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Chapter 4: Delivery

Hounslow 2013/14: An integrated delivery plan. Chapter 4: Delivery. June, 2012. Progress to date: Delivery QIPP 13/14 plans. ü. Identified areas that are critical to deliver the QIPP plans and that need investment. ü. Identified gaps in current capability and capacity to deliver. ü.

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Chapter 4: Delivery

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  1. Hounslow 2013/14: An integrated delivery plan Chapter 4: Delivery June, 2012

  2. Progress to date: Delivery QIPP 13/14 plans ü Identified areas that are critical to deliver the QIPP plans and that need investment ü Identified gaps in current capability and capacity to deliver ü Identified practical ways to improve governance and programme management ü Laid out specific actions by QIPP initiative to deliver and to mitigate risks

  3. Contents • Priority areas for delivery • Overall capacity & capabilities • PMO & Governance • Workplans

  4. Executive summary: We have identified the following priority areas that require additional investment to ensure delivery Specialist capacity, particularly Programme Management and Analytics, required to deliver 13/14 QIPP. Current gap of ~11 FTEs to do so Reduced commissioning budget / responsibilities, efficiency through specialisation, rebalancing of other activities can part close, but further budget likely needed Technical FTE to support GPs with ongoing training and debugging Current SystmOne resource will be lost yet system issues are ongoing; without resolution full value of the system will not be captured Primary care transformation Skilled primary care team (5 FTE) to work closely with challenging GP practices in order to reduce variation and identify cost effective ways of working At least 1 senior commissioner who understands general practice in detail and at least 1 senior FTE who understands finance and contracting in detail Hounslow dedicated capacity is required, ideally with a team of 3-4 senior people to go beyond technical reporting functions and support teams to deliver Programme delivery needs to be strengthened by creating a high priority meeting schedule, simplified tracking and reporting and strong connections to CSS Investment needed QIPP PMO management Managing provider contracts Clear, accountable CCG FTE to manage and influence CSS contracting CSS contract leads must report into Managing Director through Delivery Board leads Additional team capacity and capability Maximising impact of SystmOne 4 1 2 3 5

  5. 1. Primary Care: Investment in primary care transformation (1/5) Current situation Overall objectives • Variation exists in Hounslow general practice • Despite ongoing engagement and training efforts, it is proving difficult to change GP behavior • Most of the chellenged practices (from a variation perspective) are large, stable practices with stable, partnered GPs; however, many are not yet fully on engaged regarding the impact of the overspend • Demand in these practices is a real challenge • Many GPs are not yet on-board with CCG • Help reduce variation in primary care performance • Support practices in changing behaviours as required to reduce variation • Be strategic in how we approach challenged practices to ensure we build buy-in and engagement and consider “hub” strategies here • Support practices and mentoring cells to develop innovative, smart ways of working that reduce costs • Get all practices on board with CCG and objectives Method of implementation Team structure & resources • CCG will work closely with the top 3 practices to engage them and develop solutions, and will also ensure practices have buddies in place (GP-to-GP) • For remaining 26, CCG will work through mentoring cells to help practices determine what support and follow-up they require from the CCG and their mentoring cells; practices will then develop action plans and mentoring cells will oversee progress • Whole practice response where Board members drive change in all 50 practices by influencing GPs • Creation of a primary care team which includes two senior leaders who understand general practice, contracting and finance in detail 1 Top 3 practices are large (therefore critical), quite engaged in OOH and ICP work and could all become hub practices, hence this is likely to be a hook

  6. 1. Primary Care: It has proven difficult to change GP behaviour, going forward we will take four major actions to address this (2/5) What we will do Help GPs understand the need for change • Support Board development to enable Board to actively lead change • Engage GPs with data through simple dashboards and reports and help them understand root causes (behavioural or other) of issues • Develop transformation story to engage and communicate with GPs • Assign competent, credible primary care liaison teams to GP practices 1 Role model the changes • Provide prominent examples of local and recent improvement: invest to ensure early programmes deliver • Give highly visible rewards for high performers • Establish Leading practices coaching networks 2 Help develop skills to deliver • HEAT events: Quarterly training opportunity, for example may focus on referrals for a certain speciality • Further develop mentoring cells: Peer review of performance and opportunity to learn from best practice and plan to address issues 3 Put in place formal mechanisms • Introduce and embed a clear escalation process that is followed through on with consequences for poor performers 4

  7. 1. Primary Care: Illustrative General Practice Summary Dashboard (3/5) Q2 2012/13 activity performance Priorities – Speak to: UCC: Elderly patients EL admissions NEL admissions • Paul Shenton CCG lead • Bath Road • West 4 Practices   -1% in 3 mths +10% in 3 mths +4% in 3 mths   EL: Obstetrics H’low ranking H’low ranking • Nicola Burbridge CCG lead • Spring Grove • Greenbrook Ch. Page 28 Page 11 Focus on: Focus on: Practices • Obstetrics • Urology • MH-related • Readmissions Page 33 Page 15 Prescribing spend A&E, UCC attendance   0% in 3 mths   H’low ranking H’low ranking • Unnecessary UCC attendance • Elderly patients • Central nervous system • Musculoskeletal Page 35 Focus on: Focus on: Page 4 Page 36 Page 5 OP 1st attendances  -2% in 3 mths  H’low ranking Page 20 Focus on: • Dermatology • Neurology Page 22

