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YHSCG ‘Improving Quality – Adding Value’ Annual Report 2010/11

Yorkshire and the Humber Specialised Commissioning Group


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Chair’s Report

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Progress on Key Objectives in 2010-2011

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Funding for Cancer Medicines

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Y&H Congenital Cardiac Network

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EMBRACE – Yorkshire and the Humber Infant and Children’s Transport Service

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Children and Critical Care Neonatal Networks

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Y&H Renal Network

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Vascular Services Review

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Adult Morbid Obesity Surgical Services

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Triage of Spine Pain Referrals

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Secure Mental Health

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Acute CQUINS Scheme

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Making Sound Financial Investments

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Directory of Contracts 2011-2012

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Glossary of Terms and Abbreviations

YHSCG annual report 2010 | 2011

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CONTENTS


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CHAIR’S REPORT Delivering high quality care with the available resources is a central priority for the NHS and is the key theme for this 2010/11 annual report. The challenge is to achieve the quality improvements in the context of limited financial growth and a national requirement for the NHS to deliver £20bn efficiency savings, for reinvestment, by 2014/15. Improving quality and improving productivity/efficiency therefore go hand in hand. The PCTs working together as the SCG to commission specialised services have a unique opportunity to improve the quality of services and clinical outcomes through consistency in commissioner decision making and, working with service providers, the development and modernisation of clinical practice. Strong engagement with clinicians, patients and the public has enabled improvements in patient pathways, better patient access to services and treatments and as a result improved patient experience and outcomes. Key achievements of 2010/11 by SCG and its supporting commissioning team lead by Cathy Edwards include:Further strengthening the governance of the SCG Board and the formal sub groups; implementing a separate SCG CQUINS scheme to drive up quality; agreeing service strategies for low secure mental health services, child and adolescent, tier 4, mental health services, (CAMHS), congenital cardiac services and inherited cardiac services; implementing a commissioning policy and service specification for specialist fertility services and completing a review of vascular services. The Specialised Commissioning Team has also supported a range of other collaborative commissioning arrangements including the administration of the Interim Cancer Drugs Fund; developed a range of commissioning policies for specialist drugs and supported the regionwide Evidence Based Commissioning QIPP programme, which introduced consistent, clinically effective criteria for treatment and drugs in a number of areas that improved value for taxpayers money. For 2011/12 the key challenge for us will be to maintain the momentum of work on improving quality and value for money whilst at the same time making the transition to the new national commissioning arrangements. The specialised commissioning teams of the 10 SCGs, across the country, are working very closely together on improving quality, sharing good practice and improving efficiency as well as the development of the new commissioning arrangements for specialised services. There is much to be gained from this collaborative approach, which becomes increasingly important as reductions in the infrastructure in all commissioning teams are implemented as part of Liberating the NHS national policy. Over the next year there will be a major focus on developing a consistent approach to commissioning in preparation for the transfer of responsibility to the new NHS Commissioning Board. Despite the rapidly changing environment and the changes in commissioning infrastructure there remains a strong continued commitment from all the PCTs to support specialised commissioning and to drive up quality, deliver improved health outcomes, and improve the productivity and efficiency of specialised services on behalf of the people of Yorkshire and the Humber. Ailsa Claire Chair Yorkshire & the Humber Specialised Commissioning Group YHSCG annual report 2010 | 2011


By the end of 2009/10 the SCG was in good shape having strengthened the governance arrangements; agreed a comprehensive commissioning strategy; increased the commissioning budget to over £600,000,000 and appointed to all the key posts in the management structure. This position enabled work to start early in 2010/11 on identifying a range of QIPP opportunities to achieve improved quality, increased productivity and savings for reinvestment. Improving the quality and the value for money of cardiac services has been a key priority for 2010/11. Commissioning activities have included working with the clinicians in the cardiac networks to develop treatment thresholds to ensure appropriate patient pathways and effective use of resources. We have also developed service strategies for congenital cardiac services and inherited cardiac conditions as well as agreed a service specification for adult congenital heart disease services. The designation of several of our paediatric cardiology outpatient services in local district general hospitals directly links to the national review of childrens congenital heart services currently in progress and will support the future implementation of the childrens congenital heart networks. Further work on services for children has made progress towards implementing the national standards for neonatal services and a 24/7 integrated neonatal and paediatric critical care transport service has been introduced. The transport service has now been fully operational for a full year and is a real success for the region, in driving up quality of care. A key priority for 2010/11 was consulting on and completing the review of vascular services across the region. The provision of complex vascular procedures will now be concentrated in 4 specialist centres and the revised arrangements will be implemented over the next year. The SCG has continued to provide regional leadership on the development of commissioning policy for cancer and non-cancer (specialist) drugs. The increasing level of consistency for the commissioning of cancer drugs has provided a robust platform from which to develop the “priority medicines list” for the Interim Cancer Drugs Fund. All of the £5.3m allocated to Yorkshire and the Humber in 2010/11 has been committed to fund cancer medicines for local patients. Significant progress has also been made in improving quality of service for patients requiring specialist mental health services. A strategic vision for low secure mental health services was approved early in the year. Further work has been undertaken to benchmark costs and improve value for money in all the contracts with low secure service providers. A service strategy and commissioning framework has been agreed for child and adolescent mental health services (tier 4). The approach outlined in these documents will underpin the next stage of the work to improve service quality, service access and service efficiency. In recent months the Specialised Commissioning Team has reviewed its management structure to ensure it is both effective and efficient in the light of the need to reduce management costs and to make the transition to the new national commissioning arrangements. A new structure has been agreed and implemented.

