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Discussion Draft

DELIVERING HEALTHY AMBITIONS IN YORKSHIRE AND THE HUMBER

Yorkshire & the Humber PCTs


Table of Contents Introduction.................................................................................................................... 2 Assumptions and Approaches ..................................................................................... 4 The Key Priorities for Local and Collaborative Action ............................................... 6 Cross Cutting Themes and Enabling Strategies ......................................................... 9 Summary of Investment 2008/9 and 2009/10 ............................................................. 13 Care Pathway Implementation Staying Healthy ............................................................................................. 15 Maternity & Newborn ..................................................................................... 20 Long Term Conditions ................................................................................... 24 Childrens ....................................................................................................... 29 Planned Care ................................................................................................ 33 Acute Episode ............................................................................................... 37 Mental Health ................................................................................................ 42 End of Life ..................................................................................................... 47

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Discussion Draft

Yorkshire & the Humber PCTs


Delivery of Healthy Ambitions in Yorkshire & the Humber Introduction Healthy Ambitions sets out the high aspirations for health and the health service across the Yorkshire and Humber region. It has provided a valued and valuable focus for ensuring quality is at the heart of the commissioning and the delivery of health care. Healthy Ambitions has created a vision for health across Yorkshire and the Humber, which sets out a challenging agenda for the NHS and its partners. It has been driven by clinicians, practitioners and users of services, stating the case for change: •

The desire and need to improve the health for people across Yorkshire and the Humber, and to reduce health inequalities

The need to meet the expectations of the public

To improve the quality, access and safety of care services

To capitalise on advances in research and science through delivering services differently

To capitalise on advances in science to change the way clinical expertise is used

To make the best possible use of taxpayer’s money

The issues and recommendations set out within the 8 Care Pathway Groups are fully supported by PCTs, and form an integral part of, and add weight to, local commissioning strategies. PCTs now need to work with their partners and stakeholders to drive forward health improvement and high quality health care, across the 8 Care Pathways. Healthy Ambitions will only be possible if the NHS across Yorkshire and Humber works in new ways to drive it forward. •

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The delivery of Healthy Ambitions can only happen if it is discussed, developed and acted upon in full partnership across and within the NHS, with Local Authorities, with other stakeholders - not least patients and users of services.

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• •

The details of delivery and implementation will mostly be best managed at a local level, although there will be a need for some collaboration beyond the local level to develop enabling frameworks and solutions. Clinicians, practitioners and staff from the NHS and their partners must continue to be involved, and must be supported in putting Healthy Ambitions into place. No one organisation can deliver Healthy Ambitions. The NHS comprises a complex system of organisations and stakeholders, alongside partners from other sectors. Together we will need to align our goals and ambitions to drive up quality.

This paper summarises how PCTs intend to support the implementation of Healthy Ambitions setting out:

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The assumptions and approaches supporting the implementation of Healthy Ambitions.

The key priorities for individual and collaborative action.

The cross cutting themes and enabling strategies underpinning the successful implementation of Healthy Ambitions.

A summary of the level of investment anticipated, for both commissioning of services and for a Healthy Ambitions Investment Fund to support strategic development approaches at a regional/sub regional level.

The proposed delivery mechanisms for each of the 8 Care Pathways.

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Yorkshire & the Humber PCTs


Assumptions and Approaches Healthy Ambitions will become reality in Yorkshire and the Humber only by working in new ways within and across the NHS, and with partners, to drive up quality decision making, the delivery of quality services, and to improve health PCTs fully support the following approaches to drive forward implementation of the Healthy Ambitions vision: •

Our goal is the successful implementation of Healthy Ambitions - to realise better health outcomes across Yorkshire and the Humber.

Quality is at the heart of all the NHS does.

The engagement and involvement of users, patients and carers will be at the core of our work.

It is recognised and accepted that the SHA will seek assurance that progress is being made in a timely and effective manner. The SHA will establish an assurance framework, which complements and aligns with the World Class Commissioning assurance process.

PCTs will commission the implementation of Healthy Ambitions, working in partnership with others. The primary vehicle for commissioning will be PCTs’ World Class Commissioning strategies, which will be aligned to address Healthy Ambitions priorities.

All aspects of Healthy Ambitions are important, but there is consensus across PCTs that some areas require further prioritisation if our goals are to be achieved: o Stroke o Mental Health o Obesity o End of Life Care o Tackling Variations in Primary Care

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For some important issues further clarity is needed about strategic direction. The SHA and PCTs will work together to agree them.

Clinical leadership and engagement is recognised as an essential and legitimate component of the commissioning process - this needs developing, in some areas improving, and needs to be sustained.

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Formal Clinical Networks will play a key role in advising PCTs. The current Network Review will set out, and support the development needs of networks to undertake this role. Where formal networks do not exist, further work will be set in train to identify how best advice can be sought.

Delivery of Healthy Ambitions will mostly and appropriately be delivered locally, unless a sub-regional or regional approach is needed (specialised services for example), or where such an approach clearly adds value. Sub-regional process will build upon commissioning and contracting consortia, reflecting clinical pathways and patient flows.

Wherever possible existing local, sub-regional and regional infrastructure will be used to lead and coordinate delivery. Some existing mechanisms may need further refinement. Additional infrastructure will only be added where necessary, and will underpin local and sub regional systems.

PCTs will drive any sub-regional/regional processes and infrastructure needed, unless it is clear that other bodies such as the SHA would be better placed to do so e.g. workforce planning, education commissioning.

A Healthy Ambitions Investment Fund will be created by PCTs to support enabling strategies for local implementation, and to support strategic aspiration. It is recognised that this Investment Fund will need to be in place for the next 2 to 3 years.

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The Key Priorities for Local and Collaborative Action Whilst recognising and supporting the Healthy Ambitions Strategy and recommendations in their entirety, the PCTs and SHA at their July meeting identified 5 areas for focused attention, both locally and collaboratively. These complement and support the delivery plans behind the 8 Care Pathways included in this plan. 1. Staying Healthy - with a particular emphasis on addressing Obesity • • • • •

Directors of Public Health’s Healthy Lifestyle Board to drive understanding and implementation of evidence based best practice for local adoption Innovative approaches to supporting children and young people – various pilots are in place locally and are being evaluated Working with the National Support Team for rapid implementation of good and innovative practice Identifying and developing a further centre for surgery Focus on social marketing approaches.

2. Stroke • • •

supporting the implementation of Hyper Stroke Units – first stage to agree strategic objectives Identifying and supporting appropriate clinical insight and inputs (through Networks) for the development and implementation of Hyper Stroke Units Ensuring a comprehensive care pathway exists within each clinical network area to support patients access the right level of intervention at the right point.

3. Improving mental health and access to mental health services • • • • •

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Developing service specifications for local development and implementation to deliver the Care Pathway Outcomes including No-Waits for assessment and referral to appropriate mental health services Ensuring the mental health service models are developed to address the social care needs, and to address the personalisation of mental health services to meet the needs of users Supporting the development of expert mental health commissioning and contracting skills and competencies Accelerated implementation of Improved Access to Psychological Therapies across the region, 2 years ahead of national requirements Leading nationally for local benefit on development of Care Pathways and Packages approach to commissioning and contracting for mental health services - full implementation within 3 years.

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4. Improving End of Life Care •

Using social marketing techniques, public service broadcasting, education and media to bring about a cultural shift in society which breaks down taboos around death and dying.

Developing and commissioning care pathways to support high quality care of patients at the end of their life whatever their medical condition. Coordination and planning is required specifically on a Yorkshire & Humber basis in relation to specialist palliative care services such as hospice beds.

Developing and introducing common and consistent standards based on the EOL National Strategy for implementation across the whole of Yorkshire & the Humber.

Developing and implementing across Yorkshire & the Humber a consistent range of training courses and other educational material to support both existing staff in dealing with EOL issues, and to introduce through to undergraduate training via education commissioning.

Collection of systematic feedback from patients, carers and families and research data across the whole of Yorkshire & the Humber to: o Assess the impact upon the quality of care and a number of best practice EOL care tools o Monitor and assess impact of introducing EOL care strategies across Yorkshire & the Humber.

5. Variations in Primary Care •

Primary Care is the hub for all NHS care, and Healthy Ambitions places a key focus on ensuring the benefits of list based general practice are realised in managing patient care.

Generally the quality of primary care is high across Yorkshire and the Humber. However we have evidence there is variation within localities and across the region in some key areas fundamentally impacting on the quality of care received; o Access to GPs and their teams o Management of long term chronic conditions to support healthy and independent lives o Prescribing patterns and practice o Referral patterns to secondary care, providing choice for patients

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Work is in hand to develop extra primary care capacity and improve access to primary care through collaborative approaches to procurement and developing quality standards. We will work on quality standards rooted at GP population level to enable PCTs to ensure that these standards are adopted by all providers.

The care pathway for the management of long term conditions has set out how it will work with primary care to drive up quality of service delivery through consistent approaches to care and case management.

An earlier Primary Care Think Tank suggested initial work on setting out the priorities and actions for the development of high quality primary care, explicitly: o o o o

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Contract incentives Practice based commissioning Patient registration and dual registration Enhanced service development

The work is now being taken forward; rejuvenating how practice based commissioning can build upon patient and registered population level data, to ensure patients get the best possible care.

10 practices across the region are piloting work to develop a quality framework to support productive and effective primary care. This will be ready for roll out from March 2009 onwards.