  8. 1. Primary Care: And we have agreed in our constitution a clear escalation process (4/5) STEP 5 Referral to the NCB STEP 4 Peer review within Council of Members STEP 3 • Council of Member referral to the National Commissioning Board Peer review within health network STEP 2 • Discuss improvement plan with tracking metrics • Transparent monitoring process Board member mentor STEP 1 • Share best practice and celebrate • Constructive dialogue on problem areas Management Support • The member will be appointed a mentor from the Elected GP membership of the Executive Board • Support from managers will be provided, to undertake site visits and develop action plans

  9. 1. Primary Care: We will focus efforts on practices who consistently overspend (5/5) Appears in bottom 10 practices1 Count Practices A&E EL NEL OP Prescribing Off budget Grand total 1 Crosslands Surgery - 1 - 1 1 1 4 2 Thornbury Road Centre for Health - 1 - 1 1 1 4 3 West 4 GPs Practice - 1 - 1 1 1 4 4 Spring Grove Medical Practice 1 - - 1 - 1 3 5 North Hyde Medical Practice - 1 - 1 1 - 3 6 Brentford Family Practice 1 1 - - - 1 3 7 Greenbrook Chinchilla 1 - 1 - 1 - 3 8 Greenbrook Bedfont - - 1 - 1 1 3 9 Grove Village Medical Centre - 1 1 1 - - 3 10 The Practice - Heart Of Hounslow 1 - - - - 1 2 11 Blue Wing Family Doctor Unit - - - 1 1 - 2 12 Cole Park Surgery 1 - 1 - - - 2 13 Greenbrook Heston 1 - 1 - - - 2 14 Jersey Practice 1 - 1 - - - 2 15 Greenbrook Isleworth 1 - - - - 1 2 16 Queens Park Medical Practice 1 - 1 - - - 2 17 Grove Medical Centre 1 - - 1 - - 2 18 Willow Practice - 1 - 1 - - 2 19 Kingfisher Practice - 1 - 1 - - 2 20 Clifford House Medical Practice - - 1 - - - 1 21 The Practice - Feltham Centre for Health - - - - - 1 1 22 St Margaret's Medical Practice - - - - 1 - 1 23 Brentford Group Practice - 1 - - - - 1 24 Clifford Road Surgery - - - - - 1 1 25 Skyways Medical Centre - - - - 1 - 1 26 Chiswick Family Doctors Practice - 1 - - - - 1 27 Manor House Practice - - 1 - - - 1 28 Mount Medical Centre - - 1 - - - 1 29 Hounslow Medical Centre - - - - 1 - 1 1 Practices were ranked on referrals or spend per weighted population: A&E attendances, EL referrals, NEL admissions, OP 1st attendances, prescribing spend and variance form 2011/12 budget SOURCE: Hounslow finance team, SUS data 2011/12

  10. 2. Strengthening of PMO: What Hounslow needs to do to deliver QIPP ü • Translate critical path milestones and actions (further detail in next section) into project tracking tool • Create a PMO of “doers” who will support teams to deliver and drive progress when issues arise • Have a full-time, senior person with commissioning experience leading the PMO • Ensure CSS contract managers report into your project teams and attend Delivery Board Steering Committees • Establish a schedule of “cannot miss”, regular delivery sessions • Do not use overly-complicated reporting for your meetings ü ü ü ü ü

  11. 3. Need to strengthen acute and other CSS contracting Current situation • Large proportion of QIPP savings come from ACV-related initiatives • Financial deficit unlikely to be sustainably overcome without the ACV • Limited success with ACV to date, especially with Imperial • ACV has shifted to the CSS Requirements going forwards • Someone senior at Hounslow CCG to be made accountable for CSS contracting initiatives • Tasked with owning and managing these • Must ensure that Hounslow’s plans and requirements are clearly articulated and explained • Appropriate CSS contractors must report formally into the CCG for all key contracts and attend the fortnightly Delivery Board meetings and CCG Board meetings when their contracts are discussed • Ideally someone at the CSS should be focused on serving Hounslow overall Challenges • Nobody at ACV specifically focused on Hounslow overall • ACV structured by provider, not CCG • More important contracts are being shifted to the CSS alongside ACV, including Mental Health and Community Services • Hounslow’s ability to influence contracts and CSS not strong at present

  12. 4. Need support for SystmOne Context • SystmOne is a critical enabler for several high priority programmes, including: • UCC • ICP roll-out • Pathway redesign • Roll-out completed - but GPs and practices require ongoing support to be able to use the system effectively Challenges • There are still several technical issues related to Systmone that are limiting delivery: • Undermined effectiveness and resistance against using the system • Slower implementation and capturing the value of initiatives • Current SystmOne resource being lost through transition arrangements • SystmOne is now heavily under-resourced • Technical and managerial support are critical for ensuring system delivers what it needs to

