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End -Year Performance Report 2010/11

Report Owner: Peter Flynn Report Author: The Performance Team

Published May 2011

Trust Board



1. National & Local Priorities: Executive Summary


2. Access to Services  Secondary Care Access


 Primary Care Access


 NHS Dentistry


 Ambulance Response Times


 Choose & Book and Choice


3. Improving Health of the Population  Obesity


 Immunisation


 Smoking Cessation


 Sexual Health


 Infant Mortality


 Substance Misuse


4. Long Term Conditions  Long Term Conditions (including Ambulatory Care Sensitive Conditions)


 Respiratory Health


 Renal Disease


 Diabetes


 Coronary Heart Disease/Cardiovascular Disease


 Emergency Bed Days


5. Patient / User Experience  Patient Safety: Infection Control/Hospital Acquired Infections


 Patient & Public Involvement


Report Owner: Peter Flynn Report Author: The Performance Team

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Contents Cont:-


6. Clinical Priority Programmes  Cancer (including cancer screening)


 Mental Health


 Learning Disabilities


 Children


 Older People


7. Cross – Cutting Strategies  Reducing Health Inequalities


 Quality, Innovation, Productivity & Prevention (QIPP)


 Local Area Agreement (LAA)


 Corporate Governance


 Equality & Diversity


 GP Commissioning Consortia (Practice Based Commissioning)


 Workforce


 Clinical Governance


 Information Management & Technology (IM&T)


 Prescribing (Medicines Management and Community Pharmacy)


Report Owner: Peter Flynn Report Author: The Performance Team

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National & Local Priorities

Executive Summary

Access to Services

Pages 16-26

Secondary Care Access: As the responsible Commissioner, the NHS Kirklees must ensure no-one is waiting for treatment longer than the national waiting time target. Since December 2008, the whole patient journey has been managed and measured as one, with no-one waiting longer than 18 weeks from GP referral through the different stages of hospital treatment, i.e. diagnostics, outpatients and inpatients. PCT performance as at 31st March 2011, for referral to treatment waiting time, validated data, shows:18-weeks+ referral to treatment - admitted Target 90%, Actual 83.3% 18-weeks+ referral to treatment- non-admitted Target 95%, Actual 97.9% 18-week referral to treatment - direct access audiology Target 95%, Actual 100% 18-week referral to treatment non achievement of standards in all specialties (including DAA but excluding Orthopaedics) Target 0 Fail, Actual 8 Fail A & E Waits: The 2010/11 Revised NHS Operating Framework published June 2010 reduced the A & E national operational standard from 98% to 95%, with immediate effect; however, there is a Department of Health expectation that where NHS organisations were achieving the 98% standard, then this standard should be maintained. The NHS standard required that at least 95% of patients spend 4 hours or less in any type of A & E from arrival, admission, transfer or discharge. PCTs are assessed on their commissioning of A & E services which includes minor injury units and walk-in centres. NHS Kirklees year to date performance as at 31st March 2011 shows:Total time in A & E: four hours or less Target 95% and Actual 94.99%

Report Owner: Peter Flynn Report Author: The Performance Team

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Primary Care Access: All patients who wish to do so should be able to see a GP within 2 working days and/or a primary healthcare professional within 1 working day – achievement of this target is seen as an indicator of progress on the overall reform of the NHS. The Primary Care Access survey (PCAS) stopped in March 2009 and has been replaced by the national Patient Survey which is undertaken by IPSOS Mori. The PCT will receive 2010/11 survey results in July 2011 but is provided with interim reports on a quarterly basis throughout the year showing a full year effect at that given quarter, i.e. Q1 for 2010/11 together with Q4, Q3, Q2 of 2009/10. The key areas of the survey as at 31st December 2010 (Q3) is showing:access to a GP within 24 hours and/or access to a healthcare professional within 48 hours National Average 79%, PCT Actual 81% advanced booking National Average 71%, PCT Actual 69% extended practice opening hours Target 85.1%, Actual 88.9% overall satisfaction National Average 79%, PCT Actual 81% Access to NHS Dentistry: Since 1st April 2006 PCTs have had responsibility for commissioning primary care dental services to reflect local needs and priorities. This includes ensuring that an appropriate out-ofhours emergency care service is available for local patients receiving continuing care from a local practice, local patients not receiving continuing care, and visitors to the area. It also includes an obligation on PCTs to provide appropriate access to urgent dental care, both in and out of core working hours. PCT performance as at 31st March 2011 shows:Number of patients with access to an NHS dentist Target 277,574 and Actual 258,885 Ambulance Response Times: Since the 1st April 2008, the clock started when the call was connected to the ambulance control room. Ambulance Trusts and PCTs have been assessed against this new standard throughout 2010/11. Ambulance Trusts should respond to 75% of category „A‟ calls within 8 minutes, 95% of category „A‟ Calls within 19 minutes and 95% of Category „B‟ calls within 19 minutes. Yorkshire Ambulance Service performance as at 31st March 2011:% response to Category A calls within 8 minutes: Target 75%, Actual 72.4% % response to Category A Calls within 19 minutes Target 95%, Actual 98.1% % response to Category B calls within 19 minutes: Target 95%, Actual 92.8%

Report Owner: Peter Flynn Report Author: The Performance Team

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Choose & Book: Giving patients more choice about „How, When and Where‟ they receive treatment is one cornerstone of the Government's health strategy. The PCT is committed to ensuring an increase in the level of choice offered each year, offering routine choice of hospital provider at point of booking for all patients. As at 31st March 2011, PCT performance shows:Unique Booking Reference Number (UBRN‟s) as a % of GP referrals Target 90%, Actual 48%

Report Owner: Peter Flynn Report Author: The Performance Team

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Improving Health of Population

Pages 27-48

NHS Trusts have a key role in helping to improve the health of communities and prevent disease occurring. Obesity: Obesity is associated with many illnesses and is directly related to increased mortality and lower life expectancy. Tackling obesity is a national and local priority. Performance as at September 2010 (school year):% of primary school age children in Reception Year with height and weight recorded Target 10%, Actual 8.8% % of primary school age children in Year 6 with height and weight recorded Target 17%, Actual 18.4% Immunisation: The immunisation programme in the UK continues to evolve, meeting the demand to improve the control of infectious diseases through vaccination. The objectives of the national immunisation programme include providing clear, evidencebased communications that meet the needs of parents and health professionals, and ensuring that those working in primary care are provided with the support required to implement vaccination programmes effectively. The PCT performance at 31st December 2010 shows:% of children aged 1 completed immunisation for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus Influenzae type b (hib)/DTaP/IPV/Hib) Target 95%, Actual 94.8% % of children aged 2 who have completed immunisation for Haemophilus Influenza type b (Hib) and Meningitis C (MenC) Target 95%, Actual 93.4% % of children aged 2 completed immunisation for Measles, Mumps & Rubella (MMR) Target 91%, Actual 90.5% % of children aged 2 completed immunisation for Pneumococcal Infection (i.e. received Pneumococcal booster Target 95%, Actual 91.6% % of children aged 5 completed immunisation for Diphtheria, Tetanus, Polio, Pertussis (i.e. 4 doses) – (DTaP/IPV) Target 95%, Actual 90.13% % of children aged 5 who have completed immunisation for Measles, Mumps & Rubella (MMR) Target 95%, Actual 88.5%

Report Owner: Peter Flynn Report Author: The Performance Team

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Smoking: A national and local priority is the reduction in the numbers of people who smoke, helping people stay â&#x20AC;&#x17E;stopâ&#x20AC;&#x; smoking and smoking prevention. Smoking is proven to lead to heart disease, stroke, cancer and many other fatal diseases. From national and local consultation exercises, many people feel this is an area in which they needed more support in addressing the problem. Many people were concerned about the affects of second-hand smoke; and also, many parents were concerned about their children taking up smoking. PCT performance as at 31st January 2011 shows:4-week smoking quitters Target 2295, Actual 1,842 Sexual Health (including screening): The PCT actively worked with all partners by improving access to services, information and support to improve the sexual health and well-being of the people of Kirklees. PCT performance as at 31st March 2011, except where indicated, is shown as:reduce teenage conception rates as at 31st March 2009 Target 24.32, Actual 48.5 % of patients offered appointments to be seen at GUM clinic within 48 hours Target 100%, Actual 100% number of people aged 15-25 accepting Chlamydia screening Target 19,636, Actual 13,552 Infant Mortality: The Government is fully committed to the promotion of breastfeeding, which is accepted as the best form of nutrition for infants to ensure a good start in life. It also recognises that helping pregnant women give up smoking leads to health benefits for themselves and their unborn children. Since the inception of the NHS Stop Smoking Services in 1999, local Services have had a particular focus on helping pregnant women who smoke to give up. PCT performance as at 31st March 2011, except where indicated:coverage of breastfeeding at 6-8 weeks Target 95%, Actual 95.39% prevalence of breastfeeding at 6-8 weeks Target 51.5%, Actual 39.9% % of women breastfeeding at the time of delivery Kirklees Plan 72%, Actual 73.8% % of women smoking at the time of delivery Kirklees Plan <15%, Actual 17% % of women smoking at the time of delivery Dewsbury as at 31st March 2010 Plan 18%, Actual 33% % of women smoking at the time of delivery Batley as at 31st march 2010 Plan 18%, Actual 30%

Report Owner: Peter Flynn Report Author: The Performance Team

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% of women who have seen a midwife or a maternity healthcare professional by 12 completed weeks of pregnancy Target 90%, Actual 88.58% Substance Misuse: Problem drug use and harmful alcohol use are public health and social issues that are exacerbated by deprivation or personal problems experienced by individuals and a lack of awareness about the risks involved. If not addressed effectively, there are wider consequences for the community in terms of increased crime, family breakdown and anti-social behaviour:-. number of people in successful drug treatment programmes as at 31st December 2010 Target 1495, Actual 1,471 The PCT, working with all health, criminal justice and social care partners, is committed to reducing the harm caused by drug and alcohol misuse through various promotions of prevention initiatives and provision of treatment programmes.

Report Owner: Peter Flynn Report Author: The Performance Team

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Long Term Conditions

Pages 49-66

The recognised outcome of improving the management of patients with enduring chronic disease is to significantly improve their quality of life. This will be achieved through a particular focus on:   

Effective management of disease related symptoms; Reduction in the overall impact of frequent hospital admission through the provision of alternative models of care; and Recruitment of community matrons.

Consequently, there is an imperative to progress work that reduces the overall number of patients who develop chronic diseases and the timely diagnosis of patients so that appropriate management of their symptoms can be established. Latest PCT performance shows:Emergency bed days as at 31st March 2011 Target 171,469, Actual 204,493 Rate of hospital admissions for ambulatory care sensitive conditions per 100,000 population as at 28th February 2011 Target 5,299, Actual 5,657 Diabetes: Diabetes is a chronic and progressive disease that has an impact upon almost every aspect of life. It affects infants, children, young people and adults of all ages, and is becoming more common. Diabetes is the leading cause of blindness in people of working age in the UK. NHS Kirklees has been working hard to ensure the needs of the diabetic population are met. It has undertaken extensive needs assessment work within at risk communities to increase uptake amongst vulnerable groups. NHS Kirklees also introduced PaSA approved software that will help improve the quality of the diabetic retinopathy screening service provided locally. PCT performance as at 31st March 2011:% of diabetic patients offered diabetic retinopathy screening Target 100%, Actual 108% Coronary Heart Disease/Cardiovascular Disease: Cardiovascular disease – heart disease, stroke and related conditions account for about two thirds of all premature deaths in England. Since the launch of the Coronary Heart Disease National Service Framework in March 2000 much progress has been made across Kirklees to develop services which are more effective, modern and timely.

Report Owner: Peter Flynn Report Author: The Performance Team

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Patient/User Experience

Pages 67 - 76

Patient Safety/Infection Control: Keeping patients safe is a key priority for NHS Kirklees and the PCT is actively working with partners; to ensure year-on-year reductions in MRSA & Clostridium Difficile infections, expanding to cover other healthcare associated infections as data from mandatory surveillance becomes available through service level agreements and contracts. PCT performance as at 31st March 2011:Number of MRSA Target 18, Actual 20 Number of Clostridium Difficile Target 150, Actual 130 Patient & Public Involvement: Kirklees PCT is committed to actively involving and working in partnership with the public and service users, to design, review, monitor and deliver quality services that meet the local population‟s health needs by:   

Making Patient and Public Involvement an integral part of PCT working when designing, reviewing and delivering services and using information to improve service user experience; Implementing a two way process of communication between the PCT, the public and service users; Recognition of the diversity of the public and service users; and Raising awareness and promoting active involvement of staff in the principles of Patient and Public Involvement.

A „Stronger Local Voice‟ sets out the Government's plans for the future of patient and public involvement in health and social care. These plans included the establishment of Local Involvement Networks (LINks) which replaced patient forums. LINks work with existing voluntary and community sector groups, as well as interested individuals to promote public and community influence in health and social care.

Report Owner: Peter Flynn Report Author: The Performance Team

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Clinical Priority Programmes

Pages 77 - 109

Cancer (including cancer screening): From 2009/10 onwards, national cancer waiting time guarantees were extended to cover no-one waiting more than 31 days for a second or subsequent cancer treatment and no-one waiting more than 61 days from referral to treatment through National Screening Programmes or by hospital specialists. Robust systems and processes to collect this additional data are still being developed and implemented at time of reporting. The PCT worked collaboratively to ensure the sustained delivery throughout 2010/11 of a maximum waiting time of 2-week from urgent GP referral to first outpatient appointment for all urgent suspected cancer referrals one month from diagnosis to treatment for all cancers and two months from urgent referral to treatment for all cancers. PCT performance as at 31st March 2011, shows:2-week from urgent GP referral to first outpatient appointment Target 93%, Actual 97.43% One month from diagnosis to treatment Target 96%, Actual 98.35% Two months from urgent referral to treatment Target 85%, Actual 85.81% % of eligible women aged 53-64 screened for breast cancer in the last three years Target 70%, Actual 78.17% Percentage of eligible women aged 65-70 screened for breast cancer in the last three years Target 65%, Actual 73.86% Mental Health: The National Service Framework (NSF) for Mental Health addresses the mental health needs of working age adults up to 65. It sets out national standards, national service models, local action and national underpinning programmes for implementation; and a series of national milestones to assure progress, with performance indicators to support effective performance management. An organisational framework for providing integrated services and for commissioning services across the spectrum is also included. PCT performance as at 31st March 2011 shows:Number of new cases receiving early intervention services Target 191, Actual 205 Number of people receiving crisis resolution services Target 850, Actual 1003 Number of people receiving Assertive Outreach Target 170, Actual 170 Number of people accessing Psychological Therapies Target 4013, Actual 4361

Report Owner: Peter Flynn Report Author: The Performance Team

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Learning Disabilities: Working collaboratively, the PCT is actively implementing standards and milestones within „Valuing People‟. Work has continued in relation to the inequalities that people may sometimes face in making use of mainstream health services. Over 80% of GP practices now implementing the Directed enhanced Services (DES). We implemented a Ten Steps to Implementing the Learning Disabilities DES to continue this improvement during 2010/11, and also developed and implemented a primary care training programme. Children: The National Service Framework (NSF) for Children, Young People and Maternity services is a 10-year plan that is expected to be delivered by 2014. The NSF standards are split into 11 key areas. The delivery of the standards outlined within the NSF is key to the delivery of the Every Child Matters agenda. Older People: A strategic aim for the NHS Kirklees is to improve and maintain the quality of life of Kirklees older citizens by promoting partnerships to deliver healthy living activities, sustain peoples‟ independence and to promote positive views of ageing. The Vision for older people sets the key areas of importance for older people living in Kirklees, which was the product of a three month consultant period, and is used as a tool for shaping the delivery of older peoples‟ services across Kirklees, in partnership with health and social care agencies.

Report Owner: Peter Flynn Report Author: The Performance Team

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Cross-Cutting Strategies

Pages 110 - 148

Reducing Health Inequalities Inequalities exist between people, both in avoidable gaps in health and in the factors that profoundly affect health. The Kirklees Partnership is crucial in tackling these inequalities as part of its aim to achieve the health and well-being of local people. We must ensure that those most at risk or in need have real equality of opportunity. The Director of Public Health has worked with colleagues across the Partnership to develop a Framework for Promoting Wellbeing and Tackling Health Inequalities in Kirklees. This sets out a clear shared framework for all partners to take action. Quality, Innovation, Productivity and Prevention (QIPP) The NHS White Paper, Equity and excellence: Liberating the NHS sets out the Government's long-term vision for the future of the NHS. The White Paper recognises the financial challenges the NHS faces and the role Quality, Innovation, Productivity and Prevention (QIPP) will play in supporting the NHS in identifying efficiencies whilst driving up quality. Local Area Agreement (LAA): The Kirklees Local Area Agreement (LAA) is a three year agreement, 2008-2011, between the health and social care organisations which make up the Kirklees Partnership, including the Council, NHS Kirklees and all other health and social care organisations and central government. It sets out our shared priority targets that need to be achieved to improve the quality of life in Kirklees. Corporate Governance: All healthcare organisations should apply the principles of sound clinical and corporate governance: Actively support all employees to promote openness, honesty, probity, accountability and the economic, efficient and effective use of resources; Undertake systematic risk assessment and risk management (including compliance with the controls assurance standards); and Challenge discrimination, promote equality and respect human rights. Equality & Diversity: By „equality‟ we mean treating people fairly and by „diversity‟, we mean “valuing people‟s differences”. NHS Kirklees is committed to ensuring that staff and service users are treated equally and the principle of embracing quality and diversity are common in relation to race, gender, age, sexuality religion and belief or disability.

Report Owner: Peter Flynn Report Author: The Performance Team

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GP Commissioning Consortia The White Paper: Equity & Excellence - Liberating the NHS, signaled the end of the term “Practice Based Commissioning” and the introduction of GP Commissioning Consortia. Much Of the work of the team has therefore been focused on supporting the transition. Workforce: NHS Kirklees has a role both as an employer and a strategic leader in workforce issues. A skilled, motivated workforce is critical to the delivery of our strategic goals, and to our Healthy Ambitions and QIPP agendas. The changing demographic profile and health needs of our local population also mean that NHS Kirklees must take a lead role in workforce planning across the local health economy. Clinical Governance: Clinical Governance is the process by which the NHS seeks to improve the quality of its services commissioned and/or provided and safeguard high standards of care. It was introduced to the NHS in 1999 in „A First Class Service, Quality in the NHS‟. Serious Untoward Incidents (SUI‟s) Following a review of the PCT‟s Serious Incidents (SUI) policy, work has focussed on performance managing SUI‟s, ensuring thorough investigation and timely reporting resulting in meaningful change to protect patients. New SUIs reported October 2010 to March 2011 include six reported by SWYPFT, three reported by CHFT and two by KCHS. The PCT has reported four SUI‟s which will be performance managed by Yorkshire and the Humber Strategic Health Authority. Reports are provided to the Risk Management Overview Group (RMOG), which has delegated responsibility to performance manage and recommend closure of SUI‟s to the Governance Committee. During this period the SHA have approved closure of three PCT SUI‟s, RMOG has recommended closure of three SUI‟s of SWYPFT, two of CHFT and two of KCHS. A supportive and developmental relationship continues to be forged with provider organisations with an emphasis on learning and sharing lessons learned Information Management & Technology: All healthcare organisations use effective and integrated information technology and information systems which support and enhance the quality and safety of patient care, choice and service planning and commissioning. Prescribing (Medicines Management and Community Pharmacy) The Medicines Management Team have consistently delivered improvements in both the cost effective use of resources and improvements in the quality of medicines management and prescribing across the PCT. Actively working with key stakeholders to develop equity and evidence based prescribing.

Report Owner: Peter Flynn Report Author: The Performance Team

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End-Year Report 2010/11

Report Owner: Peter Flynn Report Author: The Performance Team

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Access to Services

2. Secondary Care Access: Director Lead: Carol McKenna and Lead Manager Rachel Carter 2.1

18 Weeks Referral to Treatment â&#x20AC;&#x201C; Admitted & Non Admitted

The new 18 week standard released by the Department of Health in 2009/10 required tighter measuring of performance for each quarter with a gradually reducing number of specialties under target. For 2010/11 all specialties were required to be above the standard and the standard met as an aggregate for the whole quarter. This has created some additional challenges. The Issues Mid Yorkshire Hospital Trust (MYHT) and Calderdale and Huddersfield Foundation Trust (CHFT) Both Trusts gave assurances that they would meet the standard in 2010/11. At MYHT, admitted performance has been below 70% since June 2010 which has largely been due to a steady backlog of patients that have already exceeded the 18 week limit. Significant work has been done throughout the year with MYHT and a recovery plan has been agreed for 2011/12 which should lead to MYHT achieving 2011/12 18ww targets on a monthon-month basis by end October 2011. However performance will not be over-recovered for the remainder of the year and therefore MYHT are expected not to achieve cumulative 18ww targets in 2011/12. CHFT consistently achieved above 95% admitted performance until October, at which point performance dropped as part of an agreed strategy not to over-perform; performance has remained above the 90% threshold.

Report Owner: Peter Flynn Report Author: The Performance Team

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Report Owner: Peter Flynn Report Author: The Performance Team

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Accident & Emergency Waits - % of patients waiting 4 hours or less â&#x20AC;&#x201C; quarterly data (Lead Manager: Tony Cooke)

The Issues The four hour target changed from 98% to 95% post election (from 4 July 2010) and performance began to fall off almost immediately, particularly at Mid Yorkshire Hospital Trust (MYHT), which has struggled with 95% in the same manner as it struggled with 98%. Since winter MYHT has continued to show erratic performance week by week and has had some particularly poor periods with inconsistent performance an ongoing issue. Calderdale and Huddersfield Foundation Trust (CHFT) have maintained performance above 95% throughout the year and continue to show consistent performance. The Action Being Taken All actions taken are to support and maintain the delivery of the 4 hour standard whilst improving quality of care and the experience for the people of Kirklees. For MYHT there is a full and recently updated comprehensive action plan, though inconsistent delivery remains an ongoing problem. CHFT have put in place a series of demand management initiatives including their â&#x20AC;&#x17E;virtual hospitalâ&#x20AC;&#x; initiative. This intends to improve patient flow around the hospital and seeks to reduce time spent on A&E and wards. Improved links with community services have also resulted in reduced re-admissions for long term conditions patients at CHFT. Commissioners continue to design demand management initiatives with consortia and the acute trusts and we know which practices are outliers for use of A&E and other urgent care services. All this is intended to design out use of A&E as the default option, though clearly these initiatives require longer term programme management before they deliver significant gains. We are also working on the out of hours contract and ensuring improved service delivery, better joint working with the ambulance service and using the predictive risk tool to help early identification of future frequent service users/long term conditions patients. In addition winter plans have been established to mitigate the potential effects of flu and other seasonal factors and these are updated and improved year on year. Winter 2010/11 was particularly problematic in respect to demand and poor weather but the partnership approach with regular conference calls and updates mitigated against the worst effects and demonstrated the impact of effective planning.

Report Owner: Peter Flynn Report Author: The Performance Team

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A & E – NHS Kirklees

A & E – Mid Yorkshire Hospital Trust

A & E – Calderdale & Huddersfield Foundation Trust

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Primary Care Access

Director Lead: Carol McKenna and Lead Manager: Mark Jenkins 2.3.1. Access to GP’s and Health Care Professionals The Key Achievements All patients who wish to do so should be able to see a GP within 2 working days and/or a primary healthcare professional within 1 working day – achievement of this target is seen as an indicator of progress on the overall reform of the NHS. The results of this are reported by the National Patient Survey which is undertaken by IPSOS Mori. The PCT will receive 2010/11 survey results in July 2011 but interim reports are published quarterly throughout the year showing a full 12 month period. One key area of the survey is 24 hour and 48 hour access targets which are combined in a single question. As at 31st December 2010, Q3 data is showing PCT performance for this indicator as 81% against a national average of 79%. 2.3.2

Supporting Measures: Extended opening hours for GP practices

The Key Achievements Extended opening hours is part of the PCT „s Directed Enhanced Services (DES). 64 practices out of 72, equating to 88.9% are delivering extended hours. The 2010/11 Plan was that by 31st March 2011 86.5% of practices will be offering extending opening hours and the plan has been exceeded. Extended hours are delivered before 8.00am and after 6.30 pm Monday through to Friday or on a Saturday/Sunday.