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Cross Cutting Themes and Enabling Strategies The programme of work and approaches needed to implement Healthy Ambitions is complex and inter-dependent. One of the key principles to support implementation is that any approaches should build upon and develop existing infrastructure. Where this isn’t possible PCTs will support other enabling approaches to address the issues. Across the Care Pathways there are common themes, and common approaches, which if managed on a collaborative basis would add value and enable solutions to be developed. •

Driving a Quality led Agenda Healthy Ambitions sets out a vision for driving up quality across the NHS. PCTs are driving a new approach to ensure quality standards can be clearly articulated, set out in a contracting environment, and that the NHS is held to account to ensure the standards are delivered. It has established a Quality Outcome Framework for Secondary and Care services - akin to the nationally developed Quality Outcome Framework for Primary Care (QOF). This model of working is applicable to all aspects of care services from acute secondary care through to mental health services, and builds in at its core approaches for capturing patient experiences and feedback. By developing core quality indicators, a first step has been taken in the development of quality standards to drive care in legally binding contracts, rather than simply be cost and activity driven. It is an important development and has already been embedded in the contracting processes during this current year, enabling the NHS to demonstrate quality improvements on the ground. The main objective of this work is to identify what we mean by clinical quality and to enable its measurement/benchmarking of performance across Yorkshire and the Humber. This will lead to improvements in patient experience and service outcomes. The need to engage with, and involve patients and carers, in implementing Healthy Ambitions and the quality agenda is critical. Other work is continuing on the broader agenda of quality and contracting. The Directors of Nursing are in the process of developing quality indicators for other commissioned services, such as community and mental health services.

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In addition, Directors of Finance have agreed to look at incentive scheme development and pulling together a set of principles to support PCTs in their thinking. Work has already been launched to develop a quality framework in primary care, and is being piloted in 10 practices. The framework and tool will be available March 2009 onwards. All our work on developing quality standards will be made available at practices population level, which will enable commissioning to support quality improvement, beyond QOF. •

Network Development and Support Extensive work has already been undertaken to better define the roles and standards of formal clinical networks, and the relationships within and between networks, and to set out how networks can best provide insight and advice to PCTs. PCTs have endorsed the key findings of the review and the proposal for the way forward. A process is now in place to set out the detailed recommendations by the end of September. It is fundamental to the implementation of Healthy Ambitions that the detailed recommendations Network Review is acted upon. A final report which aligns the development of networks, commissioning for a (specialised and non- specialised) and contracting consortia, Healthy Ambitions will set out the programme of work over the next 18 months to 2 years. Networks and PCTs will need focused support to ensure the finding can be implemented. There are currently untapped opportunities for the networks to work more collaboratively on key issues to enable: o o o

Sharing of best practice Development and sharing of pathways, protocols and standards Development and sharing of innovation and service improvement approaches

It is recognised and supported that networks need to operate within subregional boundaries, aligning to clinical flows, and natural communities of interest. Some key areas of Healthy Ambitions will require approaches beyond the current scope of established Networks, and/or will require other forums to provide clinical opinion and insight.

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Of critical importance is the need to support the developing of Stroke care pathways and service models. The 3 Cardiac Networks have set up approaches to support the implementation of the National Stroke Strategy and have to date undertaken detailed work to underpin this. However it is now acknowledged that further pan Yorkshire and Humber work is needed to both: o Develop and agree some strategic decisions/declarations to support the Healthy Ambitions aspirations to address Stroke o Ensure the engagement of all relevant clinical expertise and insight •

Clinical Engagement and Leadership At the heart of the Healthy Ambitions programme is the need and wish to ensure clinical decision making drives the pattern of service delivery. Whilst there are many examples of this being the case, and in particular through formal clinical networks, there are also examples where this is not so. The need to support and develop clinical leaders, primary, secondary and tertiary care, is also recognised. PCTs support working with clinicians both locally and collaboratively to address these issues. The Network Review and subsequent development programme will be a key vehicle for engaging with clinicians, as will the development of primary care commissioning, and tackling variations in primary care. The regional think tank on primary care has also provided a clear focus for taking this work forward. PCTs and Clinical Leads for the Care Pathways have agreed in principle to support and invest in a Clinical Leaders development programme (s) aligned to: o o o o

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Primary Care Think Tank proposals Aspiring Directors programme PEC Development Programme Healthy Ambitions

Health Intelligence and Analytical Capacity PCTs recognise that a step change is needed to develop health intelligence capacity and capability across and within the region. Work is in hand both at individual commissioner and commissioning consortia levels. However it is also recognised that there is a need to address this at a regional level, and there are a number of key issues which require a focused approach to support local implementation.

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Following extensive discussions between the PHO and PCTs, final discussions will take place on 8 September to agree the focus and the deliverables to the HIYAH proposal. All parties support the need to align the HIYAH work programme to Healthy Ambitions. •

Workforce Development and Commissioning of Education Programmes Healthy Ambitions sets out the case for change to support new clinical practice and models of care for delivery of health care. Across the programme of work there is a clear steer for new roles, skills, and ways of working. Support will be needed to ensure both the development, training and support of current professionals, staff and practitioners, and for future commissioning of education programmes for basic, qualifying and post qualification training. New ways of working with education providers need to be developed to enable the appropriate training to be commissioned for the future workforce. Discussions need to take place to agree whether there are opportunities for collaboration on workforce commissioning.

Research, Innovation and Change PCTs recognise that generally the current system does not effectively enable or support innovation or adoption of new/good practice. Work has been undertaken with both PCTs and Providers to scope out the need and approaches for supporting Innovation and Change. It is proposed that an Innovation and Change programme is established and 3 strands are currently being developed: • • •

Commissioning for Strategic Innovation (alignment with R&D, scenario testing, trends - demographics and technology) Care System Innovation - linked to Healthy Ambition Care Pathways, clinically driven pilots Business System Innovation-leadership, engagement, business development, IT, knowledge management.

A full set of recommendations are to be presented to Chairs and Chief Executives in October 2008.

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Summary of Investment 2008/09 and 2009/10 Healthy Ambitions has given a further and important focus to local commissioning priorities. Whilst acknowledging some recommendations introduce new areas for action, the report builds upon already identified issues - albeit in a much more focused and coherent framework. By developing this further clarity on the scale of the challenge and actions to be taken, this has enabled PCTs to: •

Give further focus and resources to investing in local key health and services areas in 2008/09. Key recommendations are already in hand, with new investment to support their implementation. PCTs have confirmed with the SHA the level of investment committed for 2008/09 into each care pathway. A further exercise has identified new investment into the 5 priority areas for 08/09. In total PCTs were able to demonstrate over £30m has been targeted this year into key Healthy Ambitions priorities. A further £16million plus has been invested into addressing variations in primary care - a key enabling strategy for the successful implementation of Healthy Ambitions, for example PCTs will all have at least one new Walk-In Centre.

Ensure that the World Class Commissioning Strategies and supporting financial strategies will support the implementation of Healthy Ambitions this work is still in progress. PCTs will be able to demonstrate significant investment into all of the Healthy Ambitions recommendations, with particular focus on the 5 key priorities. At this stage of the PCTs’ World Class Commissioning Strategies and underpinning Financial Strategies it is not possible to quantify the final level of investment targeted at the implementation of Healthy Ambitions. However an early and outline review has indicated at least £50m will be aligned to the 5 key priority areas. PCTs will set out their Investment Strategies as part of the World Cass Commissioning process. PCTs will work with the SHA to ensure there is transparency in how investment is to be targeted to support Healthy Ambitions.

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Identify the need to resource a Healthy Ambitions Investment Fund initially for 2008/09. Consensus has been reached across the PCTs on the initial focus for the Fund to enable collaborative and enabling approaches to be developed and supported.

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Yorkshire & the Humber PCTs


PCTs recognise and support the need to develop a Healthy Ambitions Investment Fund. An initial set of priorities identified in June/July 08 have now been further refined. Arrangements are in place for PCTs to contribute their share towards the £2.2m for 08/09, and for the SHA to manage the fund on PCTs’ behalf. The table below sets out the Commissioner agreed priorities. Enabling strategy Clinical Engagement • With evaluation of WCC Strategies • With regional level infrastructure • Clinical Expert Panel Clinical Leadership Programme(s) • Initial set up costs • Kick start of programme(s)

Level of Investment 08/09 Up to £450k

Supporting development of Health Intelligence aligned to Healthy Ambitions HIYAH Events/ conferences Workshops Supporting Regional Service Reviews Social Marketing Further development of HA priorities and care pathways

Up to £550

Up to £200k

Up to £200k Up to £300k Up to £400k Up to £100k Total £2.2m

Recognise the need for the continuation of the Healthy Ambitions Investment Fund beyond 08/09, and PCTs have set up a collaborative approach for identifying the priorities and the scale of investment needed. It is recognised that those areas prioritised for the Investment Fund for 08/09 will continue into 09/10, and in most instances beyond. Other areas will be identified as each of the Care Pathway implementation plans are further scoped out and actioned. PCTs have agreed a set of criteria for funding work areas out of the Healthy Ambitions Investment Fund: o o o o

Enabling Strategies to support local implementation Development of Clinical Engagement and Expertise Supporting service reviews Funding conferences and events in line with above

By Autumn PCTs will be in a position to confirm their anticipated investment into the 2009/10 Healthy Ambitions Investment Fund and confirm a more detailed breakdown of priority areas and anticipated benefit/outcomes.