YHSCG annual report 2010 | 2011

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PROGRESS ON KEY OBJECTIVES IN 2010/2011


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FUNDING FOR CANCER MEDICINES Through the Excellence in Decision-Making work programme and the Tri-Network Cancer Drugs Group, SCG made an important contribution to the development of consistent, regional commissioning policies for high-cost specialist treatments in 2009/10. This work was consolidated in the establishment of the Regional Policy Sub-Group in 2010/11. However, the launch of the Interim Cancer Drug Fund in 2010 required a review of arrangements for the funding of cancer medicines in the region. The Specialised Commissioning Team was appointed to support the Strategic Health Authority in managing this work and, through its clinical networks, ensure that individual patients would be able to receive clinically-recommended treatments that they had been unable to have funded by their Primary Care Trust. In 2010, the Secretary of State for Health announced plans to establish a Cancer Drugs Fund from April 2011 to improve patient access to cancer drugs prior to the anticipated reform of arrangements for the pricing of branded medicines from 2014. In anticipation of this, an interim fund of £50million was allocated from central budgets to Strategic Health Authorities to provide in-year funding for cancer drugs from October 2010 to March 2011. NHS Yorkshire and the Humber received an allocation of £5.3million to use for the purchase of cancer medicines. The Specialised Commissioning Team worked closely with the SHA to provide important links to clinical networks in the region. Since October 2010 the SCT has provided operational support for the Fund.

(Cumulative Figures)

Key steps in establishing the Interim Cancer Drug Fund included: • Working closely with PCTs, provider Trusts and local cancer networks, in particular network pharmacists, to identify those medicines not currently funded by Primary Care Trusts in the region • Establishing regional tumour-specific groups of clinicians to provide advice on the medicines to be prioritised for funding • The development of a ‘notification’ process to ensure that clinicians and their patients can access prioritised treatments without delay • The development of an individual application process to allow treatments for rare cancers to be considered for funding • Providing regular feedback to clinicians, PCTs, provider Trusts and patients (via the SCG website) on the use of the Fund

By the end of March 2011, the total £5.3million allocated to Yorkshire and the Humber had been committed for funding local patients’ cancer medicines. The Cancer Drug Fund became operational on 1 April 2011 and £20million was allocated to Yorkshire and the Humber. Experience in managing the Interim Cancer Drug Fund has enabled the SHA and SCT to develop its processes to support implementation of this new Fund, with the support of local cancer specialists remaining one of the key elements to its successful operation. YHSCG annual report 2010 | 2011


The Yorkshire and Humber Congenital Cardiac Network covers the Yorkshire and Humber SCG region and part of East Midlands SCG area. The Network supports two main specialised service areas: (i) paediatric cardiology and cardiac surgery, and (ii) adult congenital cardiology and surgery. It provides a forum for clinicians, mangers and commissioners to discuss ways of working together to improve services and is a driving force to ensure that the discussions result in actions, which have a beneficial effect on patient care. Over the past year the Network has worked to improve care and add value in the following areas: • The Network has developed a Strategy for Congenital Cardiac Services in Yorkshire and the Humber, which was the subject of a regional consultation involving all key stakeholders, patients and parents. It describes how care will be standardised and continuously improved for patients across the region in the coming months. • The Network has worked closely with the regional Child and Antenatal Screening Team to develop and implement a regional programme of cardiac training for the staff that carry out pregnancy scans. An aide memoir ‘concertina card’ that can be carried by staff when they are in a clinic has also been developed by the Fetal Scanning Training Team. • Feedback from patients and parents has been used to develop a leaflet for parents of children and babies found to have a murmur. The leaflet gives guidance for parents who are waiting for a further appointment, and tells them the sign and symptoms to look out for if they are worried. The leaflet can be found on the Network website, and it will be distributed in Neonatal Clinics during the coming year. • Over the past two years the Network has become the driving force for improving the standard of local expertise. The standards that we have developed have been used to designate a number of our paediatric cardiology outpatient services; this has already resulted in the appointment of a number of Paediatricians with expertise in cardiology, and more appointments are planned. This strengthens the clinical quality of local services and ensures that there are good links with the specialist paediatric cardiologist. • The regional Paediatric Cardiology Network, a clinician’s forum, has developed guidelines for GPs and hospital staff to standardise the way children with suspected heart problems are managed. • The Network has agreed a set of standards and a service specification for the specialist Adult Congenital Cardiac Service centre, based on a national template. These standards will be used to assess current services and drive forward improvements.

YHSCG annual report 2010 | 2011

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CONGENITAL CARDIAC SERVICES


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CONGENITAL CARDIAC SERVICES The Patient Parent Carer Engagement Steering Group, which is a formal sub-group of the CCN, ensures that parents and patients are fully engaged and involved in the CCN’s work. This group has two ACHD patients and two parents of children with cardiac conditions as members. The group meets routinely two weeks prior to network board meetings, in order to review all board papers and provide feedback to the board. The group also has a growing work programme of its own. Examples of the Group’s activities include: •

Embarked on a rolling programme of patient and parent involvement activities around the region, and provided feedback to those who have been involved so far;

Developed a series of leaflets to empower patients to get the most out of NHS service;

Aided the specialist centre in the production of patient held records so that every ACHD patient without one can receive one at their next clinic appointment;

Worked with Yorkshire Ambulance Service in order to ensure that a handful of patients around the region with severe ACHD can bypass local hospitals and be transferred directly to the specialist centre in Leeds if necessary;

Begun to trial some standard diagrams of the heart for use by consultants and nurses when explaining a particular condition to a patient or parent – this work was the result of patient feedback.

