Hillingdon CCG Commissioning Intentions 2015/16 Page 1 Finance Report Month 3 2012-13 Commissioning Intentions 2015/16 Ian Goodman, Chair of the CCG Ceri.

Hillingdon CCG Commissioning Intentions 2015/16 Page 1 Finance Report Month 3 2012-13 Commissioning Intentions 2015/16 Ian Goodman, Chair of the CCG Ceri Jacob, Chief Operating Office

Hillingdon CCG Commissioning Intentions 2015/16 Page 2 Contents Glossary of Terms About Hillingdon CCG & Aim of the Commissioning Intentions Inputs into the Commissioning Intentions Hillingdon CCG’s Vision for Quality Health Challenges in Hillingdon NHS England’s 8 Focus Areas North West London – The Strategic Context Shaping a Healthier Future (SaHF) Collaborative Projects Across NWL and BHH Personal Health Budgets Hillingdon’s Health Landscape Feedback from Patients & Carers The Provider Market in Hillingdon QIPP Requirements for 2015/16 Commissioning Principles for 2015/16 Commissioning Priorities for 2015/16 Commissioning Intentions QIPP Projects QIPP Financial Planning Summary 2015/16

Hillingdon CCG Commissioning Intentions 2015/16 Page 3 Glossary of Terms TermMeaningTermMeaningTermMeaning A&EAccident & Emergency DepartmentFUP/sFollow Up AppointmentsPCIPractice Commissioning Iniative AECAmbulatory Emergency CareGPGeneral PractitionerPHBsPersonal Health Budgets AIDSAcquired Immune Deficiency SyndromeHCCGHillingdon CCGQIPP Quality, Innovation, Productivity & Prevention BCFBetter Care FundIAPT Improving Access to Psychological Therapies RBHRoyal Brompton & Harefield NHS FT BHHBrent, Harrow & Hillingdon CCGsICPIntegrated Care ProgrammeRTTReferral to Treatment CAMHSChildren’s & Adolescent MH ServicesIM&TInformation Management & TechnologySaHFShaping a Healthier Future CCGClinical Commissioning GroupLALocal AuthoritySSoCShifting Settings of Care CHCContinuing Health CareLASLondon Ambulance ServiceTBTubercolosis CHDChronic Heart DiseaseLBHLondon Borough of HillingdonTHHThe Hillingdon Hospital NHS FT CHFChronic Heart FailureLDLearning DisabilityUCCUrgent Care Centre CIP/sCost Improvement Programme/sLTCLong Term ConditionWSICWhole Systems Integrated Care Project CMCCoordinate My CareMHMental HealthWTEWhole Time Equivalent CNWLCentral North West London NHS FTMIUMinor Injury Unit COPD Chronic Obstructive Pulmonary Disorder MMTMedicines Management Team CVDCardio-Vascular DiseaseMSKMusculo-Skeletal CYPChildren & Young PeopleNHSENHS England DHDepartment of HealthNWLNorth West London EDEmergency DepartmentOBCOutline Business Case ENTEar, Nose & ThroatOOAOut of Area FTFoundation TrustOOHOut of Hospital or Out of Hours

Hillingdon CCG Commissioning Intentions 2015/16 Page 4 About Hillingdon CCG & Aim of the Commissioning Intentions About Hillingdon CCG Hillingdon Clinical Commissioning Group (CCG) is the public agency responsible for purchasing all of the health services for the people of Hillingdon. We operate within a financial budget and aim to ensure that we use the money given to us to purchase health services that are appropriate, effective, safe and offer value for money. Our stated vision is to: “Ensure that the residents of Hillingdon can access high quality, evidence-based care in a setting appropriate to their needs by transforming the way care is delivered to keep Hillingdon people healthy, independent and enjoying a better quality of life Aim of the Commissioning Intentions The aim of these Commissioning Intentions are to provide an overview of Hillingdon CCGs plans to purchase (commission) high quality health care to improve the health outcomes for Hillingdon’s registered patients for the financial year 2015/16 and to set the scene for how we envisage services developing over the next 3 years. In achieving the aim of these Commissioning Intentions we have sought to engage our patients, carers and the wider public along with our member practices and other providers and have drawn on a wide range of sources of information and feedback as shown on the next page. The Commissioning Intentions are a living document that will evolve over time based on further engagement activities with the public, partners and providers.