Report Owner: Peter Flynn Report Author: The Performance Team

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Access to NHS Dentistry

Director Lead: Carol McKenna and Lead Manager Lead: Clare Priestley Access to NHS Dentistry

The introduction of a new process to commence with new requests from April 2010 has enabled patients to contact a practice of their choice from a list of practice accepting patients on a monthly basis this system has worked very well and continues to do so into 2011. Continued robust contract management will result in claw back from some practices that had persistently underachieved UDAs, however it is anticipated that this will be significantly less that other years due to a better understanding of the situation by GDPs. The DH setting of the expected patient charge revenue from practice in 2006 continues to impact on the PCT budget. The funding is no longer ring fenced to dentistry from April 2011. Discussions with the SHA and the Performance team in the PCT have taken place but the DH refuse to accept the reason for the unrealistic trajectory which remains at a suggested 5% increase in access by March 2011. Access improves month by month and a meeting is to be held with the DH, SHA and the PCT during 2011 to understand the situation better.

Report Owner: Peter Flynn Report Author: The Performance Team

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Ambulance Response Times

Lead Director: Carol McKenna and Lead Manager: Rachel Carter The Key Achievements The performance for the year to end of March 2011 for YAS overall (the CQC measure) was Cat A 8 underachieved, Cat A 19 achieved and Cat B19 underachieved. This compares favourably with the position at 2009/10 year-end with performance having improved in all areas (A8 +2.9%, A19 +0.7%, B19 +2.6%). Performance has dropped in all areas since the half-year report; this is largely due to a prolonged period of adverse weather. Performance for patients in the NHS Kirklees area is lower than that of YAS overall performance for the A8 and B19 targets, and higher than YAS overall for A19. Cat A8 Cat A19 Cat B19

Target 75% 95% 95%

Performance for YAS 73.7% 97.4% 93.7%

Performance for Kirklees 72.4% 98.1% 92.8%

Within NHS Kirklees there is a huge variation in performance across different localities.

Cat A8


Best Kirklees Performance YTD (Feb) Huddersfield North; 84.7%

Cat A19


Spen; 99.2%

Cat B19


Dewsbury & Mirfield; 95.2%


Worst Kirklees Performance YTD (Feb) Denby Dale & Kirkburton; 23.8% Denby Dale & Kirkburton; 91.8% Denby Dale & Kirkburton; 80.1%

For the first time this year, activity is being paid for on a cost and volume basis. Overall activity for Kirklees is up 5.7% for the year. At ÂŁ192.28 marginal rate, this translates to a full-year overspend of ÂŁ532k. The Operational Improvement Plan for 2010/11 focussed on two main areas, staff abstractions and system efficiency improvements. There has only been a marginal improvement in abstraction rates, but YAS now has a better understanding of issues which are being played into 2011/12 plans. System efficiency improvements of 4% have been achieved, but these fall short of the 10% target. A 2011/12 Operational Improvement Plan is in development and will focus on:

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Improvement required

New targets and deployment

A change in the deployment of ambulance resources based on the new categories of calls Enhanced deployment management through training and management of dispatchers Development of status plan tools

Reducing response demand

Increase in clinical triage Increase in utilisation of alternative pathways Clinical support for front line staff through the clinical hub to support managing patients at home or through alternative pathways Increasing appropriate non conveyance

Reducing time

Providing performance management information to individuals to support productivity and quality improvements Reductions in time at scene especially when multiple resources on scene Continuing to work with acute trust to reduce hospital turnaround

New rotas

Complete the implementation of new rotas for the front line crews that help to ensure we have the right staff, with the right skills in the right place at the right time

Report Owner: Peter Flynn Report Author: The Performance Team

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Report Owner: Peter Flynn Report Author: The Performance Team

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Choose & Book and Choice Director Lead Carol McKenna and Lead Manager Rachel Carter

Usage of Choose & Book (C&B) figures continued an improving trend until May 2010, when the highest ever performance was achieved for NHS Kirklees at 60%. Since then, performance has deteriorated each month to December (39%), recovering to 48% in March which is 11th of 14 PCTs in Y&TH. These trends (May peak, subsequent deterioration and recovery) mimic both National and Regional performance; for March, Kirklees was below both SHA and National performance (National 51%, SHA 54%). Performance for our main providers in March was 57% for CHFT and 43% for MYHT. The Kirklees Local Enhanced Service for Choose and Book usage was discontinued for 2010/11 (through the QIPP programme), and this may have contributed to the deterioration in performance. Directly-bookable appointments continue to be available at both CHFT. 100% of C&B referrals are now processed through the DBS system at CHFT, whilst DBS usage at MYHT is consistently around 85%. MYHT has been a national outlier in slot availability issues (i.e. no slot available for patient to book into when accessing C&B). Performance has improved this calendar year and progress in this area is being monitored at operational and Executive contract management groups. Following discussion of C&B performance at the PCT Senior Management Team meeting, a mini-summit was held on 6th January to look at improving C&B performance. The meeting was attended by a GP and Practice Manager, together with the C&B lead and PCT Directors and Officers. Discussions/actions included the following areas: Importance of timely attachment of referral letters; Analysis of whether Kirklees is an outlier in not offering a C&B LES; Continuing exclusions (i.e. services not on C&B) at acute providers; Report Owner: Peter Flynn Report Author: The Performance Team

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Identification of mid-range performing practices in C&B usage; Revised guidance explaining the different ways of using C&B. The Yorkshire & Humberside SHA have introduced a new initiative for â&#x20AC;&#x17E;Optimising Electronic Referringâ&#x20AC;&#x; (OER). The aims of this initiative are to increase the utilisation of Choose and Book and reduce the use of paper referrals to an exception only basis. NHS Kirklees, CHFT and MYHT have all agreed to be a part of OER.

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Improving Health of the Population

3. Obesity Director Lead: Judith Hooper and Lead Manager: Liz Messenger Background The Obesity Programme focuses on halting the increase in the number of children and adults in Kirklees who are obese. The programme includes those who are already overweight and gaining weight and those who are obese. The programme focuses on helping them to lose weight including medical interventions where appropriate. There are complimentary plans in place to prevent obesity through improving diet and increasing levels of physical activity. Strong links have been built between the physical activity, food, emotional well being and health in schools programmes. This enables the Obesity Programme to focus on those people who are at a greater risk due to their weight. Key Achievements The Kirklees Weight Management Service has received over 1750 patient referrals this year. The service adopts a tiered approach offering a range of interventions tailored to meet the needs of the patient. All weight management programmes are now in place; of those patients who have completed a weight management programme 1 in 3 patients achieve at least a 5% weight loss at 12 weeks. In addition the establishment of a primary care multi-disciplinary team (MDT) ensure that only those patients deemed appropriate for bariatric surgery are referred to the secondary care bariatric MDT. This has resulted in a substantial decrease in the number of patients being referred on for bariatric surgery. The National Child Measurement Programme (NCMP) continues to develop well; all schools have engaged in the programme again this year. The results from the 2009/10 programme show that Kirklees levels of childhood obesity are similar to the national picture. In Reception, 1 in 5 (20.5%) children were either overweight or obese. In Year 6, this rate is 1 in 3 (33%). Routine feedback to parents will be rolled out across Kirklees this summer following the successful pilot project in Huddersfield South. This will provide all parents with the results following their child being weighed and measured. The social marketing project focusing on tackling obesity in 16 to 24 year old students attending FE/HE in Kirklees is now complete. The outcomes and learning from the project are now being disseminated; the project was presented at the World Social Marketing Conference and will be included in a workshop that is being delivered at the Public Health Congress in May. Successful initiatives have been embedded within the FE and HE settings and continue to be delivered.

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Services for children and young people (Start and MEND programmes) continue to provide physical activity, healthy eating and emotional wellbeing support for obese young people and their families. Recruitment to the Start programme has exceeded the performance targets set and retention to the programme is excellent. The new holiday programme which aims to provide intensive support for moderately and severely obese children and their families during school holiday periods continues to develop well; a total of 36 families have now attended. Work continues with the roll out of the national Change4Life initiative locally. A small grants scheme has been launched to build capacity within local organisations to deliver change4life activity. A total of ten organisations have been given a grant to develop work across Kirklees. The MEND 2-4 programme has been commissioned to improve the knowledge and skills of early yearâ&#x20AC;&#x;s staff to enable them to play a key role in the prevention of overweight and obesity among children. To date 58 front line practitioners have attended Talking about Weight training which equips participants with the facts, language and interpersonal skills to raise the issue of weight. Additionally 23 members of staff have been trained as facilitators for the MEND 2-4 programme; this will enable them to deliver a programme that is suitable for at-risk and overweight or obese children and their families within early years settings; A public health pharmacy campaign was run to deliver key messages to target groups and raise awareness about weight management services in Kirklees. This resulted in an increase in the number of referrals to the weight management service. A workshop has been held with representatives from Mid Yorkshire Hospital Trust, NHS Wakefield and NHS Kirklees to explore compliance with NICE guidance and RCOG recommendations regarding weight management before, during and after pregnancy. Key actions have been identified around data collection, primary care involvement and early identification. A similar audit has been completed with NHS Calderdale and representatives from CHFT. Issues Capacity within the School Nursing Team to undertake measurements for the 2010/11 NCMP has been reduced and there are concerns that this could impact on the participation rates within the programme and the ability to give routine feedback to parents. Routine feedback to parents will be implemented across Kirklees. PCTâ&#x20AC;&#x;s have experienced negative media interest following the implementation of routine feedback to parents. The Obesity Programme is working closely with the Communications Team to proactively work with the local press around the National Child Measurement Programme and provide information about local initiatives and services for overweight children, young people and their families. Referrals to the Weight Management Service dropped below target in quarter 3 and 4. The adverse weather in December affected attendance to the service and this, together with the holiday period will have had an effect on referral numbers. The service has developed a

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communications and marketing plan and is reviewing patients who consistently DNA to gain insights into the reasons. Next Steps  Monitor the implementation of the adult weight management service to ensure it is fit for purpose and meeting the needs of the target group. Ensure learning from the DNA audit is utilised by the service to enable them to make changes to service delivery;  Conduct detailed analysis of the data from the 2009/10 National Child Measurement Programme to track trends and identify localities with above average levels of childhood obesity.  Working in partnership with Huddersfield Giants and Huddersfield Town, develop, implement and evaluate the project aimed at 45-65 year old overweight and obese men and their families through local sports clubs/matches. If successful this will be rolled out to Dewsbury and Batley.  Implement actions identified through the maternal obesity audits to ensure compliance with the new NICE guidance: Dietary interventions and physical activity interventions for weight management before, during and after pregnancy.  Continue to share learning from the UpforIt project and support partners deliver and sustain interventions within FE and HE establishments;  Roll the MEND 2-4 programme out to Children Centre‟s in South Kirklees using the NCMP data to ensure these are targeted to areas of high prevalence of childhood obesity

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Director Lead: Judith Hooper and Lead Manager: Jane O‟Donnell (Children who complete immunisation by recommended ages) Immunisation continues to be one of the most effective, safe, beneficial and cost effective interventions to prevent infectious diseases. Quarter 4 data is not available at the time of writing this report. NHS Kirklees Quarter 3 COVER data October to December 2010 Children reaching their first birthday on 31 December 2010 receiving: ●







Pneumococcal vaccine



Children reaching their second birthday on 31 December 2010 receiving: ●




Pneumococcal vaccine



Hib/Men C booster






Children reaching their fifth birthday on 31 December 2010 receiving: ●

DTaP/IPV/Hib booster



MMR vaccine receiving two doses



The vaccine uptake for children reaching their first birthday is slightly lower than in Quarter 2 of 95.08% and below the Yorkshire and Humber percentage uptake of 94.9%. The uptake of MMR (two doses) at five years is above the Yorkshire and Humber region Uptake of 87%. In February 2011, North Kirklees achieved 95% for the booster dose of DTaP/IPV/Hib for the first time ever.

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Immunisation update data split by north Kirklees and Huddersfield for Quarter 3 North Kirklees 95.4% uptake for DTaP/IPV/Hib at one year. 96.1% uptake for PCV(pneumococcal) at two years 96.3% uptake for Hib/MenC at two years. 94.8% uptake for MMR at two years. 93.1% uptake for DTaP/IPV booster at five years. 92.2% uptake for MMR one and two dose at five years. Huddersfield 94.2 % uptake for DTaP/IPV/Hib at one year. 87.7% uptake for PCV at two years. 90.8% uptake for Hib/MenC at two years. 86.8% uptake for MMR at two years. 87.4% uptake for DTaP/IPV booster at five years. 85% uptake for MMR one and two dose at five years. The vaccine coverage in Huddersfield continues to be lower than the overall Kirklees COVER uptake. HPV Vaccine Programme The HPV vaccine programme was introduced into the national immunisation programme in September 2008. The aim of the HPV vaccination programme is to reduce the incidence of cervical cancer in women. The routine cohort (school year 8), females aged 12 – 13 years. The denominator for the programme is from the school roll for PCTs. The annual vaccine coverage for Kirklees 2009 / 2010 was: first dose 87.5%, second dose 86% and third dose 83.8%. The target set by the Department of Health is 90%. Coverage for HPV vaccine 2009 / 2010 routine cohort was very slightly below (0.5%) than that achieved in 2008 / 2009. Factors that may have had an impact on the vaccine coverage in 2009/2010:● ● ●

Adverse media publicity (sudden death of young girl in Coventry – no link established to vaccine). Data quality in 2008 / 2009 - organisations were unable to provide an adjusted denominator for the annual return. H1N1 pandemic vaccination programme.

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Smoking Cessation

Director Lead: Judith Hooper and Lead Manager: Rachel Spencer-Henshall The Key Achievements Kirklees Tobacco Control Alliance, a multiagency partnership to deliver comprehensive tobacco control measures in Kirklees, is reviewing its structure to implement “Healthy Lives, Healthy People: A Tobacco Control Plan for England” published March 2011 at a local level. Cessation subgroups are already established for WOCBA/Pregnancy and Routine and Manual (R&M) workers which remain priority groups in the new plan. Each group is developing and implementing an action plan to tackle smoking in its target population. Smoking cessation pilot groups targeting R&M workers following social marketing insight work are now complete and final evaluation is underway to inform future service provision. A project focused on raising awareness of dangers of “niche tobacco products” in BME communities in Kirklees and Bradford is underway led by WYJS. A Community worker has been appointed to develop materials, messages and engage with community groups around this agenda. The Issues Smoking prevalence in Yorkshire and Humber region has increased from 22% in 2007 to 25% in 2008 making it the region with the highest smoking rate in England. Reducing smoking in 'routine and manual' groups where 32% people smoke and stopping smoking during pregnancy are the biggest challenges regionally as well as in Kirklees The Action Being Taken Total quit numbers are below target for January 2011 (1842 against target of 1911). The specialist service is performing above target (470 against 364) however we need to be sure they are reaching those most in need of support. Both the reach and outcomes for the service are being audited currently in the Health Equity Audit. Reduced targets for the specialist service require good quit rates from intermediate advisors (via LES schemes) in order to meet the cumulative target. The specialist service have been asked to increased peer support to practices, particularly in areas of high prevalence, to strengthen commitment to smoking cessation prior to the new LES scheme being launched. A Children & Young People‟s interest group is being launched to develop an action plan to support prevention work taking a Social Norms approach supported at a regional level. Other key target populations are people living with severe Mental Health conditions, certain BME and minority groups. Work in these areas needs to be developed. Reducing Exposure to Second Hand Smoke (SHS) is a priority nationally and locally. Funding is being sought to mainstream smoke free homes work across Kirklees following a successful pilot project in North Kirklees. Stakeholder support remains strong on this agenda.

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The service specification with the Stop Smoking Service for 2011-12 is being developed building in quality measures and increased support for identified target populations. The service 4 week quitter target is also being reviewed in line with new targets set by the DH for NHS Kirklees. Results of a Health Equity Audit of the service will help guide service development to meet identified need. GPs and pharmacists provide an intermediate stop smoking service via a locally enhanced service, both schemes are under review to increase activity in areas of highest smoking prevalence and improve access to treatments. A similar scheme for Dental practices is in development and will be piloted in 2011-12. Systems are being reviewed to improve quality of maternity data and monitoring forms are being amended, alongside training on their completion, to capture occupation status more accurately. Brief interventions training is being recommended for all front-line workers in contact with target populations, an audit of training needs of identified staff has been completed. In response an e-learning package has been developed with colleagues from Calderdale, Wakefield and Bradford which will increase front line workerâ&#x20AC;&#x;s access to this training.

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Sexual Health: Reduce Teenage Conception Rates

Director Lead: Judith Hooper and Lead Manager: Rachel Spencer-Henshall The Key Achievements A Comprehensive Sexual Health Needs Assessment (cSHNA) has been commissioned and the final draft completed. The recommendations from the SHNA will ensure that local sexual health resources and services are being developed to fulfill the identified local need; help further improve access to sexual health services with a view to reducing the number of teenage conceptions. Pharmacies across Kirklees continue to offer the „sexual health in pharmacies‟ Local Enhanced Service (LES) across the District. Those accredited are offering emergency contraception, pregnancy testing, Chlamydia screening and condom distribution. A LES for GPs to supply long acting reversible contraception (LARC) is in place across Kirklees, with a greater number of GPs now offering the intrauterine device (IUD) and Implanon as part of this service, following PCT commissioned training. Work is underway to review this service and gather data around uptake and LARC usage. The Kirklees C-Card scheme is steadily expanding. Thirty Seven organisations are registered with the Kirklees Young People Friendly kite marking scheme (Kirklees Young People Friendly). Twenty four of which have received kite mark status and a further thirteen are working towards the standard. This is an increase of four accredited services and 14 services registered. Sexual Health Youth Workers (SHOW, x2) – Continue to register young people to the C-Card scheme, having registered ca 500 young people since the schemes inception. They are about to undertake Kirklees Training the Trainer in sexual health in order to roll out Level 2 training to all staff working for Young People‟s Service. A new Service Level Agreement (SLA) has been signed, ensuring that this support will be available for a further 12 months, taking the project into its third year. A Sexual Health Workforce Development Operational Group was established to take forward the final preparations for the launch of the Kirklees Sexual Health Training the Trainer scheme and the three tier training programme. Kirklees training the trainer in sexual health will be run for the first time in May followed by a program of level 1 and 2 sexual health training throughout the year. A Pilot Sexual health planning framework has been rolled out at a high school in Kirklees. The planning framework will identify need and gaps for relationships and sexual health provision / education and will involve all year 10 students, parents/carers and staff. The results of the planning tool will enable increased access to sexual health support, services and education for the whole school community.

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The Issues The annual conception data for 2009 was released by the ONS in February 2011. The Under 18 conception rate in Kirklees has increased from 47.7 in 2008 to 48.5 in 2009. Overall, Kirklees has achieved a reduction in its under 18 conception rate of 0.2% (since the baseline year of 1998). Data for 2010 will be available during February 2012. The Action Being Taken The SHNA highlights a number of actions and improvements that need to take place in Kirklees to work towards the reduction of sexual health inequalities including teenage pregnancy. Work will be undertaken to improve integrated working across CASH services and GUM in order to offer Level 2 CASH provision as part of GUM services ensuring increased access to contraception and support for Children and Young People. The Sexual health workforce development program will be rolled out to all organisations across Kirklees and embedded in the local authority children and young people‟s workforce development plan. The results of the Sexual health planning framework in schools will be used to develop a tool that will be initially offered to schools in teenage pregnancy „hotspot‟ areas and eventually to all high schools in Kirklees. A trial will be undertaken with a company called „Go Get Info‟ this is a new mobile information service for teenagers accessed via a text messaging service. The trial will provide statistical evidence on the information young people are requesting bye topic, age and gender and will be promoted to 10,000 young people across the district. At the end of the trial evidence will be collated and reviewed and there will be an option to commission the services if successful. Launch of the Sexual Health Communications strategy which will aim to provide information, education and support to children and young people across Kirklees via social media tools with the main objectives to increase service and LARC uptake. Continuance of the outreach work by the sexual health youth workers, including ongoing CCard delivery, acting as champions within the Young People‟s Service for the scheme, promotion of LARC methods to young people and promotion of delay methods. Explore the opportunities to develop LARC provision in non-clinical settings, specifically Further Education settings.

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Sexual Health â&#x20AC;&#x201C; 48 Hour Access to Genito Urinary Medicine (GUM)

Director Lead: Judith Hooper and Lead Manager: Rachel Spencer-Henshall % of Patients offered an appointment to be seen within 48 hours The Key Achievements Both Genito Urinary Medicine (GUM) clinics offer a mixture of drop in and booked appointments at a variety of times. Work has taken place between the two GUM clinics and the Contraception and sexual health service to enable more STI testing in community settings, reducing pressure on GUM services Performance as at 28th February 2011 for Kirklees is 100% offered. The take up of those appointments 'seen' is 97%

The Action Being Taken The recent sexual health needs assessment has identified 8 key recommendations, including continuing with the integration of sexual health services. These recommendations will be looked at throughout 2011/12 with the intention of improving access and availability to sexual health services.

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Sexual Health – Chlamydia Screening

Director Lead: Judith Hooper and Lead Manager: Rachel Spencer-Henshall The Issues The PCT has not met the target of 19,644 screens for (April – March) 2010/11. The total number of screens performed as at 31st March 2011 is 13,552 (inclusive of those screens obtained direct from the lab). The Key Achievements Despite not achieving the target, considerable progress has been made and we are closing the gap in order to meet the overall target of 19,644 by April 2011. Local Enhanced Services (LES) for sexual health in pharmacies – Screens are still very low, work is being undertaken with pharmacies in particular in Teenage Pregnancy hot spot areas to increase screening and promote the service to target groups. Brunswick Centre is continuing to deliver high screening numbers in South Kirklees. Numbers in North Kirklees are lower, Brunswick suggest this is due to differences in population and the fact that there are less pubs and clubs to provide outreach services in North Kirklees. Young People‟s Service and Sexual Health Youth Workers – Screening has increased to around 20/30 screens per month with more targeted work being undertaken and greater links with C Card. GPs screening has increased slightly in general practice, however work still needs to be undertaken to improve screening as part of the core service. Chlamydia Screening Officer‟s (CSOs) are working with NHS Kirklees commissioners in order to identify prevalence and at risk groups for Chlamydia across Kirklees, Health Intelligence are also providing support for this using Mosaic. NCSP have released guidance on the proposed new Chlamydia target with greater emphasis on „diagnosis rate‟ (number of positives), In order to significantly reduce the prevalence of Chlamydia. The new target will require a diagnosis rate of 3000/100,000 young people aged 15 – 25. The new service specification for Kirklees has been adapted to reflect this target. The Action Being Taken The following actions are taking place to obtain the additional screens needed to meet the trajectory of 19,644 35% screens by March 2011. Continue to implement the recommendations from the NST visit.

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Screening programmes will continue to providing a comprehensive package of support to all screening sites including GPs and Pharmacists in order to increase screening levels particularly in core services. The Service Level Agreement (SLA) for Sexual health youth workers has been agreed for a third year with a target of 20 screens a month and support to other youth service screening sites. New service specifications are being consulted upon for 2011/12.

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Infant Mortality: Smoking During Pregnancy

Director Lead: Judith Hooper and Lead Manager: Rachel Spencer-Henshall The Key Achievements A multiagency sub group of Kirklees Tobacco Control Alliance focused on cessation in Pregnancy and WOCBA population has been established. The group is working to an action plan to implement NICE Guidance 26 “Quitting Smoking in Pregnancy and following childbirth” 2010 and deliver the 8 high impact actions in “Reducing smoking pre-conception, during pregnancy and postpartum” with additional focus on Dewsbury and Batley. All midwives have been provided with CO monitors to validate women‟s smoking status at booking and enable signposting to appropriate support. Through partnership working with Children‟s Centres, each CC will have access to a CO monitor and provide information and signposting to service users wanting support to stop smoking. The regional pilot, “Significant Other Supporter” (SOS) project worked with women for the duration of their pregnancy and beyond to tackle high relapse rates in pregnancy (approx 60%). In Kirklees 82% of women enrolled remained quit at 2 months postpartum. Kirklees outcomes are among the best in our region. Smoke Free Homes are publicised across Kirklees as harm reduction for children and families, also as a route to commitment to quit from parents. Funding is being sought to mainstream smoke free homes work across Kirklees following a successful pilot project in North Kirklees. Strategic and stakeholder support remains strong on this agenda. The Issues The target for this indicator is to reduce smoking at delivery in Dewsbury and Batley to 18% from the baseline of 33% and 28% respectively in 06/07 (excluding SA women). Figures for 09/10 show Batley at 30% and Dewsbury at 33%, both worse than for the previous year but within expected variation (95% confidence interval). This may be due to improved data collection coverage with smoking status now a mandatory field on both acute trust IT systems. Errors in data recording recently identified may also impact on this figure. Additionally it is likely to be a reflection of increasing smoking prevalence across the population in these localities, Kirklees and the region. Smoking at time of delivery across the whole of Kirklees (all women) was 4th lowest in the region at 15.5% in 2009-10. There is wide variation across localities (24%-7%) with rates highest in localities with highest numbers of infant deaths The Action Being Taken A Smoking in Pregnancy “summit” is planned with all interested and affected parties to look at data collection issues, implementation of NICE Guidance and training needs.

