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Working together for excellent healthcare in North Norfolk and rural Broadland

Introduction and Vision

The local health and care system needs to change. We should rightly be proud of the services being delivered. Over the past few years, the NHS has improved significantly – cancer outcomes have improved, avoidable deaths have decreased, waiting times have generally shortened and public satisfaction with the NHS has increased.

At the same time, demand on the NHS has increased. Long term conditions now account for a much larger percentage of the NHS budget, people are living longer, new technologies and drugs are driving new treatments and patients expectations are increasing. Unfortunately, funding for the NHS has not followed this rise in demand and has led to a system that is unsustainable if it does not adapt to the world around it. If we do not change we will face a gap of almost £500m across the Norfolk and Waveney Health System by 2020/21. We need significant and rapid transformational change to bridge that gap.

This transformation can only be achieved by continuing to work jointly with colleagues across the health and social care system to bring about improved outcomes for our communities.

Planned Care

Our approach to planned care will be a progressive one over a period of time. CCGs have already begun reviewing local processes of pathway design and this will continue into 2017/18 and beyond but with more consistency across the Norfolk and Waveney CCG footprint. Pathway analysis will cover everything from pre-referral through assessment and diagnosis to specific operation and procedure interventions, subsequent follow-up, recovery and leading as fulfilling lives as possible.
We are conscious of the ability of our Providers to accommodate the current levels of demand and so part of our focus will be on introducing new pathways that utilise less capacity within secondary care hospitals. Equally though, we must appreciate that for a given cohort of patients, a secondary care hospital may present the only feasible option and this needs to be accommodated within the Providers capacity planning. In some areas, this will require a more collaborative approach between the CCGs and our NHS Trust Providers.

In addition to the strategic detail highlighted above, areas of focus across the Norfolk and Waveney footprint are identified below:

  • We wish to explore the potential for a system which GP and other referrers can access for advice from a secondary care consultant prior to referral. 
  • We wish to improve the efficiency of the follow up process within secondary care. 
  • There will be the expectation that any procedure that is clinically appropriate to be performed as an outpatient procedure will be performed and billed as such regardless of the setting in order to support the transition of these activities to the community services e.g. intravitreal injections, skin excisions.
  • We will implement a consistent prior approval/procedures of limited clinical value policy that will be clinically informed and will reduce demand where there is not a strong clinical case for its efficacy.
  • We will utilise all capacity available to Commissioners outside of secondary care to cater for patients that would otherwise need to be seen within secondary care. 
  • We will roll out a new diabetes prevention service that provides targeted intervention and education for patients and aiming to either prevent or delay the onset of diabetes.
  • We will continue to work with clinicians in primary and secondary care to develop pathways in light of new national guidance, e.g. NICE and will look to primary and secondary care to adhere to these.
  • We will continue to monitor primary care variation and work with clinicians to understand and eliminate any unexplainable variation.
  • Shared focus on achieving best value from supplies of equipment e.g. wheelchairs, orthotic products, insulin pumps, continence products including how personal health budgets might support choice and good value.
  • We will work to implement consistent eligibility criteria across Norfolk and Waveney CCGs for non-emergency patient transport.
  • Where patients can be followed up in the community there will be an expectation that the acute providers and the community services will collaborate to provide a seamless service closer to the patients home, e.g. cataracts/glaucoma.
  • We will review the viability of the community paediatric team in its current form and consider alternatives to make the service more sustainable.

In addition to the above, there are proposals specific to certain CCGs.