  13. 5. Capacity: Decisions on workload, budget and skill mix are required to provide the capacity and capabilities for 13/14 QIPP delivery More than 50% of commissioning activity currently appears to be QIPP-related: But capacity and specialised skills required for 13/14 QIPP delivery • Total capacity: around 20 Hounslow commissioning FTEs, plus around 2 FTE equivalents at ACV • Capacity equivalent to 8 FTEs has been developing QIPP initiatives for 13/14, plus Finance, Information and Estates support of ~0.5 FTE • Capacity equivalent to 7 FTEs is expecting to deliver 13/14 QIPP • Programme management for complex initiatives, e.g. MH ICP, End of Life • Provider liaison where strong engagement/support required, e.g. RFS, ICP • Analytical support where development is ongoing, e.g. AEC, ICP • Required support equivalent to around 11 FTEs • Could be filled by high-level commissioners (potentially from existing team) or specialised staff Next steps • Assess team’s capacity to provide further 13/14 delivery support. Will reduced commissioning budget free capacity? Is less initiative development required for 14/15? • Identify opportunities for further budget / capacity. Can the DSU provide budget or the CSS provide staff? Can Finance and Information provide further delivery support? • Choose skill mix to fill capability gaps based on needs, budget and candidate availability.High level multi-skilled staff or lower lever specialists?

  14. Contents • Priority areas for delivery • Overall capacity & capabilities • PMO & Governance • Workplans

  15. But the team also has to find capacity for multiple roles Hounslow commissioning team Work they do Sue Jeffers • Janet Cree • Anindita Debnath • Sarah Herdman • Vince Makin • Lorraine Norris • Das Sulu • Mary Crawford • Geralyn Wynne • Jacky Lynch (joint with LA) • Pauline Fahy • Munya Nhamo • Baljeet Dhanda • Bernadette Molloy • Saima Shaikh • James Hearn (joint with LA) • Brian Howard (joint with LA) • Graham Sowter • Nicola Burbridge • Opportunity identification • Writing business plans • Obtaining clinical input and support • Working with finance and information colleagues to evidence proposals • Programme management • Liaising with providers across the health and social care ecosystem • Liaising with ACV to ensure appropriate contracting • Recruitment • Procuring new providers • Contract negotiation • Ramping up new services • Data analysis and interpretation • Reporting • Sangeeta Sharma • Francois Strydon • Tabassum Khan • Medicines management

  16. We have analysed Hounslow’s staff utilisation for planning and delivering QIPP initiatives In the next pages we analyse the capacity needed to plan and deliver QIPP initiatives This is not a full time analysis For the purposes of this analysis we have considered time as being spent in three ways: Planning QIPP (primarily in 2012/13) 1 Delivering QIPP (entirely in 2013/14) 2 Other activities (e.g. monitoring, reporting, admin – on an ongoing basis) 3

  17. 1. Planning time for 13/14 QIPP initiatives1: Commissioning time spent not proportional to savings, many larger initiatives relying on external support Planning top 10 QIPP initiatives active in 2013/14 – savings and time spent Commissioner time spent2, man days 12/13 and 13/14 savings, £k Prescribing ACV initiatives MH ICP and other MH ICP HRCH productivity UCC ICRS HoH rental income RFS AEC service End of Life MSK Corporate budget Diagnostics Learning disabilities Heart failure Continuing care ENT COPD Corresponds to around 8 FTEs planning new initiatives, costing around £740k p.a. 1 Including for those already active in 12/13 2 Time spent to implementation. I.e. design, business planning, syndication, approval, initial commissioning. Includes estimates for remaining time requirements to initial commissioning if not yet completed. Includes time spent by joint commissioning and ACV staff. Does not include ongoing monitoring, oversight and routine renegotiations. Does not include time spent by non-commissioning staff, e.g. clinical, finance, estates, information SOURCE: Team analysis

  18. 2. Delivery time needed in 13/14: Commissioning time to be spent delivering 13/14 QIPP initiatives is fairly evenly spread Delivering top 10 QIPP initiatives in 2013/14 – savings and estimated capacity allocated Est. commissioner time allocated2, FTEs 13/14 savings, £k 1.803 Prescribing ACV initiatives MH ICP and other MH ICP HRCH productivity 04 HoH rental income ICRS AEC service End of Life RFS UCC1 04 Corporate budget Learning disabilities Diagnostics MSK Continuing care ENT Heart failure COPD Corresponds to around 7 FTEs allocated so far delivering 13/14 initiatives 1 Including primary care savings not to be delivered by CCG 2 Time spent on ongoing monitoring, oversight and routine renegotiations 3 QIPP delivery activity difficult to differentiate from other activities 4 To be managed by Finance and/or Estates SOURCE: Team analysis

  19. 3. Capacity and capabilities for 13/14 QIPP delivery:Significant specialist capacity is desired Unmet need Some need Need met Commi-ssioning Analytical/Finance Prog. mgmt. Liaison Comments 0.8 1.0 Prescribing 0.5 0.25 ACV initiatives Needs CCG input 0.5 0.75 0.5 MH ICP and other MH Needs clinical support 1.0 2.0 0.5 ICP To be supplied initially by NWL 0.2 0.2 0.1 HRCH productivity 0.15 UCC 0.3 0.5 0.25 ICRS Large team expansion HoH rental income 0.25 3.3 RFS Needs clinical, admin support 0.7 0.5 AEC service Commissioner to be replaced 0.4 1.0 0.25 0.25 End of life care at home Complex, needs support 0.05 MSK Diagnostics 0.95 0.25 0.5 6 other initiatives 1.0 2.0 1.0 PMO Working across initiatives Total FTEs desired for 13/14 delivery 6.8 4.7 7.6 2.9 • Liaisons offering 1) Practice support, 2) Provider liaison • Fewer may be required due to overlap between initiatives SOURCE: Requirements desired for delivery by Hounslow commissioning team; Team analysis