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An e-learning package for very brief advice and brief advice is being developed with colleagues from NHS Wakefield and Calderdale to improve access to training for frontline staff in contact with WOCBA. Public Health programmes are working together; tobacco, alcohol and obesity, around menâ&#x20AC;&#x;s health to engage the partners of WOCBA who are a key influence in their health behaviour.

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Infant Mortality: Breastfeeding

Director Lead: Judith Hooper and Lead Manager: Keith Henshall The Key Achievements Coverage rates at 6-8 weeks (the number of records of breastfeeding status relative to the number of 6-8 week checks due in primary care) continued to improve and have hit the 95% target by end 2010/11.

The Issues Analysis of 2010/11 data for 6-8 weeks shows a difference in prevalence between North and South Kirklees, indicating that maintenance of breastfeeding beyond 6-8 weeks is linked to cultural and socio-economic factors associated with different communities in Kirklees, along with many other health related outcomes. These deprivation linked factors are intractable and difficult to address in the short term. Q4 2010/11 figures showed a steady decline since Q2 in prevalence rates on a Kirklees basis. South Kirklees prevalence remained relatively consistent (around 45%) whilst north Kirklees prevalence declined from around 40% in Q2 to 34% in Q4. Work continues to increase prevalence (i.e. maintenance) of breastfeeding at 6-8 weeks through the development of peer support projects including 2 baby cafes in Kirklees and a bistro in each locality. Kirklees Community Healthcare Services including Kirklees Sure Start Children Centres achieved stage 1 of the UNICEF UK Baby Friendly Initiative (BFI) staged programme.

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Prevalence of Breastfeeding at 6-8 weeks

The Action Being Taken The Childrenâ&#x20AC;&#x;s Trustâ&#x20AC;&#x;s Children and Young People Plan identifies and seeks to utilise the interdependencies between programmes to address inherent cultural and socio-economic factors in areas with low B/F prevalence. Kirklees Community Healthcare Services are working towards Stage 2 of the BFI accreditation process as the next stage. This focuses on breastfeeding knowledge and skills in all health visiting teams across Kirklees and will be assessed to BFI best practice standards. The development of an infant feeding training package conducive to community practice will soon be made available to support the learning and development of all relevant staff in the community. Collaboration with Kirklees Partnership continues to develop since the first workshop in Jan 2011 to support women/employees who wish to breastfeed for longer through the development of family friendly breastfeeding policies in workplaces across Kirklees. Since October 2010, the development of Breastfeeding Resource Packs have been accessed by over 800 women across Kirklees from Health Centres and now KCHS are piloting a Health visiting team in Cleckheaton (where prevalence of formula / bottle feeding is higher than in other areas in north Kirklees - sourced from quarterly locality based 6-8 week breastfeeding data) to distribute breastfeeding resource packs to all mothers at the antenatal visit. The Breastfeeding Face Book site continues to develop with a steady increase in numbers and now has 135 breastfeeding fans which offers information and a social network of support. The training of breastfeeding volunteers continues to support the Baby Bistro programme which currently stands at 67 trained breastfeeding peer supporters in Kirklees. Plans are in place to develop a series of Buddies Baby Bistro's (BBB), with the pilot in Report Owner: Peter Flynn Report Author: The Performance Team

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Dewsbury town centre targeting teenage and young mums and dads. Young trained breastfeeding volunteers will support the BBB programme and add support to collaborative working with the Family Nurse Partnership, teenage pregnancy midwives and existing young parent groups in Sure Start Children Centres. To aid a consistent approach in raising awareness of supportive breastfeeding drop in groups in Kirklees, the Personal Child Health Record (Red Book) which mothers receive at delivery of their baby, will include an A5 insert of all local supportive groups, such as all Baby Bistro's in Kirklees.

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Infant Mortality: Early Access for Women to Maternity Services

Director Lead: Judith Hooper and Lead Manager: Keith Henshall 3.8.1. Healthy Pregnancy and Early Access to Maternity Services Women are encouraged to book an appointment with a midwife as soon as they know they are pregnant so they can have a full health and social needs assessment as early as possible and any additional support, advice and information needed can be given in plenty of time before their baby is born. The Key Achievements Out of 6120 pregnancies in 2010/11 5470 were under 13 weeks when they had their assessment. This is a ratio of 89.4% against a target of 90%. Over the year there were 5365 births to Kirklees women. The Risks In order to focus on the more vulnerable women and families, pregnancy care still needs to increase community midwifery capacity and skill mixing with Maternity Support Workers. Investment in staffing still seems to be an issue. This may be due to providers investing income from maternity services into other priorities. Whilst over 89% of women are booking into maternity services before 13 weeks of pregnancy there are still around 10% of women who book later than this. Although our insight shows that some women do not know they are pregnant until well after 12 weeks and many others prefer to „conceal‟ it, we need to understand much more about the needs of the women and families who do not book into maternity services within 13 weeks. Many of these families may be from communities who are particularly vulnerable to poorer outcomes for their babies and themselves. The Actions Being Taken The shortfall in investment from tariff into maternity services and the accuracy of activity coding is being analysed by commissioners. This will be addressed through the contracting process. In line with work nationally, local commissioners are considering introducing a birth tariff to rationalise and align the range of tariffs attached to pregnancy including ante and neo natal screens, labour and post partum/natal care. A qualitative audit of women‟s experience of labour and birth in north Kirklees is proposed for spring 2011, together with an analysis of the needs of women and families in the 10%+ who do not engage with services before 13 weeks. In north Kirklees, a joint initiative with Action for Children has seen the recruitment of Family Support Workers in Children‟s Centres specifically to work with pregnant women, in order to help address some of the health and social needs of the most vulnerable families. 72 families were supported in 2010/11, nearly all being referred during pregnancy or with their new born

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infant, and many of whom were first time parents. Each family had multiple support needs and therefore multiple outcomes were targeted for these families. For most of the families the service enhanced their capacity to cope with difficulties in times of stress, by offering advice and support to increase parental skills and confidence so that difficulties are better managed. For some families, identifying the strengths and limitations of parental capacity was a key focus including assessing their ability to understand and meet the needs of their child and enhancing parentsâ&#x20AC;&#x; capacity to support their childâ&#x20AC;&#x;s health and development. Work is continuing to develop the role of the north Kirklees Maternity Services Liaison Committee (MSLC) to inform our understanding of the needs of very vulnerable families using maternity services. The MSLC is seeking to increase its input from a wider range of women and families from vulnerable communities by taking the forum on tour of community venues across north Kirklees, opening up the meetings to informal discussions and questions from any member of the community. An equivalent south Kirklees and Calderdale MSLC is under development in order to help inform the development of maternity services and our understanding of the needs of the most vulnerable families. Antenatal screening programmes have been audited against national standards and best practice in order to ensure that we offer women a first class healthy pregnancy experience. 3.8.2. Percentage of women who have seen a midwife or a maternity healthcare professional, for assessment of health and social care needs, risks and choices by 12 completed weeks of pregnancy.

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Substance Misuse

Director Lead: Carol McKenna and Lead Manager: Tony Cooke 3.10.1. Drugs Misuse

Performance on the drug treatment agenda remains strong overall. There are 1,700 people in treatment for drug misuse (primarily heroin and crack cocaine) and 90% of service users are classed as being in „effective treatment‟ and 50% of leaving treatment in a planned manner (up from 33% three years ago). Likewise, numbers of people leaving treatment free of all dependency has increased by over 40%. The most recent data indicates the end of year target for numbers in treatment might not be met (assessment: Amber) as most problem users are already known to services and due to the effectiveness of treatment, criminal justice and young people‟s services there are less problem drug users in the system (this has been confirmed by Glasgow University who note a statistically significant reduction in the number of heroin users between 2005 and 2009). Substance misuse services have often been stretched by the level of need in Kirklees, and the improvement in outcomes for service users (health, housing, offending) is almost certainly linked to the improvement in capacity made possible by reduction in overall numbers of heroin users, making more structured and focused clinical and psycho-social work possible. The focus going forward is threefold. First to improve support to „entrenched‟ users who are typically hard to engage, older, often offenders and with limited employment history through a range of community engagement and assertive outreach approaches. Second to better support individuals to identify their personal goals and progress through treatment, and thirdly to improve treatment outcomes and support community integration. The shift of the focus from specialist treatment to more use of GP and nurse led shared care is central to this.

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Improvements in the clinical management of care that commenced in 2009/10 will continue in 2011/12 with the commissioning of Kirklees Community Health Care service to deliver clinical support and nurse led interventions and Lifeline structured treatment and additional support to offenders and other vulnerable groups. Work is ongoing to improve the identification of children of substance users needs within treatment services and young people‟s services have, for the first time, started to deliver significant outcomes after a retendering exercise in 2009. 3.9.2

Alcohol Misuse

Key Challenges 16,000 dependent drinkers in Kirklees, 1000 treatment places annually; Alcohol related hospital admissions almost doubled since 2002 (NWPHO, 2010); and Kirklees in worst quartiles for „hazardous and harmful drinking‟. Progress Performance exceeds regional and national averages (NTA, 2011) with 73% of service users leaving treatment in a planned manner; Improvements on all points of the „Outcome Star‟ for service users; Integrated team across public and voluntary sector providers; Development of new pathways with acute trusts and criminal justice services; and Work with YAS and community safety to target Huddersfield town centre. Driven by the Kirklees Alcohol Strategy and after an effective partnership tendering process, On Trak, the new adult alcohol service commenced operation from October 2009. The first 18 months performance has seen the development of a highly effective service, with over 70% of service users having a successful outcome. An effective partnership between Lifeline, KCHS and Community Links has established pathways with criminal justice, the acute sector and social care and a focused and skilled team are already delivering evidence of real change amongst the service user group as measured by the Outcome Star. Nonetheless, the need for specialist alcohol treatment continues to exceed capacity and service was initially over-subscribed and had long waiting times for treatment, though these are now reduced to an average of two weeks after an effective process mapping event. There is an ongoing push to improve the quality of alcohol treatment interventions from NICE and the National Treatment Agency. In Kirklees this is supported by new alcohol clinical lead who is driving clinical governance developments in partnership with commissioners. In addition to optimising specialist resources the focus remains on further developing earlier interventions via the alcohol stepped care model, including the ongoing support and development of the alcohol identification and brief advice local enhanced service in primary care, and developing prevention orientated activity such as targeted social marketing in the community. Kirklees has an ongoing problem with „hazardous and harmful‟ drinking and we are focusing on reducing harm in the communities with the deepest problems in North Kirklees.

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We have also developed a series of initiatives in Huddersfield town centre, the Probation service and with the acute trusts to minimise the impact of alcohol related crime and offending. These include specialist nurses in A&E, criminal justice focused arrest referral and Alcohol Treatment Requirements for alcohol related offenders and work with Yorkshire Ambulance Service to improve their response to town centre alcohol related incidents.

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Long-Term Conditions

Director Lead: Sheila Dilks Lead Manager: Joanne Crewe 4.1

Long Term Conditions

The Generic Long Term Conditions (LTC) pathway is significantly enabling people to manage their care more effectively this is demonstrated by reductions in hospital admissions for the LTC ambulatory care conditions where services have been resigned or implemented and measures of health functioning which show improved feelings of control and wellbeing. Further integration of services and additional whole system transformation will achieve greater & more equitable coverage of service utilization. Local trajectories and performance measures have been set to reflect the benefits of the PCTs investment into the programme and meet the target for hospital avoidance and reduction in emergency admissions for ambulatory conditions. Community Matrons, Case Managers and Generic Workers have been allocated to practice units with the expectation that each unit will identify people at risk of future hospital admission who may require additional support to help them manage their condition more effectively. Community Matrons and Case managers will support people with complex health and social care needs and Kirklees Generic Workers will provide health or social care support to individuals in their own home to prevent hospital admissions or facilitate early discharge. Referrals to these services are coming from a wide range of sources including carers, GPs, community matrons, district nurses, ambulance service and Accident & Emergency.

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Practices have taken part in the Local Incentive scheme to: Review and support patients from their practice who are high risk of future hospital admission thereby reducing inappropriate hospital admissions. Meet regularly with the Community Matron, District Nurse and Generic Worker and using the information provided by the Predictive risk tool and discuss those people at high risk of hospital admission who would benefit from active case management and develop an action plan to meet the individualâ&#x20AC;&#x;s health and/or social care needs. 71 of the 72 practices in Kirklees have predictive risk, 63 reached the full incentive, 6 received a titrated element and 2 chose not to participate. Consequently we are seeing a rise in the number of Very High Intensity Users being managed within the LTC services and practices becoming more proactively engaged in identifying people at risk of future non elective admissions The NHS Kirklees Predictive risk tool is available to support health need assessments and more proactive local commissioning. Seventy one of the Kirklees General Practices receive their Practice Predictive risk tool quarterly Successful implementation and embedding the use of predictive modelling will help commissioners and clinicians identify; those who are most vulnerable and at risk of hospital admission or readmission in the Kirklees population; Variation and gaps in care using GP and secondary care data sets; and the best opportunities to realise benefits to reduce cost and improve quality. The Kirklees Predictive risk model is helping to design and monitor new intervention strategies to achieve the right care for our population and improve proactive disease management. The model will help target those areas where care can be moved from the acute provider setting to the community setting along with better utilization of existing resources and service capacity. Benefits: Find the most cost effective intervention; Delivers service configuration or decommissioning evidence base; Quickly identify and manage more appropriately LTC patients; Avoid costly admissions; Manage demand across primary and secondary care; and Target intervention at patient groups with high cost or gaps in care. People of Kirklees are able to access telehealth monitoring equipment that supports and facilitates self care, enables the clinicians and other Practitioners to have remote access to an individualâ&#x20AC;&#x;s vital signs and monitoring, allows a clinician to enhance the individuals personalised action plan and will consequently reduce dependence on health or social care professionals along with inappropriate use of emergency health or social care services and a reduction in unplanned admissions.

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Increased use of assistive technology is being explored with our health and social care partners and is an enabler to further transformation in health and social care assessment, monitoring, management and self care. A highly significant outcome for the population is to significantly improve their quality of life and independence by offering a personalized care plan. Personalised care planning will support individuals to establish in partnership with their clinician their own action plan and will ensure the person feels informed, know when to self care and when to seek clinical support can control their Long Term Condition (LTC) much more effectively. The aim is to empower the patient by giving them the tools to self manage their condition. Self care support will radically change the provision of support to groups of people at high risk of, or with, chronic conditions to help them to: Identify their personal health needs; Feel able to make changes; Take control and effectively self manage their condition using self-care approaches, problem solving and making informed decisions; and Emergency/contingency care plans will support individuals to respond appropriately and prevent deterioration or crisis interventions. This is being achieved by: Providing patients with a variety of accessible and appropriate excellent resources and support so that they are enabled to self-manage their condition; Family and carer support through the development of information and advice appropriate to the needs of carers and the family; Self care support training â&#x20AC;&#x201C; planned and supported individualised programmes with appropriate education and training; Expert patient programmes linked to rehabilitation and in some cases targeted at disease specific or community groups; Voluntary sector â&#x20AC;&#x201C; support groups and networks to provide or sign post to appropriate services including the health trainers or gateway workers; and Increasing the skills and knowledge of professionals so they can work in partnership with patients to improve their health and well-being by supporting lifestyle behavior change. We have built on our approach to service user involvement by involving people with a long term condition or physical/sensory impairment (LTC/PSI) in the LTC/PSI Partnership Board. The overarching goal is for people with a LTC/PSI to live as independently as suits them, have the same opportunities, choice, control and freedom as other people living in Kirklees and experience the best possible physical and mental health and well being. The Partnership Board is also preparing a joint strategy outlining the detailed work that will be undertaken over the next three years to move towards achieving our goals. The UK Vision Strategy states that too many people are living with sight loss that could have been avoided through earlier detection or treatment. And too many people who have lost some Report Owner: Peter Flynn Report Author: The Performance Team

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or all of their sight do not receive the support they need to enable them to deal with the emotional trauma of sight loss or manage basic everyday tasks. The Blind and Low Vision group made up of blind people, people with a visual impairment, health, social care and voluntary sector professionals are currently updating the Visual Impairment Strategy for Kirklees to include a wide range of issues related to such things as mental health, learning disability, stroke and dementia. Blind or partially sighted people can now receive support at the point of diagnosis via the Eye Clinic Liaison Officer Service (ECLO) operating from Huddersfield Royal Infirmary and Dewsbury District Hospital. The ECLO service supports patients of all ages, living in Kirklees, newly diagnosed with low vision, deteriorating vision, blindness or impending blindness. The support is both practical and emotional and is extended to carers and family members for example information and advice, emotional support and assistance in achieving an appropriate referral to community based services. Housing adaptations have the power to change peopleâ&#x20AC;&#x;s lives achieving outcomes for individuals such as improving quality of life, increasing independence and reducing the fear of accidents. With the Local Authority we have developed an Adaptations Strategy for Kirklees to identify where we are now, where we need to be in 2013 and the work we will do to achieve our vision â&#x20AC;&#x17E;For people, of all ages, experiencing a disabling environment to identify individualised solutionsâ&#x20AC;&#x;. Alongside this an Accommodation Strategy is also being developed to ensure people with a LTC/PSI have choice and control in achieving their wishes about where they live. The Blue Badge scheme provides a range of parking concessions for people with severe mobility problems who have difficulty using public transport. February 2007 the Government reviewed the scheme and the resulting Blue Badge Reform Strategy outlined a number of commitments designed to ensure that it stays fit for purpose in the 21st century, and improves the lives of more disabled people. As part of this we have worked with the Local Authority to tender a service for Blue Badge Mobility Assessments so that anyone applying for a Blue Badge from March 2011 will receive a mobility assessment from an independent Occupational Therapist as opposed to their GP.

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Respiratory Health Improvement

Lead Director: Sheila Dilks and Lead Manager: Sandy Smith Key achievements The procurement of an integrated Community Integrated Specialist COPD service is now complete and will commence on the 6th June 2011, This service will be provided by Locala and will incorporate specialist COPD community services including oxygen and nebuliser assessments, specialist COPD community clinics, education of Health Care Professionals and Palliative Care, this will ensure that people with COPD have access to specialist care within their community according to their individual need. The Early Supported Discharge Service for COPD patients is now embedded into both acute hospitals across Kirklees. A Business Case has been developed to avoid acute admissions for COPD and Heart Failure and NHS Kirklees are joining up with Social Services as part of the reablement work to look at providing a joined up holistic approach to admission avoidance. In addition to this an acute pathway for COPD patients is under development Stakeholder engagement and strong links into key dependencies have been made and joint partnership working across neighbouring PCTs have been established resulting in a SHA Respiratory Commissioners Forum. The development of the primary care pathway is now taking shape and will result in a primary care service that is provided in an equitable manner and addresses the inequalities that currently exist across Kirklees. Key tranches have been identified for 2011/12 and are detailed as follows:Reducing non-elective admissions for people with COPD and Asthma across the Kirklees population incorporating an Early Supported Discharge Service; Improving the patient pathway for oxygen assessment and management, and minimizing the risks of inappropriate prescribing encompassing oxygen efficiencies; Transferring specialist respiratory services from secondary to primary care to provide care closer to home by a workforce who are skilled and competent in respiratory care; and; Improving access to palliative care services for respiratory people in Kirklees approaching End of Life and provide the highest quality of care based on their health needs regardless of geographical location. Key outcomes of the programme More people with respiratory disorders will be accurately diagnosed and will have a better understanding of their medication and improved compliance;

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Respiratory patients will have a personalised care plan and will have the skills to self manage their condition and reduce the need to access acute and GP services and improve their quality of life; Patients will have symptom management and receive palliative care when they need it; People with respiratory illness will have their respiratory needs appropriately managed in the community wherever possible and will receive care from a skilled and competent workforce within primary care; and People with respiratory needs within Kirklees will have equitable access to holistic care within the community setting and will receive evidence based assessment and management of their respiratory disease within primary care. Key challenges for 2011/12 The key challenges will focus around reducing hospital admissions and improving acute management of COPD and Heart Failure in Primary care. Close monitoring of the implementation and maintenance of the Community specialist COPD service and the Early Supported Discharge Service to ensure they deliver will also be challenging. Development of the primary care workforce is paramount and will help to put structures in place to accommodate the transfer of specialist COPD care from secondary to primary care.

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Renal Disease

Lead Director: Sheila Dilks and Lead Manager: Julie Wood Key Achievements: PPT event well-evaluated Renal guidelines launched Good response to general practice survey, results collated Early detection of renal disease included in NHS Health Checks Four practices engaged in e-consultation project Next steps: To work closely with Wakefield on developing a Renal Redesign Business Case To learn from lessons in implementing e-consultation for diabetes and extend to renal To scope out the following projects: - Local IV Iron infusions. - Local Conservative Care out-patients provision. - Introducing a Renal nurse to support out-patient provision; training and IV Iron. - Joint renal and diabetes working. - Further renal education for primary care. Benefits: Increase the identification and recording of people with renal disease; Increase the management of renal disease in primary care; Improve the education of primary care clinicians in renal disease. Bring elements of renal care closer to home

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Lead Director: Sheila Dilks and Lead Manager: Julie Wood 4.4.1. Diabetes Health Improvement Key Achievements:Practices now engaging with DiabetesE Managing Injectables course ran in January, and evaluated well. Next course planned for June. Group membership sessions followed and again, evaluated well. Managing Type 2 diabetes course planned for July LES funding now available to support practices in managing patients using Insulin and GLP-1 E-consultation pilot commenced with four pilot practices in May. New footcare model launched, foot care courses for May and June are full, further courses to run in September and October. Accreditation programme to start following foot care courses. Further support for care planning practices given via the development of the Advanced Development Practitioner training, starting in July. Care Planning Local Incentive Scheme data now being submitted, early indications show an improvement in the use of â&#x20AC;&#x17E;patient-centred goalsâ&#x20AC;&#x;. Patient Self Care Handbook (diabetes) in draft form, 50 copies to be printed this month and piloted by patients. Next steps: Continue professional education and mentorship programmes Begin to accredit practices for LES Pilot Self-care Handbook Work with Huddersfield University and NHS Diabetes for the evaluation of the Diabetes Redesign project Extend care planning to include secondary care patients Review secondary care diabetes service specification Share learning and good practice with NHS Calderdale

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Benefits:  Reduction in secondary care referrals; YAS and A&E call outs; admissions and readmissions.  Supports high quality care accessible closer to home.  Supports behaviour change in primary care  Impacts positively on patient safety  Impacts on patient experience  Links stakeholders together 4.4.2

Diabetic Retinopathy Screening (Lead Manager: Gaynor Scholefield – CPCT)

Background Diabetic retinopathy is the most common cause of blindness in working age people in England. If untreated, 50% of those who develop proliferative diabetic retinopathy will lose their sight within two years, and some of these within 12 months. Early detection of sight threatening diabetic retinopathy and treatment (usually with laser therapy) halves the risk of blindness. The aim of the Programme is to reduce the risk of sight loss amongst people with diabetes by the prompt identification and effective treatment if necessary of sight threatening diabetic retinopathy, at the appropriate stage during the disease process. Diabetic retinopathy screening (DRS) is a national screening programme and the English National Screening Programme for Diabetic Retinopathy (ENSPDR) provides advice, support and facilitation to Strategic Health Authorities, Primary Care Trusts, and local programmes implementing systematic diabetic retinopathy screening programmes as well as requiring quality assurance standards reporting. In Calderdale and South Kirklees, the service is provided as follows: Administrative function by NHS Kirklees (the host) and NHS Calderdale;

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Screening and grading by 1st Retinal Screen Ltd (1st RS Ltd) who are contracted until 31 December 2011; and Assessment and treatment following referral is delivered by Calderdale and Huddersfield NHS Foundation Trust (CHFT). The Programme utilises Digital Healthcare (DH) Ltd provided management software (Version 2). Images are captured across the geographical area by 1st RS Ltd screeners at NHS premises and by optometrists in their own premises, who sub-contract with 1st RS Ltd, some of whom undertake slit lamp biomicroscopy as required. NHS Kirklees is the Programme Lead Commissioner, however, due to capacity issues, Lead Commissioner responsibility lies with NHS Calderdale in continuum from June 2010 until further direction from respective Directors of Public Health. The Key Achievements Successful implementation of the Action Plan by stakeholders following the External Quality Assurance visit on 27 November 2009; Efficient Register management following the gap in screening invitation (27 Nov 09 - 15 Feb 10); Effective data management following the installation of new PASA approved management software (version 1.11) provided by DH Ltd in September 09 and upgrade to version 2 in July 2010; Purchase and installation of a Medisoft Connector to enable data transfer to the Programme software for CHFT patients; Improved and ongoing local monthly MDT meetings established; The Care Quality Commission acceptance of the extenuating circumstances request that related to the national commitments indicator „Diabetic retinopathy screening‟ in September 2010; „Business as usual‟ despite lead commissioner capacity reduction from June 2010; Completion of the look back for digital screening (709 image sets) and slit lamp biomicroscopy (717 patients); CHFT triage pilot initiated to address inappropriate referrals; Removal from the risk register; DRS and pregnancy pathway reviewed; Renewal of gold cover 3 year maintenance contract for 3 Canon cameras; Submission of the Programme Annual Report to the ENSPDR; Submission of new quarterly UK National Screening Committee KPIs for Screening starting December 2010; Agreement of revised Steering Group Terms of Reference with extended membership; Funding allocation and purchase of the latest version 3.6 DH Ltd management software; Successful negotiation to extend the current provider contract until 31 December 2011; Personal invitation to participate in the ENSPDR Pathway Expert Reference Group (first meeting 28 March 2010).