  • Across Central Norfolk CCGs, we will introduce a revised foot and ankle pathway across the system for both adults and children that will focus on patients seeing the right clinician at the first time of asking and will also reduce unnecessary demand.
  • Across Central Norfolk CCGs, we will review the provision of epilepsy specialist nursing and its impact on reducing emergency admissions.
  • Across Central Norfolk and Great Yarmouth and Waveney CCGs, we will review rehabilitation services with specific focus on why two services are delivered both in secondary care and the community. 
  • Across Central Norfolk CCGs, we will look to commission a new treatment service within community inpatient units that can accommodate cohorts of patients currently being treated within secondary acute hospitals, e.g. iron infusions.
  • Across Central Norfolk, we will look to re-commission a Level 2 Fertility service directly with the successful bidder.
  • Across Central Norfolk and Great Yarmouth and Waveney CCGs, we will review the use of ultrasound guided injections, the volumes undertaken and the pathways into the service.
  • In North and South Norfolk, we will introduce a new respiratory service within the community that acts as an intermediary between primary and secondary care, both preventing referrals to secondary care and catering for earlier discharge from secondary care.
  • In Great Yarmouth and Waveney CCG we will continue working to provide an integrated pain service linking the acute, community, primary care and mental health services.

Urgent and Emergency Care

The provision of a sustainable urgent and emergency care service remains a key priority going into 2017/18 and beyond. Transformational change is required alongside operational management to ensure this happens. Solutions to achieve this will be based on the agreed Norfolk and Waveney STP guiding principles, our systems overarching priority of “keeping me at home” and will be consistent with the wider strategy as set out in the Urgent and Emergency Care Review.

The solution to a sustainable model of care lies both in the management of patients prior to attendance at a Provider (i.e. the typically transformational change) and then what happens to them should there not be any alternatives than secondary care.

Beginning with the former, the primary aim to the management of patients prior to referral is to identify those whose care can be provided in an out of hospital setting and thus minimising onward transfer to 999 and Acute Care. The specific intentions we have for affecting this change involve:

  • The development of the integrated clinical hub model to manage 111 and 999 calls both in and out of hours. We will consider options to expand this to cover management of demand for all same day/urgent care requirements.
  • The development of Single Points of Access into Providers in order to manage demand, effect clinically appropriate access and aid flow through to discharge and recovery applicable to all Providers including secondary care and mental health.
  • Collaboratively working to share and review data to identify gaps in pathways, service provision and or communication/understanding of services available. This will be supported by ensuring that the Directory of Services is up to date, accurate and its use and functionality is maximised.
  • The development of a ‘Supported Care’ service focused on providing support to patients to enable them to be care for in their own home, preventing the chances of emergency admission and a potential resulting stay in a community inpatient unit.
  • Building on the 2016/17 Frailty CQUIN, CCGs wish to focus on the identification of the pre-frail and align services to support such patients and carers to minimise risk of escalation.
  • For those patients who do require further care, a more sustainable solution needs to be in place that does not result in patients defaulting to A&E departments. Commissioners’ focus will be on establishing more integrated alternatives to A&E that provide access to same day urgent care and ensure a clinically appropriate response by ambulance services to 999 and with access to timely and clinically appropriate secondary care treatment as required. The specific intentions we have for affecting this change involve:
  • Working with EEAST to develop an operational model in order deliver the clinically appropriate response (hear and treat, see and treat or convey) that is integrated across the health system.
  • Implementing the NNUH A&E Front Door Redesign model to ensure access to the appropriate clinical intervention, including transfer into secondary care.
  • Fully embedding the new contract for delivery of the Norwich GP-led Walk in Centre and develop to support both planned and unplanned care models.
  • Reviewing current services for provision of out of hours primary care to identify options for aligning with the integrated model and improving most effective use of that resource.
  • Evaluation of the ambulatory care centre at JPUH.

Whilst consortium contracting arrangements for ambulance services may previously have worked on the large scale with which they work at the moment, Commissioners are very keen to move to a model that is less centralised, better reflects the needs of the local population and is integrated with all the other local system changes we expect to see. Norfolk and Waveney will actively explore ways in which we can achieve more local influence and control over how ambulances services fit within our local system and drive better outcomes for our population.

Performance of the system will be measured by the achievement or otherwise of the 4 hour A&E target, achievement of ambulance and A&E handover targets, reduction in unnecessary ambulance conveyances, the achievement of 999 response targets, volume of calls and more crucially, management by 111 and the achievement of their subsequent targets.