YHSCG annual report 2010 | 2011


Embrace is the Yorkshire & Humber Infant and Children’s Transport Service, commissioned by the Y&H SCG with the service provided by Sheffield Children’s NHS Foundation Trust. Established in December 2009, Embrace is the first service of its kind in the UK, and has attracted significant interest from other regions looking to set up integrated paediatric and neonatal transport services of their own. Its uniqueness lies in the concept of critical care transport for infants and children as a specialism in its own right. The Embrace workforce consists of specialist consultants, middle grade doctors and transport nurses. In addition there are call handlers and Yorkshire Ambulance Service (YAS) ambulance drivers. Embrace provides a simple means by which clinicians caring for infants and children can access regional services and arrange transfers. A single phone number puts the clinician through to a call handler who takes some basic information before bringing in one of Embrace’s specialist transport doctors or nurses who can arrange for specialist advice to be given and/or a transfer arranged. Over 2010, the focus of the work has been developing and embedding the Embrace service, and building resilience to cope with peaks and troughs of pressure. The final phase of the implementation of the service took place in September, with the provision of 24/7 coverage for both neonatal and paediatric transfers. During the snow in December 2010, Embrace proved itself invaluable, providing support to severely stretched hospitals and ensuring priority transfers were undertaken. The service is on track to have undertaken in excess of 2000 transfers during its first full year of operation. Strong relationships have now been formed across the clinical community which have greatly improved the patient’s care pathway, and these relationships are the backbone of Embrace, enabling the staff to provide an efficient and effective service. Deputy Prime Minister Nick Clegg said that “Embrace is a pioneering example of what can be done when health care professionals work together. It helps sick children get the treatment they need quickly, wherever they are and it reassures parents across Yorkshire and Humber”. Regular feedback from hospital teams and parents has enabled Embrace to be responsive to the needs of those it serves and to modify the service. “The team were very organized, kept us involved all the way through. The team were very compassionate and understanding. Thank you, we couldn't ask for a better service”. “We would like to express our thanks to the whole team who were reassuring and explained the whole process through a traumatic experience”. “I thought the Embrace team were amazing, and by sending a text to update us on our daughters progress/journey put our minds at rest. Both my husband and I couldn't sing their praises enough. Thank You”. In recognition of the ever-changing environment in the NHS, Embrace is continually looking to the future. National reviews of children’s services, including paediatric neurosurgery and cardiac surgery, are ongoing and will come to a conclusion within 2011. Critical care transport services are crucial to both of these reviews, and Embrace will be a key stakeholder in the consultations, looking to shape and influence the organisation of services in the best interest of the patient. In addition, the implementation of ‘Liberating the NHS’ makes 2011 a year of transition for Embrace, and the strong foundations built between commissioners and providers so far will serve as a robust platform for this work. YHSCG annual report 2010 | 2011

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EMBRACE


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CHILDREN’S AND NEONATAL CRITICAL CARE NETWORKS The Children’s and Neonatal Networks have continued to work with provider organisations and local commissioners to steadily drive up standards and improve health outcomes for babies, children and young people, as well as their parents, who need these specialised services. Patient involvement forms a significant part of the Networks’ strategies. Both neonatal networks have parent representatives as full member of the Network Board meetings. One parent representative has had an article published in a nursing journal as well as being part of the parent-led benchmarking programme of hospital facilities. These benchmark results will now be used to inform a part of the forthcoming Neonatal Network Strategy. The networks continue to develop good practice in other areas too and this year has seen the introduction of children’s early warning scores that are consistent across the paediatric intensive care referral pathways. This means that when one clinician calls another for assistance, they are both working from the same assessment criteria and therefore will have a shared understanding of the child’s level of need. This supports better informed discussions, sometimes leading to earlier interventions which prevent a child deteriorating further and avoid the need for the intensive care resource. Working together to develop and deliver training and education remains a key function of the networks. Common network guidelines have been developed and training given where needed to improve long-term outcomes and standards at all parts of the pathway, and avoid unnecessary transfers. For example, the neonatal teams have introduced a Hypoxic Ischaemic Encephalopathy pathway and guideline for babies who become short of oxygen either at or near delivery. A new cooling treatment means that some babies may not suffer the same levels of brain damage that have been seen in the past, avoiding the need for a lifetime of care. The paediatric critical care networks have introduced common guidance for managing Epilepticus for local hospitals to follow, which for some children will mean that a trip to the specialist unit can be avoided, with care being provided closer to home in the local hospital. A further significant improvement in healthcare has been the introduction of a common patient information system for neonatal units. The system chosen was ‘Badgernet’ which is used by 95% of all neonatal units in the UK. This system supports the sharing of pertinent information from clinician to clinician when a baby is transferred; it facilitates the gathering of information for national clinical audit programmes and also supports commissioning and contracting by collecting information about conditions, locations and lengths of stay. The use of the system is still in its early days but as the skills in using the system grow it has the potential to be a significant tool for cultural change and quality improvements.