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The Issues The percentage of people screened reached target at Quarter 3 and this has been sustained. The percentage over plan can be explained by the changed recall period at upgrade from version 1.11 to version 2 of the DH Ltd management software. Following the upgrade in July 2010, the recall period was increased from 10 months to 11 months. In operational terms this means that those patients who responded to recall promptly to book an appointment will have had two invites within the year. There may also be patients who have received an invite prior to being moved into the inactive state and those who have been persuaded to attend for screening by their GP who subsequently request an additional invite be sent. The same would apply if there is a change of address and the invites have gone to the old address, in this case the invite process would be restarted for these patients. The Action Being Taken Installation of version 3.6 DH Ltd management software; General Practice on site training (to include patient consent, GP web access, DRS and pregnancy, Slit lamp biomicroscopy, Non-DR referral, Updating the DRS register, DRS and QOF exception reporting); Review of the Non-DR Protocol; Service provider procurement with the new contract to be in place from 1 January 2012; Ongoing contribution to the ENSPDR Pathway Expert Reference Group. Ongoing reporting as required.

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4.5. Coronary Heart Disease/Cardiovascular Disease enal Disease Lead Director: Sheila Dilks and Lead Manager: Alison Bragg 4.5.1. Coronary Heart Disease (Lead Manager: Alison Bragg) Revascularisation & Local Percutaneous Coronary Intervention Through collaborative working between local commissioners, local providers and the West Yorkshire Cardiac Network (WYCN), a local PCI service began on the Pinderfield's hospital site in December 2010 with patients being able to access the same service at Calderdale and Huddersfield NHS Foundation Trust In August 2011. Expected Outcomes Ensure patients are treated within best practice treatment timeframes; Improve quality and experience of care for patients, reducing the need for two procedures; Patient care is delivered by one hospital provider; Services are delivered closer to home; Hospital service governance is accredited to deliver a quality assured service; Reduce the number of inter hospital transfers; Reduce the number of admissions on the patient pathway; Reduce current lengths of stay for PCI patients; and Financial efficiencies are gained. Thrombolysis “call to needle” of at least 68 percent within 60 minutes, where thrombolysis is the preferred local treatment for heart attack Achievement NHS Kirklees providers have achieved this existing commitment target to date. The number of patients receiving this procedure is very low as thrombolysis is not the first line treatment for patients in West Yorkshire. Outcome Patients requiring emergency treatment for heart attack are treated using primary angioplasty at Leeds Teaching Hospital. The (WYCN) releases the data to PCTs on a quarterly basis and the information is discussed at the quarterly WYCN Board meeting. Information on both thrombolysis and primary angioplasty is reported. Heart Failure - Key Drivers The National Institute of Clinical Effectiveness (NICE) updated the guidelines regarding Chronic Heart Failure in August 2010. The guidelines highlighted a number of „gaps‟ in service provision for NHS Kirklees commissioners. These include diagnostic testing in primary care, availability of two week assessment clinics in secondary care and the provision of cardiac Report Owner: Peter Flynn Report Author: The Performance Team

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rehabilitation for Heart Failure patients. There are also an increasing number of patients being admitted acutely who have a diagnosis of Heart failure. Expected Outcomes A consistent approach to care and management of Heart Failure patients is adopted within the community; Increased knowledge and skills in primary care using best practice for the care and management of heart failure patients; Deliver care closer to home; Avoid hospital admissions and readmissions by supporting primary care services in the management of Heart Failure patients; Reduce the length of stay for those patients who are admitted to hospital; Ensure heart failure patients who require access to a heart failure specialist nurse have access when appropriate; and Ensure robust disease registers are produced in primary care and enable more proactive management of patients at risk of hospital admission. Action Being Taken A business case is in development so the expected outcomes can be achieved though the commissioning of the evidenced based pathway as NICE suggests. Mortality Rate from all circulatory diseases (CVD) under 75 per 100,000 population The Issues Circulatory or Vascular disease, which includes Diabetes, Stroke, Renal Disease and Coronary Heart Disease, accounts for the largest number of premature deaths nationally and locally. Disability and avoidable ill health associated with vascular disease such as stroke and heart disease imposes high personal, social and economic costs. The NHS is committed to achieving the national life expectancy health inequality target and a key aspect of achieving this target is identification of those at high risk of vascular disease (>20% over ten years) who have not yet developed symptoms and to offer them a health check assessment, advice and where appropriate referral to reduce their risks. Three established risk factors for Coronary Heart Disease (cigarette smoking, high serum total cholesterol and high blood pressure) account for at least four-fifths of the attributable risk of CHD during middle age. Also, there is growing emphasis on the importance of tackling health inequalities in relation to vascular diseases, as people in lower socioeconomic groups and those from specific ethnic groups are at higher risk. The Action Being Taken In December 2010, the practice-based NHS Health Checks service in North Kirklees was decommissioned. During the year a total of 6011 people who met eligibility criteria, were offered a health check, and 1912 people received one. Report Owner: Peter Flynn Report Author: The Performance Team

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NHS Kirklees has commissioned a new NHS Health Checks Outreach Service for people aged 40-74 years in Kirklees. The service is provided by Locala (previously known as Kirklees Community Healthcare Services) and went live on 1st April 2011. The service will provide health checks on an outreach only basis to people who are not already on a disease register, and will initially target communities with the worst health and deprivation in Kirklees. Public Health information states that people in most deprived areas are more likely to die from CHD; people with South Asian ethnicity have a higher premature death rate from CHD and; over 80% of people with South Asian ethnicity live in the worst deprived areas in Kirklees. The service will identify people who are at 20% or greater risk of developing vascular disease within the next 10 years, who will require further investigations by their GP Practice. The service may also identify people who are highly likely to already have disease, who will need reviewing by their GP and adding to the appropriate GP disease register. The service will also see people who have risk factors and will offer initial advice and refer onto appropriate lifestyle services, such as stop smoking, weight management etc NHS Kirklees have set a target of 7000 new health checks to be carried out during 2011/12 and for the service provider to develop a recall system to call relevant people back for a further health check after 1, 2 or 5 years, as appropriate. 4.5.2. Stroke Care: Health Improvement (Lead Manager: Hayley Haycock) The impact of stroke on an individual and their family and friends cannot be underestimated. Of all strokes that do occur, about 25 â&#x20AC;&#x201C; 30% will die within the first Month and about 30% will be left with long term disability. Also, of all people who experience transient ischaemic attack (TIA) or mini stroke, 20 â&#x20AC;&#x201C; 25% of these will go onto have a full stroke. 80% of strokes are preventable and those who do experience stroke or TIA, the risk of death and disability can be dramatically reduced, if risk factors and signs and symptoms are detected, treated and managed promptly. Key Drivers and Commitments The National Stroke Strategy (NSS) published in 2007 set twenty quality markers aimed at improving patient outcomes, reducing disability and saving lives from the cause of stroke. To help drive forward improvements, the Department of Health developed a 2008-11 National Vital Sign indicator for stroke care (VSA14), where emphasis is on emergency transfer and immediate access to acute stroke care and also for the assessment and treatment of high risk TIAs. The Department of Health (DH) also launched a programme in 2010 to accelerate improvement in stroke care (ASI). They have developed seven key indicators for trusts to strive towards, which are focused around speedy access to imaging, faster admission to specialist stroke units and access to reviews and post-hospital stroke rehabilitation.

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Performance For the stroke Vital Signs indicator, we have achieved all but one quarter above target. In quarter 2 there was a slight fall, due to resource and bed factors at Mid Yorkshire Hospitals Trust. However, we have completed the end-year target with 80% of people who were admitted to hospital with stroke in Kirklees during 2010/11 spending at least 90% of their time on an acute stroke unit. We feel confident that we can sustain this throughout 2011/12.

Performance data for the TIA Vital Signs indicator, which measures â&#x20AC;&#x153;the proportion of people with high risk TIA who are seen and treated within 24 hoursâ&#x20AC;? shows that we have had an unsettled year, starting at 57% in quarter 1 to completing the year at 33% (against a target of 60%). This indicator has posed a challenge for most trusts in West Yorkshire. Contributing factors have included data capture issues; clinic capacity and insufficient resource to be able to assess and treat patients within the required 24 hour timescales and to the Yorkshire and Humber Stroke Assurance Framework (Y&H SAF) standards. Both acute provider trusts have started from a low baseline against the SAF standards and now have development plans in place to achieve these during 2011/12.

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Key challenges during 2010/11 Both acute provider trusts will start implementing plans to establish 24 hour hyperacute stroke services, which will include thrombolysis and 7 day week TIA clinics, supported by telemedicine and consultant on-call rotas. This will involve rapid recruitment and training of additional nursing and medical staff who will support delivery of specialist stroke assessment and hyperacute care. Focus will also shift to further service developments around stroke prevention, particularly around better management of patients with TIA and Atrial Fibrillation. Another key development for 2011/12, will be to provide acute rehabilitation for a number of people who could benefit having this delivered at home or in the community, to help promote more independent living following stroke and reduce length of stay in hospital.

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Emergency Bed Days

Lead Director: Sheila Dilks and Lead Manager: Pat Andrewartha The Key Achievements Work continues with GP practices and the new consortia looking at the variation in use of urgent care services. This is helping practices to identify and understand local issues and work towards eliminating the differences. The Local Incentive Scheme for A&E attendances continues to show positive results with GP Practices identifying inappropriate (in hours) attendance at Accident & Emergency. A patient leaflet has been developed to support the work. Assistive technology (Telehealth monitors) is beginning to show positive results. Generic workers now form a part of the rapid response teams providing direct support to individuals with low level health and social care needs to prevent hospital admission and facilitate early and timely discharge. The predictive risk tool is now well established in practices, with patients at risk of admission being identified. The embedding of the predictive risk tool is ongoing, this is enabling us to identify people at risk of admission and allocate resources appropriately to manage risk The â&#x20AC;&#x17E;streamingâ&#x20AC;&#x; services within both A&E departments continues to provide primary care support to A&Es allowing appropriate patients to be seen by primary care practitioners. Plans are in place to integrate the Walk in Centre with the A&E department at Dewsbury hospital once building works are completed. The joint work between community matrons and Yorkshire Ambulance service with frequent callers has been recognised nationally as best practice. Various work streams are supporting a reduction in emergency bed days, such as YAS frequent callers; development of pathways to prevent attendance at A&E and the ongoing work through the Local Incentive Scheme for A&E. Continued investment and development in the primary care streaming services within accident and emergency services supports achievement of the emergency standard target â&#x20AC;&#x201C; this alongside other investments in ambulatory care management continues to impact on unplanned admissions and overall bed day usage. The urgent care HIT has become a well attended group of stakeholders with a wide range of clinicians attending regularly. Discussion and information sharing across the acute and primary care sector representatives has led to greater understanding of the pressures and current issues. The Current Concerns A&E activity continues to be high for both acute trusts, with MYHT in particular continuing to experience heightened pressures and difficulty in meeting the 95% standard. Ongoing analysis of the data continues to better understand the reasons for increases along with more detailed analysis of service utilisation across care pathways and further development work to existing services; this is being undertaken across many areas (older people, long term conditions,

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care homes etc) to provide a more complete picture.

Key Challenges: Continuing the focus on reducing inappropriate attendance at A&E, with a particular focus upon in-hours, which GPs can influence with their own patients; Facilitating the work between YAS and the A&E departments to improve the „handover‟ time of patients; Working with all partners and service providers to ensure „business as usual‟ during surge and escalation periods (winter, Bank Holidays etc); and Future planning in relation to the shape of GP commissioning and ensuring primary and secondary clinicians are working well to facilitate an integrated system.

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Patient / User Experience 5.

Patient Safety – Infection Control/Hospital Acquired Infections: MRSA

Director Lead: Judith Hooper and Lead Manager: Jane O‟Donnell 5.1.1. MRSA NHS Kirklees – MRSA bacteraemia cases

The MRSA objective for NHS Kirklees in 2010 / 2011 was no more than 18 cases; this includes all post and pre 48 hour MRSA blood culture samples in patients that NHS Kirklees has responsibility for. The final outturn objective for MRSA bacteraemia is 20 cases.  13 pre 48 hour cases (6 of the pre 48 hour cases were in care home residents).  7 post 48 hour cases (2 CHFT, 4 MYHT, 1 LTHT). Nine of the cases have been deemed avoidable following robust root cause analysis investigations. Work continues on: Health economy approach to catheter insertion and continuing care; MRSA screening and suppression treatment An action plan has been developed to assist in achieving the MRSA objective for Report Owner: Peter Flynn Report Author: The Performance Team

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2011 / 2012 as the target is a further challenge â&#x20AC;&#x201C; no more than 13 cases. The action plan will be monitored by Kirklees Infection Control Committee. Mid Yorkshire Hospital Trust (MYHT) incidence of MRSA bacteraemia cases A total of twelve MRSA bacteraemia has been reported to the end of 2010 / 2011. The MRSA objective for 2010 / 2011 was no more than 11 post 48 hour cases. Four of the 12 cases were in Kirklees residents

Work continues on review of peripheral and central line care as it is known to be an area of high risk for patients requiring interventional procedures. In 2010 / 2011 there has been no incidence of blood culture contaminants following the Blood culture training and assessment of competence. Calderdale and Huddersfield Foundation Trust (CHFT) incidence of MRSA bacteraemia cases

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The MRSA objective in 2010 / 2011 was no more than 5 post 48 hour cases attributable to CHFT. There has been a total of 4 cases to the end of year of these 2 cases were residents of Kirklees. The last post 48 hour case was 13 November 2010. Following the review of the blood culture policy and the competence assessment implemented for aseptic non touch technique there have been no contaminants identified from root cause analysis investigations from Quarter 1, 2010 / 2011. 5.1.2. Clostridium Difficile (C.difficile) Infections – NHS Kirklees

The Clostridium difficile target for NHS Kirklees in 2010 / 2011 was no more than 150 cases, this included all pre and post 72 hour cases in patients that NHS Kirklees has responsibility for. The total number of cases reported in 2010 / 2011 was 130. Actions that continue to be taken to reduce the incidence of Clostridium difficile infections: Appropriate antibiotic prescribing / stewardship Antimicrobial guidelines for primary care. Extended local surveillance by NHS Kirklees infection prevention and control team, and local surveillance of antimicrobial usage of key agents in secondary and primary care Clostridium difficile infections at Mid Yorkshire Hospital Trust (MYHT) The target for 2010 / 2011 was 168 post 72 hour cases. MYHT has reported 123 post 72 hour cases in 2010 / 2011. Daily reviews continue of all patients with Clostridium difficile by the infection prevention and control nurses and matrons, with further assurance by spot checks during “out of hours” by senior nurses

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Clostridium difficile infections at Calderdale & Huddersfield Foundation Trust (CHFT) The total number of cases of Clostridium difficile in 2010 / 2011 was 66 against the target of 151 post 72 hour cases.

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Patient and Public Involvement

Director Lead: Helena Corder and Lead Managers: Dáša Farmer / Kirsty Wayman Listening to what people tell us about the local NHS services, instead of relying on existing knowledge and assumptions enables us to better meet people‟s needs. We can develop better, more responsive services when we involve and listen to those who are already using services and to those who are not. Apart from the ongoing involvement of patients and the public to gain their views, ideas and needs, we make sure that people understand our plans and why some services need to be changed. In the last financial year, we were subject to a new duty to inform the public of our engagement and consultation activities which had influenced our decisions about the services we buy (commission) on your behalf. To demonstrate how NHS Kirklees met this duty, we published a detailed patient and public involvement annual report which can be accessed at The annual report for 2010/11 will be published by September 2011. Public Consultations: i)

Pharmaceutical Needs Assessment (PNA)

NHS Kirklees had a statutory duty to develop and publish a Pharmaceutical Needs Assessment (PNA) by 1 February 2011, reflecting local health needs. This work was led by the Pharmaceutical Needs Assessment Project group and consisted of representatives of community pharmacy contractors, practice based commissioners and public health. Mapping of existing pharmaceutical services against future need supported the assessment to develop our services and plan for the years ahead. The objectives of this PNA were: to have a clear picture of the current services provided by community pharmacies to be able to plan for future services to be delivered by community pharmacies to make sure that any gaps in service provision are adequately addressed to make sure that community pharmacies are used as a means of reducing health inequalities. As part of the development of our PNA, a pre-consultation exercise took place to gain staff and patients‟ views on current pharmaceutical services within each locality, also looking at which future services they might wish to have available. The information gathered was used to prepare a draft PNA and this was consulted on during August and October 2010, with drop-in sessions running across the Kirklees area and feedback being used to further develop the document.

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Single Equality Scheme (SES)

Between August and November 2010, NHS Kirklees consulted with the public and key stakeholders on our draft Single Equality Scheme 2010 - 2013. This replaced our previous scheme (2007-2009) and aimed to demonstrate our commitment to delivering our legal duties in this area and also paved the way for changes in legislation and responsibilities, which are anticipated in the near future. To develop the draft scheme, we built on the feedback we received from our first equality scheme and made sure that we listened to the views of a range of different individuals, organisations and members of our staff. The feedback we received was used to amend the draft Single Equality Scheme with the final document being approved by the Board in March 2011. iii)

Mid Yorkshire Service Strategy

In 2009, Mid Yorkshire Hospitals NHS Trust, NHS Kirklees and NHS Wakefield District held a public consultation on the proposed development of services in the Mid Yorkshire Hospitals NHS Trust. Following on from the consultation, the Joint Health Overview and Scrutiny Committee for Kirklees and Wakefield agreed that the plans for the three hospitals in the Mid Yorkshire Hospitals NHS Trust could go ahead. This meant that the new hospital buildings in Wakefield opened fully at the beginning of 2011 with Dewsbury and District Hospital still providing a full range of services for patients, including midwifery and Accident and Emergency. iv)

NHS White Paper consultations

The NHS White Paper: Equity & Excellence – Liberating the NHS was published in July 2010 with supporting consultation documents following soon after. NHS Kirklees encouraged local people and organisations to give their views on the proposals. Local events were also organised in conjunction with Kirklees Local Involvement Network to hear the views of local people on the initial consultation documents issued by the Department of Health. NHS Kirklees also submitted responses on behalf of the organisation. v)

National Carers Strategy

In summer 2010, the Government announced their intention to „refresh‟ the Carers Strategy with a view to producing, before the end of that year, a clear plan of action for 2011 to 2015. NHS Kirklees worked with the Local Authority to hold a joint event in August. The feedback received from the session informed a joint response submitted on behalf of both organisations. vi)

Specialised Commissioning

NHS Kirklees works with other PCTs in the region through the Yorkshire and the Humber Specialised Commissioning Group to commission those services that have a national

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classification as „specialised‟. These are services provided in relatively few specialist centres to catchment populations of more than one million people. These services are not provided in every hospital. vii)

Vascular services review consultation

As part of this work, NHS Kirklees took part in the review of vascular services. These consist of planned treatment for conditions where there is not enough blood reaching an organ or parts of the body such as the arms, legs or head, caused by a partial or total blockage. Vascular services also include planned treatment for aneurysms, a fluid-filled bulge in an artery that can weaken it and treatment for other types of abnormal blood vessels. In addition, vascular specialists are needed to support other medical treatments such as kidney dialysis or chemotherapy access. As well as planned treatment, vascular services also include emergency treatment, including life threatening emergencies, such as when a large artery bursts, where there is a critical lack of blood to a limb, when the lack of a blood supply can be limb threatening or injuries from road traffic accidents. The consultation ran between October 2010 and January 2011 to seek the views on these proposals. The responses to the consultation shaped the recommendations on future steps in commissioning of these services. viii)

Children’s congenital heart services in England

A consultation was launched in February 2011 as part of the Specialised Commissioning Group and will run until July 2011. This work looks at the future of children‟s congenital heart services and seeks the views from the public on the proposed changes. ix)

Patient experience

There were several areas of work this year where NHS Kirklees asked local people what they thought about the services provided with several methods being used. The following provides a few examples. One such initiative was around control of infection, where the organisation‟s Infection Prevention and Control team looked at getting more public feedback about the standard of hand hygiene and the quality of healthcare environments within GP and dental practices throughout Kirklees. A patient survey was designed to assess current standards of hand hygiene by health professionals within the community as well as the cleanliness of the environment in which healthcare was provided. The survey was officially launched at an event at Dewsbury Health Centre on 5 May 2010 to coincide with the World Health Organisation‟s „SAVE LIVES: Clean Your Hands‟ day. We received 599 responses and the information gathered provided an interesting and informative insight. The feedback we received was extremely positive about the current levels

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of hygiene within community healthcare throughout Kirklees as witnessed by the users of those services, although it also highlighted some key areas for the Infection Prevention and Control Team to focus upon over the forthcoming months. One of the main conclusions drawn from the survey responses has been that people are unaware of how they can report any specific concerns that they might have. To address this, a week of events was organised for the end of October 2010 to coincide with the National Infection Prevention and Control Week and schools‟ half-term holidays. 1200 people attended four separate events held throughout the week at Dewsbury Sports Centre, Huddersfield Sports Centre, Red House Museum in Gomersal and Huddersfield‟s Kingsgate Shopping Centre. Attendees were able to take part in interactive activities such as seeing the effectiveness of their own hand washing technique using a light box, and playing the „Banish the Bug‟ electronic game. The Infection Prevention and Control Team‟s mascot, „Dirty Bertie‟, also showed up to encourage children and adults alike to take part and learn about a wide variety of different health subjects including good hand hygiene, food safety, meningitis and much more. x)

'Face It – Our Opinions Count!'

Was an innovative project commissioned jointly by NHS Kirklees and Kirklees Council, which used social media and two young 'peer researchers'. It was developed in order to explore the health and wellbeing issues of 18 to 24 year olds across Kirklees. The project was a progression of the Current Living in Kirklees (CLIK) surveys that have been conducted since 2001. In order to capture views and information for this year, a key element of the project was the construction of a Facebook page to interact with a wide-range of young adults. The project also provided invaluable support, training and hands-on work experience for two young 'peer researchers' from Kirklees who had been appointed under the Future Jobs Fund through Kirklees Council. Both 'peer researchers' were actively involved in all stages of the project, including planning and recruiting young adults to focused events across Kirklees, keeping video diaries and developing and maintaining the CLIK Facebook page. The findings of the project were published in February 2011 and will help to inform future commissioning decisions. xi)

Chronic Obstructive Pulmonary Disease (COPD)

NHS Kirklees has been conducting a Health Needs Assessment of Chronic Obstructive Pulmonary Disease services. As part of this process we wanted to know what the perceptions and needs were of those who suffer from this condition to be able to support the development of services which meet the needs of local people.

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We have been holding discussion groups with patients diagnosed with this condition to ascertain their views on current services, what they wanted to see improved and what services they would like there to be available. We aim to carry out more work in the next financial year to build on the information we have. xii)

School House Practice

As part of gathering patient views on local services, we conducted a survey with patients accessing the School House Practice in Dewsbury. The views were used to find out how patientsâ&#x20AC;&#x; own GP services could be improved. xiii)

Capturing patient experience

Apart from surveys and focus groups relating to the development of various local services, NHS Kirklees also produced several DVDs on the experiences of local people. The work that was captured in this way included: Expert Patient Programme Diabetes video diary capturing the experiences of participants Family Nurse Partnership, which was developed with input from staff talking about the benefits of the service and feedback from users of the service. This was screened at a Family Nurse Partnership conference. Feedback of service users attending the Itâ&#x20AC;&#x;s My Health Day event which took place in January 2011. xiv)

Voluntary and Community Sector

As in previous years, we have been keen to develop the relationships we have with the voluntary and community sector and to make sure that organisations were given the opportunity to be involved in the development of services. We therefore worked with Voluntary Action Kirklees (VAK) to find out if voluntary groups felt that they were given the opportunity to be involved and if not, if they would like to be. This led to meetings with organisations across the area which has helped in building a knowledge base of the sector. To keep the sector up to date with the ongoing NHS changes, we organised a community event in February 2011 for members of the voluntary and community sector. Representatives from Public Health, GP Consortia and Kirklees Community Healthcare Services delivered presentations and answered questions. Seventy one people attended representing fifty six community and voluntary organisations throughout Kirklees. We are aiming to hold a follow up event in the new financial year. We are keen to keep abreast of the developments within the sector and especially in the forthcoming months as the Local Involvement Network prepares for transition into HealthWatch. Equally, the development of the Kirklees Health and Wellbeing Board will be a key milestone in the changing landscape.