Norfolk and Waveney CCGs will also undertake a review of stroke services across the region.

Mental Health and Learning Disability

Mental wellbeing is fundamental to a person’s quality of life. It is linked to good physical health, better cognitive and physical functioning, increased productivity, better interpersonal relationships, longer life expectancy and a greater capacity to deal with stress and adversity. As in previous years, Norfolk and Waveney CCGs will continue to apply parity of esteem, namely an uplift in funding to the sector consistent with the uplift received by CCGs in the planning guidance.

The challenges the Health and Social Care systems in Norfolk and Waveney face in meeting their population’s mental health needs are replicated nationally. Doing nothing is no longer an option. The Norfolk and Waveney CCGs working with Norfolk County Council and wider partners are committed to taking forward a system wide transformational approach to securing future mental health service provision.

In 2017/18 to 2018/19 the predominate focus will be on reviewing key elements of the Norfolk and Waveney mental health system, the determination of future models of care and the commissioning/contracting means by which these will be secured.

Our vision is to ensure the provision of excellent, safe, sound, supportive, cost effective and transformational services for people with mental health needs that in turn promote independence and empower, wellbeing, and choice and that are shaped by accurate assessments of community needs.

We will do this by focusing on the following key priorities, all of which will be driven forward through the principle of supporting people’s mental health needs through securing integrated operating models and responses.

1. Mental health prevention and early intervention including improving quality in services offered locally and within primary care
2. Rehabilitation and recovery; supporting people with complex needs
3. Crisis Care and suicide prevention
4. Securing a future whole systems model to the delivery of Child and Adolescent Mental Health Services (CAMHS) and ensuring the delivery of peri-natal mental health services.

Children's and Young Health

Our vision is that all children and families in Norfolk and Waveney have the right to: be kept safe, the best education, physical and emotional health and successful preparation for adulthood and employment.

The CCGs are committed to the healthcare of children, young people and their families. To do this effectively, it is important that we work collaboratively with the Norfolk and Suffolk local authorities, education departments and public health Commissioners and police wherever possible in terms of services for children and young people. We will focus on areas where it has been identified that closer integrated working will achieve the maximum impact for both individuals and organisations alike, and we intend to build on existing projects and examples of good practice, where the benefits of integrated working can be shown and with the children and young people at the centre of all we do.

In all the commissioning work to be undertaken, we will ensure that the voice of children and young people is heard through working with Healthwatch, and other representative organisations, and seeking out ways to innovatively gain input and involvement.

Specific streams of work that are in place or due to commence are as follows:

  • Priorities for Prevention, Reducing Inequalities and Improving Health - our priorities will include the right care identified areas of improvement for Norfolk and Waveney within maternity and early years. These include:

a. Reduction of smoking levels, especially in pregnancy and at time of delivery.
b. Improving uptake of flu and whooping vaccination in pregnancy.
c. Improving childhood obesity.
d. Undertake system wide work to reduce unplanned paediatric admissions to hospital, including the rate of emergency admissions for health needs as highlighted by Right Care (e.g. emergency admissions for asthma).

  • Collaborative commissioning arrangements - with the local authorities and between the CCGs:

a. Formalise joint commissioning arrangements and governance, to include arrangements for shared care and tripartite funding
b. Continue to work together to sustain the improvements made to the quality and timeliness of health assessments and review assessments for Looked After Children
c. Consider the service offer available for care leavers
d. Ensure that the health needs of children and young people with complex needs are met in community settings (home, school or local authority short break provision) – by reviewing the CCNT and health funded short breaks nursing offer
e. Working jointly with Norfolk and Suffolk Local Authorities, continue to implement the requirements of the Children & Families Act 2014 including those for children and young people with - Special Education Needs and Disability (SEND) - taking forward the Governments commitments to improve services for vulnerable children and young people including development of personal budgets.