YHSCG annual report 2010 | 2011


In May 2010 the Yorkshire and the Humber Renal Network published its ‘Renal Services Strategy for 2009-2014’. The aims of the Network are set out in this strategy: To reduce the development of kidney disease, through ensuring high coverage of disease management interventions across primary and secondary care. • To ensure early identification and referral of patients likely to need Renal Replacement Therapy, and adequate preparation and choice of treatment type. • To ensure timely availability and access to Renal Replacement Therapy. •

These aims will be achieved through the delivery of a comprehensive five year work plan, which will be supported by the development of clear standards, performance monitoring mechanisms and commissioning frameworks, and strengthened by clinical leadership and patient and carer engagement. Work plan priorities during 2010/11 have included:Quality, Innovation, Productivity and Prevention (QIPP) QIPP continues to be a very high priority for the Renal Network. There are four QIPP projects for Renal Services. These are: • Appropriate Access to Conservative & Palliative Care • Increasing Kidney Transplants • Increasing Home-Based Therapies & Self-Care • Introduction of Mandatory Tariff Appropriate Access to Conservative & Palliative Care Conservative Care is full supportive treatment for those with advanced kidney failure who, in conjunction with the clinical team, decide against starting dialysis. Conservative care can relieve many symptoms, and maximise a person’s health during the remainder of their life. The challenge for 2011 will be to develop a strategy for increasing appropriate access to conservative care; a Network Clinical Lead for Conservative Care has been appointed, and a regional forum has been established to facilitate this process and share learning and best practice. A final strategy, including patient pathways, is due to be published in October 2011. Increasing Kidney Transplants Successful renal transplantation offers an enormously improved quality of life for the patient with end stage renal disease and there is also good evidence that it offers a survival advantage. The Department of Health estimates that a successful renal transplant saves the NHS between £250k and £300k in the first ten years following transplantation. A transplant sub-group of the Y&H Renal Strategy Group has been established to consider and plan for further increases, of up to 50%, in transplantation in future years in line with the recommendation of the Organ Donation Taskforce.

YHSCG annual report 2010 | 2011

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YORKSHIRE AND THE HUMBER RENAL NETWORK


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YORKSHIRE AND THE HUMBER RENAL NETWORK Increasing Home-Based Therapies & Self-Care The Y&H Renal Network is committed to improving choice for patients with end stage renal disease. There is good evidence that both home dialysis therapies and sharing haemodialysis care offer advantages for suitable patients. The ‘Y&H Renal Services Strategy for Kidney Care Home Therapies and Shared Haemodialysis Care (2011-13)’ includes the aim ‘to increase the number of patients undertaking home-based therapies and self-care and ensure that all patients are offered these options, where clinically appropriate’. Education and information are central to the strategy both for patients and staff, with patients and carers involved in decisions about their care and about service delivery. Additional funding has enabled a two-year project to transform hospital based haemodialysis across the region. This exciting development along with the increasing commitment of Renal Units to implement changes, supported through a regional forum, will act as a catalyst to deliver the strategy, alongside clinical leadership, the empowerment of staff, patients and carers and robust commissioning. Additional Renal Network Projects and Work Streams Improving the standard of Patient Transport Services remains a high priority for many patients on haemodialysis. A pilot exercise involves 3 patients from the Barnsley Satellite Haemodialysis Unit who receive a direct payment for their renal transport. There will be an evaluation and recommendations for further implementation regionally and nationally. Successful pilot for the delivery of intravenous iron in the community in the Sheffield area, which was well received by patients and has led to a rethink of the delivery of iron at Sheffield Teaching Hospitals. The Development of a Y&H Tool to allow GP practices to monitor, compare and benchmark their Quality & Outcomes Framework has subsequently been developed by NHS Kidney Care into a national tool. The 2010-2011 Renal Network Annual Report can be found at www.yhscg.nhs.uk

Challenges and Next Steps for 2011/12 The Yorkshire & the Humber Renal Network continues to engage with a range of clinicians across the region as well as positively engaging with patients. Key challenges for 2011-12 include ongoing implementation of the Renal Services Strategy, development of existing programmes of work and continued responsiveness to national and local priorities. A particular challenge to the Yorkshire & the Humber Renal Network will be to ensure delivery and implementation in spite of the significant changes to the NHS over the coming year. However, the ground work undertaken in 2010-11, coupled with the enthusiasm and commitment of the members of the Yorkshire & the Humber Renal Network, form a robust basis upon which to rise to these challenges.

YHSCG annual report 2010 | 2011


Between October 2008 and October 2010 the SCG conducted a review of vascular services with the aim of: •

Improving patient outcomes from vascular intervention

Developing the resilience of vascular services and the workforce

Improving access and equality of access to the full range of vascular interventions

The SCG was asked to carry out the work by the Strategic Health Authority as part of implementing the regional health strategy: Healthy Ambitions. The work involved: •

Assessing the level of need for vascular services across Yorkshire & the Humber

Agreeing the most appropriate patient pathway for patients requiring these services

Developing service specifications and standards for the provision of these services