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Get involved, share your views

To keep the public informed of our work and to provide information on involvement opportunities, we have continued to publish our Get involved, share your views newsletter as well as sending information direct to those who have signed up to our database. We have found this to be a valuable tool in sharing the information and feeding back on the work that had taken place as we appreciate the time that people invest in helping us to better understand the needs of local people.

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Clinical Priority Programmes 6.

Cancer (including Cancer Screening)

Lead Director: Carol McKenna and Lead Manager: 6.1

Cancer Health Improvement

More than 1 in 3 people will develop some form of cancer during their lifetime. The 4 most common cancers in Kirklees - as for the whole of England - are cancers of the breast, lung, colorectal (bowel) and prostate. The mortality rate for all cancers in people aged under 75 (measured as a three year rolling average) has been declining steadily over recent years. The rate of this improvement in Kirklees is faster than the national average, and moved steadily towards the target of 1.0 per 1000 for 2010, although there are differences between localities in Kirklees. In early 2010, The Yorkshire Cancer Network completed a PCT profile/baseline assessments for the four most common cancers which provides for the first time a comprehensive source of cancer data in one document relating to cancer prevention, raising awareness and early diagnosis including cancer screening data, and lifestyle factors; incidence, mortality and survival; and treatment data as well as some basic PCT/Network specific demographic information such as population size and projections, life expectancy, deprivation, and ethnic mix. There will be further work to extrapolate the full picture for Kirklees which will influence the local cancer strategy and action plans which are currently being finalised. For the purposes of this report the mortality rates and one year survivorship data has been pulled out from the baselines assessments so we can see where improvements have been made and where more focus is needed. Breast Cancer: Breast cancer mortality rates in Kirklees have increased by 2.4% since the 1995-97 baseline. The difference between the male and female breast cancer mortality rates compared with England is not significant for the 2005-07 cohorts. One year survival from breast cancer is increasing: There has been a significant increase in 1 year survival from 1993-97 to 2005-07 at both the National level and for the Yorkshire Cancer Network (from 90.2% to 95.2%; and from 93.6% to 96.1%, respectively). At PCT level, there has been a significant increase for four out of the six Yorkshire Cancer Network PCTs including NHS Kirklees from 92.7% to 96.2%. Colorectal Cancer: Colorectal cancer mortality in Kirklees met the 2010 target, with a 26.4% reduction since the 1995-97 baseline: This is a significant overall reduction for males (-26.4%), but a slight increase for females (+7.6%).

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There has been a significant increase in 1 year survival from 1993-97 to 2005-07 at both the National level and for the Yorkshire Cancer Network (from 66.1% to 72.4%; and from 69.9% to 73.1%, respectively). NHS Kirklees is slightly above both the national and network levels. Lung Cancer: Lung Cancer Mortality rates in NHS Kirklees have surpassed the 20% target with a 29.0% reduction since the 1995-97 baseline. The difference between the male and female lung cancer mortality rates compared with England is not significant for the 2005-07 cohort. There has been a significant increase in 1 year survival over the time period from 1993-97 to 2002-06 for both England (22.7% to 28.2%) and for the Yorkshire Cancer Network (from 24.3% to 27.0%). However, NHS Kirklees is below the national and network levels. Prostate Cancer: None of the PCTs across the Yorkshire Cancer Network met the 20% reduction target for prostate cancer. However the biggest has been at NHS Kirklees (13.9%). In 2005-07, the lowest mortality rate is in NHS Bradford and Airedale (7.1 per 100,000 population). In Calderdale, Leeds, Kirklees, Wakefield, and North Yorkshire and York mortality in 2005-07 varies from 9 to 9.4 per 100,000 population. One year survival from prostate cancer is increasing: There has been a significant increase in 1 year survival from 1995-97 to 2005-07 at the National level, the Yorkshire Cancer Network level, and for each of the respective YCN PCTs (except NHS Calderdale). Overall, we can be pleased in the reduction of the mortality rate for all cancers in people aged under 75 and the increase in one year survival in all four of the common cancers except in Lung which is below the national and network levels. This picture is the same for the 5 year survival figures although the data for those patients diagnosed in the most recent cohort (19982002) shows that NHS Kirklees has the lowest 5 year lung cancer survival which is also significantly lower than England. There is no one intervention that delivers a reduction in cancer mortality or increases one and five year survival rates. At a cancer mortality reduction workshop held in last year by the National Cancer Action there was a presentation which set out a requirement to focus on 7 interventions. These, and their respective contributions, are: Reduction in tobacco consumption (7%); Improvement in provision of treatment services (4%); Increase in fruit and vegetable consumption (4%); Breast screening with incremental improvement in quality (2%); Reduction in heavy alcohol consumption (1%); Cervical screening with incremental improvement of quality (1%); Colorectal screening (0.5%); and Reduction in domestic radon levels (0.2%). Efforts locally and national have been focused on making improvements in the provision of treatment services but there is a growing recognition that in the coming years there needs to Report Owner: Peter Flynn Report Author: The Performance Team

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be a refocus on raising cancer awareness and diagnosing cancer earlier. Mike Richards – the National Cancer Director has stated that „up to 10,000 lives could be saved in England each year by diagnosing cancer earlier. This is an average of 66 lives per PCT per year‟. Our local cancer strategic position statement and subsequent action plans will be setting out how we should re-prioritise our efforts and resources into the areas of work which will have the biggest impact on reducing cancer mortality rates. As seen by the information above we will need to target additional efforts in colorectal (women), lung cancer and prostate cancer. Key achievements: Achievements in other interventions to address reductions in cancer mortality are set out under smoking cessation, screening (breast, cervical and bowel) and obesity. Achievements under the heading of the provision of treatment services include:  Lean processing of lung cancer pathway which identified improvements which could be made to the current state and what a future state could look like with service changes. An action plan was developed and is implemented to ensure the improvements are made to the current state. Plans to move to a future state have not yet been developed due to other priorities. Locally improvements to the current state have already been made and local performance is good.  Current cancer waiting time targets continue to be sustained with one or two exceptions which are being closely monitored. The last extended cancer waiting target for 31 days for subsequent treatment in radiotherapy went live in quarter 4 this year.  The annual assessment against national quality measures for services through peer review took place in September for Urology, Upper GI, Breast, Colorectal, Gynaecology and Level 1 Paediatric Oncology at CHFT and for Skin, Head and Neck, Upper GI, Colorectal and Gynaecology at MYHT. The internal validation process assessed an overall strong level of compliance against the measures. External Verification is took place in November and final reports were due out in December.  Action plans are being developed to address the recommendations made by the National Chemotherapy and Radiotherapy Action Groups in collaboration with the Yorkshire Cancer Network.  We are implementing the new model of breast cancer follow up for low and intermediate risk patients at CHFT after positive evaluation, this began in the summer. We are currently working through the contracting implications of this as part of the QUIPP agenda. The YC board agreed this was a model of good practice which should be rolled out across the network. Other achievements:  The results of the YCN project to audit late presentations of colorectal cancer to better understand barriers, and to promote awareness and early diagnosis were due out by the end of the year.  The PCT and other PCT partners within the Yorkshire Cancer Network (YCN) secured more than £500,000 from the Department of Health to work collaboratively on a cancer awareness and early diagnosis project.

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ď&#x192;&#x2DC; The money was awarded following a bid submitted by the YCN and PCT partners with a proposal to support the National Awareness and Early Diagnosis Initiative (NAEDI) work programme. The 12 month project will focus on common cancers such as breast, lung and colorectal and aims to embed cancer awareness and early diagnosis in PCT and future GP consortia planning frameworks and local Joint Strategic Needs Assessments. Issues/Risks The majority of cancer spending and effort goes on improving treatment services which as shown above makes a 4% contribution to delivering reductions in cancer mortality. In order to have the biggest impact on reducing cancer mortality rates we need to refocus our efforts on the areas which will make the greatest impact and contribution. This means reprioritising where our resources are targeted at. . Sustaining the new cancer waiting time targets proved challenging in 2010/11, particularly with the 2 week symptomatic breast target where there is capacity issues relating to radiology at MYHT. We also closely monitored the action plans at Leeds in the delivery of the radiotherapy waiting time target. Cancer Key Performance Indicators 6.2 Two Week Wait The number of patients first seen by a specialist within two weeks when urgently referred by their GP or dentist with suspected cancer, 1st April 2010 to 31st March 2011. The Key Achievements The Two Week Wait Cancer Standard for 2010/11 is being met. The year to date performance is 97.43%, against an operational standard of 93%. The Action Taken The Cancer Local Implementation group designed a leaflet for GP's to issue to patients at the time of referral if cancer is suspected. The leaflet was distributed in February 2010. The leaflet supports the GP's in informing patients of the urgent suspected cancer and the cancer waiting time process.

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The number of patients first seen by a specialist within two weeks when urgently referred by their GP with any breast symptom except suspected cancer, 1st April to 31st March 2011. The Key Achievements The Breast Symptom Two Week Wait is achieving the national operational standard of 93%, but, under-achieving against the local plan of 100%. Performance as at 31st march 2011 is 94.65% against the operational standard of 93%..

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6.3 One Month Wait The number of patients receiving their first definitive treatment within one month (31 days) of a decision to treat (as a proxy for diagnosis) for cancer. The Key Achievements The 31 day First Treatment was met for 2010/11. The Year to Date performance as at 31st March is 98.35% against an operational standard of 96%.

The number of patients receiving subsequent treatment (surgery and drug treatment only) within one month (31 days) of a decision to treat: 1st April 2010 to 31st March 2011. The Key Achievements We achieved 96.17% Year to Date for Surgery against a target of 94%. We achieved 100% Year to Date for Drug Treatments against a target of 98%.

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The number of patients receiving subsequent treatment (Radiotherapy treatment only) within one month (31 days) of a decision to treat (Shadow Indicator up to December 2010) The Issues Non admitted care tumour type breast and urological are under performing against target. Present systems and processes are currently unable to manage the pathway. This was a shadow indicator target up to December 2010 and consequently work has progressed towards achieving the national standard of 96%.

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The Key Achievements Year to date we have achieved 98.36% against the 31st March 2011 operational standard target of 96%. This indicator was a shadow performance indicator until December 2010.


Two Month Wait

The number of patients receiving their first definitive treatment for cancer within two months (62 days) of GP or dentist urgent referral for suspected cancer The Key Achievements The 62 day Cancer Standard was met. Year to Date performance as at 31st March 2011 is 85.81% against an operational standard of 85%.

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The number of patients receiving their first definitive treatment for cancer within two months (62 days) of urgent referral from the national screening service The Issues Low patient numbers influence this target and as a consequence it is easy to underachieve against target. The Key Achievements We have achieved the operational standard of 90% for the 62 day Cancer Screening Service, the Year to Date performance as at 31st March 2011 is 98.31%.

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The number of patients receiving their first definitive treatment for cancer within two months (62 days) of urgent referral from a consultant (consultant upgrade) for suspected cancer The Key Achievements The operational standard for CRS 62 Day Upgrade Standard (Tumour) is yet to be advised by the Department of Health, in the meantime, for 2010/11, the 62 day operational standard was used for local plan purposes. Performance as at 31st March 2011 is 90.63%.

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Cancer Screening Services: Lead Manager: Nicky Hoyle Population screening is of vital importance in preventing cancer, and is a vital plank in the Awareness and Early Diagnosis Initiative referred to in the main cancer section above :6.5.1. Breast Screening Breast screening is a method of detecting breast cancer at a very early stage. The NHS Breast Screening Programme provides breast screening every three years for all women in the UK aged 50 and over. The mammogram can detect small changes in breast tissue which may indicate cancers which are too small to be felt either by the woman herself or by a doctor. Over 32,400 women (over 70% of those eligible) are screened in Kirklees over each 3 year screening cycle. This equates to approximately 65 lives saved. The NHS Breast Screening Programme is phasing in an extension of the age range of women eligible for breast screening to those aged 47 to 73 (started in 2010). The Consequences and associated risks Continued additional investment will be required over the next few years to achieve the Cancer Reform Strategy requirements, particularly the age extension and incorporation of those with high familial risk, and to ensure the capital investment needs of the programme can be planned and implemented. The Actions Being Taken The Collaborative Screening Group continues to work with all commissioners, the provider, the Quality Assurance Reference Centre and the SHA Lead to ensure robust planning for and implementation of the Cancer Reform Strategy requirements. 6.5.2

Bowel Screening

About one in 20 people in the UK will develop bowel cancer during their lifetime. It is the third most common cancer in the UK, and the second leading cause of cancer deaths, with over 16,000 people dying from it each year. Regular bowel cancer screening has been shown to reduce the risk of dying from bowel cancer by 16 per cent. The NHS Bowel Cancer Screening Programme offers screening every two years to all men and women aged 60 to 69. The test does not diagnose bowel cancer, but the results will indicate whether further investigation (usually a colonoscopy) is needed. The Calderdale,

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Kirklees and Wakefield Bowel Cancer Screening Programme is still relatively new. People in the south of Kirklees began to be offered screening in April 2009, those in the north of the district following in August 2009. The uptake of the programme as at September 2010 was 58% of test kits returned, which is broadly to be expected at this stage of the programme roll-out and compares well with other areas. From April 2011 age extension will be implemented, starting with the south of Kirklees, so that people aged 70-75 are invited. 6.5.3. Cervical Screening Cervical screening is not a test for cancer. It is a method of preventing cancer by detecting and treating early abnormalities which, if left untreated, could lead to cancer in a woman's cervix (the neck of the womb). All women between the ages of 25 and 64 are eligible for a cervical screening test every three to five years. Early detection and treatment can prevent 75 per cent of cervical cancers developing. If overall coverage of 80 per cent can be achieved, the evidence suggests that a reduction in death rates of around 95 per cent is possible in the long term. In Q3 of 2010/11 the coverage of eligible women in Kirklees was reported as 81%. Proportion of women receiving cervical cancer screening test results within two weeks: at Q3 was 97.7%.

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Mental Health

Lead Director Lead: Carol McKenna and Lead Manager: Vicky Dutchburn The Key Achievements: All key performance indicators fully met and exceeded planned trajectories at year end. The maintenance of the improved position of the key indicators has been facilitated through the utilization of the contract levers and sanctions: Assertive Outreach Service - Number of people receiving assertive outreach services; Plan 170, Actual 170; Early Intervention Service â&#x20AC;&#x201C; Number of people receiving early intervention services; Plan 191, Actual 205; Crisis Resolution Service - Total number of episodes crisis resolution services; Plan 850, Actual 1003; Improved Access to Psychological Therapies - Total Minimum Number of people to be treated annually by the service; Plan 4013, Actual 4361; Employment - Total number who enter employment from leaving benefits; Plan 74, Actual 93.

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2010/11 Plans - Highlights i)

Introduce a single point of access for mental health services: (SPA)- Multi partner work has been undertaken & an agreed model has been developed. Work is ongoing to implement the agreed model over the remaining part of this financial; the anticipated timescale slipped, due to the relocation of services from the St Lukes site, as part of the site closure. The revised timescale for full implementation is end of quarter 1 2011/12.


Re Tender 3rd sector contracts; - work has been undertaken to agree the strategic requirement of these contracts & a process to deliver within the current climate. A phased approach to the tendering process was agreed by both NKS Kirklees senior management team & LA. Phase 1 was completed for implementation April 2011.


Introduce wider mental health resources to primary care; - joint work has been developed in partnership with Huddersfield University to cascade evidence based, web resource, to promote primary care management of low level mental health problems. Training across primary care is been delivered in partnership with the university to primary care practitioners during the final half of the year.


The 10/11 contract included improved quality outcomes through the CQUIN framework, which has supported improvement across service delivery, this work has been led by NHS Kirklees on behalf of Wakefield & Calderdale PCTs. There has been a constant improvement, against the indicators throughout the year, with only one trajectory failing to meet the planned level of improvement.


To support the delivery of NHS Kirklees financial plan in line with QIPP; - The required savings to be achieved across MH & LD for 2010/11 is ÂŁ850,000. This was achieved by mid Nov.

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The Plans for 2011/12: The main aims and objectives of the Plans for 2011/12 are to:  Demonstrate the added value and sustainability given through co-production across the mental health programme, with people who access services, family carers, clinicians and providers of services. Highlight the benefits across the „whole‟ system of all areas of NHS commissioning. This will have increasing significance as GP commissioning becomes more embedded. Identify if, and how, the various proposed options delivery impact on the quality of outcomes realised.  To ensure that contractual requirements are achieved and stretching performance targets are set and continue to be robustly monitored & to ensure that they are fully achieved.  Develop robust QIPP plans to ensure the delivery of efficiency savings during 2011/12  Phase 2 of the 3rd sector tendering process will take place during 2011/12.  Specify and commission a sexual assault referral centre on behalf of West Yorkshire PCTs

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Learning Disabilities

Director Lead: Carol McKenna and Lead Manager: Vicky Dutchburn The Key Achievements  The 10/11 contract included improved quality outcomes through the CQUIN framework, which has supported improvement across service delivery, this work has been led by NHS Kirklees on behalf of Wakefield & Calderdale PCTs. There has been a constant improvement, against the indicators throughout the year.  Development of the Learning Disability DES: NHS Kirklees has worked in partnership with GP colleagues to review & refresh the Kirklees health check tool, to improve the quality of the outcomes achieved. 98% of practices quality checked their registers & declared their intention to complete individuals‟ annual health checks, by the end of Q4, 93% had achieved this standard. The Issues There continued to be significant risk in relation to delivering redesigned specialist learning disability service, which would ensure compliance with recommendations from „The Mansell Report & with DH „Commissioning Specialist Adult Learning Disability Health Services standards, due to the ongoing financial position. However, work has progressed on delivering elements of the pathway through re-engineering within the existing financial envelope, with a range of partners. This includes the development of a service specification of a Step Up/Step Down Service to meeting the complex needs of individuals with learning disabilities who are leaving secure services or who are already living in the community but are at risk of embarking on the „offender pathway‟. This innovative service, which will commence April ‟11, will offer a high quality professional intervention at a critical point on the path. Prevention and early intervention work will be undertaken as well as work to address established patterns of behaviour which have resulted in repeated admissions often referred to as the „revolving door‟ phenomena. This service development will support planning for 2011/12 to prevent/reduce Out of Area placements. The delivery of a complex health needs respite service, commenced during Q4, this increased respite capacity by an additional 4 beds across Kirklees. The Plans for 2011/12 The main aims and objectives of this Programme are to: Demonstrate the added value and sustainability given through co-production across the Learning Disability programme, with people who access services, family carers,

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clinicians and providers of services. To Improve the sound principles of equality to provision of high quality, recovery focused care whilst providing Care closer to home The step up/step down service development will support ongoing plans during 2011/12 to prevent/reduce Out of Area placements. A compliant specialist assessment & treatment service will commence April 2011, with a bespoke 5 bedded unit. This has been facilitated through the development of robust QIPP plans, the complex health respite service will support the delivery of new model.

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6.8 Children Director Lead: Carol McKenna and Lead Manager: Helen Severns 1. National Plans and Guidance Achieving Equity and Excellence for Children, published in September 2010, set out a vision in which: Services will be personalised to individual needs, and the settings in which they are provided, will be appropriate for children, young people and their families. Age-specific information should become routinely available and accessible. Children, young people and their families will be at the centre of design and delivery of services, facilitated by local professionals Improvements will be measured in terms of outcomes for children and young people rather than just time-focused targets. Healthy Lives, Healthy People was published in November 2010 with the aims of creating local freedom, accountability and protected funding to ensure public health is responsive to the different needs of each community. A suite of consultation documents supports the publication including public health services for children under 5, the delivery of the Healthy Child Programme, health promotion and prevention interventions by the multi professional team and the Family Nurse Partnership. The NHS Operating Plan â&#x20AC;&#x201C; Key priorities for 2011/12 has identified that families with young children will be offered improved help and support as part of the ambitious new plans to expand and rejuvenate the health visiting service. A number of these areas are reflected in the performance updates below. 2. Family Nurse Partnership The Family Nurse Partnership (FNP) is a preventive programme offered to young mothers, aged 19 years and under, having their first baby. It begins in early pregnancy and is oriented to the future health and well-being of the child. The Family Nurses who deliver the programme come mainly from health visiting and midwifery and they receive extra training to equip them for the new role. The FNP has three overarching goals: To improve ante natal health; To improve child health and development; and To improve economic self-sufficiency. The Family Nurse Partnership visits do not replace midwifery care but they do deliver most of the Healthy Child Programme until the child is two years old. Visits take place on a

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weekly/fortnightly pattern. NHS Kirklees is a third wave pilot of the Family Nurse Partnership in England along with other PCTs and Local Authorities to find out if the programme benefits children and families in this country. The programme has had 30 years of development and three large scale randomised control research trials in the US. These have shown consistent short and long term benefits for children and families which include: Reductions in smoking in pregnancy; Greater intervals between and fewer subsequent births; Fewer accidents; Reduction in child abuse and neglect; Better language development in children; Increases in employment; and Greater involvement of fathers. Eligibility criteria for FNP are that the young person should be: a 1st time mother; aged 19 years or under and less than 28 weeks pregnant Progress to date: The pilot programme has now reached capacity and the Children‟s Commissioners have been successful in developing the business case and having the finance agreed for „small scale permanence‟ as identified by the national programme. The operating framework for 2011/12 also has identified the doubling of the FNP capacity by 2015. For Kirklees this is one additional post that will be built into the health visiting development plans. The Kirklees service has also received praise from the DoH Team especially the innovation in the delivery of the service to the agreed model and the high number of service users who attend the Board. Service users had made a DVD of their involvement in the programme and this has now been shown nationally and the DoH Team has invited them to attend one of their meetings. A clear model of safeguarding supervision is in place and FNP continue to be supported by the safeguarding team in the management of complex cases. 3. The Healthy Child Programme The Healthy Child Programme is the early intervention and prevention public health programme that lies at the heart of the universal services for children and families. The programme offers every family a programme of screening tests, immunisations, developmental reviews, and information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing. The programme supports a model of progressive

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universalism – a core programme for all children, with additional services for children and families with particular needs and risks. Risks: There are risks to the delivery of the core offer to all children and families due to the lack of available capacity of the existing services. This has been added to the PCTs risk register for both the health visitor and school nursing elements of the programme. Risk management: As part of the operating plan for 20112/12 The Health Visitors Expansion and Implementation Plan sets out the full range of services that families will be able to expect from health visitor teams, depending on their needs. It will create a bigger, rejuvenated workforce with an extra 4,200 health visitors by 2015 and an improvement in the quality of the health visiting service for children and families. Current estimations are that this will be approximately 27.6 WTE additional health visitors for Kirklees. The new service model will:  Develop, support and promote the services set up by families and communities themselves as part of the „Your Community‟ service;  Deliver the Healthy Child Programme - ensuring all children get the essential immunisations, health and development checks - as part of the „Universal Services‟;  Ensure a rapid response with expert help for problems like postnatal depression or a sleepless baby - as part of the „Universal Plus Services‟; and  Provide ongoing support as part of a range of local services working together and with disadvantaged families, to deal with more complex issues over a period of time - under the „Universal Partnership Plus‟ service. The Implementation Plan also reinforces the importance of the relationship between children‟s centres and health visitors. Many health visitors already work closely with their local Sure Start Children‟s Centre providing services to local families and promoting health and wellbeing alongside the Sure Start staff. Children‟s centres are accessible to all families with young children and have an important role in identifying and supporting families in greatest need. . 4. Safeguarding and Promoting the Welfare of Children and Young People Progress to date: All safeguarding policies and procedures continue to be reviewed to reflect local and national guidance Safeguarding Children and Vulnerable Adults Commissioning policy developed to clarify NHS Kirklees responsibilities with regard to all services commissioned Section 11 Audit undertaken in line with Working Together 2010 and submitted to Kirklees Safeguarding Children Board. Significant progress demonstrated. Monitoring continues via Trusts Safeguarding Committee