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Care Pathways Implementation Care Pathway Group - Staying Healthy Leadership Clinical Leader PCT Chief Executive NHS Y&H support Non-Executive Director SHA

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Wendy Richardson Simon Morritt Carol Massey Sarah Harkness

Yorkshire and the Humber infrastructure See diagram showing draft integrated delivery model which reports through the DsPH network meeting and the RDPH. Connection with PCT CE – dedicated sessions with DsPH leads for three ‘Staying Healthy’ risk areas. Timescale for implementation Overall Initial baseline gap analysis completed by all PCTs setting out where work is already underway across all 3 key risk areas Contribution of region wide social marketing programme (based on NSR review) Workforce analysis to assess potential gaps in delivering recommendations with ensuing workforce plan based on findings. To be undertaken by PHWAG Confirmation of core role of DsPH network and reporting routes for ‘Staying Healthy’ Alignment of work of new posts to support delivery of NHS Review be confirmed (Paul) Obesity PCT obesity network to collaborate on producing service specification for adult weight management services Bariatric commissioning on agenda for next PCTs’ Obesity Network probably September, led by Specialist Commissioning Group Launch of national 4life campaign (actions to be confirmed) Food and nutrition working group being established: remit and work programme to be clarified Physical activity network being established for PCTs Children and Young People Prog Bd reviewing food in schools Child weight management process via schools (national roll out)

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complete Scoping Summer 2008 November 2008 September 2008 September 2008 November 2008 September 2008 Autumn 2008 October 2008 November 2008 January 2009 Autumn 2008

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Alcohol Agreement to develop specifications for services agreed across PCTs in the region through regional alcohol group ‘Great Drink Debate’ set up to implement across Y&H Additional post funded at regional level by DH – ‘Alcohol Delivery’ Brief interventions – support for PCTs to develop locally from regional group Smoking Rolling out Good System Guide ensuring systems in place to support industrialised delivery of ABC approach to brief interventions by all front line staff. Regional programme of work being discussed with DsPH, Directors of Commissioning and CEs to extend smoke free environments, cheap and illicit tobacco etc. NRT – set up commissioning framework in PCTs (where needed) and implement: assess progress and impact across the region Additional post funded at regional level by DH – ‘Improvement and Delivery Manager’ and Social Marketing Manager

January 2009 Autumn to Christmas 2008 Post in place September 2008 February 2009

Rolling programme

Autumn 2008

March 2009

In post Sept 2008

Investment fund To be agreed Assurance and outcomes Action needed to develop robust processes:Chief Executives • An explicit agreement with the CEs Network for the delivery of Staying Healthy (as part of Healthy Ambitions) as an agreed overall work programme for the DsPH network • The interface with and reporting mechanism to CEs Network needs to be developed Directors of Public Health • DsPH ‘leads’ on each Staying Healthy recommendation area to be accountable as part of their role in the network. • DsPH Network agenda to focus on delivery of key actions and hold the various working groups to account • DsPH to offer professional leadership, advice on evidence-base and evaluation. • DsPH need to operate in an integrated way with the resources and staff at the disposal of the RDPH (i.e. SHA and Government Office) • DsPH to provide peer support at regional network level to develop local implementation plans that meet individual PCT strategic aims and objectives

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Working Groups (Tobacco, Healthy Lifestyles, Alcohol) • •

To have an accountability route direct to Directors of Public Health Staying Healthy ‘leads’ (and NHS Chief Executives) and to ensure that groups are structured to deliver Staying Healthy recommendations Develop objectives and work programmes which can be monitored by RDPH and DsPH ‘leads’

Regional Tier • Integrate recommendations into overall work programmes and individual objectives • Provide support at regional level to enable local delivery • Facilitate local delivery by supporting local PCT prioritisation decisions and investment and implementation plans Accountability In this model the RDPH Prof Paul Johnstone has accountabilities already in place across this operational framework. • RDPH attends CE network • RDPH attends DsPH network • RDPH chairs Promoting Healthier Lifestyles Board • RDPH has management line accountability for operation of Regional Alcohol Board and Tobacco Control Group/Board • RDPH has management line accountability for deployment of delivery support resources and staffing within the regional tier (several new posts funded by DH 2008/9) • RDPH has professional accountability for every DPH in the region. Given the centrality of the RDPH position, both in terms of influence, accountability and ability to direct resources, it would make sense for the RDPH to be the key lead for this framework alongside Simon Morritt and Wendy Richardson.

Role of the clinical lead • • •

To preserve the integrity of the Staying Healthy recommendations and report To act as guardian of the recommendations To advise on delivery processes

Simon Morritt PCT Chief Executive

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Wendy Richardson Clinical Lead

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Chief Executives Network

DELIVERY AGREEMENT

HEALTHY AMBITIONS RECOMMENDATIONS

DsPH Network

Promoting Healthier Lifestyles Group

RDPH & Team Resources

Regional Alcohol Group

Tobacco Control Network/Board

Obesity Leads

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Staying Healthy levels for delivery Recommendations

Local delivery

YH wide coordination and collaboration Regional Alcohol Group

The NHS in Y&H should improve screening and identification of people with alcohol use problems. PCTs should commission the systematic use of brief interventions on alcohol to ‘industrialise’ their use across NHS services. PCTs should commission a range of tiered services to cope with people who present with different levels of dependency and ensure simple referral routes are accessible from screening points. PCTs should commission alcohol services separately from drugs misuse services. NHS should work with other organizations to reduce the accessibility of alcohol, including an increase in its price. Every PCT should commission localized weight management services for their local population. To meet life expectancy targets these should focus on adults at mid-life.

Regional Alcohol Group Regional Alcohol Group Promoting Healthy Lifestyles Board Obesity leads Group

Services could be commissioned on the smoking cessation service model, using similar referral protocol to enable quicker implementation.

Promoting Healthy Lifestyles Board Obesity leads Group

NICE guidance on brief interventions should be implemented consistently by a wide range of NHS settings and staff. Ideally this would include primary care, secondary care, community services, family centres, local authority and voluntary settings. Surgery for people who are morbidly obese. PCTs should proactively collaborate on setting the specification and agreeing when these services should be commissioned so that there is a common standard across the region. There should be a systematic programme of local work to reduce the levels of obesity through the development of: Food policy & better food skills for adults. Transport and the built environment – making activity easier/safer More opportunities for active leisure Local employment Quality of school food, drink and activity programmes The recommendations of the SH Group – which are focused on adults – should be linked to the Gov initiative on child weight management which is aimed at tackling rising obesity levels amongst children. Every PCT should commission the systematic and industrialised use of brief interventions and referrals into effective smoking cessation services. In addition there should be training for as many other front line services as possible in carrying out brief interventions and referrals to services. PCTs should commission free NRT for the smoking population and make it widely and freely available. Change the headline measure from number of quitters to smoking prevalence in order to align incentives better to what will make the biggest impact on health. Primary Implementation

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YH wide implementation

Comments

Regional Alcohol Group Regional Alcohol Group

Tier 4 (high level) Poss SCG

Promoting Healthy Lifestyles Board Obesity leads Group Promoting Healthy Lifestyles Board Obesity leads Group

SCG

Promoting Healthy Lifestyles Board Obesity leads Group

Promoting Healthy Lifestyles Board Obesity leads Group Tobacco control network Tobacco control network PCTs can do via WCC

Tobacco control network

Nationally change is being worked up

Coordination and Support

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Care Pathway Group - Maternity and New Born Leadership Clinical Leader PCT Chief Executive NHS Y&H support CSIP support Non-Executive Director SHA

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Dotty Watkins Andy Buck Jean Hawkins Susanne Cox Kathryn Riddle

Yorkshire and the Humber infrastructure YH Maternity Forum • • • •

a forum for clinical leaders (with commissioners and providers) to guide and advise on implementation, and to share and develop best practice bi monthly chaired by Dotty Watkins facilitated by Susanne Cox

YH Maternity Commissioners Forum •

• • • •

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a forum for PCT commissioning managers to consider outcomes of Maternity Matters self assessments and HCC Scores , identify priorities for improvement, and share best practice and solutions to priority issues, track progress on Maternity Matters implementation key outputs will include shared results of Maternity Matters self assessments, shared results of model specification, progress reports bi-monthly chaired by Andy Buck facilitated by Jean Hawkins

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YH Specialised Commissioning Group Timescale Maternity Matters self assessments completed and shared PCTs to agree choice and access action plans with providers PCT strategies to include all aspects of Maternity Matters (inc. infant mortality plans) Workforce Gap analysis Safer Childbirth workforce assessment and 2008 workforce plans completed and shared YH wide social marketing initiative for smoking in pregnancy and breastfeeding Model service specification for maternity services agreed with providers Contracts with providers to include Maternity Matters and Safer Childbirth requirements and compliance Performance monitoring tool developed by Dec 2009 and implemented First performance report, including workforce and vital signs on early access and breast feeding (Quarterly)

31 August 2008 30 September 2008 30 September 2008 31 December 2008 31 December 2008 31 March 2009 31 March 2009 30 April 2009 31 July 2009

Investment fund o Not identified at this stage Assurance and outcomes o o o o

agreed standards and outcomes performance monitoring tool peer audits of Maternity Matters assessments and action plans Monthly risk assessment of progress on action plans

Andy Buck Chief Executive

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Dotty Watkins Clinical Lead

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Maternity and new born – levels for delivery Recommendations Maternity matters (published by DH in 2007) should be used as a firm foundation for the future commissioning and delivery of maternity and the newborn services across Y&H. Maternity matters and self assessments in all communities should lead to action plans to address priority gaps identified in these assessments; these should also take into account of the Healthcare Commission report mentioned above. The workforce recommendations set out in Safer Childbirth should be implemented; PCTs and providers should include this in all subsequent contract negotiations until significant progress is made. These should reflect the workforce plans submitted to SHA in 2008 In particular of out 19 obstetric units, there are 8 units delivering under 2500 births a year. The CPG recommend applying the same standards to these units as if they had 2500 births. All out units currently have 40 hour consultant cover, and should plan therefore to reach 60 hours cover in 2009 at the latest. Outcomes at these smaller units need to be kept under regular review to ensure that women and their babies are not disadvantaged. A Y&H Maternity and Birth Commissioning Network should be formed. Early work should focus on agreeing action from the Maternity Matters self assessments, including an escalation policy and procedure to manage demand variations The introduction of the maternity phase of connecting for Health should be accelerated. There should be a radical step up in action to reduce smoking in pregnancy and breastfeeding performance should be improved. Already PCTs are including action to improve breastfeeding and/or reduce smoking in pregnancy in their Local Area Agreements. There should be selective introduction of ‘case loading’ as a means of targeting vulnerable and disadvantaged women and so ensure that they in particular receive a high degree of continuity of care. We should get ‘the basics right’ by: improving ‘customer care’ and responsiveness to the needs of women during their maternity pathway improving the quality and consistency of information for pregnant women (in particular vulnerable women, women whose first language is not English, and women with special needs) adopting a more systematic and sustained approach to gathering patient experience data, and using this to inform further action to ensure personalised service delivery. There should be a focus on reducing health inequalities and improving health outcomes for both mothers and babies with the aim to reduce infant mortality rates for the manual groups by 20% by 2010.