  • Continuing Care - review the local arrangements and service availability for children and young people with continuing care needs, to ensure children and young people do not remain in hospital unnecessarily and have their needs met in a timely, effective way:

a. Continue local work around market development and availability/sustainability of packages of care – including how specialist mainstream services support the needs of children and young people
b. Continue local work to ensure care available is at the right place and right time
c. Consider expansion of personal health budgets
d. Consider need for case management services.

  • CCGs in central Norfolk will review their offering of residential short breaks for children and young people working with Norfolk County Council to identify a joint commissioning process including joint referral criteria. Alongside this, Central Norfolk CCGs will review the Children’s Community Nursing and Therapy Team and whether it meets the needs of the population.

Maternity

Within maternity, our priorities are:

  • To increase flu and whooping cough vaccine uptake in pregnant women.
  • To decrease the numbers of pregnant women smoking at the time of delivery.
  • To implement the saving lives care bundles (aim to reduce stillbirths and neonatal deaths).
  • To develop a local maternity system (LMS) to deliver the maternity services outcomes as part of the STP.
  • For the maternity services liaison committees to work more closely and to be involved in the LMS.
  • Perinatal mental health, taking heed of the new national guidance.

Cancer

The commissioning vision, aims and objectives for cancer care in Norfolk and Waveney are aligned to the new National Cancer Taskforce report, Achieving World Class Outcomes: A strategy for England DH 2015-2020, the national performance indicators for cancer waiting times, Right Care and the new Quality Premium for cancer. Cancer care shall be provided and commissioned as part of the East of England Strategic Clinical Network for Cancer (EOE SCN) and as part of the forthcoming EOE Cancer Alliance.
CCGs will continue to work with Providers to achieve world class outcomes and the sustainable delivery of core cancer standards. Recognising the predicament that local services are in, Commissioners will expect Providers to work closer together as a way to sustain delivery and quality of care provided.
Specific intentions for how this will be achieved include:

  • Continuing to support the integrated care pathways project at the NNUH and JPUH including survivorship, holistic needs assessment and risk stratified pathways across all Providers.
  • The implementation of the national cancer taskforce recommendations.
  • Reviewing the feasibility and potential implementation of supportive cancer care and chemotherapy administration in the community, building on the transfer of work into the community that has already taken place.
  • Supporting the roll out of evidence based best practice cancer pathways.
  • Supporting general practice and working with Public Health England to improve earlier cancer diagnosis and prevention.
  • Clinical service review of local cancer services in Great Yarmouth and Waveney.
  • Implementation and monitoring of the national quality of life measure for all local cancer patients once it has been published nationally.
  • Implementation of the local cancer dashboard in line with national guidance.

Palliative and End of Life Care

The CCGs will work collaboratively to optimise delivery of generalist and specialist palliative care to support people to live and die well in their preferred place of care and prevent avoidable admissions to an acute setting. This will include the phased implementation of EPaCCS and consideration of a 24/7 patient/carer helpline. We will also explore the potential to enhance levels of community provision to facilitate early supported discharge from specialist inpatient care and to support people at home (or as close to home as possible) at the end of life where it is safe to do so. CCGs will continue to promote the Thinking Ahead documentation (Yellow Folders) to support Advance Care Planning.

Out of Hospital Care

For the sake of explicitness, out of hospital care is intended to cover intentions for the primary care and community sectors (including community mental health). These have deliberately been amalgamated to reflect the future direction of travel whilst also addressing the current arrangements, e.g. individual practice contracts.

The Norfolk and Waveney STP highlighted that well-designed schemes to move healthcare closer to patients own homes can deliver benefits in the long term and that costs of delivering care in the community may be lower than delivering care in acute hospitals. To that end, Norfolk and Waveney CCGs will actively look to shift care out of hospitals and into the community on a system wide approach.

Given the national emphasis on clinically led GP commissioning it is a key component of the transformation and change programme in Norfolk and Waveney that any system-wide planning must be owned and created locally with ownership from primary care.