  20. Specialist roles to support commissioners would improve delivery and increase team efficiency Commissioning • Existing team primarily consists of commissioners performing wide range of activities • Commissioners each have strengths but typically not in all the activities currently required – specialist support would improve efficiency • Commissioners could then focus on planning, monitoring and improvement Programme management • Insufficient capacity from existing Programme Management Office • Lack of programme management capability / discipline among commissioners leads to delivery issues • Sufficient dedicated programme management capacity would reduce delivery risk and free commissioner time Liaison • Commissioners currently liaise with GPs and other providers • For many initiatives far more intense provider engagement and support is required • Dedicated liaisons with relevant understanding can operate more effectively Finance & Analytical • Finance and analytical support are currently focused on initial business planning • Support for monitoring / programme management currently obtained by commissioners primarily on an ad hoc basis • Dedicated programme management analytical support would improve delivery Clinical • All initiatives require clinical input, currently provided by CCG members • CCG time perhaps sufficient, but education required for clinicians to support effectively • Some initiatives (RFS, MH ICP) have significant ongoing clinical requirements SOURCE: Team analysis

  21. To deliver 13/14 QIPP we would need ~11 FTEs additional to those already planned, particularly around programme management and liaison Commissioning • In majority of cases commissioners involved in planning initiative will go on to support ongoing implementation • Routine ongoing activities may require less capability than planning • New commissioners for PMO, ICP (senior people required) to be hired in 12/13. Could be retained in 13/14 if budget found (e.g. with NWL support) • Reduction in budget managed may free overall team capacity, closing gap Desired Needed1 Allocated Gap Programme management • PMO to be established with 2 PMs in 12/13, but no 13/14 budget yet • Crucial to overcome risk with regards to overall 13/14 delivery, particularly of complex programmes such as MH ICP, End of Life • High priority to secure PM capability to drive delivery, even potentially at the expense of commissioning capacity 0 Desired Needed1 Allocated Gap Liaison • Required to engage primary providers, particularly for initiatives such as RFS, ICP and Prescribing • Some existing activity from GP commissioners and medicines group • Dedicated practice support planned for 12/13, not budgeted for 13/14 • Perhaps can seek DSU support given primary transformation programme • Otherwise, wider commissioning team must pick up load 2.0 Desired Needed1 Allocated Gap Financial and Analytical • Some capacity currently provided by Finance, Information and ACV • ACV capacity likely to reduce under new structure • PMO to include analyst in 12/13 but no 13/14 budget yet to retain • Further support on QIPP delivery could be sought from existing Finance and Information teams and via CSS Desired Needed1 Allocated Gap 1 Numbers adjusted to consider overlap between initiatives and support from PMO SOURCE: Team analysis

  22. Overall, the CCG will rely on CSS support for ~80% of overall QIPP savings, with high dependence on them for >50% Examples of initiatives Savings value of 13/14 initiatives by most influential entity, £’000 Further detail 14,800 • Estates • PropCo will own and manage estates PropCo 700 (5%) NCB 2,200 (15%) • Primary care • NCB will commission primary care • Largely contractual, e.g. Acute (ACV), CHS, UCC • Prescribing • AEC • High dependence on CSS, who will negotiate and manage major contracts • CSS will provide prescribing support • CSS will support CCG with analytical and business intelligence support as well as provide corporate services CSS 7,800 (53%) • Pathway and service redesign • ICP • RFS • ICRS • CCG will design, develop and deliver pathway and service redesign • Contracts (CSS) need to reflect plans • CCG will support delivery in general practice, e.g. variation, mentoring cells CCG 4,100 (28%) CCG recognises its role in delivering the transformational change needed alongside contracting and other CSS roles (e.g. MH ICP, UCC, EOL care) 2013/14 QIPP SOURCE: Team analysis

  23. Despite this high dependence on the CSS, the CCG is ultimately accountable for delivery and thus needs to manage CSS closely High Low 13/14 QIPP savings, £’000 Dependence on CSS CSS primary responsibilities • Initiative identification and contract negotiations • Full savings delivery • Business intelligence ACV metrics 1,700 Corporate 400 MH and LD 1,600 • Contract negotiations (incorporating CCG plans): • Acute (ACV) • Mental Health and Continuing care • Community Health • Business intelligence Community health 850 Continuing care 200 Urgent care 650 End of life care 650 • Budgeting • Contract management • Some BI support • Prescribing advisory and liaison AEC 800 Prescribing 1,600 Pathway / service redesign 900 RFS 650 • Incorporating activity plans into contracts ICRS 700 ICP 1,200 Estates 700 • None – Estates to PropCo and primary care to the NCB Primary care 2,200 SOURCE: Team analysis