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NHS Kirklees Safeguarding Committee continues to monitor safeguarding performance and activity The Training Policy has been updated and uptake of training continues to be monitored. Further audit planned for 2011. Regular training and supervision continues to be delivered across the workforce in line with statutory requirements. A number of Practice Protected Time safeguarding training events have taken place over 2010/2011 for Independent Contractors, including General Practice, Dental Teams and Community Pharmacists. Clear supervision policy in existence which continues to be audited on an annual basis Safeguarding Intranet site continues to be developed and updated Safeguarding newsletter continues to be circulated twice yearly as a means of updating staff. 5th edition due for circulation in May/June 2012. As part of Transforming Community Services the Named Nurses for Child Protection have now transferred to Kirklees Community Health Care Services. Memorandum of Understanding developed and agreed between Kirklees Community Health Care Services and NHS Kirklees outlining safeguarding roles and responsibilities Named Doctor for Child Protection appointed for 1 session per week A Safeguarding Pack, including safeguarding standards for General Practice have now been developed and agreed. They have been circulated to all practices with 100% acknowledgement from practices. A Safeguarding pack, including safeguarding standards for Dental practices have now been developed and agreed circulation to practices is now underway. Safeguarding continues to be reflected in service specifications and contracts Practice Framework developed for information sharing between Health Visitors and General Practice and Link Health Visitors continue to meet with General Practice on a regular basis to discuss vulnerable families and ensure appropriate support and interventions are in place. Work continues with SHA in relation to Serious Safeguarding Untoward Incidents Links with Adult services strengthened Representation on KSCB and its work streams continues Assistant Director for Safeguarding currently vice chair of KSCB and chair of KSCB Serious Case Work stream Safeguarding assurances - the Governance Committee continue to receive quarterly safeguarding updates and the Annual Report to the Board continues. Performance of Mid Yorks NHS Trust , CHFT and SWYFPT continues to be monitored via their Safeguarding Committeeâ&#x20AC;&#x;s and Quality Boards Lessons from Serious case reviews acted upon and learning cascaded. Links with patient safety and risk continue. Professional development of the safeguarding team at Post Graduate level continues to ensure a skilled team Compliance with Core standard 2

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Developments in electronic record keeping and Read code development continues. The Risks: At a time of major changes within health and social care and the development of GP consortia, work must continue to ensure any risks to safeguarding services are identified and appropriate actions are taken in order to ensure vulnerable groups are protected. Discussions are ongoing to ensure Kirklees Safeguarding Children Board is represented by GP Consortium in Kirklees. 5. Disabled Children, Young People and those with Complex Health Needs A Programme Board for Disabled Children as a sub group of the Childrenâ&#x20AC;&#x;s Trust Board has now been established. NHS Kirklees and Kirklees Council have signed up to the Charter for Every Disabled Child Matters and a joint action plan has been agreed. This includes work on the following areas: Developing a joint strategy between the PCT and Local Authority; A joint directory of services; Increased support needed for parents through the assessment process; Better information sharing across the agencies; Better support through transition and links with adult services; Development of a disability register Ensuring the lead professional role and team around the child processes are fully implemented Responding to the Special Educational Needs Green Paper Risks The impact of the SEN Green Paper will need to be assessed on all commissioned services. There is a strong move to the provision of a school, health and care plan which will lead to a review of the existing commissioned services and their capacity to deliver. 6. Equipment and Wheelchair services Work is ongoing with the commissioned providers of wheelchairs and equipment to refine systems and processes and service provision. The current process has been highlighted by parents as a key area of frustration. There will be a project group working across the Kirklees, Calderdale, and Wakefield cluster with health and local authority colleagues to review the current position in relation to the provision of wheelchairs and equipment, and how we can share good practice working to improve the systems and processes that are in place. The outcome of the review of the speech and language service specification has identified the growing unmet need of communication aids for children and young people. While this

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may in the future be a nationally commissioned service, in the short term we need to address how the identified gaps between needs and service provision can be met. 7. Transition The Transitions Board has identified a number of areas for action. The Transition Board should ensure all young people and their families are well supported in the transition into adulthood and adult services including: The development of a clear process and key people to provide support and guidance to young people and their families/carers; That every family has a lead professional identified and that team around the child meetings consider transition to adult services from age 14 Links are clear between the Local Authority and PCT in how they work together; and; There are clear guidelines for complex case/continuing care referrals. 8. Palliative Care Palliative Care is an area that needs development and funding within the PCT. This includes the development of a contract and service specification with the children‟s hospices that we use, in line with national recommendations. This has now been taken forward at a national level and work is underway to develop a national tariff for hospice provision. The report is due in the Summer 2011. At a local level we need to develop community support and 24/7 access across the area as currently the service is not in place for families. This has been identified as a key gap in service and as a risk. This is due to the lack of commissioned activity to meet the identified needs of children, young people and their families. Risk Management: We will continue to work with partner agencies, including the voluntary and independent sector to commission effective services and avoid duplication and overlaps. With the review of the complex case process we will look at the options for tendering services against an agreed service specification. 9. Psychological Wellbeing and Mental Health of Children and Young People Psychological wellbeing has been defined as: “A positive state of mind and body, feeling safe and able to cope, with a sense of connection with people, communities and the wider environment.” Mental health has been defined as: “A state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” Both terms are used in the Psychological Wellbeing and Mental Health Strategy for Kirklees to build the local case for investing in mental health promotion, prevention and Report Owner: Peter Flynn Report Author: The Performance Team

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specialist treatment services and to take account of the needs of those children and young people who are more vulnerable to developing mental health problems. Early intervention is at the heart of the Government‟s approach to improving outcomes for children and families. This is set out clearly in the public health White Paper Healthy Lives, Healthy People and the mental health strategy No Health Without Mental Health. 9.1 Perinatal and Infant Mental Health The strategy and overarching care pathway for Perinatal and Infant Mental Health was agreed by the Board in March 2011. The strategy focuses on the intricate relationship between women, their social context and their mental health. This is probably at its most pivotal when considering the interrelationship between women, pregnancy, children and the family. We know that for many women, pregnancy and the transition to motherhood are welcome. However, this is not a universal truth. For many women, the reality is that pregnancy and childbirth maybe unwanted, complicated by violence or poverty and have negative effects on maternal health, particularly mental health. To implement the strategy we have established a multi-agency working group to produce an integrated care pathway and identify needs, plan actions and develop a systemic service model for meeting the family‟s needs in the ante and postnatal period. The action plan highlights support for parents and carers as the key way of promoting children‟s mental health during the perinatal phase and in the early years. A secure parent/child relationship is a key building block for the development of positive attachment and helps to build emotional resilience in children. 9.2 Target Mental Health in Schools (TaMHS – Tier 2) One of the unique strengths of the Kirklees TaMHS programme is the emphasis on collaborative, interdisciplinary working between the different services engaged with the pilot. The TaMHS delivery Hub articulated a vision for itself in terms of its internal working practices and innovative partnerships. School staff were supported to think in new ways about the inter-connections between different areas of mental health practice. They were encouraged to consider how they could deliver evidence based approaches to support those children who were vulnerable to or experiencing mild to moderate mental health difficulties. From the learning gained through the TaMHS pilot we are working as a wider partnership to develop a Tier 2 model. This will improve mental health outcomes for vulnerable groups.

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9.3 Meeting the Psychological and Mental Health needs of Looked after and Adopted Children Many looked after children have complex needs and high levels of mental health problems. This is often as a result of abuse, neglect, loss or attachment difficulties prior to coming into care. This makes CAMHS support vital, yet there is sometimes local confusion about who provides what level of intervention. We have established a Task and Finish group between CAMHS and social care to develop an integrated care pathway based on the NICE guidance for Looked after Children (2010). The group is exploring evidence based and cost effective interventions for Looked After and Adopted Children and their families to meet their identified needs in relation to emotional, behavioural and mental health difficulties. The Task and Finish group plan to launch the new service in September 2011. 9.4 Care Pathway A revised pathway and specification for CAMHs is under development. This will include a review of the competencies required, role of the primary mental health workers and the Tier 3 service, with a specific focus upon the needs of vulnerable children including looked after children. The finances supporting the CAMHs existing commissioned services form the LA and NHS Kirklees will also be fully evaluated as part of the process. 9.5 CAMHs/Learning Disability A multi agency working group has been established to develop a CAMHS/LD pathway and service model. This will shortly be available for consultation with the wider stakeholders including children, young people and carers. It is planned that the revised pathway based on the national â&#x20AC;&#x17E;Do once and Shareâ&#x20AC;&#x; will be agreed for implementation from September 2011. Risks: To fully implement a number of the priorities in the strategy will require additional resources. Redesign has taken place wherever possible within the existing finances but there are some new areas of work that have never been commissioned. This includes the comprehensive pathway for perinatal and infant mental health. Risk Management: Work is continuing across the partnership through the CAMHs Group to ensure that current resources are changes to pathways are used to best effect. We also are trying to ensure that identified needs are appropriately met at the right place on the pathways that have been developed to prevent inappropriate referrals into the specialist services or for out of area placements. Invest to save schemes are also under development.

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10. Kirklees Children’s Trust The role of the Kirklees Children’s Trust - The stated intent of the Kirklees Children’s Trust is: „The Kirklees Children‟s Trust has been established by all partners working with children and young people in Kirklees with the belief that working together is essential if we are to improve life chances for children and families. We have set out our vision and priorities for action in the Children and Young People Plan and we are committed to partnership working as the foundation of achieving our ambitions. The statement of intent recognises the difficult and changing times ahead and with this in mind the need to re-affirm, as a partnership, our commitment to working together for the benefit of children and young people in Kirklees‟. (The Kirklees Children‟s Trust Board, September 2010) Children‟s and young people‟s plan (C&YPP). The Plan will now influence specific commissioning plans that will focus on addressing the priorities identified for the local area. Board members agreed to use the revised list of priorities as a basis for their business planning process for financial year 2011/12 and for the plan to form the basis for the Joint Commissioning Unit commissioning strategy. The final plan will be presented to the Trust in May 2011. As part of the planned implementation and performance monitoring of the plan, there will need to be effective links to existing partnership groups. These include the Well-being and Health Inequalities Steering Team, key strategic boards such as the new Health and Well being Board and ongoing performance monitoring systems. A consistent theme is to ensure that as resources are reducing they are used as effectively as possible and also to avoid duplication of effort. This will need effective communication between strategic boards as the agendas and roles develop. The priorities for the Children‟s Trust are: Improving life chances and outcomes for the following vulnerable groups of children and young people:  looked after children and care leavers  teenage parents and those at risk of teenage pregnancy  women of child bearing age at risk from infant mortality  disabled children  Development of integrated working in Dewsbury

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The Trust also agreed to areas of partnership work for children and young people that will always be central to activities and service delivery. These will be the core business of partners, even if not named as a core priority by the Trust. These include;     

educational attainment, targeted early years provision safeguarding vulnerable children and young people , universal health provision targeted health provision crime prevention and offender management

11. Joint Commissioning Unit There is a developing joint commissioning unit across Kirklees Council and NHS Kirklees for the joint commissioning of children and young people‟s services. Two posts in the unit are jointly funded. Current work includes the monitoring of the re-commissioned substance misuse service, taking forward the work plan of the Disabled Children Commissioning Group, recommissioning the Speech and Language Service to a new service specification, work on mainstreaming the services to reduce teenage conceptions, actions from the CAMHs Group on the TaMHS development, work with Looked After Children Sufficiency Guidance and the review of the Complex Case process and out of area placements. 11.1 Young Person’s Substance Misuse The jointly commissioning service provision between NHS Kirklees and Kirklees Council for young people‟s substance misuse was subject to a competitive tender process last year. The successful provider, CRI has now been operating the new provision for 3 whole Quarters. The focus of the provision following the retendering specification has been to target those most vulnerable and at risk of developing problematic substance misuse e.g. Looked After Children and those young people at risk of being or who are NEET. The provision has also been focused on shorter spells for young people in treatment, reducing the number of young people in “specialist” treatment to ensure young people‟s needs are met at the lowest possible tier of provision and increasing planned discharges back to within the Integrated Youth Support Services in Kirklees. The performance throughout the year has been excellent and has meant that Kirklees performance continued to move from being below regional and national averages to being above regional and national averages in most areas of performance:Referrals and treatment for LAC are 17% of all referrals , this is 5% above regional and national average

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TOP compliance is 89% at Start , 100% at review and 100% at exit all well above target 100% of Young People have a care plan within 2 weeks of treatment start date Average time in treatment for young people in Kirklees is 11.8 weeks , regional average is 21 weeks and national average is 19 weeks Planned discharge rate is 91.9% with 99% of Young People being referred back into other service provision The 16-25 year old provision which is has been commissioned in response to changing substance misuse profiles is also operational and becoming more focused upon those at risk of or involved in the criminal justice arena. 11.2 Teenage Pregnancy High rates of teenage conceptions in the UK resulted in this being a key target nationally, regionally and locally. The original target was to reduce teenage under 18 conception rates by 50% by 2010. The latest data shows actual number of conceptions down by 2 (372 to 370) against a 1998 baseline of 48.6%, reflects a drop of only 0.2%. This had led to a revised Kirklees Teenage Pregnancy Joint Commissioning Plan which has six priorities aimed at reducing under 18 conception rates and improving sexual health and well being outcomes. Two areas of work under development include Young Advisors to work across all Children & Young People Plan priorities and commissioning & Peer Education. A teenage pregnancy ad-hoc scrutiny panel has been established. The terms of reference for this include understanding the picture of teenage conceptions in Kirklees, PSHCE & sex education, available support, identification of gaps and recommendations. A Kirklees PSHCE education Toolkit includes a number of emotional health and wellbeing and sexual health education programmes. One of these â&#x20AC;&#x153;Alco-sexâ&#x20AC;? has been provided free to all high schools. Whilst PSHCE education is not a compulsory curriculum subject, a recent audit indicated that all Kirklees High Schools were delivering programmes which included emotional health, health and wellbeing, risk taking behaviour and sexual health issues. A Further Education wellbeing toolkit, currently being written, will be available for FE colleges, 6th form schools & alternative providers in June 2011.The toolkit contains seven units two of which include resources around teenage pregnancy & sexual health.

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12. QIPP - Quality, Innovation, Productivity and Prevention The Childrenâ&#x20AC;&#x;s Team are continuing work on a number of projects on the QIPP agenda including: Evidenced based commissioning policies â&#x20AC;&#x201C; Elective Myringotomies and Elective Tonsillectomies Regional Leads for the Asthma Project Invest to save for the development of an intensive support at home service to reduce admissions to Tier 4 CAMHs inpatient services. Review of complex cases and out of area placements Development of the pathway for children who are technologically dependent to reduce the inpatient bed days for paediatric intensive care. Reviewing the maternity spend and NICE pathways Reviewing the spend on paediatric HDU Reducing unnecessary attendance at A/E. Piloting the use of a paediatric community nurse to reduce referrals to paediatric outpatients. Risks: The risks are to the financial savings plan for the PCT. If the above projects do not achieve the planned level of financial savings the PCT will not meet its QIPP target. Risk Management: Monthly meetings are in place and the inter dependencies with other programme boards are managed to ensure the planned schemes are on track. There is also monthly reporting to the PCT and SHA.

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Older People

Lead Director: Sheila Dilks and Lead Manager: Paul Howatson Older People The challenging consequences of the global economic downturn and the change in government led to an ongoing process of rationalisation within NHS Kirklees. The organisational priorities are aligned to the expectations of the nationally driven Quality, Innovation, Productivity and Prevention (QIPP) agenda and for older people this left the programme to focus on the following areas: general hospital care, falls, mental health and care homes. General Hospital Care Performance against the delayed transfers of care indicator and excess bed days target remains a challenge for colleagues working across adult services including older people. By closely working with colleagues across provider organisations during the year commissioners have made significant progress by enhancing the timeliness, robustness and quality of the performance management information collated. In order to reduce the number of delayed transfers of care, a high level, multi-stakeholder group comprising both commissioners and providers was established in March 2010. During the busy Winter season, this group continued to meet to provide workable solutions to operational issues affecting this client group and the challenging performance target. This work has now been transferred to existing workstreams under the Urgent Care programme. During 2010, and in partnership with the local general hospitals, further work took place around clinical effectiveness and better understanding of patient experiences and outcomes as a measure of the quality and range of services provided on discharge. Falls Based on national guidance, a draft Falls and Bone Health Strategy for health and social care was devised by commissioners. An implementation plan detailing how the health and social care economy would deliver the short, medium and long term goals has been developed and coincides with the work to review existing falls pathways and service delivery. One of the key CQUINs challenges for 2010-11 is to reduce the time from admission to procedure to within 48 hours for patients with a fractured neck of femur. A further challenge for acute trusts is to prevent and reduce the number and severity of falls sustained on trust premises by patients aged 65 and over. A further falls business case was submitted for approval and funding to invest in developing falls services was secured. Mental Health Mental health in older people remains a priority area and this has been exemplified by the release of both the National Dementia Strategy and also the Kirklees-wide Dementia Strategy.

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Building on the excellent partnership working evidenced by the Dementia Collaborative (which was recognised by the Regional Peer Review of Dementia Services), significant progress has been made to raise the profile of dementia across the wider community. The funded dementia advisers (funded by the Department of Health) continued to work well with several GP practices in both North and South Kirklees to sign-post members of the South Asian community to the available services and support groups for those clients with dementia. The implementation of the Kirklees Dementia Strategy is key to preparing health and social care services as well as the wider community for the challenges ahead. This implementation will be closely monitored using the CQUINs scheme to improve the quality of care for people with dementia across care settings. The introduction of simple measures, such as improved signage, has led to increased levels of independence with those clients suffering from dementia. To ensure that services are „dementia-friendly‟, colleagues across health and social care will receive training on how best to help individuals with dementia and their carers. In summer, a practice-protected time-out for General Practitioners and other community colleagues took place which focused on dementia, the dementia protocols and latest developments in treatment. Although significant work is being generated around dementia, there also needs to be some additional work on depression and delirium - the former especially due to social isolation and the latter arising from potentially avoidable infections. New NICE guidance on delirium encouraged secondary care providers to review local treatment pathways in line with evidenced-base practice. Care Homes In close partnership with Kirklees Council, work to establish a performance dashboard for care homes has been undertaken. This enables colleagues at a glance to understand areas for development and also to highlight good practice. From the Health Improvement Team for Older People, a care homes workstream has been established which will better understand the needs of care homes, their residents and also how the care homes interface with local health and social care services. The annual audit of all care homes in Kirklees (which aims to establish the care homes managers‟ perceptions of availability and access to primary care and community services) has been completed. The response rate exceeded 75% compared to the rate of 50% achieved last year. A well-attended best practice event around audit and self-audit tools was held in November and a further event to introduce end of life care to home care and care home colleagues was held in March 2011. If the pilot report is favourable, it is hoped that this initiative will reduce the number of inappropriate admissions to general hospitals from care homes by providing specialist advice and access to more appropriate services, tailored to the residents‟ needs. Associated Activities In accordance with legislation and best practice guidance, excellent work has been achieved with the Safeguarding Team for Vulnerable Adults and with the Mental Capacity Act Deprivation of Liberty Safeguards Project Officer.

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The Dignity Champions network ensures that all colleagues work to high standards in maintaining and treating clients with dignity and respect at all times. In response to a request by elected members of the Scrutiny Panel for Health and in conjunction with other pieces of work, a group was established to tackle Pressure Area care. During 2010/11 a campaign was launched across all health and social care settings with a particularly striking visual campaign highlighting pressure area hotspots on a poster. Again, the success of the campaign will be monitored using CQUINs to ensure there are no hospital acquired Grade 3 and 4 pressure ulcers. Intermediate Care The latest update to the National Service Framework for Older People (2001) was released in summer 2009 entitled, â&#x20AC;&#x153;Halfway Homeâ&#x20AC;?, which demonstrated the growth in provision of intermediate care services. The comprehensive provision of services within Kirklees extends from community hospital settings to nursing home provisions, from residential placements to support within someoneâ&#x20AC;&#x;s own home and with the appropriate level of support from staff within homecare services through to specialist health and social care professionals. The continuing development of a single point of access has been widely welcomed. This system requires further development to improve responsiveness and call streaming. The close collaboration of colleagues from multiple providers has enabled more people to function more independently in settings closer to home, if not in their own home. Although intermediate care has mainly been used as a step down facility from general hospital settings, it is anticipated that the facilities will be used increasingly as a step up service by GP referral from the community, to prevent avoidable hospital admissions and further work is ongoing in this area. Further work will be undertaken for those individuals who require rehabilitation on discharge from a general hospital setting but whose needs are more complex. Identifying and anticipating their requirements earlier up the intermediate care pathway will lead to more timely discharges for individuals to seamlessly continue their care in a safe environment appropriate to their needs. Ongoing work to develop and revise the service specification will ensure that the providers of intermediate care are aware of the high standards of care that NHS Kirklees commissions and that these provisions will be subject to operational scrutiny and regular review using the recently agreed Key Performance Indicators. Further work to capture the patient experience along the pathway will be developed during the latter half of the year. End of Life Care The Strategic Network for End of Life Care has been established and features a mixture of colleagues across health and social care with a strong interest in or specialist skills pertinent to end of life care. As spiritual care has been typically understated in other areas, the Network warmly welcomed representatives from both acute hospital providers chaplaincy services to ensure spirituality is an integral part of the Network. In accordance with the national strategy a major focus for the Strategic Network will be on the non-cancer diagnoses and representatives from these areas are being actively sought as members of the Network.

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The End of Life Care Project Facilitator has demonstrated an admirable degree of enthusiasm for the role in leading the work across Kirklees in conjunction with colleagues from a range of providers. The Gold Standards Framework in Nursing Homes project continues at strength and is led by two Macmillan Nurse Specialists. Due to the level of success in spreading and sustaining this project, the team of two have attracted much interest nationally and link in strongly to the other initiatives to support care homes across the district. Community Equipment Services and Wheelchair Services All services continue to perform well in a challenging environment given growth in activity over the past few years as care shifts closer to home. The current climate is even more challenging and commissioners are working closely with local authority colleagues as well as the service providers in an attempt to address the challenges faced by these services and other services which are closely linked to them.

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Cross – Cutting Strategies 7.1

Reducing Health Inequalities

Lead Director: Judith Hooper Inequalities exist between people, both in avoidable gaps in health and in the factors that profoundly affect health. The Kirklees Partnership is crucial in tackling these inequalities as part of its aim to achieve the health and well-being of local people. We must ensure that those most at risk or in need have real equality of opportunity. The vision for health and well-being inequalities is that people across Kirklees stay as healthy as possible by: feeling more able to look after themselves, more in control of managing their problems and more able to make healthy choices; being able to easily choose and access the type of opportunities and help they need, when they need it; having opportunities for social support and being involved, participating fully as members of their communities, as defined by them personally; ensuring those most at risk or vulnerable have opportunities available to them to help reduce their risk or vulnerability and narrow the avoidable gaps in experience; having appropriate access to education, jobs, transport, housing, health care and a decent environment to live and work in. The Director of Public Health has worked with colleagues across the Partnership to develop a Framework for Promoting Wellbeing and Tackling Health Inequalities in Kirklees. This sets out a clear shared framework for all partners to take action. The Director of Public Health chairs the Well-being and Health Inequalities Steering Group, which oversees and directs the Well-being and Health Inequalities Programme. The focus of the Programme is on changing cultures and mind-sets to ensure the Partnership understand how they can improve wellbeing and tackle health inequalities…and then does. Early developments have included:-

Dissemination of the new Framework including a launch event with over 100 senior managers from across the partnership


Development of a co-ordinated approach to „Every Contact Counts‟ across the partnership, with roll-out starting in December 2010


Identification of key strategies and plans which need to be influenced, and using a set of core questions to identify opportunities for those strategies and plans to make a greater contribution.

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Initial plans to be challenged have been Tobacco Control and the Integrated Regeneration Strategy.


Initial work on establishing a more coherent approach to involving local people in developing and delivering services based on our experience in using social marketing approaches.