Following significant engagement work with a wide range of stakeholders including healthcare professionals, commissioners, providers, patients and the public, proposals for the future provision of vascular services in each of the Yorkshire & the Humber sub regions were put forward for formal public consultation. The proposals recommended that hospitals work in partnership to deliver vascular services, with complex and emergency operations carried out in fewer specialist centres and the remainder of care continuing to be provided locally. This would mean establishing four centres for vascular services within Yorkshire & the Humber (and Bassetlaw) region. This would give patients the best chances of survival and improved quality of life after treatment, enable service providers to meet national standards and achieve best practice, ensure availability of specialist doctors at all times, and ensure equal access for everyone to new and innovative procedures such as keyhole techniques. The formal public consultation period ran from October 2010 to January 2011. There was a comprehensive response to the consultation from a range of organisations and individuals, NHS and members of the public. Some respondents questioned the case for change whilst others expressed strong support for the proposed changes. At the SCG Board meeting in March 2011, after carefully considering all the evidence and the consultation responses, it was concluded that the recommendations should be accepted. There will therefore be single vascular services, with hospitals working in partnership, established in North and East Yorkshire and Humberside; West Yorkshire Central; West Yorkshire West; and South Yorkshire. Complex and emergency surgery will only be carried out in seven hospitals. The changes will be fully implemented throughout the region by June 2012. The pace of change and deadlines for each sub region vary and local detailed implementation plans are now being produced. The detailed consultation findings and the post consultation recommendations and implementation plan are available on the SCG website. YHSCG annual report 2010 | 2011

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VASCULAR SERVICES REVIEW


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ADULT MORBID OBESITY SURGICAL SERVICES What we have done We have established a Morbid Obesity Expert Panel which is attended and represented by a range of clinicians across the region and from a multiple of providers, including surgeons, anaesthetists, dietician and specialist nurse. The group has been able to share good working practice across different providers. Following the interim designation of all providers in 2009/10, the panel has assisted in the development of the designation standards to enable providers to progress to full designation in 2011/12. The panel has also played a significant role in the development of proposed revised eligibility criteria for surgical services, which has drawn on specialised knowledge, experience and evidence base. What are we doing We are currently reviewing the interim commissioning policy and criteria to determine who should be eligible for surgery. This has involved a three month engagement process with members of the public and patients, including focus groups with pre and post surgery patients from across the region and an online questionnaire targeted at the general population. The engagement of stakeholders in the review of the criteria for funding for morbid obesity surgery has been steered through the SCG Patient and Public Involvement Leads Steering Group ensuring the use of professional PPI expertise and the sharing of good practice across the SCG and the associated 14 Primary Care Trusts in the Y&H area. This engagement process has enabled us to gain a useful and informative viewpoint of the experiences witnessed by patients who have been treated by the surgical services across the region and gain a public view as to who should be funded for morbid obesity surgery. The following summarises some of the views expressed during the period of engagement: • The NHS should fund morbid obesity surgery. If not there may be higher costs to the NHS later on in terms of further support; • Priority should be decided according to clinical need. There may be other medical conditions to be considered; • A clear, open framework should be developed by the SCG – use same referral rules / guidelines for everyone across the region but clinical judgement is key; • Preventative and educational measures should be taken in terms of eating issues e.g. start in schools, encouraging exercise and healthy lifestyles; • Programmes such as weight management should be tried before surgery is undertaken. Programmes tailored to suit individuals rather than a one-size fit would be better; • Surgery should be a last option, issues need to be discussed and information provided before surgery is undertaken, priority for surgery should be given to those with the potential for most long term health gain; • GPs, nurses and other health professionals should be well informed about all of the aspects and issues involved with this type of surgery, GPs should have a set of criteria to use for referral; • Psychological assessment and support is very important both pre and post surgery, support groups are needed – not currently provided by the NHS; and • Plastic surgery should be considered where there are medical reasons to support it and after a minimum time period (allowing for a psychological assessment and assurance that weight is stable), individual needs should be considered before plastic surgery is undertaken. The views and opinions, along with input from the expert panel are being used to frame a revised commissioning policy for surgical services that will be implemented in 2011/12. YHSCG annual report 2010 | 2011


In February 2009, Yorkshire and the Humber SCG Board received and accepted guidelines for the referral to neurosurgery of patients with spinal pain. The guidelines had been developed collaboratively by neurosurgeons in Leeds, Sheffield and Hull - the three neurosurgical centres in Yorkshire and the Humber – and led by the Specialised Commissioning Team (SCT). As the referral guidelines were being implemented during 2009/10, discussions with clinicians determined that significant numbers of patients were being referred for a neurosurgical opinion, even though they would not benefit from neurosurgical intervention. This meant that patients were being inconvenienced by an unproductive visit to an out-patient appointment, and the neurosurgical service was not operating in the most effective manner - all at unnecessary cost. As the largest neurosurgical centre, the greatest impact was felt at Leeds Teaching Hospitals Trust (LTHT). Working together the SCT, local commissioners and the LTHT agreed that referrals to neurosurgery for patients with spinal pain would be triaged to determine whether a face to face appointment was required or whether an alternative course of action would be more appropriate. It was agreed that all referrals should be accompanied by a recent MRI scan and that a small team of clinicians would review the referrals and scan to determine whether surgery was a potential option. If not, referrers would be given advice on how best to help the individual patient. The system commenced on 1st April 2010 and has been developed and improved during the year. During the year, over 2,200 referrals were triaged and over 600 patients have been subsequently saved an unnecessary visit to a neurosurgical clinic. Prior to the start of the scheme all 2,200 patients would have had a first out-patient appointment at full cost. Under the new scheme those patients who did not require a neurosurgical out-patient appointment only incur a small charge to commissioners which equated to 6.5% of the first out patient charge. The scheme therefore has provided more appropriate care for patients at a lower cost, and is a key example of improving care and adding value for both the service provider and the patient.