  24. Contents • Priority areas for delivery • Overall capacity & capabilities • PMO & Governance • Workplans

  25. Hounslow needs to strengthen the PMO to deliver QIPP ü • Translate critical path milestones and actions (further detail in next section) into project tracking tool • Create a PMO of “doers” who will support teams to deliver and drive progress when issues arise • Have a full-time, senior person with commissioning experience leading the PMO • Ensure CSS contract managers report into your project teams and attend Delivery Board Steering Committees • Establish a schedule of “cannot miss”, regular delivery sessions • Do not use overly-complicated reporting for your meetings ü ü ü ü ü

  26. Within ONWL, Hounslow currently receives support from an interim Programme Delivery Office that also supports Hillingdon and Ealing Interim ONWL Hounslow ONWL ONWL Sub Cluster Director QIPP Delivery QIPP Finance Support (1) Helen Whitehall Programme Delivery Office (3) Debbie, Leigh, Nina1 QIPP Informatics Support (0) Never recruited Hounslow Director Sue Jeffers Delivery Board Leads Initiative Leads Project Manager & Project Teams 1 Team of 3 (a hierarchy) which works for Hounslow, Ealing and Hillingdon and reports to ONWL SOURCE: Hounslow PDO

  27. There are several risks as NWL moves to a new structure, including disruption of QIPP monitoring and delivery Hillingdon CCG INWL sub- cluster (Daniel) NCB ONWL sub- cluster (Rob) Ealing CCG K & C CCG Hounslow CCG Westminster CCG Brent CCG Harrow CCG Hounslow Corporate H & F CCG • CSS (full support function) • Includes all non-GP contracting, business analytics and other support functions New structure Notable risks • Disruption of reporting and delivery focus of PDO teams • CSS serves several CCGs and may have insufficient focus on Hounslow e.g., for provider negotiations • Delegation of several contract negotiations to CSS is high risk given high value of associated QIPP savings • Separate data sources being used by CSS, CCG and Finance will result in additional uncertainty and issues regarding monitoring and reporting • Ongoing uncertainty regarding whether Finance will sit under ONWL or CSS • CCG GP engagement with delivery of QIPP plans

  28. A clear PMO structure must therefore be put in place quickly to avoid risks to QIPP delivery, with a dedicated team recommended for Hounslow ONWL • Ideally, Ealing and Hillingdon would receive PMO support from Brent and Harrow, where this function is well-established • Hounslow unlikely to receive sufficient PMO support from INWL given different financial circumstances, thus current ONWL PDO should move to Hounslow Hillingdon Brent and Harrow • Has its own, strong programme management office Ealing INWL • Other CCGs face do not face as challenging a situation and thus have different programme management requirements Hounslow SOURCE: Team analysis; interviews

  29. PMO action list: We must take the critical actions needed to strengthen our current delivery process ü ü ü ü ü ü ü ü ü ü ü Critical actions to take Key success factors Clear reporting • Define metrics to track and ensure all teams have a shared definition and work from a single data source (finance, commissioning and PMO) • Determine critical path milestones and associated actions for each initiative [see next chapter] and embed within tracking tool • Simplify reports that are used in meetings Accountability and escalation • Establish single line of reporting through Managing Director and define clear reporting responsibilities for finance, commissioning and PMO • Define PMO accountability and how projects / Delivery Boards report in • CSS contract managers to report to CCG project leads and Delivery Boards Resources • Change PMO remit from technical support to “doing” and unblocking • Increase PMO capacity and capability Disciplined meeting schedule • Establish a cycle of regular, robust programme delivery sessions to reinforce QIPP as high priority, manage programme and escalate issues Stakeholder engagement • Engage wider general practice and other providers better and more often • Engage and support clinical leads in delivery of QIPP initiatives SOURCE: Team analysis

  30. This will ultimately be achieved through creating a PMO for the remainder of 12/13 which has the following structure … Programme Manager Programme Manager ONWL Hounslow Managing Director Delivery Board Leads Programme Delivery Director • Accountable for initiatives • Accountable for QIPP delivery • Senior and credible Reporting and Information Manager • Each PM supports specific delivery boards • Support projects with delivery as required • Supports all projects • Works closely with PMs

  31. … and the following capabilities and responsibilities Team member Capabilities Responsibilities Delivery Director • Senior director-level skill set • Commissioning expertise • Negotiations expertise • Accountable for QIPP programme delivery (including enablers, e.g. Systmone) • Supervise CSS contract negotiations (e.g. ACV) • Support teams with problem solving and unblocking • Escalate highest risk issues to Managing Director Programme Managers x2 • Service delivery expertise • Operate hands-on and with a “can do” mindset • Flexible and able to work across several projects • Problem solving expertise • Provide project management support to project teams facing challenges or lagging on delivery • Challenge Delivery Board leads and project leads • Help teams develop and execute solutions • Quality assure and support project teams’ reporting Reporting and Informatics Manager • Technically competent • Operate tactically • Experience working with senior Commissioners and Finance Director • Manage tracking tool and reporting processes • Strengthen existing reporting tools, including developing full metric sets to be tracked • Support project teams with delivery issues (e.g. root cause analysis) using information and data available • Work alongside Finance and CSS to align reporting processes and data sources All full-time roles