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Quality, Innovation, Productivity and Prevention (QIPP)

Lead Director: Bryan Machin and Lead Manager: Steve Brennan Background The NHS White Paper, Equity and Excellence: Liberating the NHS set out the Government's long-term vision for the future of the NHS. The White Paper recognised the financial challenges the NHS faced and the role Quality, Innovation, Productivity and Prevention (QIPP) would play in supporting the NHS in identifying efficiencies whilst driving up quality. At a regional and local level there are QIPP plans which address the quality and productivity challenge, and these are supported by the national QIPP workstreams which are producing tools and programmes to help local change leaders in successful implementation. There are 12 national workstreams in total. Five deal broadly with how we commission care, covering long-term conditions, right care, safe care, urgent care and end of life care. Five deal with how we run, staff and supply our organisations, covering productive care (staff productivity), non-clinical procurement, medicines use and procurement, efficient back office functions and pathology rationalisation. There are two enabling workstreams covering primary care commissioning and contracting and the role of digital technology in delivering quality and productivity improvement. Local context The PCT had a plan to deliver £14.9m of QIPP efficiencies during 2010/11. We had a programme approach to deliver these efficiencies with each of our strategic programme areas having an individual QIPP target to deliver. NHS Kirklees delivered all of the required efficiencies. The majority of this, £10.4m, was delivered from the planned actions put in place during the year. The remaining balance of £4.5m was delivered through specific mitigating actions put in place to address slippage on QIPP plans. This slippage mainly related to QIPP schemes designed to reduce demand and spend in secondary care settings.

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2010/11 QIPP Plans Dashboard:-

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Plans going into 2011/12:-

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Local Area Agreement (LAA)

Lead Director: Judith Hooper The Kirklees Local Area Agreement (LAA) 2008-2011 ended in April 2011. The LAA was a three year agreement between the organisations which make up the Kirklees Partnership and central government. It set out our shared local priority targets that needed to be achieved to improve the quality of life in Kirklees. It was a key vehicle for the Partnership to ensure delivery of local action to tackle the health and well-being inequality challenges. The 2008-2011 LAA is presented in four themes: Children and Young People Increase education attainment and progress beginning in the early years Improve the life chances of vulnerable children and young people Tackle the factors that contribute to physical and emotional wellbeing, so children and young people develop healthy minds and bodies Provide opportunities for young people to enjoy themselves Safer Stronger Communities Develop cohesive communities where people from different backgrounds and ages get on well together Increase resident satisfaction with their local area Promote a strong community and vibrant voluntary sector Reduce crime, anti social behaviour and the fear of crime Address the factors that relate to offending and so reduce re-offending Reduce the harm caused by drugs and alcohol to the people of Kirklees, including users, their families and the wider community Healthier communities and older people Enable older people to enjoy more years in good health and to be active and independent Support people with long term conditions to be independent and in control of their own condition Promote healthy life styles for all and improve mental well-being Improve maternal health and so develop healthy babies and reduce the number of children dying before their first birthday Economic development and the environment Reduce worklessness and narrow the gap between disadvantaged groups and the rest of Kirklees Increase skill levels of the working age population to increase the employability of the local labour market Grow and sustain local businesses Report Owner: Peter Flynn Report Author: The Performance Team

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Combat and plan to adapt to climate change Reduce waste and increase recycling Increase the number of affordable homes available in Kirklees Tackle congestion on our roads and increase the number of local community based bus services

The outcomes of the LAA are currently being collated to provide a summary of the achievements of this partnership working towards the priorities in this three year period. It is not clear at this time whether there will be a further local area agreement in Kirklees. There is no indication from Central Government to suggest that there will be a similar coordinated mechanism in the near future. However it may be that the Kirklees Partnership will introduce their own priority agreement between partners at a local level. It is only through developing ways of working together and using resources in an effective, coordinated manner that we will tackle some of the more difficult and cross cutting issues. The Well-being and Health Inequalities Programme will support this.

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Corporate Governance

Director Lead: Helena Corder and Lead Manager: Terry Service This section of the Report covers overall governance and the review of the PCT‟s governance structure and processes in line with changes set out in the government‟s White Paper. It includes information governance and risk management. In the last 3-4 months the PCT has been discussing proposals for changes in its governance arrangements to support the development of GP Commissioning Consortia and the formation of Clusters. Proposals for changes were agreed at the April Board meeting and will take effect from 1 st June 2011. The Risk Management The PCT has had in place the revised Board Assurance Framework generated through the performance plus software system and this is able to show where risks are identified and how they feed up to the Board Assurance Framework where they are deemed to have a significant impact on the delivery of the PCT‟s strategic objectives. Each Board sub-committee and Directorate has a risk register and the performance plus system is able to show all the linkages between these which enable a coordinated approach to the management of risk within the PCT. The PCT continues to provide a range of training for both the Board and staff on risk issues and overall risk management including information governance. Information Governance The PCT has updated a range of information governance policies as part of the action plan to achieve compliance with the IG Toolkit. However because of the very specific requirements set out in the toolkit version 8 the PCT has not met level 2 in all areas. This issue has been identified on the PCT‟s risk register and discussed at both the Governance and Audit Committee and reported formally to the Board. The PCT achieved 67 % score for the toolkit for the 31st March 2011 return.

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Equality & Diversity

Director Lead: Helena Corder and Lead Manager: Kate Bell At NHS Kirklees, equality, diversity and human rights are at the heart of our business activities. We are committed to tackling health inequalities and commissioning high quality healthcare services based on the needs of the whole community. We are also committed to treating our workforce fairly and providing a working environment that promotes equality of opportunity and helps them to develop to their full potential. The Key Achievements Working closely with partners, staff and the public, we developed a three year Single Equality Scheme, which describes how we will fulfil our moral, social and legal obligations to put equality at the heart of everything we do. This was approved by the board on 30 March 2011. In partnership with NHS Calderdale, we delivered a series of lunchtime Equality Act 2010 briefing sessions for staff in Kirklees and Calderdale. We also published an Equality Act 2010 briefing on the intranet and included a bulletin and link to the document in the staff newsletter. To help us deliver on the requirements of the new Equality Act 2010 and make sure that equality and diversity remains a priority during the transition period, the board agreed to adopt the new Equality Delivery System (EDS) for the NHS. The new performance framework will be implemented as soon as the final version has been approved at a national level. In February 2011, the board received training on Equality Impact Assessments. During 2010, the Equality and Diversity Manager delivered equality and diversity updates to senior managers and attended several team meetings to raise the profile of the equality and human rights agenda. In partnership with NHS Calderdale and Wakefield District Primary Care Trust, we are currently working on a joint equality impact assessment toolkit to be used across the new cluster. Once this has been approved, we will develop new training and guidance for managers undertaking equality impact assessments. All questionnaires and surveys produced in partnership with the Patient and Public Involvement team include equality monitoring forms, so that feedback can be disaggregated by protected group. The Joint Strategic Needs Assessment (JSNA) makes reference to the different health needs of equality groups.

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The risks Loss of focus on equality and diversity due to transitional issues. Failure to embed equality and diversity into the new commissioning and provider organisations. Loss of significant progress made to date in relation to equality and diversity. Loss of the Strategic Health Authority. Weak links with Public Health as it moves out of the NHS to Local Authorities. Risk management Adoption of the Equality Delivery System as a framework to help us fulfil our statutory obligations and ensure that equality is not lost during the transition. Communicate the new equality duty and the EDS to GP consortium, the new provider organisation and public health. Implement and monitor the Single Equality Scheme 2010-2013. Roll out the new equality analysis toolkit for the cluster and deliver training to policy authors and managers. Continue to work closely with partners and share good practice with peers. Take part in regional equality meetings to facilitate shared learning and support. Continue to engage with local interest groups and update them on the new equality duty and the EDS.

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GP Commissioning Consortia

Lead Director: Carol McKenna and Lead Manager: Jan Giles The Key Achievements Following publication of the White Paper, Equity & Excellence – Liberating the NHS, published in July 2011, the White Paper signalled the end of the term Practice Based Commissioning and the introduction of GP Commissioning Consortia. Much of the work of the team has therefore been focused on supporting the transition. Two project groups were set up, one in North Kirklees and one in Greater Huddersfield, and this resulted in 100% of practices agreeing to form one Consortium in each area. The consortium in North Kirklees will be known as North Kirklees Health Alliance and the one in Greater Huddersfield will be called the Greater Huddersfield Commissioning Consortium. A selection process was undertaken to identify the new leaders of the 2 Consortia and both were established as Shadow Boards in readiness for the 1st April 2011. The 2 Consortia successfully applied for third wave pathfinder status. The focus on Quality, Innovation, Prevention and Productivity (QIPP) for Practice Based Commissioning (PBC) has been within the PBC Financial Incentive Scheme and the evaluation of PBC business cases. The Financial Incentive Scheme includes supporting practices to use Predictive Risk, and 71 practices are now regularly using the tool. The Issues The transition from Practice Based Commissioning and supporting the formation of the GP commissioning consortia is the main focus of work. In addition: The web browser information system is felt to be in need of improvement or replacement with many practices advising that it is difficult to use. The change in policy on „freed up resources‟ necessitated by the financial position has caused some concern. Next Steps NHS Kirklees is developing an Induction Programme for each Consortium. Terms of Reference and Governance of the Shadow Boards to be finalised. Both consortia working on inter-practice agreement to gain constituent support. An interim position for the web browser has been agreed which delivers some improvements. However, the system will probably need to be replaced to support the transition to GP Commissioning Consortia.

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Director Lead: Sue Ellis and Lead Manager: Laura Campbell 2010/11 has been a year of significant challenge arising from a combination of factors and all existing PCT employed staff are feeling the impact of organisational change â&#x20AC;&#x201C; either through management cost reductions, or preparing for provider staff transfer under the Transforming Community Services arrangements. Further since the launch of the White paper in July 2010 announcing abolition of PCTs by 2013 and potential transfer of functions, there is uncertainty regarding security of employment and frustration for staff. The demand for our services to support such change has been significant and we have refocused to lead relevant workforce work streams and provide individual staff support as described below. With the advent of PCT Clusters enabling NHS Kirklees to work more closely with neighbouring NHS Calderdale and NHS Wakefield District, a skilled, motivated workforce that is â&#x20AC;&#x17E;system wideâ&#x20AC;&#x; is more critical than ever for the delivery of our strategic goals. We are developing effective and flexible use of existing staff resources, leading to innovative, cost-efficient roles and services that will deliver the best possible value for money and quality services for our population. Supporting organisational change Robust and proactive HR&OD support is vital during times of organisational change. We have delivered a range of initiatives and projects this year to support and guide the organisation, including: Organisational change briefings for managers and staff Career management workshops Independent financial advice sessions Pensions planning seminars 1:1 HR surgeries and coaching Detailed TUPE consultation plans and materials (Provider only) PCT function mapping Development of GP Consortia shadow board roles Voluntary redundancy and severance schemes Staff briefings and FAQ production Annual staff survey and associated action plans Management of restricted vacancies (Clearing House) processes Online surveys gauging organisational motivation and mood We continue to work hard to facilitate the ongoing organisational change processes. During 2011/12 we expect to action the transition guidance and enable staff assignment of PCT functions and roles with the future structure of healthcare commissioning. In doing so, we will Report Owner: Peter Flynn Report Author: The Performance Team

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work increasingly closely with the emerging GP Commissioning Consortia, as well as with staff and trade union colleagues. We will also be supporting the functioning of PCT Clusters, in particular our own Cluster across NHS Kirklees, NHS Calderdale and NHS Wakefield, and the development of Commissioning support services that are appropriate and cost effective for our local GP consortia needs. Workforce Planning March 2011 saw the further integration of workforce planning with finance, QIPP and activity planning, when for the first time NHS Kirklees produced a fully integrated 4 year Operational Plan. We are committed to submitting regular refreshes to these as required, in order to reflect the changing landscape of our organisation. The successful production of integrated plans was partially facilitated by our constructive working relationships with our key Provider partners, with whom we meet regularly to discuss workforce issues and challenges in the healthcare economy. In July 2010, NHS Kirklees again led a health economy wide approach to its annual workforce risk assessment cycle, working in partnership with other NHS organisations across Kirklees, Calderdale and Wakefield to identify anticipated workforce risks across the next 12 months. This approach was adopted in 2009; all involved organisations agreed to continue using this format due to the successful improvement it made to the process. In support of the management cost savings and efficiencies challenge faced by the organisation, a range of measures were introduced during 2010/11 to control and reduce the size of the workforce during 2010/11 and subsequent financial years. These measures have included the continuation of robust vacancy control measures and the launch of a set of Voluntary Schemes during summer 2010. Such measures have seen the organisation reduce in size from 1251.4 to 1145.9 whole time equivalents in the 12 month period to 31 March 2011, a decrease of 8.4%. As described in the Organisational Change section above, a key focus and priority for our workforce planning in 2011/12 will be on aligning PCT roles and functions with the future shape of healthcare commissioning. Workforce Information The demand for workforce information and the scope of the Electronic Staff Record (ESR) has grown significantly over the last 18 months. To meet this increased demand and complexity, one of our existing HR Assistants now works alongside our Workforce Analyst to provide support to the production of workforce information. The Workforce Scorecards which we introduced in 2008 continue to be a key source of workforce information to inform business decisions and specific reports are now produced for various meetings. For example, the NHS Kirklees Governance Committee receives a report focussing solely on commissioning data while the KCHS workforce committee receive a tailored report to their quarterly meeting. This reflects the increase in demand for the ability to

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monitor workforce performance in areas including sickness and turnover. Please see our workforce profiling across the adjoining pages for further information. We continue to take part in the SHA‟s regional data quality programme, which has been the catalyst for much work undertaken to improve the quality of data that we record on the ESR system. As a result of the work undertaken around this, NHS Kirklees were recently ranked 2 nd out of 37 organisations in the Yorkshire and Humber SHA‟s data quality league. We have now met almost 90% of the data quality targets set by the regional data quality programme, and we make it our priority to ensure that the improvements gained in data quality are maintained and developed further. Following last year‟s introduction of NHS Smartcards to access the Electronic Staff Record, 2010/11 has seen progress towards further ESR benefits realisation with a project to streamline User Identity Management during the recruitment process. Working closely with IT colleagues, this project will allow new employees to be given faster access to necessary IT systems, whilst improving IT security processes. Human Resources & Organisational Development Support The HR & OD Shared Service continues to provide a range of support in organisational development, training, policy, people management and ensuring we meet statutory requirements and regulations in our employment of staff. The Shared Service has remained focused on supporting NHS Kirklees and Kirklees Community Healthcare Services in the Transforming Community Services (TCS) agenda. The activities of the Shared Service-led TCS Workforce Workstream will be critical to ensuring the timely and effective transition of Kirklees Community Healthcare Services to its new organisational form. With effect from 1 April 2011, the Shared Service moved a core of HR&OD team members into KCHS. These team members will work solely with KCHS into 2011/12 and beyond, TUPEing with KCHS to its new organisational form in autumn 2011. The development of commissioning knowledge and skills across NHS Kirklees has been a priority through the successful delivery of the Kirklees Way Programme. The Shared Service has been working in partnership with all directorates to ensure that any areas of development identified through the staff survey have been addressed; including the delivery, quality and performance monitoring of Performance Development Review. PDR training has been updated and new monitoring systems established. The results from the 2010 staff survey suggest that, despite the level of organisational change, staff recognise and welcome the amount of support and effort provided to them by the organisation. NHS Kirklees‟ move to its new headquarters in March 2010 has proved, as anticipated, to be an excellent catalyst for the development of 21st Century working practices, with more staff undertaking home working during their contracted working hours and hot desking becoming “business as usual”. Commissioner staff are now fully settled in the new headquarters.

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Following the Boorman Report on staff health and wellbeing, 2010/11 saw the popular launch of the Cycle to Work scheme, and the rollout of well-attended Health at Work roadshows in partnership with colleagues from Kirklees Council. Meanwhile NHS Kirklees was the first PCT in the Country to sign up to the “challenge to get staff healthy” campaign which was inspired by the forthcoming Olympic Games.

As in previous years, employee relations remain positive, and we operate upon a solid foundation of working in partnership with our Trade Union colleagues. Successful partnership working has been more important than ever in 2010/2011 as we work together to support the organisation through forthcoming change and transition. In particular during 2010/11 we have been pleased to welcome 5 new local trade union representatives to our Partnership Forum. The Shared Service is focused on its value added approach and our Service Level Agreements with our clients ensure alignment with the business and continued high performance in all HR&OD matters. 2010/11 has seen us working even more closely with our clients to ensure that the Shared Service‟s own structure and services matches their requirements and plans for their future. The HR & OD Shared Service is prepared for the challenge it will also face from a changing organisational and financial environment in the next 2 years. We are collaborating extensively with other PCTs in West Yorkshire to ensure resilience of the service and by a forward focus to build a potential business offer in any revised organisational system. From 1 April 2011, following joint project work, we will be working as a cluster-wide HR&OD team across NHS Kirklees, NHS Calderdale and NHS Wakefield. This approach will allow us to make maximum use of the skills that we have, and facilitate a resilient and flexible approach to the changes to come.

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NHS Kirklees Commissioning Workforce Dashboard as at 31st March 2011

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Dashboard continued:-

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Dashboard continued:-

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Staff Demographics at 31st March 2011 Staff by Disability

Staff by Gender

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Staff Demographics cont:Staff by Age

Staff by Ethnicity

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Staff Demographics cont:Staff by Pay Band

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Clinical Governance

Director Lead: Sheila Dilks and Lead Manager: Sue Smith The continuous improvement in the quality of services offered to patients in the NHS remains at the heart of the governmentâ&#x20AC;&#x;s agenda. The Chief executive of the NHS Commissioning board has reinforced this message and has signalled this intent through strengthening the role of the National Quality Board. Whilst national bodies such as the Care Quality Commission and The National Quality Board will be responsible for reviewing and publishing performance data at a local level, PCTS have a duty of care to the local population to commission services that meet the highest quality standards. The imperative for Primary Care Trusts to monitor and review services is even more important in these challenging times of organisational change and financial challenges. As we move to a new system of clinical commissioning through GP consortia we need to focus on the three indicators of high quality care: Patient experience, patient safety and clinical effectiveness. Much of what we do as commissioners is to ensure quality markers are in all contracts and service specifications and we have the systems and processes in place to monitor these. We also need to horizon scan bringing together National information with local intelligence to get the true picture of patient experience, clinical effectiveness and quality improvement. In Kirklees we have been proactive in working with organisations to drive improvements in quality but also to recognise downward trends and take mitigating action. Regular reports to the board highlight areas of improvement and concern and maintain Board grip on the quality of services we commission on behalf of our population. Developing a local Integrated Quality Framework To meet the quality agenda the Quality Improvement Team focus on the domains of quality articulated in â&#x20AC;&#x17E;High Quality Care for Allâ&#x20AC;&#x; working with each directorate to ensure quality is at the heart of all we do. Notable achievements are: We have a clinical quality board with all providers where performance and improvement issues are implemented and monitored. We have better systems and processes to performance manage and receive assurances about clinical audit and effectiveness including NICE guidance. We have a prioritised audit programme that concentrates resources on key priorities such as care pathways, engages clinicians, is outcome focused and aims to demonstrate impact and outcome. Further work is needed to demonstrate value for money; We have worked with are key providers to develop a range of quality metrics to drive Report Owner: Peter Flynn Report Author: The Performance Team

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continuous quality improvements e.g. regional and local CQUINs, Quality Matrix indicators, quality indicators within primary care contracts; We have worked with regional and research networks to ensure we have fit for purpose Research Management and Governance (RM&G) support. This has enabled us to continue to full compliance with national research governance standards. GP Appraisal and Revalidation continues to adapt in response to national reforms; Last year the work with the SHA and colleagues across Yorkshire and Humber has resulted in a number of initiatives to drive quality improvements e.g. a range of regional and local quality outcome measures have been embedded within contracts via the CQUINS scheme, we have also ensured providers have achieved the performance targets of Delivering Single Sex Accommodation within the wider Privacy and Dignity agenda; Measuring outcomes from the patient perspectives specifically PROMS and PREMS has been a priority for all trusts. We have started work with providers across the region to develop innovative ways of capturing real time patient experience data which is then promptly acted upon to improve services; Throughout the year we have responded to recommendations from internal audit about our quality and clinical governance arrangements; and We have made the transition to the new regulatory framework of the Care Quality Commission and ensured this aligns with other performance assessments e.g. Use of Resources, national and local targets. In April 2010 all NHS Trust providers were required to register with the Care Quality Commission (CQC) and by September 2011 all GP providers will be required to register . We continue to keep quality as the focus of everything we do and to both support and challenge our providers to drive up standards in safety, effectiveness of care and patient experience:

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Information Management & Technology (IM&T)

Director Lead: Peter Flynn and Lead Managers: Ian Wightman and Helen Bridges 7.9.1. Information Technology (Lead Manager: Ian Wightman) The General picture in the IT space is that the hardware, both back office and desk top is that it is fit for purpose kit. There are appropriate processes in place for both ensuring dynamic assets register and for the replacement and repair of IT kit. In terms of the clinical applications KCHS has a small number of services awaiting the deployment of the new version of SystmOne (S1) to allow appropriate patient confidentiality, this version is expected to be deployed in mid year 2010-11, and other specific services (Community Dental) are now live on a non- NPfIT (National Programme for Information Technology) product. In the GP practices, there has been further movement towards TPP (The Phoenix Partnership) S1. The PCT has contributed to the annual benefits statement by the Strategic Health Authority and have continued to include benefit expectations and monitoring in its IT programmes and will measure and report on these over the next two years. 1.

IT Infrastructure and Hardware To ensure that IT equipment is appropriate, in place and meets the PCT and dependant partners IT requirements for: a. Provider Services; b. GP Practices; and c. Corporate Services.

Actions required are; A complete and dynamic Asset register: Revamped dynamic testing completed and asset register being validated this is still ongoing and being finalised. In addition to this a proactive approach to new starters and leavers is being adopted that ensures each IT asset has a named person responsible for that particular device. This piece of work is ongoing and expected to be complete in 4 th Quarter 2010/11 Ensure IT kit is of NPfIT specification and/or the kit is functioning at the required level: Completed replacement of non compliant IT kit in provider and corporate space completed by April 09, GP space 90% completed with detailed programme of completion developed. All GP and Commissioning IT equipment has been updated to compliant standard. This has not been

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realized in KCHS as capital expenditure was prioritized on Agile working initiative. Within this initiative non compliant desktop kit will be phased out of service. Ensure IT infrastructure and back office functions are appropriate for PCT functions/requirements: There has been a number of back office IT function initiatives that have been completed – Email migration and central file sharing databases and GP desktop encryption. The roll out of Office 2007 to all KPCT staff has also been completed as has the separation of the PCT from the provider unit and other local PCT‟s in terms of the active directory structure. The Management of the THIS relationship and contract has been agreed for 2011/12 . 2. Clinical Applications a. Provider Services b. GP Practices c. National Applications Actions required are;

a. Deployment of CfH LSP TPP System 1 to provider services in PCT: : Roll out of version 3.01 awaiting first of type evaluation and national programme confirmation from CfH to proceed expected 2nd Q 2011/12. CaSH and Chlamydia screening expected to be completed 1st Q 2011/12. b. Implementation of GPSoC scheme (GP Clinical systems meeting national IT requirements): All practices on GPSoC scheme. All practice agreed to PCT-Practice agreement. All practice on LSP or GPSoC. Support GP practice to migrate if requested to other GPSoC systems -11 Practices migrated to LSP 2010/11. In 2011/12 2 practices have agreed to migrate to the LSP (S1) and 2 more practices are considering migrating to S1. c. Commenced roll out of the Summary care record with 12 practices booked to upload their summary care records of consenting patients by September 2011. Commenced roll out of the Electronic Prescription Service release 2, we have been notified of the secretary of state‟s agreement to commence and have 3 practices agreeing to be pathfinders in Kirklees. 3. Benefits Realisation Use IT as an enabler to support the realisation of benefits to the Organisation: Use IT as an enabler to support the realisation of benefits for patients; clinical safety, patient choice and confidentiality: Completed Work with the SHA benefits realisation team and provider service improvement team to describe the realised benefits in areas of deployments. Annual statement of progress has been completed by NHS Kirklees.