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Local delivery

YH wide coordination and collaboration

YH wide implementation

Comments

YH Commissioning Forum YH Commissioning Forum

YH Commissioning Forum YH Commissioning Forum YH Commissioning Forum

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Recommendations Breastfeeding rates should be improved, with breast feeding initiation rate increased by 2% in disadvantaged groups with subsequent year on year improvement targets. Where in-utero transfer does not take place, the reasons should be monitored and improvements made. If ex-utero transfer is required, their needs to be appropriate equipment and up to date skilled staff for the transport. Commissioners should work with stakeholders to develop regional guiding principles for transfer times when the place of birth alters during labour.

Local delivery

YH wide coordination and collaboration YH Commissioning Forum

YH wide implementation

Comments

SCG

SCG

Primary Implementation Coordination and Support

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Care Pathway Group – Long Term Conditions As there are several long term conditions with high degrees of prevalence. In particular, these are Coronary Heart Disease, Stroke, Chronic Obstructive Pulmonary Disorder, Diabetes and Asthma. It is also the case that many people, particularly the elderly, live with 2 or more of these conditions. Rather than cover each of these areas in turn, the focus of the LTC framework has been set out on the basis of each of the 5 themes arising from Healthy Ambitions:• • • • •

Clinical Integration Information Systems Local Access to Services High Prevalence Conditions Estate

Overall Position Much of the existing infrastructure at SCG, Network and local health community levels can be utilised. An analysis of the existing networks and projects in light of the long term condition priorities is required to identify whether additional networks or projects are required. The following approach will be followed: • • • •

• •

Frameworks for models of care will be developed regionally, informed by national frameworks on Stroke, Diabetes Year of Care and so on, with appropriate clinical input and implementation will be at local level Clinical networks will have to work both individually and collaboratively in developing the frameworks for pathways and models There are some established regional networks for LTCs, primarily for Cardiac and work is in hand to look at what other regional support mechanisms are needed, e.g. for Stroke. Appropriate clinic input will be required in other clinical areas that are not represented by a network (e.g. Diabetes and COPD). This will be achieved through clinical insight and forums. The CPG will inform the development of any new groups and enhancements of the CPG arrangements as required. It is likely that the CPG for Long Term Conditions will need to be expended or restructured in the light of this new role.. Frameworks for core competencies should be developed regionally, building on the regional workforce expertise in place, and locally implemented Frameworks for clinical standards should be developed regionally, building on national clinical frameworks and input from clinical networks and a redefined CPG.

The approach will be tested through an immediate and early priority, and focus will be placed on addressing diabetes and stroke, and will interface with the Staying Healthy, Planned Care, and Children’s Pathway Groups.

24

Discussion Draft

Yorkshire & the Humber PCTs


Y & H Infrastructure Clinical leadership 1. Clinical Integration a. Networks b. Local

2. Information Systems a. Regional b. Local 3. Local Access to Services 4. High Volume Procedures 5. Estate

PCT CE

Support

Other

Network clinical directors/leads

PCT CE Network chair

SCG

Network review and Developing Prog.

Medical directors Network directors PEC chairs

Local PCT CE

PBC Consortia Clinical teams

Deanery and Y & H Public Health Observatory Communication team

Y & H NPfIT Board Lead clinicians

Y & H NPfIT Board PCT CE reps.

Y & H NPfIT CFH teams

PCT IM & T Board Lead clinicians Medical Directors Nurse Directors PEC Chairs

PCT CE Chairs of IM&T Board

Y & H NPfIT CFH Teams SCG (+ chairs) Contracting consortia Clinical networks Public Health) PCT Collaborative SCG

All PCT CEs

Network leads

Rob Cooper

Medical Directors, Nurse Directors PEC Chairs

All PCT CEs

NHS Estates

LIFT

The clinical pathway group (CPG) have produced thirteen recommendations for improving care and services for people with long term conditions. The CPG will provide the core clinical leadership on generic recommendations for the Long Term Conditions (LTCs) Pathway. The CPG will consider whether and how it needs to amend its structure or membership in the light of these changes. Frameworks for core standards, competencies and models of care should be developed regionally with appropriate clinical input on content, to ensure a consistency of approach. Clinical networks and forums will have strong input into work within their own disease areas on developing the necessary standards, pathways and embedding the new models. They should work individually and collaboratively. Appropriate clinical input will still be required where LTCs are not sufficiently represented through regional networks and forums. The CPG will help to bridge some of the gaps in clinical input on a regional level. Individual PCTs, local commissioning and partnership groups and local networks should also be fully engaged and inform implementation of the standards and models. New systems and processes will need to be developed to facilitate this, with collaboration and support regionally. Partnership working and integration will be core elements of implementing the thirteen recommendations.

Rob Webster Chief Executive

25

Eileen Burns Clinical Lead

Discussion Draft

Yorkshire & the Humber PCTs


Long Term Conditions Care pathways– levels for delivery Recommendations Care Plans – Through a co-produced care planning approach, patients and their carers should be supported informed and empowered to better manage their condition within their capabilities and enabled to make choices about their care and services. Those who are newly diagnosed should be offered a care plan at the outset.

Care choices – Patients should be offered choice following the ‘Choice and Personalisation’ model approach, which is patient centred and takes into account lifestyle factors. This will allow services to be designed and commissioned allowing patients the independence of choice throughout their contact with services, including residential, intermediate, outpatient and hospital based care. Year of Care (YoC) approach – Commissioners and providers should define patient pathways based on the two models referred to in this report. For example, this should be reflected in a programme of work to roll out excellent stroke services, in line with the National Stroke Strategy recommendations. Diabetes services in particular should be developed using emerging learning from the Year of Care pilots. Both models are exemplars for further work in other LTCs. Care Conductor – a role should be developed to help with the management of care for people with LTCs, their families and carers and ensure care plans and care choices are co-produced for better outcomes.

Local Implementation

Yes

Yes Regional networks and forums

Yes

Yes Regional networks and forums

Yes Driven through PCTs and PBC Consortia

Yes

26

YH wide coordination and collaboration

Yes Informed by YoC Pilots and regional networks and forums

Yes Regional networks and forums

YH wide implementation

Comments The framework for Care Planning should be agreed and developed regionally and integrated within the self care and choice agendas. The design should be informed by appropriate networks and forums – individually and collaboratively. Where other conditions are not represented through networks and forums, they will still require appropriate clinical input. The CPG will inform this work where they are able Need to embed model and principles through PCT commissioning, informed by regional networks and forums. 'Choice and Personalisation' is core to any service development. PCTs should work with local Commissioning groups to ensure they are fully supportive of YoC approach - and should build on YoC pilots and stroke strategy to ensure excellent service models and pathways for all LTCs.

This should be jointly supported by health and social care - could be new or existing role. Role should be developed with regional input to ensure consistency of core skills/competencies. Implementation should be local and will require godd Partnership Board working with LAs. This work should also link with Mental Health Advocacy.

Discussion Draft

Yorkshire & the Humber PCTs


Recommendations Coordination – Primary care should remain the hub of coordinating and arranging care outside hospital for people with LTCs. Practices should support individual health to improve population health. Commissioning – Practices and PCTs should commission services based on quality clinical information. Where there are variations, robust monitoring should be used to challenge the quality of disease registers and improve case finding.

Joint commissioning, joint strategic needs assessments (JSNA), Local Area Agreements and practice based on commissioning should be fully exploited in order to design and develop services which reflect the standards, the choices of patients and the clinical and professional knowledge within health communities.

Local Implementation

27

YH wide implementation

Yes

Yes with Commissioning Consortia

PHO

Yes Local Partnership boards

The use of incentives and/or penalties should be explored to improve better quality information and better commissioning.

Integration and partnership working – Commissioners and providers should work in an integrated way to better support delivery of patient pathways for example: - - Services such as Intermediate Care that support primary and secondary care, should be speedy, responsive and work with case management. - Specialist Clinical Services (particular for stroke) and comprehensive geriatric services need to be further developed to meet the needs of the growing elderly population. - There should be a collaborative approach to voluntary, health and social care sector planning.

YH wide coordination and collaboration

Yes

Forum needed for this work.

Yes

Yes

Need to build on quality Work. Scope for Directors of Finance or Commissioning ?