YHSCG annual report 2010 | 2011

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TRIAGE OF SPINAL PAIN REFERRALS


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SECURE MENTAL HEALTH Patient Involvement Service user involvement is a core function in commissioning mental health services and the SCG have built upon the success of previous years in ensuring that patients influence and drive the commissioning agenda whenever possible. An involvement group regularly has up to 40 service users from secure services across the region meeting to discuss topical issues and the development of services. This group has been able to generate a range of service user defined developments being taken forward nationally. For instance national standards in relation to therapeutic activities, recovery planning and choice have been initiated and developed within the Yorkshire and Humber involvement group. The group is recognised as the only secure service user regional forum in the country and is being used to develop and lead on national programmes of work. As a result of its success the group is now being formally evaluated by the University of Central Lancashire in order to identify how the approach can be disseminated across the country. The group has also been influential in developing improvements in quality and performance in order to reduce costs in a climate of financial austerity. Key regional and national initiatives have been driven by service users and staff from within Yorkshire and Humber which are creating enthusiasm for change across the country. Two national events jointly organised by the SCG, services users, and secure services were held in York to promote a national approach to care within secure services which aims to improve quality, patient experience, and reduce costs by meeting mental health outcomes more efficiently. This ‘Shared Pathway’ approach has been developed and led by the SCG and service users and is shortly to be piloted across a range of secure services in regions up and down the country. The ‘Shared Pathway’ aims to place much more responsibility into the hands of service users for managing their mental health needs, which aims to reduce risks both for themselves and the public. The work has generated a great deal of interest within the Royal College of Psychiatrists and the Ministry of Justice, and both are keen to be closely involved. Personality Disorder Services The Swale Unit, a 15 bed medium secure service for men with a diagnosis of personality disorder was commissioned by the SCG and opened in April 2010 at the Humber Centre for Forensic Psychiatry in Hull. The service is delivered by a dedicated multi-disciplinary team and utilises a psychologically based approach to care. Treatment is delivered in an interdisciplinary way and is based on a psychological formulation influenced by Cognitive Analytical Therapy. This is the first NHS service specialising in this complex care established in Yorkshire and Humber and there are very few like it in the country. The commissioning plan for the new service went smoothly and despite the operational and clinical difficulties associated with this innovative development the service has finished the year with full occupancy and a successful first year of operation. The unit has also provided a dedicated gate keeping service to the SCG which has helped manage access to specialist medium secure provision for men with personality disorder, and ensure that wherever possible secure services are used only when necessary. This has provided added impetus to exploring alternative pathways for a number of individuals resulting in a reduction in the increasing trend of admissions to these scarce specialist services. The secure unit is now one of a range of dedicated services for individuals with a diagnosis of personality disorder within Yorkshire and Humber, and will provide a pivotal link in the developing Offender Health Strategy for Personality Disorder soon to be published by the Department of Health/National Offender Management Service.

YHSCG annual report 2010 | 2011


The Acute CQUIN scheme for 2010-11 was the first for the SCG. We learnt a great deal from the experience of CQUIN schemes developed by PCTs commissioned for 2009/10. The SCG Strategy set out priorities which were used to select the key services for CQUIN indicators. The CQUINs for 10-11 were: Treating Lung Cancer Why this target? This disease is now the biggest cancer killer in men and women in the region. Ideally, people fit for surgery or other active treatment should be offered this as soon as possible. What were we trying to achieve? Before the introduction of this indicator, we were monitoring performance based on performance from 18 months before. We asked hospitals to tell us what proportion of patients diagnosed with lung cancer were being offered active treatment each quarter- and asked them to tell us how they were planning to increase this number. What did we find? Results in the region have improved over recent years and this improvement continues. All parts of the lung cancer pathway need to be kept under constant attention and now systems are in place for in-year reporting we hope trusts will continue to monitor these closely. Blood and Marrow Transplantation Why this target? This procedure is being used for more and more people to help beat cancers of the blood and other rare conditions. Although all centres are subjected to rigorous standards to be allowed to perform transplants, commissioners were not reviewing patient deaths. What were we trying to achieve? The number of deaths is very small but by asking the clinicians to describe the circumstances and lessons learnt we are ensuring the quality of this high risk service. What did we find? The number of deaths is small, but there are often lessons to be learnt. Findings of these reviews are being shared with other units in the region to benefit from the learning. Neonatal Intensive Care Why this target? There are a number of national standards which measure how well children are being cared for in NIC units. We wanted to encourage additional effort to maximise the achievement of these. What were we trying to achieve?We wanted to show improvements in three areas: • Premature babies can sometimes be damaged by the oxygen given in the early stages of life. Checking for this should take place in line with national guidance. • Temperature recording in the first hour of life is an important part of initial care. • Where a child needs a neonatal intensive care bed, the nearest available bed should be used. What did we find? Over the year performance against all indicators improved. We have chosen to continue to monitor temperature recording and transfers in the 2011-12 indicators with providers agreeing to strict targets: aim for more than 98% of temperatures recorded and less than 5% of transfers refused.