Hillingdon CCG Commissioning Intentions 2015/16 Page 5 Inputs into the Commissioning Intentions 2015/16 Commissioning Intentions Joint Strategic Needs Analysis Joint Health & Wellbeing Strategy Feedback from Patients & Carers Health Care Providers CCG Board Local Authority Healthwatch North West London Health Care Strategy NHS England CCG 5 Year Strategy CCG Outcomes Framework Voluntary Sector

Hillingdon CCG Commissioning Intentions 2015/16 Page 6 Hillingdon CCG’s Vision for Quality Hillingdon CCG’s ‘vision for quality’ is that that every person deserves a quality and safe experience wherever they are cared for in NHS services, and our ambition is to work with the providers of services to continually improve in order that this will be the case. Quality at the heart of our commissioning cycle. Our quality strategy outlines the framework for ensuring that quality is at the heart of everything we do. It is built around the priorities identified by Hillingdon Clinical Commissioning Group (CCGs) for commissioning high quality healthcare services for its residents. Our local framework for quality is informed by national policy for delivering quality and patient experience, and is set against three main drivers:  Planning for high quality services  Developing and commissioning high quality services  Assuring the services we have commissioned deliver a quality service Our quality strategy covers: Quality Governance: The Governing Body has agreed a quality assurance structure for identifying; monitoring and challenging quality in the organisations we commission services from. Good quality information is a pre-requisite to understanding current services, for gaining improvement and planning future services. It supports our role to commission the right services and best possible care for our resident population. Quality Assurance: We take responsibility for Quality Assurance by holding providers to account for delivery of contractual obligations and quality standards. We also take responsibility for working closely with providers to ensure service delivery continually improves and that they have in place processes to drive this continual improvement including the adoption and sharing of innovation. We have a system of quality assurance and early warning processes in place which provides information about the safety, effectiveness and patient experience of services we commission. This system enables us to be proactive in identifying early signs of concerns and take action where standards fall short. Patient Experience: Using guidance from The Department of Health’s ‘Building on the Best: Choice, Responsiveness and Equity in the NHS (DH, 2003)’ and their Patient Experience Framework, we will monitor elements that are critical to the patients’ experience of services we commission. Quality Improvement & Learning: We are committed to improving quality and sharing learning and best practice and to using this information to inform commissioning decisions at each stage of the commissioning cycle. Quality Goals: Our priorities build on national policy, our commissioning strategy, and areas of higher risk and identified concerns. We have set ourselves three specific quality goals for the lifetime of our strategy:  Compliance with National NHS Constitution expectations  Delivery of local quality improvement objectives  Delivery of a quality team operational work plan

Hillingdon CCG Commissioning Intentions 2015/16 Page 7 Health Challenges in Hillingdon Unplanned Care The number of patients attending A&E at Hillingdon Hospital is increasing and there is an increase in the number of admissions. Fewer patients are being taken home via our Intermediate Care programme and utilising the Ambulatory Emergency Care pathway than we had expected. Planned Care The number of patients being referred for onward treatment by GPs is increasing and whilst many are being routed to community based services we have not seen the expected reduction in Outpatient activity we had expected. Long Term Conditions Hillingdon has a large number of patients suffering from Long Term Conditions and we must continue to both help identify patients who currently have undiagnosed conditions as well as supporting those already identified to manage their conditions more effectively. Mental Health Approximately 55,000 people in Hillingdon suffer with a mental health condition and yet Hillingdon has an under- diagnosis of depression/anxiety compared to similar boroughs and an increasing attendance at A&E for Mental Health issues. Primary Care We must continue to work with GP Practices to help them manage more patients in primary care and also improve the ability of practices to adhere to the pathways so that patients are routed correctly and safely to the right care setting.