Comments This should be driven through local PCTs and commissioning groups. There are clear links to the Primary and Community Care Strategy implementation and clarity is required on SHA role in this area. There needs to be a consistent approach to information sources and commissioning. Processes and systems need to be in place so that commissioners can be confident that information is accurate - The Primary Care Intelligence dataset work should be seen as an important vehicle for LTCs and will also support the PBC developments in train. These should be the core mechanisms for commissioning services and Joint service models with H&SC should be explored further and driven through local partnership board. This also sits within the development of WCC. There needs to be clear criteria and guidelines around the use of incentives. Need to build quality mechanisms into contracts, e.g. Bradford - quality of care in nursing homes incentives for meeting standards. Rules of competition and cooperation need to be explored and clarified further and the PCT Collaborative is leading on this work. Procurement and Commissioning of services should stipulate integration and partnership working as a core element to any service. Integration of information and systems is also key to delivering truly integrated services.

Discussion Draft

Yorkshire & the Humber PCTs


Recommendations Care Standards – A common set of standards should be developed to support and standardise care delivery. These should be applicable in all settings, including primary care, secondary care and in particular to ensure quality of care in nursing and care homes.

Core competencies – A core set of competencies should be developed for patients, carers and staff, aligned with the above care standards so individuals and organisations know what to expect from quality service and care provision. These will also help facilitate any shift in behaviours and culture.

A key proposal for reforming adult social care (Department of Health’s transforming Social Care Local Authority Circular January 2008) is to give personal budgets to all people receiving social care services. There is scope to see if this could be extended into some aspects of health care also. In order for these recommendations to become reality, it is vital that support is given to providing the necessary joined – up IT, information, premises and trained workforce. The CPG members understand these will be national priorities.

Local Implementation

Yes

YH wide coordination and collaboration

Yes Regional networks and forums

Yes

Yes Regional networks and forums

Yes

Yes

Yes

YH wide implementation

Yes

Role for Workforce Directorate and Deanery at SHA in training and accreditation

NPFIT Board Y&H Deanery

Comments There should be a core set of standards developed regionally. These could be developed with support from CSIP taking learning from YoC pilots and stroke strategy work.There should be a link to YPHO to ensure standards are measurable at practice level. These should be built into organisational and individuals objectives across health, social care and partner organisations. They should be a core part of any commissioned service specification and embedded locally through KSF indicators and through contracts - should include H&SC elements. They should build on Skills for Health work and focus on 'Values' rather than competency levels. PCTs should pursue individual or indicative budgets at individual or practice level and local and regional mechanisms should be developed to support further exploration in this area. PCT CE's should be the SRO for IT solutions within his/her organisation - informed by clinical networks and national programme for IT - joined up info systems are vital as a core supporting function across health and social care LIFT

Primary Implementation Coordination and Support

28

Discussion Draft

Yorkshire & the Humber PCTs


Care Pathway Group – Children’s

Leadership Clinical Leader –Ian Lewis PCT Chief Executive – Jayne Brown NHS YH support – Jean Hawkins Yorkshire and the Humber infrastructure Business Network/Forum for Commissioners The Strategic Health Authority currently hosts the Children’s Business network/ forum for commissioners, which to date has supported commissioners by focussing on information sharing, sharing of good practice and providing network and peer support opportunities. Levels of influence vary within the current membership, and it is recognised from within the group that there is a need to refocus its terms of reference and ensure that the outcomes from the group play a key role in supporting the development of Children’s services. It is recognised that the opportunities to share innovation and better understand commissioning for children’s services have reflected the fact that commissioning for Children’s services is still at early stages and many services for children are part of block contracts. Despite this there are examples of excellent commissioning leading to innovative and responsive service provision. SOAPs A Network of networks is in place across West, North and East Yorkshire - supporting commissioning (specialised and non-specialised) and clinical development. As part of the Regional Network review steps are in hand to ensure appropriate network scope, governance and configuration across these geographical patches. North Trent Children’s Commissioning Forum A commissioning network is in place across South Yorkshire (and into the East Midlands). The development programme following the Network review will support its continued development. Next Steps A new infrastructure needs to be developed to support commissioning for innovative and responsive services across heath, education and social care.

29

Discussion Draft

Yorkshire & the Humber PCTs


An early priority for this group is to set out proposals for a robust infrastructure to be developed which meets the needs of all commissioning agencies, supports providers and engages clinicians and practitioners. It will also need to interface with all the other Care Pathway Group approaches, and the recommendations of the Network review to ensure that there is no duplication of effort. Work now needs to take place to get agreement on what infrastructure is needed to deliver the complex Children’s agenda- both networks and other business forums. Timescale

Complete network review and SCG new arrangements Asthma Summit Agree infrastructure for taking forward Children’s Care Pathway(s) Needs to interface with LTC/ Planned and acute care pathways Develop and review GP training and quality standards Development of risk assessment tool Review of specialist surgical care •

Sept 08 Dec 08 Nov 08

April 09 June 09

Dec 08

Define scope

• Conclude review CAMHS Tier 4 review Mapping palliative care and development of action plan Dental health pathways

Dec 09 Dec 08 March 09 June 09

Investment fund o

to be agreed

Assurance and outcomes o o o o

agreed standards and outcomes performance monitoring tool peer audits assessments and action plans risk assessment of progress on action plans

Jayne Brown

Ian Lewis

Chief Executive

Clinical Lead

30

Discussion Draft

Yorkshire & the Humber PCTs


Children’s Care Pathway – levels for delivery Recommendations Prevention and early Identification: The CPG recommended that a risk assessment tool should be developed for every child starting from known pregnancy onset through birth, infancy, pre-school, school and into teenage years. This would inform targeted primary care and social support. Parents and particularly vulnerable parents should be offered parenting education on the prevention, recognition and care of sick children. Assessment, diagnosis, and referral pathways: Access to services for children and families should be improved. Children should be able to access primary care services from 8 to late; thereafter there should be a single phone line for advice on children staffed by an experienced children’s practitioner. Urgent Care Centres, as proposed by the acute CPG, should include expert assessment of children by GPs and/or paediatricians. Primary Care: The CPG advised we need properly constituted children’s multidisciplinary primary care teams that include health visitors, midwives, school nurses, community children’s nurses, paediatric therapists and GPs. This team requires strong leadership from within primary care. The CPG recommended a range of ways in which standards in primary care could be raised to the levels of the very best on offer in Y&H. This includes strengthening the training requirements of GPs in respect of paediatrics, asking a cohort of GPs to develop expertise to act as a ‘beacon’ within a practice or groups of practices with a clear aim of raising standards and improving outcomes, or potentially piloting a specific new role of a children’s GP. Acute management/treatment: 30 years ago children stayed in hospital for a wide range of common conditions such as whooping cough. Now children are unlikely to stay in hospital unless they have a severe or urgent condition which requires the care of specialists such as paediatric surgeons and anaesthetists. Whilst the vast majority of children can be treated in their local hospital, some will need the expert skills available in tertiary centres; networks will need to be in place to link these centres with local hospitals. The CPG therefore recommends that: For planned surgery, Trusts and PCTs need to create more opportunities for children to have surgery carried out in local hospitals by competent surgeons and anaesthetists. Occasional practice should cease. For the small numbers of children that may require specialist surgical care, better outcomes may be achieved through concentrating care into larger units. We need to develop expertise and facilities to meet the health needs of teenagers.

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Local delivery

YH wide coordination and collaboration

Yes

Yes

Yes

Yes

YH wide implementation

Comments

Collaborative commissioning of tool& Pilot of tool 0- adolescent

Interface with Acute Episode workstream

Develop Primary care teams Yes

Nursing teams For children Develop Quality standards

Yes

Yes

GP Champion pilots Review GP Training

Review local A&E usage Yes

Yes SCG/ Collab

Yes SCG

Utilise reviewed Children’s networks

Yes

Yes Yes

Undertake review of expertise in surgery and anaesthetics for children

SCG

SCG where relevant

Networks as above

Yes SCG Where relevant

Training Care Pathways

Discussion Draft

Yorkshire & the Humber PCTs


Recommendations

Child and adolescent mental health: Children and young people should have the same thresholds and access to services across the region. In addition there should be rapid access teams, drop in services, specialist on-call services in all areas and paediatric mental health liaison for children and young people with physical health conditions. Services should be age sensitive and focus on prevention and early intervention. There should be investment in training for professionals and non professionals in order to improve the emotional and behavioural support for children and young people in primary health care, schools and communities Improving outcomes in diabetes by developing a focused Yorkshire and Humber wide approach. Improving outcomes in childhood asthma, with a clear aim of reducing acute admissions and improving overall disease control. The proposal is similar to diabetes but in this instance would also involve primary care to a much greater extent. The first step would be to hold a ‘Y&H Asthma Summit.’

Local delivery

YH wide coordination and collaboration

Comments Benchmark access thresholds to CAMHs

Yes T4 CAMHs

Yes

Locally review access to EI/CR services (interface with mental health workstream) Capacity and capability review T4 CAMHs Commission education and training programme for T1 services for universal coverage

Yes

Year of Life programme

Yes

Clinical summit

Young People palliative care

Yes

CSIP

Children with neuro-disabilities

Yes

Yes

Dental Health: Primary care dental services need to be developed to better cater for children with significant dental disease within the primary care sector. Additionally: There needs to be better integration between primary dental care and specialised services. Referral pathways into the specialist services need to be more clearly defined. The effective delivery of preventive dental care within primary care dental services needs to be encouraged and supported. Commissioning: There is a need to commission whole pathways of care. The CPG were not opposed to some elements of pathways being provided by different providers as long as commissioners are clear about the whole pathway and that performance management and incentives are directed towards providing a service integrated around the needs of each child and family. Effective financial levers: There is a need for clear outcome measures – of both clinical relevance but more importantly of relevance to each child and family. This demands involvement of users in determining and being aware of outcomes.