YHSCG annual report 2010 | 2011

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ACUTE CQUINS SCHEME


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ACUTE CQUINS SCHEME Children’s critical care Why this target? We applied the same target for transfers to the PIC units as for NIC units. What were we trying to achieve? We wanted to maximise the use of local beds and reduce transfers to units at a greater distance from patient’s homes. What did we find? There has been some improvement over the year but we have agreed strict targets for 2011-12 to ensure neither of the two regional units turns away more than 5% of children requesting transfer. Adult Cardiac surgery Why this target? Emergency cardiac surgery is life saving and needs to be provided urgently in a small number of cases. Usual waiting time targets are inadequate and unlike cancer there are no “two-week wait” standards. What were we trying to achieve? This CQUIN imposed a 2 week standard on emergency surgery. What did we find? Initially, performance was very variable, with some unacceptable waits. But in recent months, the 2 week standard is being delivered consistently across providers. HIV and AIDS Why this target? The number of people who are HIV positive and requiring treatment is increasing faster in this region than elsewhere in the UK. What were we trying to achieve? We included indicators on offering treatment to patients where guidance suggests this should be available and on speed of diagnosis. What did we find? Both of these indicators have shown marked improvement in-year with more patients being offered treatment- and more of these being treated quickly. Renal Why this target? Renal services represent the largest portion of the SCG budget in acute providers locally and nationally. Dialysis and transplant are the best treatments for patients in end stage renal failure. What were we trying to achieve? We wanted to see that patients: • are offered dialysis when they need it • are considered for transplant when appropriate • are given the opportunity to have peritoneal dialysis if that is their preference. In addition, we sought a guarantee that acute renal unit beds were not being used to offer dialysis as a temporary solution to capacity problems in dialysis units What did we find? We have seen improvements in all measures and next year we have agreed to strict targets with providers for consideration for transplant and use of renal in-patient beds.

YHSCG annual report 2010 | 2011


Strong financial governance arrangements The Yorkshire and the Humber SCG is hosted by NHS Barnsley with statements in its Standing Orders, Standing Financial Instructions and Scheme of Delegation governing the operation of the SCG both in terms of its management activities and contracting role. The SCG Board is a sub committee of each of the 14 PCT Boards within the Yorkshire and the Humber area. The SCG is subject to both internal and external audit via its host organisation. A review of the SCG has been undertaken by the Audit Commission again in 2010/2011 that gives assurance to the 14 PCTs within the Yorkshire and the Humber area. The accounts of NHS Barnsley, which incorporate the SCG resources, were approved in June 2011. SCG Management Costs During 20010/2011 the SCG held a management budget for specialised commissioning, some clinical networks and a number of nationally funded initiatives totalling £7.516 million and achieved a breakeven position. The overall management budget for the SCG for 2011/2012 is as detailed below:

Specialised Commissioning Collaborative Arrangements Clinical Networks

£’000 2,721 176 1,561 4,458

Given the national position of little or no growth in NHS funding, the SCG has developed and is refining a QIPP programme to ensure that the resources that are currently used for the commissioning of specialised services are used more effectively and that there are productivity, efficiency and performance gains throughout all contracts that are held. QIPP savings in 2010/2011 totalled £2.1 million.

YHSCG annual report 2010 | 2011

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MAKING SOUND FINANCIAL INVESTMENTS


Commissioned Services in 2010/11 During 2010/11 the total value of spend on specialised services was £611 million This will rise to £627.6 million in 2011/12. The increase in 2011/12 is as a result of the full year cost of changes implemented in 2010/11 being paid in full, business cases approved in previous financial years being implemented and the impact of such things as changes in population growth and new technologies. Yorkshire and the Humber SCG expenditure as percentage of overall PCT spend £m’s Y&H SCG spend 2010/2011

611

Y&H PCT total spend in 2010/2011

9,137.8

% of SCG spend as a total of all Y&H spend 2010/11 Actuals

Other 18%

Secure Services 23%

Vascu l

ar 3%

Services Children’s

10%

Cancer 10% Ha

rd iol

YHSCG annual report 2010 | 2011

9%

Renal 10%

em op hili a

ry rge su uro

Ne

og y1 0%

3% ids A / HIV

Ca

19

MAKING SOUND FINANCIAL INVESTMENTS

4%

6.69% Specialty Secure Services Cancer Haemophilia Neurosurgery Renal Cardiology HIV/Aids Children's Services Vascular Other Total

£000 2010/11 Actuals 134,576 62,615 23,959 53,545 61,266 62,412 19,351 62,593 19,722 111,297 611,338

Breakdown of Others Cystic Fibrosis BMT Genetics Spinal Other National Contracts Infectious Diseases Specialised Immuniology CQUINS Prosthetics Specialised Ear Sub-Fertility Burn Care Morbid Obesity Hepatology Others Total Others

£000 2010/11 Actuals 9,184 9,010 8,514 8,280 7,893 7,468 7,002 6,670 6,305 5,337 5,333 5,247 5,207 4,748 15,099 111,297


Y&H Provider

2011/12 Contract Value (£ million)

Leeds Teaching Hospitals Sheffield Teaching Hospitals Hull and East Yorkshire Hospitals Bradford Hospitals Sheffield Children’s Mid Yorkshire Hospitals Doncaster & Bassetlaw Hospitals Healthcare at Home York Hospital Calderdale and Huddersfield Hospitals SPIRE Hospitals Hull IVF Unit Nova Healthcare Rotherham Hospital Care Fertility Sheffield Derby Hospitals Barnsley Hospital

170.97 147.80 75.30 23.30 22.89 9.68 6.37 3.11 1.42 1.20 1.07 0.78 0.69 0.49 0.49 0.32 0.11

TOTAL

465.99

Mental Health Provider

YHSCG annual report 2010 | 2011

2011/12 Contract Value (£ million)