  32. A series of high priority sessions must also be established to solve problems, build rhythm, address accountability and facilitate escalation Objective Timing Delivery Board Steering Committee (Fortnightly) • Review progress across all areas of QIPP • Problem solve issues in 3-4 Delivery Boards • Understand challenges • Agree resolution • Clear actions / owners • Review programme resourcing, communications and mindsets • Managing Director • Delivery leads • Executive • Clinical • PMO lead • Finance lead • Project leads as required • 2 hours 2 Operational Meeting (Weekly) • Provide brief update on progress to all • Review all high priority risks/issues • Problem solve jointly • Agree appropriate actions as required to move forward • PMO (full) • Project leads • 1.5 hours (collective or individual meetings with each team) 3 Meeting Attendees CCG Board Review (Monthly) • Review progress across all areas of QIPP • Problem solve issues for 2-3 Delivery Boards where clinical input is required • Understand challenges • Agree resolution • Clear actions / owners • CCG Board • Managing Director • PMO lead • Finance lead • Delivery leads • 2 hours 1 • Detailed agendas and planning cycles provided in back-up • Daily / weekly project meetings not included in this schedule; project leads should meet with their teams regularly each week

  33. The PMO should consider expanding its existing monitoring to include the following dimensions for each initiative… • Resources • Sufficient time from delivery board lead • Sufficient involvement from clinical lead • Sufficient capacity within project team • Communications • Specific plans for this project have been refined with stakeholders • Stakeholders are receiving project performance information • Mindsets • Programme teams are succeeding in building momentum/quick wins • Stakeholders are behaving and thinking differently • GPs engaged in their new CCG responsibilities and accountabilities • Roadblocks • We understand root causes of any roadblocks • Roadblocks have rapid and agreed process for resolution • Delivery • Monthly milestones and timing are approved • Milestones are being delivered to plan (and not slipping) Metrics (sufficiently comprehensive to track savings) • Operational indicators moving in the “right” way • Financial savings showing “on trajectory” delivery • Process metrics – milestones and actions SOURCE: Programme Management Tracking

  34. …which can be done through RAG rating criteria as follows but must be aligned to the NWL reporting vision and embedded into existing tools Potential criteria for monitoring key areas • Monitoring of resources, communication and mindsets must be added to tracking tools • Roadblocks covered to some extent in risk reports • Delivery plans to be added to existing tools Metrics to be strengthened Whilst more robust tracking (covering all categories above and correct metrics) is needed, reporting must be simplified

  35. Contents • Priority areas for delivery • Overall capacity & capabilities • PMO & Governance • Workplans

  36. Programme management: Workplans and Actions The new PMO in Hounslow should take the following workplans and milestones as a starting point and incorporate into a simple and consistent tracking tool These actions have been worked up in consultation with local team members and are owned More detail on specific dates for delivery need to be added

  37. End of Life: Major delivery risks and mitigations END OF LIFE PRELIMINARY Lack of provider co-operation and collaboration Critical path for delivery and risk mitigation Major risks Lack of data to enable operation and improvement • Ensure implementation of SystmOne across providers • Ensure metrics to monitor are identified and agreed with providers • Make use of analytical capacity to understand impact and outcome of system, and identify required improvements • Establish open dialogue and information sharing • Work with ACV to adopt an integrated and robust approach to contract management across the relevant providers • Actively monitor contracts and work together to address issues Delayed roll-out of Co-ordinate My Care • Hire programme manager to drive roll-out • Ensure training and forms are prepared and delivered early to minimise the impact of any IT delays SOURCE: Team analysis

  38. End of Life: Activities required to assess and refine service and promote utilisation Programme management and analytical capacity for End of Life Support from ACV in ensuring an integrated approach to contract management and data collection Support from ICP around GP engagement 2012 2013 Q2 . . Q3 . . Q4 . . Implement Co-ordinate My Care Ensure IT availability (inc. SystmOne) Ensure phone/fax access for care homes (which lack IT access) Ensure form availability Training Ongoing monitoring and support Q1 Analyst Geralyn Wynn Understand impact, assess resource usage, plan to adjust service spec Providers Collect initial dataset and understand patient flow through system Geralyn Wynn ACV Ensure relevant data is captured by all providers Key activities Responsible Engagement and education of GPs, social services Educational programme Engage via MDGs Ensure creation of advanced care plans Ensure social services assess and deliver required extra care packages Collect and analyse data to enable contract management END OF LIFE PRELIMINARY GP liaisons Geralyn Wynn Additional resources required for this initiative Programme manager SOURCE: Team analysis

  39. RFS: Major delivery risks and mitigations RFS PRELIMINARY Benefits not realised through contract changes Critical path for delivery and risk mitigation Major risks Insufficient GP engagement • Ensure leadership from CCG in planning, delivery, role modelling • Provide CCG with regular reporting and choices with clear, evidenced consequences • Work closely with the LMC, keeping them engaged and informed • Develop and utilise mentoring cells and peer reviews to provide feedback and support • Provide practice-level support staff and educational materials to assist practices, particularly low-performing ones • Engage ACV leads, clearly communicating expected impact and required contract changes. Regularly brief and follow up • Engage acute providers, setting appropriate expectations at contract performance meetings • Analyse performance data to provide supporting evidence Poor acute engagement around IGRs • Incorporate handling of internally-generated referrals through RFS in contractual discussions with trusts, particularly Imperial, building on experience gained at WMUH • Develop clinician-to-clinican relationships at key trusts SOURCE: Team analysis

