered to vulnerable women • Agreeing the enhanced offer for vulnerable women • Roll out joint antenatal visits, midwifes and health visitors, for vulnerable women. • Review of community midwifery: • Improved patient experience; • Ensuring low risk births receive their care in the community rather than in a hospital setting; • Ensuring maternity services are provided in high quality, patient friendly compliant sites; • Improved access to community provision; • Improved communication between GPs and midwifes. • Review of antenatal classes • Review of the full spectrum of Parentcraft provision to see where improvements can be made • Input from the Maternity Services Liaison Committee parent reps • Review of settings and times of classes to increase accessibility • Training for midwifes

5. Urgent Care Programme Board

6. Commissioning Intentions • Accident and Emergency (A&E) performance • Review of senior staff (decision makers) presence in A&E and compare against other London A&Es • Frequent attenders group • To develop improved relationships with our practices, providing data and improved collaboration with other teams; • Improved winter planning • Preparation and provision of additional funds to cope with recognised capacity challenges. • Observational Medical Unit (OMU) and associated pathways • New pricing to be agreed to avoid duplication of costs; • Increased utilisation and encourage direct referrals from GPs; • Additional pathway development and implementation – Cellulitis is ready for implementation, Chest pain, Tonsillitis/Quinsy and sudden onset headache are under development. • Primary Urgent Care Centre (PUCC) • Development of new service specification taking into account changing needs and the local environment.

7. Commissioning Intentions • Out of Hours (OOH) • Embed new provider (City and Hackney Urgent Healthcare Social Enterprise (CHUHSE) into the system; • Strategic marketing of service; • Review likely implementation of additional sites to deliver base services closer to City and the rest of Hackney; • Improved collaboration with local providers, delivering integration where possible. • Access in primary care • Increase access and support for same day urgent appointments for practices; • Development of the duty doctor responsibilities and activities; • Increased interaction with Trust A&E and OMU regarding admission and discharge; • Increased capacity for patient visits referred via community services; • Extension of practice hours; • To consider evening and weekend coverage; • To consider individual and collaborative working for practice provision. • London Ambulance Service (LAS) • Collaborative review and assessment of existing pathways and the current impact in order to agree necessary changes; • Development of GP support to LAS paramedics in a car service. Pilot to be developed for January 2014 to provide support to emergency calls where GP intervention may help avoid conveyance to hospital and increased interaction with patients GP and community services.

8. Planned Care Programme Board

9. Programme Board Objectives • City and Hackney CCG aims to: • Improve the equality of healthcare for our registered patients • Ensure our health care system is affordable, of high quality and improves patient experience • Work with our partners to reduce health inequalities and improve outcomes • The Planned Care Board is responsible for commissioning services from hospitals that are arranged by your GP – for example outpatient appointments, planned operations as a day patient or inpatient. • Our approach: • Agreed pathways for patients with GPs and hospital doctors working together • Providing training to keep GPs informed • Hospital consultants providing support and advice • Services in the community

10. Commissioning Intentions • Commissioning an integrated multidisciplinary community based pain management service • Educating and supporting patients to improve quality of life whilst continuing to live with persistent pain.    • Reduced uptake of interventional therapies (injections), promoting a psychosocial approach • An increase in self-management strategies and tools • Increased peer support for service users with persistent pain • Total Knee Replacement Pathway • Improved health gain for people who have a Total Knee Replacement procedure • A simplified pathway reducing number of ‘steps’ in the process • Shared Decision Making with patients from all clinicians involved in the new pathway   • Ophthalmology • Working with Optometrists to provide more testing for glaucoma in the community and to increase numbers of people referred for a cataract operation direct from the optometrist after being supported to make an informed decision about the procedure

11. Commissioning Intentions • Dressings care • Dressings care will be provided by the right person in the right place through a coordinated service model. • Commissioning specialist dressings care for venous leg ulcers from community nursing service and commissioning for post-operative and ‘other’ wound care from a community provider(s)        • Diagnostics • Re-commissioning diagnostic tests directly accessed by GPs • Increasing direct access booking for Colonoscopy as part of the implementation of Cancer Best Practice Pathways • Community Health Services • Review of current service specifications for ‘Locomotor’ (physiotherapy)   Foot Health, Dermatology GPSI and Community Gynaecology services • Cancer - Early diagnosis • Working with primary care to improve early detection and treatment of cancer, supported by the Planned Care Board cancer lead in partnership with Macmillan.  

12. Children’s Services Programme Board

13. Programme Board Objectives • Improve the equality of healthcare for our registered patients • Improving the health and wellbeing of vulnerable children and families in the longer term • Improve working arrangements between practices and community practitioners; • To improve the management of long term conditions including asthma, diabetes & epilepsy • Ensuring child mental health is a higher priority and that assessment of a child’s mental wellbeing becomes routine across primary care • Ensure we are commissioning child friendly services • Safeguarding children and young people

14. Commissioning Intentions • Improving the management of LTCs in children: • Standardised care plans for children with a long term condition • Annual reviews for all children with a long term condition • GP Practices following up children & families who frequently attend A&E. • Patient education programmes to help children and families manage their long term condition • Early identification and enhanced support for vulnerable children and families: • Early identification of vulnerable children and families and enable practitioners to recognise, assess, plan and provide for children as well as parents who need extra support in bringing up their children. • To ensure more pro-active care to address inequalities for those families who may not seek help. • GP Practices to follow up children & families who frequently attend A&E. • Improving children’s mental wellbeing • Every family which completes a treatment with CAMHS/First Steps to be offered a follow up appointment in primary care within 3 months of discharge • Every child who presents with self-harm/OD at A&E to be proactively followed up