Hillingdon CCG Commissioning Intentions 2015/16 Page 8 NHS England’s 8 Focus Areas A&E Referral to Treatment (RTT) CancerDiagnosticsHealth VisitorsIAPTDementiaWinterbourne NHS England is an executive non- departmental public body of the Department of Health. NHS England oversees the budget, planning, delivery and day-to-day operation of the NHS in England as set out in the Health and Social Care Act 2012. NHS England work with NHS staff, patients, stakeholders and the public to improve the health outcomes for people in England and have indicated that they wish CCGs to prioritise these 8 issues in 2015/16.

Hillingdon CCG Commissioning Intentions 2015/16 Page 9 The Strategic Context Hillingdon CCG is one of 8 CCGs covering the inner and outer areas of North West London. These 8 CCGs are involved in strategic redesign activities that affects the design of health care services across North West London in a programme entitled “Shaping a Healthier Future” (SaHF). Hillingdon CCG’s Commissioning Intentions fit within this structure as shown in the diagram below. IM& TEstatesWorkforce Primary Care Development Plan LTC Strategy & Delivery Plan Mental Health Strategy & Plan OOH Delivery Plan Integration Plans BCF & WSIC Financial Recovery Plan Primary Care Led Networks Out of Hospital Strategy Shaping a Healthier Future (SaHF) – North West London Commissioning Intentions

Hillingdon CCG Commissioning Intentions 2015/16 Page 10 Shaping a Healthier Future (SaHF) SaHF Acute Reconfiguration The acute reconfiguration programme in NW London will centralise the majority of emergency and specialist services (including A&E, Maternity, Paediatrics, Emergency and Non-elective care) to deliver improved clinical outcomes and safer services for our patients. Agreed acute reconfiguration changes will result in a new hospital landscape for NW London – the SaHF Reconfiguration programme will oversee: The existing hospital landscape of nine hospitals reconfigured to provide five Major Acute Hospitals; Ealing and Charing Cross sites redeveloped, in partnership with patients and stakeholders, into Local hospitals; Hammersmith Hospital established as a specialist hospital; and Central Middlesex Hospital will be redeveloped as a Local and Elective Hospital. The programme supports the achievement of enhanced clinical standards. As part of the original development of NW London’s vision, NW London’s clinicians developed a set of clinical standards for Maternity, Paediatrics, and Urgent and Emergency Care, in order to drive improvements in clinical quality and reduce variation across NW London’s acute trusts. These clinical standards, along with the London Quality Standards and the national Seven Day Services Standards, will underpin quality within the future configuration of acute services, including along the urgent and emergency care pathway. North West London is committed to delivering seven day services across the non-elective pathway by March 2017, based on the national clinical standards, in order to improve the quality and safety of services and to support emergency care flow. The acute reconfiguration is dependent on significant take-up of existing and new out of hospital services being delivered locally by all CCGs to ensure that patients only go to hospital when they need to. As part of a common commitment across NW London, CCGs will commission services from Acute Trusts that meet the agreed clinical standards, including those defined by the Shaping a Healthier Future programme, London Quality Standards, and national Seven Day services standards. In 2014/15 the baseline of delivery against the Seven Day standards has been established, and a NWL prioritisation has been agreed to guide the sequencing of Seven Day standard achievement through until March 2017. Following the ‘full’ support of the Secretary of State in October 2013 following the review of the Independent Reconfiguration Panel, priority service changes are being delivered in 2014/15: Transition of services from the Emergency Unit at Hammersmith Hospital Transition of services from the A&E at Central Middlesex Hospital All Urgent Care Centres (UCCs) moved to a common operating specification, including a 24/7 service The programme has also been undertaking contingency planning for the potential transition of Maternity and Paediatrics services at Ealing Hospital