  40. RFS: Activities required to support GPs in reducing referrals variation Implementation of SystmOne in practices to support understanding and improvement GP educational materials: Classes, training, templates Q4 2012 2013 Q2 . . Q3 . . . Q1 Responsible GP practices Practice support Mentoring cells Key activities Communicate action plans to practices via mentoring cells Discuss benchmarking Discuss action plans Recognise issues and improvement Identify potential role model practices / GPs Identify specific actions to be taken to improve performance Develop practice-specific action plans Practice performance metrics reviewed Poor performers and issues identified Action plans created Take action to improve Practices communicate with role models to understand good behaviours Practice support (focused on worst performers) helps to identify opportunities for improvement Practices act internally to change behaviours RFS PRELIMINARY . Additional resources required for this initiative RFS panel Relationship managers Relationship managers Mentoring cells Practice support SOURCE: Team analysis

  41. ICRS: Major delivery risks and mitigations Major risks Establish strong programme board with strong chair Target CEO-level buy-in in all organisations: HRCH (and/or new provider) Primary clinicians Social services Hospital trusts Commissioners ICRS PRELIMINARY Demand / capacity imbalance Critical path for delivery and risk mitigation Failing to achieve buy-in • Understand existing impact – activity and outcomes • Establish extent of desire for increased ICRS scale, as opposed to increased core community capacity • Clearly define referral criteria – assess potential cohort • Clearly define nature and extent of team’s role • Establish multi-stage growth path for team • Control pathway marketing/promotion to throttle inbound activity Exceeding scope i.e. to avoid becoming a community hospital, with other providers leaving ICRS to deal with their responsibilities: • Define clear profiles and delivery expectations for team • Clearly define role of ICRS within health and social care ecosystem • Ensure buy-in and understanding of GPs, community care staff • Ensure sufficient community care capacity available • Effective contracting / co-commissioning SOURCE: Team analysis

  42. ICRS: Activities required to expand team Q3 . . Analytical and programme management capacity Strong senior leader for programme management board Clinical engagement for design and to ensure appropriate referrals . . . Q2 2012 Q4 2013 . Q1 Key activities Provider Hiring Work with provider to recruit Design effective training, appraisal Planning Establish programme board Engage diverse stakeholders Establish clear role and scope Change provider if appropriate Design new structure Specify clear role descriptions Plan pathway marketing/promotion strategy Identify new facility Ensure appropriate community care provision Agree funding Understanding Analyse latest data on impact, outcomes Assess impact on community services Review skill mix Understand equipment, prescribing costs Re-launch with GPs for clinical input, acceptance ICRS PRELIMINARY Responsible Additional resources required for this initiative Geralyn Wynn Analyst Clinicians Programme manager Geralyn Wynn • Ramp up • Work with provider to establish facilities • Provision IT (notebooks) • Provide training Team manager Clinical leadership IT support SOURCE: Team analysis

  43. UCC: Major actions required to deliver fully functioning Urgent Care system by 15 March 2013 URGENT CARE CENTRE PRELIMINARY 12/13 actions for Urgent Care Centre Other 12/13 UC req’ments • Triangulate urgent care attendance and outcome data from all sources • Review end of June position • Communicate Urgent Care plan with the public • Procure UCC and other OOH strategy elements • Ensure UCC,111 and other OOH strategy elements working as co-ordinated system • Ensure UCC is redirecting inappropriate cases back to practices, and that practices are caring for these patients • Commission appropriate ED capacity • Implement 111 • Deliver ICRS expansion • Commission AEC service • Ensure appropriate levels of community discharge support Full Urgent Care system Ongoing 2013/14 contract monitoring SOURCE: Hounslow; Team analysis

  44. ACV ACV: Overview of major risks ACV-related savings initiatives PRELIMINARY Critical path for delivery and risk mitigation Major risks Identification of savings areas and opportunity for 13/14 • Identification of opportunities must start by September • Ensure Hounslow has a named, senior ACV QIPP planning lead to support the development of savings initiatives with the ACV and challenge the size of the opportunity as appropriate • Hounslow lead should own the programme and work closely with the ACV to understand plans in detail • Update plans for ONWL readmissions reductions if the national framework supports this Contract negotiations to capture savings • Ensure Hounslow activity decommissioning plans for each Trust are provided to ACV with clear rationale and assurance of reprovision capacity where appropriate • Escalate the issue that Hounslow is fully reliant on the ACV for 13/14 contracts to NWL Contract management • Co-operate with ACV teams and ensure contracts are managed robustly such that savings are captured SOURCE: Team analysis