YH wide implementation

SCG

Mapping and scoping palliative care services SCG where appropriate CSIP

Yes SCG where relevant

Yes

Yes

Yes

Develop clinical care pathway for specialist dental services

Yes

Networks SCG

Yes

Agree metrics PHO to develop tool kit Link to Quality framework benchmarking

Yes

Yes

Yes

Primary implementation Coordination and support

32

Discussion Draft

Yorkshire & the Humber PCTs


Care Pathway Group - Planned Care As there is not just one specific area of focus this feedback has been set out on the basis of each of the 5 themes arising from Healthy Ambitions:• • • • •

Clinical Integration Information Systems Local Access to Services High Volume Procedures Estate

Overall Position Much of the existing infrastructure at SCG, Network and local health community levels can be utilised. An analysis of the existing networks and projects in light of the planned care priorities is required to identify whether additional networks or projects are required i.e. upper GI surgery, vascular, interventional radiology. It is noted that Mike Collier will be the SHA sponsor. Y & H Infrastructure Clinical leadership 1. Clinical Integration a. Networks b. Local

2. Information Systems a. Regional b. Local

3. Local Access to Services

4. High Volume Procedures

5. Estate

33

PCT CE

Network clinical directors/leads Medical directors Network directors PEC chairs

PCT CE Network chair Local PCT CE

Y & H NPfIT Board Lead clinicians

Y & H NPfIT Board PCT CE reps. PCT CE Chairs of IM&T Board

PCT IM & T Board Lead clinicians Medical Directors Nurse Directors PEC Chairs

All PCT CEs

Dr. Ian Jackson Professor Mark Baker

Jan Sobieraj

Medical Directors Nurse Directors PEC Chairs

All PCT CEs

Support SCG PBC Consortia Clinical teams

Other Network review and Developing Prog. Deanery and Y & H Public Health Observatory Communication team

Y & H NPfIT CFH teams Y & H NPfIT CFH Teams SCG (+ chairs) Contracting consortia Clinical networks Andrew Clark (Deputy Director Public Health Y&H SHA) PCT Collaborative SCG NHS Estates

LIFT

Discussion Draft

Yorkshire & the Humber PCTs


Timescales 1. Clinical Integration a. Networks

Each Network should have a strategy and clear work programme to meet national and local timescales. This will be agreed by January 2009. Each PCT will need to develop its priorities in line with its Strategy and Operational Plan.

b. Local 2. Information Systems a. Regional

Timescales governed by NPfIT Contract and Y & H Rollout programme

b. Local 3. Local Access to Services

PCT IM&T Board work programme Local agreement required on shift of appropriate activity from hospital to community in each LHC Review of existing Networks and scope in light of three challenges required:- High volume procedures i.e. day cases - Complex treatments - i.e. upper GI surgery, interventional radiology, vascular - Other planned care specialities i.e. hips, knees Review by January 2009. Agreement of additional infrastructure – March 2009 Local Agreement required on impact of shift in activity on existing estate.

4. High Volume Procedures

5. Estate

Investment Fund Not required at this stage but may be required in 2009 to support more networks/projects.

Assurance and Outcomes -

Fit for purpose infrastructure i.e. networks A renewed focus on tackling variation at local level i.e. GP referrals, day case rates Shared priorities Shared best practice

Jan Sobieraj Chief Executive Sponsor

34

Professor Mark Baker Clinical Lead

Dr Ian Jackson Clinical Lead

Discussion Draft

Yorkshire & the Humber PCTs


Planned Care Pathway– levels for delivery Recommendations

Local Implementation

YH wide coordination and collaboration

YH wide implementation

Comments

Clinical Integration To exploit the potential of new technologies, and reduce journeys to hospitals, GP services could be contracted to provide a wider range of access and services to reflect the needs of their populations. It is very likely that this will need greater integration between practices and should provide the building block for integration with community nursing services and social care. Independent contractor services should be ‘levelled up’ to reduce the significant variation in services provided. Community based generalist clinicians should be integrated locally with specialist clinicians. Local people. This will support the transfer of specialist sessions out of the hospital setting – the aim being to provide a ‘virtual polyclinic’ service. Generalist and specialist clinicians must have significantly greater access to diagnostic services with robust referral mechanisms to ensure clinical skills of diagnostics are fully utilised. The team approach to clinical care should be enhanced to free up GP time to enable full use of their unique skills and enable sub-specialisation. This will entail much more skill mixing to manage much of the first contact and long-term conditions work. Communication at critical points of the care pathway should be timely and robust; this means improved communication in both directions of the pathway. There should be a standardisation of referrals from specialists to generalist services. Similarly generalist referrals to specialist services should be standardised to ensure that all essential information is provided with each referral.

Yes

Networks YHPHO etc

Yes

Deanery support

Engage with NHS Confederation

Yes

Local practices

Yes

Local practices

Yes

Networks Deanery

Local practices

Yes

Deanery

Links to LTC CPG

Yes

Local practices

Yes

Information Systems Clinical IT systems must be integrated, and fully utilised by clinicians. Integration of safe clinical services will not happen without robust IT systems.

Yes Local IMT Board

NPFIT

YH NPFIT Board Will need regional NPFIT support

Local Access to Services Clinical services should be localized when possible and centralised when necessary and the impact on other services properly understood.

Yes

Many people would like more care to be provided at home. In our focus group work, more follow care at home attracted the most support from a range of proposals. Technological developments in treatments and health monitoring means that the current range of home treatments should be expanded and be more widely available.

Yes

35

Yes SCG Contract consortia Networks

Will need regional agreement

Local practices

Discussion Draft

Yorkshire & the Humber PCTs


Recommendations

Local Implementation

YH wide coordination and collaboration

YH wide implementation

Clinical Networks

Review of clinical forums etc to ascertain where clinical insight can be sought

Networks

Regional reviews of upper GI, radiology, vascular , etc.

Comments

High Volume Procedures People requiring ‘high volume’ procedures should be offered day case services as routine when it is clinically appropriate. These should be provided in dedicated elective units and/or dedicated elective centres. Bearing in mind the geography and variable sparsity of communities in the SHA area, there should be reasonable access to these services. This should not interfere with the individual’s opportunity to choose where they are treated.

The provision of complex treatments or ‘high volume’ procedures on people with high operative or anesthetic risk factors must be provided in clinically appropriate settings. It is likely this means that, to improve outcomes, patients with this level of clinical risk would be better served being treated in appropriately staffed and resourced units. The CPG recommend that a review of critical care services should be commissioned across the region to ensure the NHS is delivering the very best care. For similar reasons the CPG also recommend a review of vascular surgery.

Yes

Yes

Emulating the organisation of modern cancer services, the role of ‘clinical network’ hubs should be developed across a range of planned care specialities.

Estate A changes to locally based care are implemented some of the estate may become redundant for their current use, for example out-patient clinics. Much of this will need to be redesigned to provide other services. This approach may well significantly reduce the need for new buildings

Networks

Regional review of networks to advise As above

Regional strategic declarations

Coordinating PCTs Contract Consortia networks

High volume procedures to be supported by review of clinical forums FFP to support work plus service reviews as above

Yes

Primary implementation Coordination and support

36

Discussion Draft

Yorkshire & the Humber PCTs


Care Pathway Group – Acute Episode Leadership Clinical Leader PCT Chief Executive NHS Y&H support Non-Executive Director of SHA

-

David Dawson Mike Potts Helen Dowdy Janet Dean

Yorkshire and the Humber infrastructure Much of this work can be delivered through existing infrastructure: Commissioning •

PCT commissioning arrangements: o Y&H Specialist Commissioning Group o Contracting Consortia o Individual PCT commissioning arrangements

Clinical advice • •

Clinical Networks e.g. Cardiac Networks addressing stroke Pharmacy Reference Groups (North and South)

However a number of gaps have been identified which need to be addressed in order to provide a robust commissioning process linked to sound clinical advice. These are as follows:

37

Trauma and Urgent Care – there is currently no structured mechanism for co coordinating clinical advice in these service areas on a regional or sub regional basis.

Hyper Acute Stroke Configuration – While each of the three Cardiac Networks across Y&H are addressing future configuration of acute stroke services in their respective sub regions there is currently no structured mechanism for the three networks to agree a pan Y&H approach.

Sub Regional Commissioning Forums (Outside SCG arrangements) – Other than for specialist commissioning and agreed contracting consortia arrangements there is no structured framework for sub regional commissioning for services other than those that meet the specialist services definition.

Vision and Direction from SHA – clarity/greater clarity required from the SHA on the anticipated models for some of the very specialist services i.e. anticipated number of Trauma Centres/Hyper Acute Stroke Units/Primary Angioplasty Centres required to serve the region. This would provide a framework to support PCT commissioning on a local/sub regional/regional basis.