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Data Quality and Information Management (Lead Manager: Helen Bridges)

The Head of Information Analysis and Data Quality is responsible for managing two distinct teams within the PCT: Data Quality and Information. The overarching purpose of the Data Quality Team is to support GP practices to improve their data quality and to maximise the benefits of improved use of clinical systems. The Information Team offers a comprehensive service to all Directorates within the PCT with considerable energy focused to support: contract management; performance reporting; patient care and professions, service redesign and improvement. The Team is also involved with developing and improving new data flows with its provider organisations. As both teams have specialist skills and expertise they are members/co-opted members of several PCT work programmes and project groups to facilitate and support effective use and interpretation of data. Key Achievements during 2010/11: Contracting information support improved and new systems developed to support rigorous data quality and challenge processes Active members of the Predictive Risk Project Team with specific responsibilities for extraction and installation processes within GP practices (energy and effort recognised at 2010 Staff Awards â&#x20AC;&#x201C; Predictive Risk Team won best Team Award). Presentation also given at PRIMIS+ Annual Conference by Team Supporting GP practices with implementation of the NHS Number Standard in primary care (this work has been recognised nationally with NHS Kirklees being used as an exemplar site on the Connecting for Health web-site) Development of an Executive Resource Update to ensure our top team has access to the latest reports and information available Data Quality support to 14 GP practices successfully migrating to SystmOne, including the development of new processes to ensure accuracy of Child Health data Successful launch of a quarterly Data Quality Team Newsletter with hints, tips and hot topics to support General Practice Robust Data Quality improvement plans included within Provider Contracts Launch of an information resources intra-net site to promote useful sources of information - Development of a local community case-load data-set to support effective management and monitoring of service specification standards Adoption of corporate reporting presentation/standards to support user interpretation In depth analysis to support Health Improvement Programmes and QIPP â&#x20AC;&#x201C; including: MSK; Older Adults; Long term Conditions; Procedures of Limited Clinical value Mapping of Pain Pathway using innovative modelling tools - Scenario Generator Close partnership working with neighbouring PCTs including shared management of NHS Calderdale Data Quality Team Continued strengthening of partnership approaches to sharing information across local authority and voluntary sector with respect to The Dementia Strategy and Long Term Conditions. Leading Pseudonymisation Implementation Programme (PIP) within PCT and developing a repository of resources -

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Although significant progress has been taken to deliver the actions outlined within the NHS Kirklees Information and Health Intelligence Strategy, progress to improve the underlying technical infra-structure to enable data to be stored, shared and presented more efficiently and effectively has been limited due to the financial and political climate. Opportunities to maximise the benefits of existing systems are still being exploited and discussions are being taken forward with neighbouring PCTs to explore how we can work together more effectively. The outcomes from these discussions will help determine the future direction of how information services are delivered. Other areas of development planned for 2011/12 include: development of a Clinical Template Service; review of contract challenge processes and routine reports in line with policy changes. Staff are also developing their technical and specialist skills to maximise the use of available technologies and maintain a pro-active and efficient service.

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7.10 Prescribing (Medicines Management and Community Pharmacy) Director Lead: Sheila Dilks and Lead Manager: Neill MacDonald Prescribing Budgets: Prescribing budget uplift for 2010/11 has been agreed at 2009/10 budget plus 3.5%. This was a very challenging budget based on average item and cost growth for the last 5 years which has run at between 5% and 7%. In September 2010, the DH announced reductions in Category M generic drug prices equating to approximately £900,000 for NHS Kirklees. As this was viewed as a windfall saving (it was not anticipated when budgets were set), GP prescribing budgets have been rebased down by this amount in year (this equates to a budget reduction of 1.4%). Based on data to February 2011, it is anticipated that the Primary Care Prescribing budget will come in close to the allocated budget, with forecast expenditure at year end of £63,250,000 against a total budget allocation of £63,323,000. This equates to an increase in prescribing expenditure compared to 2009/10 of approximately 1.8%. This is one of the lowest increases in primary care prescribing expenditure across Y & H Strategic Health Authority area. GP Practice Support The Medicines Management team provide medicines management support to GP practices using a team of Practice Pharmacists and Pharmacy Technicians. The Medicines Management team has recently rearranged the practices that staff support such that there are now two distinct practice support teams; one supporting North Kirklees Health Alliance and another supporting Greater Huddersfield Commissioning Consortium. The work of the Practice Teams is governed by an annual work plan agreed by the Medicines Management Committee and GP commissioners. During the financial year two staff left the team and has not been replaced as part of the PCT vacancy freeze. The team currently has one member on maternity leave having recently had two members return from maternity leave. This has placed increasing pressure on the medicines management team in the delivery of the annual prescribing plan. GP Practice Prescribing Reports GP practices have been provided with quarterly reports outlining practice performance against key prescribing indicators and progress with the Medicines Management Work Plan for 201011. The progress reports were also discussed with PBC consortia prescribing leads and headlines shared with the PBC consortia executive boards. These reports are used to support ongoing conversations with practices around good prescribing practice and PCT prescribing initiatives, and have facilitated benchmarking of

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clinical practice across GP practices. The information provided to practices was refreshed for 2010-11 to reflect the Medicines Management Work Plan for 2011-12. Medicines Management QIPP Initiatives The Medicines Management team was set a challenging QIPP savings target of £1.2 million with a £1.7 million stretch target for 2010-11 for the work carried out in GP practices. The Medicines Management team has exceeded the stretch target set for the year and saved £1.87 million (annualised savings) with an in year savings effect for 2010-11 of £1.21 million. The work of the practice support team has contributed £1.59 million annualised savings as part of the work carried out in GP practices. Scriptswitch has contributed further £276,000 annualised savings. The key work areas where savings have been made are in lipid prescribing, specials, glucosamine and miscellaneous (which covers practice level individualised work areas).

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Quality Initiatives The Medicines Management team led a series of quality initiatives in practice:1. A methotrexate audit was carried out in GP practices. This was a re-audit of an audit undertaken two years ago. This demonstrated that methotrexate is not being prescribed in many GP practices in line with NPSA and shared care guidelines. It also demonstrated that there were some ongoing issues concerning communication between secondary and primary care. Actions are under way to address the issues identified. 2. The PCT ran quality initiatives as back up indicators as part of the PBC incentive scheme: a. Eleven practices carried out an audit of their medicines reconciliation processes. b. Eight practices carried out two medication reviews on care home patients on their registers. The audit summary reports returned are in the process of being collated and analysed. 3. The Medicines Management team launched a series of initiatives on antibiotic prescribing in the autumn of 2010 to improve local prescribing practice. Practice Pharmacists and Technicians had 1:1 discussions with primary care prescribers outlining detailed information on the antibiotic prescribing patterns including benchmarking data for total antibiotic prescribing, quinolones, cephalosporins and coamoxiclav. Prescribers were also given a list of the practiceâ&#x20AC;&#x;s top 20 prescribed antibiotics by volume with anomalies highlighted and discussed, and action areas identified. In addition to this work, a promotional stand was run at the PPT in September 2010, where a substantial number of prescribers came to discuss antibiotic prescribing issues and collected a printed version of the primary care antimicrobial prescribing guidelines. 4. GP practices were required to undertake two audits as part of their QOF (MM6 + MM10) a. An audit of prescribing of lithium to patients against NPSA standards. b. An audit of prescribing of inhaled corticosteroids above the maximum licensed doses to under 12s. Individual practices were required to identify local practice actions to resolve any issues identified in relation to the audits. The practice summary reports for these audits are currently being collated and analysed to identify any additional recommendations for implementation across NHS Kirklees.

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Scriptswitch project The Scriptswitch project is on track to deliver savings in excess of the investment in the software package. In addition to providing cost effective advice on prescribing, the locally developed profile has delivered a significant number of important safety messages to prescribers, which has improved awareness of key safety issues in relation to medicines. As indicated above, Scriptswitch has delivered annualised savings of ÂŁ276,000. As part of the ongoing evaluation of the project, the Medicines Management team has reviewed the effectiveness of Scriptswitch prescribing decision support in GP practices. Most practices have responded positively to using the software, and have agreed to continue to support the project. More work is being undertaken to improve the use of the software in practices, and to further improve the local profile. However, as part of the review, a number of practices have ceased using Scriptswitch software. Two additional practices have joined the Scriptswitch programme. Quality and Outcomes Framework All GP practices have had a medicines management QOF visit for 2010-11. The three Medicines Management QOF areas the GP practices worked on are: working with Practice Pharmacists and Technicians to improve cost effective prescribing in defined therapeutic areas, auditing and implementing the NPSA safety alert for lithium auditing prescribing of inhaled corticosteroids to under 12s. Engagement with practices in relation to QoF has been very good, with 65 of 72 practices having fully achieved the three QoF work objectives for medicines management for 2010/11. Medicines Management Website The Medicines Management team have worked on development of the medicines management section of the PCT website to make it more user friendly. The revised section was launched in January 2011. The website has information including copies of current guidelines, protocols, policies, formularies, Patient Group Directions, newsletters, links to Area Prescribing Committee website and resources, Specialist commissioning Group website and other prescribing advice. The management of this has been passed to a member of the team to enable new resources to be uploaded as they have been approved. Medicines Management Campaigns The Medicines Management team has launched a campaign in the autumn to improve prescribing of antibiotics in primary care. Posters, balloons and information leaflets with antibiotic prescribing letters were sent to GP practices and community pharmacies to display in public areas. The launched the new primary care antibiotic prescribing guidelines; a number of initiatives have been undertaken to support this including setting a stand up at the PPT event in September, and having 1:1 meetings with prescribers at all practices in the PCT.

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Community pharmacy Developments within community pharmacy has been maintained and ongoing service delivery sustained despite significant staffing reduction within this team due to recruitment to the Community Pharmacy Services Manager vacant post occurring 6 months into the financial year. Advanced Services There is on average over 1000 Medicines Use Reviews (MUR‟s) conducted each month by accredited pharmacists within Kirklees Pharmacies. Full year figures are not yet available but for the 10 months from April 2010 to January 2011 10,850 MUR‟s have been undertaken within Kirklees. Two new advanced services were available from April 2010. These are Appliance Use Reviews and Stoma Appliance Customisation (SAC). So far we have 3 pharmacies able to undertake both services and another 20 pharmacy offering SAC alone. In the first seven months of the year there were 63 SAC‟s undertaken through 15 pharmacies but no AUR‟s had been performed. Enhanced Services The Sexual Health Service launched in September 2009 has expanded is now available in at least 20 Pharmacies. The voucher scheme for Nicotine Replacement Therapy is being trialled in one pharmacy with the aim to progress to further rollout. To date the pilot has been a success and plans are afoot for further roll out. The number of pharmacies offering a needle exchange service has nearly doubled and now stands at 15. The Minor Ailments Pilot has been extended for an extra 6months past its initial termination date of Dec 2010 and an evaluation of this service is due to be undertaken in May 11. The Palliative Care enhanced service has been reviewed resulting in launch of the new scheme on 1st April 2011. There have been revisions to the number of pharmacies recruited to provide the service (now12 pharmacies in the scheme - 2 per locality) and an updated palliative care drug list. Review of the scheme has led to a more cost effective service with better access over evenings and weekends. The annual schedule of community pharmacy contract monitoring has been completed, with 1/3 of pharmacies inspected during 2010/11. Action plans and recommendations of all those inspected have been circulated to contractors. All pharmacies in Kirklees have now had a contract monitoring inspection visit over the past 3 years. Electronic Prescription Service (EPS) Phase 2 rollout of the Electronic Prescription Service has progressed during the course of the year with NHS Kirklees achieving Secretary of State Directions to implement EPS 2 in Feb 2011, with anticipated roll out of the service in 3 pilot GP practices during the summer of 2011. Two training evenings have been held for community pharmacy staff to explain the system

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which allows them to become sponsors and obtain Smart Cards for their staff. A nomination policy has been developed and is published on the Kirklees website. Pharmaceutical Needs Assessment (PNA) PCTs‟ were statutorily obliged to produce a PNA by 1st Feb. 2011. A project board containing Director level support and medicines management strategic leadership was developed which managed the production and publication of the PNA for NHS Kirklees. The document went out for consultation during the period 9th August to 15th October. Responses from the consultation were considered by the project board and the PNA updated for formal ratification by the PCT Board on 26th January 2011. The PNA was published on 1st February 2011 and is available on the Kirklees website. Audits & Information Governance Multidisciplinary audit for 2010/11: The multidisciplinary audit undertaken in March 2011 was on the topic of monitoring aspects of lithium therapy and adherence to the „‟Safer Lithium Therapy‟‟ Patient Safety Alert (NPSA 1st December 2009). The results will be available in May 2011. Results of 2009/10 audit: The 2009/10 audit report on quality of Medicine Use Reviews showed that 85% of patients found the process useful or very useful and pharmacists reported that patient‟s knowledge of their medicines had improved in 84% of reviews undertaken. However around half of all GP‟s did not see the benefits so further inter professional development work is needed in this area. The service specification for MUR‟s is currently under review at a national level with proposed amendments focusing target groups of patients. Information Governance (IG): By the end of March 2011, 73 pharmacies had completed a satisfactory IG return meeting the required level 2 compliance for the necessary criteria. 10 had part completed or fully completed but not submitted their on line return However 10 had not recorded any evidence of meeting the requirements. Safeguarding Training All community pharmacists and their staff were given the opportunity to undertake safeguarding training covering child and vulnerable adult protection during March 2011 at two evening events organised at Broad Lea House. Controlled Drugs The Controlled Drugs Local Intelligence Network (CD LIN) continues to meet every quarter. A number of organisations have been identified where engagement / attendance has been poor. A number of actions have been taken to address these concerns; this has resulted in two organisations engaging more effectively with the CD LIN, other actions are in progress to further improve stakeholder engagement. In September of 2010, the CD LIN held a Controlled Drugs Accountable Officers workshop. This was hosted by NHS Kirklees as LIN lead, and was well received by all participants, and has informed further developments for the LIN to undertake over the coming months. Feedback from other LINs suggests we are the only LIN in the SHA to hold a local workshop. Report Owner: Peter Flynn Report Author: The Performance Team

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Due to capacity issues, and NHS reforms, it has not been possible to undertake GP practice inspections during 2010/11. However, where controlled drugs have required witness for destruction, the approved witness has assessed if there are any concerns needing highlighting to the Accountable Officer for further action. Community pharmacy contractors continue to be monitored by the Royal Pharmaceutical Society Inspectorate (this function has recently transferred to the General Pharmaceutical Council â&#x20AC;&#x201C; the new regulatory body for pharmacists), with copies of CD inspection reports being forwarded to the CD Accountable Officer for the PCT. In the year to date 17 inspection reports have been received. Controlled drugs assessment is also included in PCT community pharmacy contract inspection reports. Any areas of concern are documented with pharmacies being given a date for resolution. CD declarations from contractors have been requested / received within the required time period. Declarations will continue to be obtained from contractors as is required. Controlled drugs use continues to be monitored, and actions taken where concerns are highlighted, these actions include meeting with contractors and referral to the PCT Performance Advisory Group and regulatory bodies as necessary. In relation to witnessing the destruction of controlled drugs, medicines management staff has witnessed destruction in 25 community pharmacies, and 3 GP practices during 2010/11. The PCT CD Accountable Officer has authorised a number of additional staff to act as authorised witnesses to ensure an adequate number of people are authorised. There have been further revisions to Controlled Drugs Prescribing Monitoring reports to enable more efficient assessment of prescribing practice, and to enable better identification of poor prescribing practice â&#x20AC;&#x201C; these are monitored on a regular basis. The speed at which Incidents involving controlled drugs have been reported to the CD Accountable Officer has improved; this is in part down to improved awareness in relation to controlled drugs following inclusion of CDs in the mandatory medicines management training. Most incidents reported have been minor in nature, often relating to adding errors. There have been some reports of missing controlled drugs, all of which have been investigated and resolved. Any learning points from incidents have been shared with staff locally to improve practice across the PCT. Community Services This area has had staffing pressures with a vacancy in the Community Services Specialist technician post for the last half of the year. In addition due to the transformational change of Kirklees Community Healthcare Service into a social enterprise, transfer of relevant staff into the new organisation has been approved including the Senior Medicines Management Advisor, LTC/IC Specialist Pharmacist and Community Services Specialist Technician posts. The following has been achieved during the course of the year:

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 Patient group directions for Holme Valley Extended Primary Care Service, CaSH Service, Smoking Cessation and the majority of immunisation and vaccination PGDs, have been reviewed and ratified.  A new policy covering the process for the development, approval and implementation of PGDs has been developed. This document outlines a new mechanism for the development and review of PGDs within NHS Kirklees, (PGDs are now the responsibility of the individual services that use them), and gives practical guidance including the minimum criteria which must be included within a PGD in order that the practice it supports is within the law.  A self-assessment questionnaire relating to Medicines Management standards was sent out to all teams and services and the results of these questionnaires compiled to highlight areas for improvement. It was planned that there would be targeted inspections based on these self assessment returns. However due to the current vacancy in the post of Community Services Technician these inspections have been delayed. In the interim a summary of the results have been distributed to all team leaders/service leads highlighting the main areas that require addressing for the majority of teams.  The Medicines Code for Maple Ward - Holme Valley Memorial Hospital, has been reviewed and updated to help ensure safe and secure prescribing, administration, transport, storage and disposal of medicines in line with current legislative requirements and best practice. Non Medical Prescribing The Non-Medical Prescribing policy has been revised and updated for use. The updated policy incorporates a change to the registration process for Community Practitioner Nurse Prescribers, which is anticipated will make the process more time efficient. Guidance around changes in legislation on use of unlicensed medicines by independent non medical prescribers and mixing of medicines has been included in the policy. To date there are 157 Community Practitioner Nurse Prescribers and 100 independent prescribers working across NHS Kirklees. This represents a steady increase in numbers of qualified non medical prescribers. Electronic prescribing is being progressed within the community nurse workforce and processes have been put in place for teams to access and store electronic prescription pads in a safe manner with an auditable trail. The terms of reference for the Non Medical Prescribing Committee have been updated to incorporate greater responsibility for medicines management within Kirklees Community health Services (KCHS). Long Term Conditions and Intermediate Care A specialist pharmacist started in post April 10 working across the patch supporting the Long term conditions (LTC) team and Intermediate care team (ICT). Achievements to date: Undertaken Medication reviews supporting Compliance/concordance in LTC and ICT patients. Also undertakes full clinical medication reviews and liaises with GP or

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Community matron as required. This work supports Key Performance Indicators for LTC team Provision of evidence based medicine advice to a wide range of people including patients, LTC matrons, case managers, intermediate care nurses, and the wider intermediate care team including intermediate care nursing home staff, generic workers, rapid response and enabling home carers. Provision of education for the teams particularly for non-medical prescribers. Support for Non Medical prescribers and those undertaking the prescribing course Clinical check of MAR chart at some ICT beds Policies, procedures, service development currently in progress: ICT medicines on admission proforma Homely remedies protocol IV administration at home by ICT nurses Ongoing work to encourage self medication as part of the rehab process in ICT beds  Medicines reconciliation on admission to ICT beds (Fieldhead Park & Batley Hall.)    

Supporting/training staff at Care homes hosting Intermediate care beds and liaising with internal and external senior managers with risk management of medication errors/incidents. Training and Education The Medicines Management Team continues to deliver Medicines Management training as part of the mandatory training programme for clinical staff. This incorporates all key aspects of medicines use, including Controlled Drugs. 84% (397) of all staff requiring such training have undertaken the programme during this financial year. Training sessions on Cold Chain and PGDs, which are delivered as part of the mandatory immunisation and vaccination sessions, have all been updated to provide a more interactive session and feedback from attendees has been very positive. These sessions are run monthly and have been delivered to approximately 194 KCHS/GP practice staff. PCT Medicines Management Committee Prescribing guidelines, local policies, prescribing plans and other support resources have continued to be developed via the Medicines Management Committee. The committee has met on average once every two months. The committee has also approved numerous Patient Group Directions, has provided comment on new and reviewed Shared Care Guidelines, has provide input into new medicines commissioning polices, and has addressed a number of patient safety issues, including the review of NPSA guidance and audits. The committee has also continued to monitor progress in relation to the development and implementation of the annual prescribing plan, including performance in relation to national prescribing indicators both at practice level and PCT level.

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The structure and functioning of the committee will need to be reviewed as GP Commissioning Consortia develop. Area Prescribing Committee (APC) Formulary and guideline review / development have continued, with revisions to the local lipid guidelines, drug monitoring guidelines, and the approval of a number of shared care guidelines. There has also been engagement work with Leeds Teaching Hospitals Trust to ensure the Calderdale, Kirklees and Wakefield APC is consulted on any shared care guidelines developed in Leeds – this will assist with continuity of care over the wider health community. It has been agreed that the Area Prescribing Committee will take on the function of the “medicines commissioning forum” and to develop common policy recommendations for PbR Tariff excluded medicines. The overarching Medicines Commissioning policy to support this has been developed following consultation with local stakeholder organisations, and was approval at PCT Board in October 2010. Following this approval, over 30 medicines commissioning policies have been developed and approved. Additional policies for development have been identified, and have been included in the APC work plan for 2011/12. All outputs of the APC are circulated to local clinicians, and are also available to download from the APC website, which is hosted on a section of the CHFT website. The continued functioning and structure of this committee will need to be reviewed as GP Commissioning Consortia develop. Wound management Formulary Development The South West Yorkshire Area Prescribing Committee wound management formulary was reviewed and published in July 2010. The updated formulary has been distributed to GP‟s, Community Pharmacists, Care Homes, Hospices, and KCHS community nursing staff and it is also available via NHS Kirklees intranet and internet websites. Medicines Commissioning Policy An overarching policy has been developed and approved by the PCT board in October 2010. This policy has been adopted by both NHS Calderdale and N HS Wakefield District, and lays the processes by which new medicines will be introduced into clinical practice locally. In addition to this, a significant number of individual medicines commissioning policies have been developed and approved through the new process. Additional work is being undertaken via the Regional Policy Sub Group of the Specialist Commissioning Group across Yorkshire and the Humber SHA for policies that have been agreed should be developed across the Health Authority area – NHS Kirklees is represented on this Sub Group by the Assistant Director of Medicines Management.

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Further development of the individual policies and the processes for policy approval will require a considerable level of staff resource to ensure that policy recommendations are based on good clinical evidence and cost-effectiveness data. Secondary Care contracting – Medicines During 2010/11, significant resource has been deployed to improve the robustness of information received from acute trusts in relation to PbR Tariff excluded drug treatments, and items that can / cannot be charged for under PbR rules. The process for commissioning high cost excluded drug treatments has also been significantly improved, with a new policy being developed and approved to guide both PCTs and acute trust providers. This work has resulted in a significant improvement in the quality of information received from acute trusts in relation to PbR tariff excluded treatments, and has led to cost reductions to the PCTs locally of between £200,000 and £300,000 over the financial year. A number of contractual clauses and standards have been agreed for inclusion in acute trust contracts for 2011/12, which will further improve the quality of service provision for patients when they attend acute trusts for treatment. Further work is ongoing to further improve the quality of information provided for PbR excluded drugs. Newsletters The medicines management team have continued to produce and circulate two regular newsletters: 1. Medicines Management Newsletter – providing guidance and advice on topical prescribing issues. This was published every 2 – 3 months throughout the year, and was sent to local contracts, and posted on the PCT website. 2. Community Pharmacy newsletter - this was published every three months throughout the year and sent to community pharmacies. This was also published on the PCT website National Patient Safety Agency Alerts The team continues to promote NPSA advice. Items have been included in prescribing newsletters, and are an integral aspect of the Scriptswitch prescribing decision support project. Pharmacy Panel During the year to date, the pharmacy panel have processed the following applications: 7 New pharmacy applications have been determined in the first half of 2010/11, of these:    

five relate to 100 hour pharmacies, all have been granted, One internet pharmacy which has been granted Two relate to standard 40 hour contracts which have not been granted. Four relates to minor relocations, which have all been granted.

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Appeals lodged with the NHS Appeals Authority – Five new appeals have been lodged in this financial year, with two additional appeals from 2009/10 being determined in this financial year. Of these:  The PCT decisions have been upheld for all seven of appeals  There are no appeals outstanding. Two applications for new pharmacies that were approved during 2010/11 have timed out, and therefore should the applicant wish to pursue these, they will be required to re-apply. As at 31st March 2011, there were 97 community pharmacies across Kirklees, this represents an increase of 4 on 31st March 2010. With applications that have been approved, but where the pharmacy has not yet opened, this would further increase the number of community pharmacies from 97 to 99. Dressings Procurement Pilot The outcomes of this have been re-evaluated, including financial, staff and other factors. This indicated that in relation to financial aspects, overall the pilot scheme cost slightly more overall than using the existing FP10 prescription route. In relation to the quality assessment, the pilot was viewed by staff involved in the process as being more convenient and efficient then the FP10 prescription route. However, a full evaluation paper that considered all implications for alternative supply routes in the longer term recommended that the alternative supply pilots be decommissioned as the benefits did not outweigh the risks – this was agreed at the Medicines Management Committee and the Business and Financial Planning Committee. Incidents and investigations The medicines management team have assisted with or undertaken a number of investigations in respect to incidents. These relate to KCHS incidents (medicines administration), community pharmacy (dispensing incidents / delivery of medicines), and GP practices (prescribing errors), with some of these relating to controlled drugs. Findings and recommendations have been made in respect to these to the appropriate parties, including risk management, and feedback has been provided to share as learning points with staff. In addition to incidents involving primary care contractors and KCHS staff, a number of local incidents relating to medicines have been attributed to local acute trusts. The PCT and acute trusts have worked together to investigate these, with any shared learning points being disseminated to local clinicians and other staff as appropriate to improve the quality of care and reduce patient risk. A number of these relate to medicines at discharge. Statistics in relation to medicines related incidents are collated via the datix system by the risk management team.

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