15. Commissioning Intentions • Delivering child friendly services • GP Practices will be required to develop policies that ensure their services are accessible and child friendly following a Department of Health Framework. • Developing child friendly leaflets • Ensure practices have knowledge of the range children’s services available locally and how to refer • Ensure the service provision, environment and atmosphere are young people friendly • Implementing the changes in special education needs (SEN) code of practice: • Rolling out personal budgets for children with complex health needs; • Working with the Local Authority and Education to roll out joint education, health and care plans for children with special educational needs and disabilities.

16. Long Term Conditions Programme Board

17. Programme Board Objectives • Improve the equality of healthcare for our registered patients • Ensure our health care system is affordable, of high quality and improves patient experience • Work with our partners to reduce health inequalities and improve outcomes • Develop integrated out of hospital services to mitigate the increasing cost of hospital based unscheduled care • Reduce the early death rates from cardiovascular and respiratory disease

18. Commissioning Intentions • Invest in an expanded integrated care programme • GPs proactively identifying people who would benefit from care planning, based on their risk of being admitted to hospital • Multi-disciplinary care planning, including comprehensive geriatric assessment, regular review of care plans and help for patients from “care coordinators” to manage their care plans • Pro-active home visiting for housebound patients who have a care plan • Additional investment in primary care to better identify and manage cardiovascular and respiratory disease, and other leading causes of illness and death in City and Hackney • Building on work to date which has meant that C&H GPs now deliver some of the highest standards of care in London • Extra focus on chronic kidney disease • Making better use of existing data and systems to identify new cases • Extra support for patient on diagnosis with extra long nurse appointments • Invest in a new fast track service to diagnose and treat people with atrial fibrillation • Atrial fibrillation is a leading cause of stroke

19. Primary Care Quality Board

20. Programme Board Objectives– shared with LTC board • Improve the equality of healthcare for our registered patients • Ensure our health care system is affordable, of high quality and improves patient experience • Work with our partners to reduce health inequalities and improve outcomes • Develop integrated out of hospital services to mitigate the increasing cost of hospital based unscheduled care • Reduce the early death rates from cardiovascular and respiratory disease

21. Commissioning Intentions • Educational support to practices to deliver our plans for long term conditions • Education and training re cardiovascular disease, respiratory disease, diabetes, hypertension, chronic kidney disease, all specifically tailored to meet the needs of GP, practices nurses, health care assistants and other members of the practice team • Training in care planning to support integrated care with protected learning time to share good practice across City and Hackney • Helping practices improve quality through intra-practice working • Enable practices to find the time to work together to share what works well, e.g., appointment systems, or to provide services for patients from neighbouring practices in order to improve equity of access to additional services • Additional support for those practices who need it the most • Practices who have been identified by NHS England (who commission general practice) as outliers on measures of performance, e.g., GP Outcome Standards – practical support to these practices on reviewing systems and procedures

22. Mental Health Programme Board

23. Mental Health Need • In physical care services • Up to 50% of people in outpatient clinics have medically unexplained symptoms • 25% of all people with long term physical conditions have depression & die earlier • Alcohol-related injury is approx. 24% of A&E presentations • Stroke patients have anxiety rates of 30-49% up to 12 years post stroke • Seniors • 1 in 6 over 65 have depression due to social isolation or physical ill- health • Dementia effects5% over 65s, 10-20% over 80 • 30% of over 65s in acute trust beds have dementia • Children/adolescents • 1 in 10 children & young people aged 5 - 16 have a diagnosable mental health disorder - around 3 in every class • Only 25% access effective care • Between 1 in every 12 and 1 in 15 children &young people deliberately self-harm – admissions have increased by 68% in 10 years • Adults • 1 in 6 at any time • 50% of all women & 25% of all men are affected by depression at some time in their life • 0.4% adults have a psychotic illness • 5.4% of men & 3.4% of women have a diagnosable personality disorder • Suicide is the greatest cause of male deaths < 35 years • People with schizophrenia are likely to die 15-25 years earlier than others • 30-50% of people with mental health problems are not acknowledged as having a mental health problem at consultation with GP

24. Groups at risk

25. Our Target Groups

26. Our plans to improve performance

27. Our plans to address user concerns

28. Prescribing Programme Board

29. Introduction • Medicines are the most frequent intervention and cost the NHS over £12 Billion in 2011 • If used appropriately, medicines can make significant impact on reducing morbidity, mortality and demand on other health resource • Research has shown that at least 6% of emergency admissions are due to adverse drug reactions and that up to 50% of prescribed medicines are not taken as intended • City & Hackney CCG will spend approximately £27M on medicines in 13/14 - this medicines expenditure is likely to grow annually • Effective management medicines activities will enable City &Hackney CCG to: • secure efficiency and value for money through cost effective prescribing choices • improve patient outcomes • ensure quality of medicines used in commissioned services

30. Our plans to improve clinical outcomes

31. Our plans to address members concerns

32. An overview of the relationship between our future plans and our strategic objectives