Hillingdon CCG Commissioning Intentions 2015/16 Page 11 Shaping a Healthier Future (SaHF) Outline Business Cases (OBCs) will be developed and centrally reviewed for all sites in 2014/15 (major and local hospitals) additionally the programme is also developing an Implementation Business Case (ImBC) to ensure that the refined solution for NW London remains affordable and aligned with the clinical vision. OBCs for Major and Local Hospitals are expected to be approved by NHSE, NTDA, DH and HMT in 2015/16, and following this Full Business Cases will be developed to allow the redevelopment of sites to continue. SaHF Primary Care Transformation A number of drivers have combined to create a pressing need to transform access to General Practice in NW London: Patient expectations: in a recent survey of NWL patient priorities for primary care, seven of the top ten issues related to improved access. Implementation of the Shaping a Healthier Future reconfiguration programme: The Independent Reconfiguration Panel (IRP) report on NWL’s Shaping a Healthier Future (SaHF) programme requires GP practices in NW London to move towards a ‘seven day’ model of care to support the agreed changes to acute services. Contractual drivers: With effect from April 2014, GMS contractual arrangements have been amended to reflect an increased emphasis on improved access to General Practice. Financial drivers: A consistent, system-wide access model has the potential to reduce costs for both commissioners (reduced service duplication) and providers (more efficient use of resources). Though it may be part of the solution, expanding capacity alone will not improve access to General Practice. There are several reasons for this: Funding: It is financially unsustainable for every GP practice in NW London to operate 8am – 8pm, 7 days a week. Workforce: There are not enough GPs and nurses in NW London for every GP practice to operate 8am – 8pm, 7 days a week. New demand: Likely that increasing the number of appointments would cater for unmet need instead of re-distributing existing demand. More of the same: Still wouldn’t give the public the type of appointments they want (e.g. doesn’t make use of new technology to offer different types of appointment and make booking appointments more convenient). Any strategy for widening access to General Practice must therefore comply with four overarching goals: 1.System-wide reconfiguration of access to all ‘General Practice’-type services: the provision of additional urgent appointments outside of core hours is unlikely to lead to sustainable improvements to access. In order to ensure that we are able to deliver services that genuinely reflect patient needs and preferences, we need to be thinking about seven day working across General Practice in its totality 2.Financially and operationally sustainable: a new model must be affordable and deliverable. In the long-term this probably means no net increase in cost or workforce 3.Meets patient expectations: a new model must deliver the type of appointments patients want, when they want them. 4.Reconfigures both supply and demand such that both are mapped more closely to clinical need: Though patient choice should be respected, every effort should be made to ensure that patients receive care appropriate to their clinical condition. This means mapping capacity more closely to clinical need.