Discussion Draft

Yorkshire & the Humber PCTs


Timescale for implementation Self Care Pharmacy Reference Groups – agree extended Terms of Reference Reach agreement with SHA/DH on approach to preparing self care management manual PCTs to target further investment in care closer to home/self care for those with LTCs in plans for 09/10 Primary and Community Care PCTs to target further local investment in these services in 09/10 PCTs to agree local integrated urgent care service delivery models Agree with SHA whether there will be a national 888 number and how it will be implemented. Potential for West Yorkshire PCTs on the back of the West Yorkshire Urgent Care Procurement to be a pilot site for the 888 number. Ambulance Services Bradford PCT as lead for the YAS Consortia to take forward these recommendations. Urgent Care Centres PCTs to agree local arrangements for Urgent Care Centres and their adjacency to A&E Departments. PCTs to agree how they will get pan Y&H co ordinate clinical advice on urgent care services. Develop a strategic Framework for use by local PCTs in the development of Urgent Care Centres. Admitted Care Facilitate arrangements for the three Cardiac Networks to agree a pan Y&H framework for Hyper Acute Stroke and Primary Angioplasty centres and the development of appropriate care pathways. Agree framework for obtaining co ordinate clinical advice for Trauma Services. Future network arrangements will be agreed following the Y&H Network Review Generic Themes Revised SCG / Sub Regional Commissioning arrangements to be agreed. Network Review completed / ongoing programme of work agreed and defined Network Review Implementation and development plan (18 month programme)

38

December 2008 December 2008 April 2009 onwards

April 2009 onwards To be agreed with each PCT December 2008 To be agreed with DoH

April 2009 December 2008 April 2009

December 2008

December 2008 October 2008

September/October 2008 October 2008 November 2008 onwards

Discussion Draft

Yorkshire & the Humber PCTs


Investment fund To be agreed Assurance and outcomes Regional Level products as detailed •

SHA Healthy Ambitions Oversight Group

Local / Sub Regional products as detailed •

PCT individual or collaborative commissioning arrangements e.g. Contracting Consortia/SCG/Individual PCTs

Supported by robust advice from clinical networks

Performance managed via existing SHA / PCT performance and assurance arrangements

David Dawson Clinical Lead

39

Mike Potts PCT Chief Executive

Discussion Draft

Yorkshire & the Humber PCTs


Acute Episode pathways – levels for delivery Recommendations

Local delivery

YH wide coordination and collaboration

YH wide implementation

Comments

Self Care PCTs should commission a wider range of services in pharmacies and primary care

Pharmacy Reference Groups

The SHA or DH should develop a Self Care Manual PCTs should commission primary and secondary care providers to work together to target care for particular groups e.g. people with LTCs; care home population to promote self directed care and avoid hospital admissions Primary and Community Care PCTs should develop, and ensure the delivery of consistent standards for acute care in the community, which apply both in and out of hours Extended access to these services should be available, especially in the evenings and at weekends. Additional services in pharmacies and other community settings should be developed Access to mental health and social care teams should be integrated with urgent care A single point of contact with a single telephone number should be introduced for urgent care e.g. 888 as part of an integrated triage and signposting system

PCT/Cluster of PCTs

? National

PCT/Cluster of PCTs

? National

Ambulance Services A single point of contact for urgent care should be introduced More options for treatment at scene by skilled staff should become available

Lead PCT

After initial assessment or on face to face contact, a wider range of referrals across the health care system should be available to make best use of all services

Lead PCT

Appropriate clinical networks

Ambulance bypass protocols should be developed to patients with stroke, acute MI, major trauma and paediatric emergencies where or when appropriate to ensure patients have access to the best treatment.

Lead PCT

As above

Urgent Care Centres The CPG recommend that urgent care centres should be introduced alongside major A&E departments

As above

A specification for services, staffing, facilities and management arrangements should be agreed based on the recommendations made by the acute CPG.

As above

Clear protocols for the movement of patients between UCC and A&E should be agreed

As above

40

Discussion Draft

Yorkshire & the Humber PCTs


Local delivery

Recommendations

YH wide coordination and collaboration

YH wide implementation

Comments

A&E Senior clinical decision makers should always be available at the front door There should be extended use of clinical decision units and short stay units Admitted Care In hospitals, systems should be improved with the introduction of care-pathway co-coordinators and an emphasis (targets) on discharge Consultant decisions should be made as early as possible in patient care and no later than 12 hours New models of care should be developed as detailed in the Acute CPG pathway report for Older People

Stroke Heart Attack Trauma Older People

Stroke/Heart Attack – Cardiac Network

Stroke/Heart Attack/Trauma SCG/PCT Collaborative. Strategic Direction from SHA

Acute providers should be commissioned to work together to develop integrated networks to support these models.

SCG/PCT Collaborative

Generic Themes Current 999 and other urgent call systems should be reviewed to produce consistent signposting of care tailored to local need and provision

PCT/Cluster of PCTs

The Y&H IT strategy should address the need for the rapid transfer of patient information in the urgent care setting. NPfIT solutions that allow the transfer of patient information should be accelerated such that it becomes the norm to share records across different parts of the NHS New and changed roles for staff will be needed. Commissioners, Y&H SHA and educational providers should take account of this in workforce planning and in commissioning educational programmes for healthcare staff

PCT Workforce plans

Appropriate clinical networks

SHA

The need to develop a world class service to acute care leads inevitably to a consideration for further integration of primary and secondary care. The NHS should consider how that can be achieved functionally or consider developing new models of provision Primary implementation Coordination and support

41

Discussion Draft

Yorkshire & the Humber PCTs


Care Pathway Group - Mental Health Leadership PCT Chief Executive Mental Health Provider Chief Exec Clinical Leader Social Care Leadership

-

Leadership Support

-

PCT Collaborative Support

-

Ailsa Claire Steven Michael Nick Morris Jonathan Phillips Calderdale DASS/ADASS CSIP Officers (aligned to CSIP Business Plan) Amanda Forrest

Assumptions • PCTs have prioritised Mental Health as a key commissioning issue, to enable improved experience and outcomes in Mental Health and Wellbeing, and improved quality integrated service delivery. • PCTs will develop commissioning capability within their organisations and in partnership with Local Authorities. The primary vehicles for commissioning will be: o o o

WCC strategies Social Care personalisation agenda Local Area Agreements

• Engagement with Social Care commissioners, users and carers, and clinicians will be developed, improved and sustained. • The Mental Health Commissioning Forum will continue to be sponsored at Chief Executive level, and will be the vehicle to support PCT/Local Authority Mental Health Commissioners. • Engagement and involvement with mental health providers is crucial, and commissioners recognise the importance of working closely with the providers • The principles, models and service specifications are applicable to all age services, ensuring there is no discrimination of mental health users • Delivery will happen at local level, wherever possible, in partnership with Social Care agencies. In some circumstances (e.g., Specialist Forensic Services) other levels will be utilised, e.g., SCG. • The new model contract offers opportunities for new ways of working locally, in the first instance the programme of work will support the development of local contracting consortia which brings together health and social care systems, services and outcomes • The outcomes implicit within the models of care- in particular the Zero Wait principle referral to assessment, and assessment to treatment for all mental health referrals are fully supported- and will be delivered through local systems of delivery.

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Discussion Draft

Yorkshire & the Humber PCTs


• Work will be put in place to support the development and implementation of Quality Accounts across Yorkshire and the Humber. • To assure the work peer audit processes will be developed and put in place- allowing for local delivery models whilst ensuring compliance with strategic aims and objectives for the care pathway models. Infrastructure 1.

Yorkshire and Humber Mental Health Leadership Group •

Clinical and Managerial leaders from commissioning organisations (health and social care) and mental health providers will form a core group to steer this complex work programme forward. They will provide a focus and framework to the infrastructure groups and systems: o o o o o

2.

3.

Developing frameworks for the principles of zero waits Supporting and driving the integration of information and health intelligence systems Driving through principles of integration assessment and provision of services Setting standards and outcomes and supporting and driving peer audit Drive the national and regional support programme available through CSIP to meet local and regional needs

Mental Health Provider Forum •

The Mental Health CE group will provide insight and focus for commissioners, in addition to providing a support and development forum for mental health providers

The Provider CEs through the Forum will co-sponsor key work areas with commissioners including the peer review for compliance with Care pathway objectives and outcomes

Yorkshire & Humber Mental Health Commissioning Forum • Forum for Mental Health and Social Care Commissioners to identify priorities for Mental Health improvement and service delivery, share solutions to problems, track progress, consider Mental Health policy across Health & Social Care. • Key outputs will include: o o o o o

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Mental Health contract implementation and management – with initial emphasis on developing contact systems to support integration of health and social care Developing care pathways to enable commissioning locally Developing and implementing quality standards and indicators Shared outcomes for commissioning for personalisation of Mental Health Care Delivering a peer audit assurance system

Discussion Draft

Yorkshire & the Humber PCTs


• Bi-monthly • Co-Chaired by Ailsa Claire/Jonathan Phillips • Facilitated by Amanda Forrest/Clare Hyde CSIP Clinical and Practitioner Network A Clinical and practitioner network needs to be established, enabling expert opinion and insights to drive the development of ‘regional ‘ frameworks for local implementation. This will build on the work and membership of the Cinical Care Pathway Group. The framework for networks will be used to support this, recognising it will need to be resourced. 5.

Care Pathways and Packages Programme Board • Programme Board for delivery of North East/Yorkshire & Humber CPP, supported by Advisory Panel and sub-groups. Responsible for 3-year implementation programme. • Bi-monthly • Co-Chaired by Steven Michael, SWYMNHT/Rosemary Grainger, Commissioner NE. • Assumes all providers/NHS commissioners participating. • Social Care commissioning to be included in scope. • Yorkshire & Humber commissioning represented by Rob Webster / Allison Cooke • Programme support Carole Green (CSIP), with commissioner input. • Y&H PCT Collaborative funding Y&H PCT contribution Year 1.

6.

Improving Access to Psychological Therapies • Forum to ensure implementation of IAPT within 2 years across whole of Yorkshire & Humber – ensuring funding, standards, workforce, training, performance targets. • Bi-monthly. • Chaired by Ailsa Claire. • Facilitated by Karen Lynch CSIP.

7.