There is consensus across Norfolk and Waveney CCGs that there is not a need for the current number of community inpatient beds in their current guise. Commissioners will focus on the alternatives that need putting in place to support patients in their own home rather than an inpatient setting.

With the forecast increase in primary care activity and the necessary shift in activity away from acute setting, new models of primary care will be needed to deliver these integrated services at scale. Nationally the Five Year Forward View gives examples of Multi-Specialty Provider (MCP), Care Homes Pilot and Primary and Acute Care are not mutually exclusive and elements of each feature in various Norfolk and Waveney developments. That said, there is a very clear and consistent consensus across all CCGs for the model to be centred around primary care with an investment in primary and community care to reduce the need for people to go to hospital unless really necessary and a resulting shift of activity away from secondary care, i.e. more in line with a MCP model.

Much debate has been happening at both locality and county level around the type, size and number of integrated community care centres across the Norfolk and Waveney footprint and whilst there are differences in current thinking about ‘form’ there is consensus that they all should reflect key design features. These design features to further shape a Norfolk & Waveney integrated community service will be likely to include:

• Shift of “acute” services into hub/spoke arrangements. The range of examples includes outpatients, diagnostic services, urgent care, diabetes, dermatology and community mental health services, gynaecology, social care and voluntary agency support.
• Systems implementation of “Integrated Urgent Care Commissioning Standards”, contractual and service integration of NHS 111, out of hours and wider urgent care services aligning to local solutions.
• Progression to “full delegated commissioning” of primary care in 2017/18, “following due diligence and appropriate authorisation and CCG governance arrangements”. This will include CCGs working closely with NHSE to ensure the appropriate implementation of the “General Practice Forward View” and the national commitments to support General Practice and Primary care.
• Development of Primary Care at scale (variations of general practice models, no single approach but based on local determination) to ensure sustainability and achieve greater access to 7 day services across localities
• Enhancement of out of hospital integrated teams, health and social care plus the 3rd sector, aligned to hub and spoke/cluster approach.
• Increasing close joint working with a range of partners, Local Authorities (County and District), including for example; aligning Better Care Fund (BCF) initiatives; mental health reablement and rehabilitation processes and pathways, prevention and early intervention programmes.

The foundations for this integration are at different stages across the CCGs and localities in Norfolk and Waveney; however it is recognised that building on these early developments whilst sharing learning and experience will give the wider system the best opportunity for optimising the necessary “shift in care”.

MCP Model

North Norfolk CCG is working with practices to develop an MCP model that will be able to take services out of hospital where appropriate into a community setting whilst also putting in place preventative care for patients, particularly those with long term conditions. The focus will be on the patient rather than the Providers of the care, ensuring that the patient receives high quality care, at the right time, at the right place. The CCG aims to build on the work that has already taken place, refining it as necessary to make sure that pathways are clear to all.

We currently have 4 clusters developed around GP practices, with patient populations of around 40,000, sharing health and social care staff resources. A team of 8 Integrated care Co-ordinators (ICCs) who work in pairs to support each GP cluster, run their MDT meetings and facilitate referrals to voluntary sector services. The ICCs have access to both health and social care databases and support the holistic care of patients.

The North Norfolk social care team and community nursing team have aligned their staff to support the 4 GPs clusters and they are also co-locating their teams at a central hub based in North Norfolk where health and social care duty and hub teams sit.

Our intention is to more formally align the community nurses with the GP practices. This is already taking place within the NN4 locality with an expectation that this will be rolled out across the locality. An admin allocator and triage nurse have been appointed to directly manage the community nurses workload at a GP cluster level and respond to a dedicated line for admission avoidance calls from GPs. They will also access the ICC’s and SWIFTS Team.

Additional services will be built on to this base including links and support from other services such as mental health service, specialists, ambulance service and out of hours. Our intention is for care to be centred around primary care and for the sector to be bolstered to deliver at scale.