Rampton Hospital (Nottinghamshire Healthcare) South West Yorkshire Partnership NHS Partnerships In Care Humber NHS Riverside Healthcare Nottinghamshire Healthcare NHS Bradford District Care NHS Alpha Hospitals Lighthouse Healthcare Sheffield Health and Social Care NHS Rotherham Doncaster and South Humber NHS InMind Healthcare Tees Esk and Wear Valleys NHS Calderstones NHS Care Principles Northern Pathways Cygnet Healthcare Leeds Partnership NHS North West SCG (High Secure) Raphael Healthcare Priory Healthcare Group St Andrews Hospital Caring Homes Leeds Community NHS North Yorkshire and York Community NHS Ashworth Hospital (Mersey Mental Health NHS) Lincolnshire Partnership NHS Broadmoor Hospital (West London MH NHS) St George Healthcare Group Jedheath Ltd Cloverleaf Advocacy Other Optima Care TOTAL

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DIRECTORY OF CONTRACTS 2011-2012

25.00 23.54 15.80 13.71 7.34 6.84 4.44 3.99 3.64 3.62 3.01 2.25 2.97 2.87 2.06 1.97 1.87 1.83 1.69 1.59 1.41 1.25 1.11 0.87 0.67 0.64 0.50 0.33 0.19 0.18 0.13 0.08 0.02 137.41


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DIRECTORY OF CONTRACTS 2011-2012 Out of Region Provider

2011/12 Contract Value (£ million)

Gateshead Health University College London Hospitals NHS Nottingham University Hospitals Guys and St Thomas Great Ormond St Hospital University Hospital Birmingham Oxford Radcliffe Royal Orthopaedic Imperial College Healthcare Royal Free Hampstead Cambridge University Hospitals (Addenbrookes) Kings College London Barts & the London Alder Hey Children’s Hospital Birmingham Children's Walton Centre for Neurology & Neurosurgery Royal Brompton & Harefield St George's Royal National Orthopaedic Papworth Hospital Moorfields Eye Hospital Southampton University Hospitals North West London Wrightington, Wigan & Leigh North Bristol Birmingham Women’s Hospitals TOTAL

OVERALL TOTAL *denotes 2010/2011 accounts figure YHSCG annual report 2010 | 2011

2.63 1.94* 1.81 1.44 1.01 0.83 0.69 0.64 0.63 0.61 0.60 0.57 0.56 0.55 0.55 0.46 0.41 0.39 0.32 0.21 0.20 0.19 0.18 0.16 0.10 0.05 17.73

621.13


ACHD Adult Congenital Heart Disease. COMMISSIONING A cycle of identifying need, identifying services to meet need, procuring services and the monitoring and review of the performance of those services. CQUIN Commissioning for Quality and Innovation payment framework makes a proportion of service providers’ income conditional on quality and innovation. EDM Excellence in Decision Making aims to provide a framework for evidence based decisions on health care interventions that are specialised or require a collaborative approach to commissioning, to be managed as an ongoing programme of business. EMBRACE Yorkshire and the Humber Infant and Children’s Transport Service, commissioned by the Y&H SCG. EPILEPTICUS Condition when a patient goes into an epileptic fit and rather than the fit coming to an end it continues to continuous fitting, leading to comprised body systems. HRG Healthcare Resource Group. Hypoxic Ischaemic Encephalopathy Was previously known as birth asphyxia, suggesting YHSCG annual report 2010 | 2011

a shortage of oxygen at birth however the new term reflects that the shortage of oxygen may have occurred sometime before birth. Intravenous Iron The administration of intravenous iron in primary care and community settings for people with the anaemia of Chronic Kidney Disease. Neurosurgery Is the surgical specialty involved in the treatment of disorders of the brain, spinal cord, and peripheral nerves. PCT Primary Care Trust is the local public body responsible for commissioning the best possible healthcare for its residents, to improve health and well being of the local population. PPI Patient and Public Involvement (PPI) is defined as the active participation of patients, including children, users, carers, community and voluntary representatives, and the public in the development of health services, and as partners in their own health care. It is giving local people a say in how local services are planned, delivered and evaluated. Patient’s experiences and feedback are also important in order for the NHS to develop and deliver services that are responsive to what people want and need. Personality Disorder Where human development is

disrupted or disturbed, the psychological, social and economic consequences can touch every part of the individual’s life, with repercussions for families, friends, communities and society in general. PICU Paediatric Intensive Care Unit. QIPP The Quality, Innovation, Productivity and Prevention (QIPP) Programme is working at a national, regional and local level to support clinical teams and NHS organisations to improve the quality of care they deliver while making efficiency savings that can be reinvested in the service to deliver year on year quality improvements. SCG Specialised Commissioning Group, responsible for the commissioning of specialised services within a Strategic Health Authority (SHA) area. Specialised Services Those services defined by the Department of Health (DH) as specialised, which require commissioning on a regional basis, through a Specialised Commissioning Group (SCG). YAS Yorkshire Ambulance Service. Y&H SCG Yorkshire and the Humber Specialised Commissioning Group (www.yhscg.nhs.uk). This is the SCG for Yorkshire and the Humber, hosted by NHS Barnsley.

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GLOSSARY OF TERMS & ABBREVIATIONS


yhscg.nhs.uk

WWW.

YHSCG ‘Improving Quality - Adding Value Annual Report 2010/11

Yorkshire and the Humber Specialised Commissioning Group

NHS Barnsley | NHS Bradford and Airedale | NHS Calderdale NHS Doncaster | NHS East Riding of Yorkshire | NHS Hull NHS Kirklees | NHS Leeds | North East Lincolnshire Care Trust Plus NHS North Lincolnshire | NHS North Yorkshire and York NHS Rotherham | NHS Sheffield | NHS Wakefield District


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