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Yorkshire & Humber Specialised Commissioning Group

Discussion Draft

Yorkshire & the Humber PCTs


• Formal Sub-Committee of the 14 PCTs, commissions and processes defined specialised services including Mental Health. • Chaired by Ailsa Claire, hosted by Barnsley PCT. • Director, Cathy Edwards, Head of Forensic Mental Health, Ged McCann. Timescales for Implementation Urgent and Non-Urgent Care Pathway Specification framework agreed for local use and development Establishment of Leadership Group Contract modality to be agreed

October 08

October 08 October/ Nov 08

Contract developed and implemented Clarification of CSIP work programme- regionally and Nationally Care Pathways and Packages

By April 09 onwards Oct 08 onwards

Revised Board TOR Summer 08 Programme Board ill have detailed action plan

Clinical Network established IAPT implemented First Peer Audits to review effectiveness of new commissioning and contracting systems

8.

By Dec 08 April 09 &10 Nov 09 onwards

Healthy Ambitions Investment Fund Funding for Clinical Network - to be scoped

Assurances & Outcomes 1.

Agreed standards and outcomes to support care models.

2.

Peer reviews of Commissioners.

3.

Performance tool.

4.

Bi-monthly risk assessment of progress.

Ailsa Claire Chief Executive

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Nick Morris Clinical Lead

Discussion Draft

Yorkshire & the Humber PCTs


Mental Health levels for delivery Recommendations

Local delivery

Of critical importance is the implementation of generic mental health pathways which the CPG describe in the models below. The key high level output of the pathway is Zero waiting times for all Mental Health referrals

YH wide coordination and collaboration

YH wide implementation

Comments

Mental Health Commissioning Forum

Integrated primary/secondary and health and social care Mental health commissioning forum Mental Health Commissioning Forum

Care planning supported by ‘advocate’ challenged care navigation. Single point to Assessment CAS model

Mental Health Commissioning Forum

Open access to a range of supportive interventions provided by a range of providers

Mental Health Commissioning Forum

Care elements/packages can be allocated a cost so that individuals can have their own budget.

CPP Board Personal advisors or advocates are available to support people in accessing the appropriate support.

National standards for services which enable benchmarking to take place.

Mental Health Commissioning Forum Peer audit

The CPG support the same aspiration for mental health outcomes as described in the report of the London review – ‘Framework for action’ – ‘all living’ in Y&H to be able to get the maximum out of life, free from discrimination, disability, and poverty – wellbeing for all is our aim’ This aspiration should feature in Local Strategic Partnerships and Local Area Agreements. The term ‘Crisis Resolution’ should be dropped completely as it causes significant confusion to referrers and commissioners alike.

Mental Health Commissioning Forum Mental Health Commissioning Forum

LSPs Mental Health Commissioning Forum

Needs regional implementation

Primary implementation Coordination and support

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Discussion Draft

Yorkshire & the Humber PCTs


Care Pathway Group - End of Life Leadership Clinical Leaders Dr David Levy and June Toovey PCT Chief Executive Alan Wittrick NHS Y&H support Paul Harrison Non-Executive Director SHA Keith Ramsay Three Chairs of Palliative care sub groups of Cancer Networks It is proposed that these people will meet as a Steering Group to oversee/ensure all Yorkshire and Humber wide activities (exclusively those activities being led locally by PCTs). Alan Wittrick would lead on behalf of 14 PCT Chief Executives and report back through YH Commissioning CEs Forum. Assumptions •

This section incorporates implementation of the national End of Life strategy as well as the YH Healthy Ambitions work;

The national strategy refers to central resources for implementation of £88m in 2009/10 and £198m in 2010/11 On this basis PCTs may expect around £½m each in 2009/10 and £1m in 2010/11. However, this may be built into PCT baselines – not known at this stage;

Most actions can take place through local PCTs;

Some limited actions require YH-wide co-ordination and collaboration. These are: • Social marketing culture change analysis; • YH media campaign; • Co-ordination of planning and analysis of specialist services beds (eg hospices); (Commissioning of specialist services would remain with PCTs) • Development of training packages – both professional undergraduate and postgraduate; • Co-ordination of audit/data to demonstrate progress.

It is suggested that YH co-ordination is through a Steering Group of lead PCT Chief Executive, two clinical leads and three Chairs of existing networks for palliative care. The lead Chief Executive would report to YH Commissioning Forum. This Steering Group would ONLY focus on those activities that need YH co-ordination.

Clinical advice to PCTs and the Steering Group should be provided from the three existing palliative care sub-groups of the Cancer Network but subject to: • • •

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expanded remit of groups to include non-cancer patients; increased infrastructure support; each group should take lead on tasks such as developing training packages, advise on quality measures etc.

Discussion Draft

Yorkshire & the Humber PCTs


The Steering Group would ensure: • • •

Development of YH action plan Appropriate resources and capacity in place to complete action plans; Annual progress report of development of EoL strategy.

Yorkshire and the Humber infrastructure Clinical advice to be provided through “revised” palliative care sub-groups of: • • •

Yorkshire Cancer Network Humber and North Yorkshire Coast Cancer Network North Trent Cancer Network

These networks would need to encompass non-cancer patients. Timescale for implementation Establish Steering Group Identify key quality measures for 2009/10 Develop education packages Co-ordination of specialist palliative care services and plan for future Marketing campaigns launched First annual report on progress of EoL strategy across YH

October 2008 January 2009 April 2010 April 2010 2009 April 2010

Investment fund -

Social marketing/culture shift issues - £50K Media campaigns - £100K Development of training packages- £100K Increased support to networks (3) - £100K

Assurance and outcomes -

Agreed standards and outcomes Performance monitoring tool Peer audits assessments and action plans Monthly risk assessment of progress on action plans Annual progress report Routine reports to Chief Executives’ Forum

Alan Wittrick Chief Executive

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Dr David Levy Clinical Lead

June Toovey Clinical Lead

Discussion Draft

Yorkshire & the Humber PCTs


End of Life Care Pathway – levels for delivery Recommendations

Local delivery

YH wide coordination and collaboration

YH wide implementation

YH Commissioning Forum and Steering Group

National and possible YH media campaigns

Comments

Culture Shift There is a prevailing ‘live forever’ mindset amongst society at large and amongst the majority of health and social care professionals, which works against the normality of death and dying, and therefore hinders advanced planning for end of life and gets in the way of a good death in the place where patients choose to die. Significant work needs to be undertaken to challenge this through the use of social marketing techniques, public service broadcasting, education and more visible dialogue and activity which breaks down taboos around death and dying. Insufficient focus is placed on EoL Care such that the experience of patients and carers is not of the consistently high standard it should be. Our clinicians have recommended that EoL should be a priority in the Operating Framework, and EoL care standards should form part of HCC and CSCI assessments. A range of targets should be set nationally for EoL care as part of the developing national strategy eg GSF, LCP etc to help drive forward improvements – national targets now in national strategy but need to agree YH wide specific quality measures/standards for SLAs. Effective Strategic joint commissioning/contracting for the provision of End of Life Services Driving up the quality and availability of appropriate EoL care which is responsive to patients’ needs and choices is a key role for PCTs. PCTs should put in place clear commissioning frameworks based on national minimum standards to be delivered across all settings, and consistent end of life care pathways across their area of responsibility which cover the following steps: • Timely conservations about EoL • Assessment and care planning, co-ordination and registration • Integrated service delivery • Review • Last days of life • Care after death • Support for carers This should be combined with local flexibility in relation to how the pathway and standards are delivered to suit local circumstances.

YH Commissioning Forum and Steering Group

Develop YH measures/ standards

In conjunction with Local Authorities build on local JSNA

Use of Commissioning to incentivise and improve access Commissioners need to specify clearly what needs to be in place to deliver good quality end of life care to their populations, and work to ensure that there is sufficient spread of care services providers available to deliver this, paying special attention to access to specialist palliative care services, hospice beds, bereavement services, pharmacy services, equipment, spiritual care and access to information. Attention is also required to out of hours services to maintain continuity of care 24/7.

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YH Commissioning Forum for Coordination and planning of specialist services beds eg hospices

Discussion Draft

Yorkshire & the Humber PCTs


Recommendations Advanced care planning – shift in place of dying from hospital to home This needs to be undertaken in all settings for all individuals with diseases which are acknowledged as being incurable and progressive, with the aim of seeing a significant shift in achieving patients preferred place of dying. Workforce development – mandatory education and training on EoL – palliative care as everyones business Training and education on EoL should be part of core curriculums, professional CPD and revalidation tailored for the range of workforces involved in providing services at the end of life. Key skills would include communications, palliative care and advanced planning.

Recommendations Research, audit, review and measurement of improvements in end of life care There should be a few key measures set nationally as part of the EoL Care Strategy and incorporated into assessment processes by the HCC and CSCI. Commissioners should also ensure effective audit processes are built into contracting processes. Crucial to this is the collection of systematic feedback from patients, carers and families, and research to assess the impact upon the quality of care of a number of best practice EoL care tools. Funding Identified funding to support the provision of EoL care, from pooled budgets across health and social services, is needed to support joint commissioning and investment. Clear partnership arrangements with charities and other voluntary sector providers are needed to ensure the balance of resource investment is appropriate to ensure support across all areas. There is a need to ensure universal adoption of a consistent end of life care pathway.

Local delivery

Delivery of training and education

Patients / carers feedback

YH wide coordination and collaboration

YH Commissioning Forum and Steering Group

Three EoL networks coordinated by Steering Group

YH wide implementation

Comments

Pre-registration/ Professional training – packages developed through SHA Workforce Directorate Development of training packages for existing employed staff through clinical networks

YH wide audit / cluster collection through network groups

In conjunction with Local Authority

Primary implementation Coordination and support

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Discussion Draft

Yorkshire & the Humber PCTs


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