  45. Additional resources required for this initiative ACV ACV-related initiatives: Critical path for ensuring delivery PRELIMINARY 2012 2013 Q2 . . Q3 . . Q4 . . Q1 Key steps in critical path Responsible Hounslow ACV local lead on-board Sue Jeffers (SJ) • Accountable lead named SJ • Lead brought up to speed on ACV aspirations and issues SJ / Helen Whitehall (HW) Local lead and ACV identify 13/14 levers and savings TBD • Challenge ACV as appropriate TBD / HW • Understand opportunity and ACV proposals in detail TBD / HW Understand national framework for readmission reductions and update savings plans and targets accordingly TBD Brief ACV in detail regarding activity to decommission and reprovision plans / rationale TBD / HW Ensure Hounslow is adequately represented at contract negotiations SJ / TBD Ensure robust management of acute contracts (ongoing) TBD • Dedicated, senior support from within the CCG is required for delivery, and should: • Work with ACV to identify savings and challenge the team • Ensure negotiations strategy and execution are robust, with contract value changing as required SOURCE: Team analysis

  46. MENTAL HEALTH Mental Health initiatives: Overview of major risks for ICP (shifting settings of care, LTCs, OA placements and psychiatric liaison) PRELIMINARY Critical path for delivery and risk mitigation Major risks Poor local owner-ship of MH ICP programme • Establish full local team and ensure ownership as well as sufficient delivery capacity • Ensure Hounslow PMO supports local project team Insufficiently strong links to NWL MH ICP • Ensure Hounslow delivery team receives full handover from NWL team and is well linked to central MH ICP work • Ensure team works closely with Annabel Crowe • Consider establishing a joint working team with NWL Delays in implementation • Establish strong links to NWL team, especially for more central aspects of the ICP such as psychiatric liaison (acute teams) and general practice training • Build capacity in primary care • Identify patients to be shifted from acute and community to primary care early • Identify out of borough placements to be shifted early SOURCE: Team analysis

  47. Additional resources required for this initiative MENTAL HEALTH Mental Health initiatives (ICP – shifting settings of care and psychiatric liaison): Critical path for ensuring delivery PRELIMINARY 2012 2013 Q2 . . Q3 . . Q4 . . Q1 Key steps in critical path Responsible Establish local ownership Mary Crawford (MC) • Create full delivery team MC • Build links with NWL MC / Annabel Crowe (AC) • Handover from NWL MC / AC • Joint working team Delivery team (TBD) • Psychiatric liaison • General practice training Build capacity in primary care TBD • Train general practice • Increase staffing Identify patients to shift from: TBD / AC • Acute MH trust WLMHT / AC • Community CMHT / AC • Out of borough TBD / AC Stakeholder engagementand communication MC Facilitate shift of patients TBD • Further delivery team resources or support required (2 WTEs – 1 with MH background, 1 delivery / PM) • Discharge manager (1 per trust), CPNs and psychiatrists for general practice training, consultant (5 hours/week) • ~ 22 WTEs (various bands) for optimal standard psychiatric liaison in each acute hospital (detail in templates) SOURCE: Team analysis

  48. COMMUNITY HEALTH Community Health productivity: Overview of major risks PRELIMINARY Critical path for delivery and risk mitigation Major risks HRCH service line review • Revise savings estimates (especially for productivity target) following the service line review and leverage suite of tools from the Productive Community Services NHS work online (time and motion, etc.) • If savings potential decreases, review other community health and/or joint working contracts for additional savings opportunities to make up the difference Contract negotiations • Following review of service line analysis and work done to date, develop robust contract negotiation strategy • HRCH dependent on CCG for FT status • Determine whether “combination of productivity and reduction in growth” or “all growth” strategy is more palatable for HRCH • Opening offer should reflect the stretch scenario SOURCE: Team analysis

  49. Additional resources required for this initiative COMMUNITY HEALTH Community productivity: Critical path for ensuring delivery PRELIMINARY 2012 2013 Q2 . . Q3 . . Q4 . . Q1 Key steps in critical path Responsible Conduct own analysis of HRCH Service Line review and leverage online NHS Productive Community Services tool Pauline Fahy (PF) • Update savings opportunity PF / PMO / Helen Whitehall (HW) • Determine specific areas for additional HRCH productivity gains • If savings potential decreases, determine additional community areas for savings Develop robust negotiations strategy Based on facts available PF / PMO / HW • Leverage service line review • Leverage benchmarking (remaining opportunity) • Leverage FT status-reliance Contract negotiations PF / PMO / HW / Sue Jeffers • 2 additional health visitors (included in contract value as recurrent posts) required for additional activity being included in contract with HRCH • Some PMO support to work with HRCH and commissioners to identify and quantify savings opportunities following the service line review that HRCH submits SOURCE: Team analysis

  50. Additional resources required for this initiative LEARNING DISABILITIES Learning disabilities: Critical path for ensuring delivery PRELIMINARY 2012 2013 Q2 . . Q3 . . Q4 . . Q1 Key steps in critical path Responsible Agree transfer amounts from NHS to LA (S28a cases) James Hearn Sign off action plan for integration of specialist dietician post with LA James Hearn Development of Supported Housing Service to come on line for resettlement of OOA clients James Hearn Market testing against current provision (for new provider of CLDHT) James Hearn • Test the market • Open to procurement Specialist assessment and treatment at WLMHT James Hearn • Scope opportunity with other health authorities • If opportunity exists, develop and deliver plans • Potentially support from the PMO for scoping and development work for additional cross-CCG opportunities • New provider of Community Learning Disability Health Team • Specialist assessment & treatment facility provision in WLMHT SOURCE: Team analysis

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