Hillingdon CCG Commissioning Intentions 2015/16 Page 12 Shaping a Healthier Future (SaHF) NW London were awarded funding through a successful application to the Prime Minister’s Challenge Fund. This is now a significant enabler to delivery of NW London’s vision for a transformed primary care landscape in allowing, through a combination of NWL and NHSE funding: Extending GP access and continuity in the short term (by the end of 2014/15) Putting in the right support in place to nuture and grow GP networks (in 2014/15 and beyond) The Challenge Fund will focus on outcomes around Urgent, Continuity and Convenient Care to ensure that patients have access to General Practice services at times, locations and via channels that suit them seven days a week SaHF Mental Health Transformation In 2015/16, CCGs wish to see continued implementation of Shaping Healthier Lives, 2012-15 core initiatives including: Urgent Care: roll out of the SPA and 24/7/365 access to home-based urgent assessment and initial crisis resolution work. Liaison Psychiatry: further benchmarking of services to drive increased standardisation of investment, activity, impact and return on investment. Whole Systems/Shifting Settings: building on work to date to implement primary care plus, to test, refine and roll out a new model of ‘community staying well’ services for people with long-term mental health needs, providing the GP (as accountable clinician) with a range of care navigation, expert primary mental health and social integration/recovery support services to deliver care closest to home and prevent avoidable referral to secondary. In 2014/15, the Board has sponsored development work streams in dementia, learning disability, perinatal mental health and IAPT. CCGs will wish to see providers of service implement the key pathway, models of care and quality standards that emerge from these work programmes. Regarding CAMHS OOH, CCGs will be commissioning a new provider of service, following that service review, due to be complete early Autumn 2014. The Board commenced review of the extant strategy, Shaping Healthier Lives, in December 2013. A new vision statement was agreed in March 2014, reflecting a much broader, recovery and prevention Mental Health and Well-being Strategy, required for 2015 onwards. This is currently under development and agreement across the 8 CCGs and LAs, Metropolitan Police, both mental health NHS provider Trusts, Third Sector, Users and Carers. CCGs will issue a tender to take this programme of work forward and will wish all providers to be engaged in development and delivery in 2015/16.

Hillingdon CCG Commissioning Intentions 2015/16 Page 13 Collaborative Projects Across NWL and BHH Hillingdon CCG, along with Brent and Harrow CCGs and, where appropriate, our other partner CCGs across North West London (NWL) are exploring opportunities to collaborate in the following areas; Mental Health projects we will seek to work on with all 8 NWL CCGs: Development of Children & Adolescents Mental Health Services (CAMHS), Strategic review of Dementia Services, Mental Health pathways for patients with Learning Disabilities, Expanding the Shifting Settings of Care programme to additional conditions, Strategic review of Perinatal Mental Health services and Development of consistent Urgent Access and Urgent Care Pathways. Mental Health projects we will seek to work on with Brent and Harrow CCGs: IAPT Market Development and increasing access to 15% of the target population and Commissioning a new service model for Psychiatric Liaison including new payment arrangements. Planned Care: We will work with the 8 NWL CCGs to develop and commission a revised spinal pathway. Continuing Health Care (CHC) and Personal Health Budgets (PHBs): The Brent, Harrow & Hillingdon CCGs (BHH) will respond to the Department of Health (DH) audit report and implement the findings from it. See the next section regarding PHBs. Medicines Management: The BHH CCG’s Medicines Management Teams (MMTs) will collaborate to share expertise and resource. Integrated Nursing: The BHH CCGs will share information and may work together to redesign the baseline service specification and procure an integrated nursing service. Whole Systems Integrated Care (WSIC): The 8 NWL CCGs collectively form one of 14 national ‘Pioneers’ in the development of WSIC and will continue our commitment to working together throughout 2015/16 in the development of this programme.

Hillingdon CCG Commissioning Intentions 2015/16 Page 14 Personal Health Budgets (PHBs) In 2009, the Department of Health launched a national pilot programme to look at the viability of personal health budgets in England (Department of Health, 2009). The pilot programme involved over 70 primary care trusts and covered a range of long- term conditions (chronic obstructive pulmonary disease, diabetes, long-term neurological conditions, mental health and stroke), NHS continuing health care, maternity care and end of life care, with 20 sites involved in an independent, in-depth evaluation. On 30 November 2012, the Government published the results of the evaluation. The evaluation concluded that personal health budgets are cost-effective (with certain caveats) and thus supported a wider roll-out. Following this recommendation, the government confirmed its intention that, as of April 2014, individuals in receipt of NHS continuing health care funding will have the right to request a personal health budget. This will include an extension of the programme to cover children with special educational needs and disabilities, who will be able to have an integrated budget across the NHS, social care and education. As of 2015, clinical commissioning groups are expected to be able to offer a personal health budget to anyone with a long-term condition who could benefit. For commissioners, personal health budgets offer a new tool to support self-management and care planning, in line with the Government’s mandate to the NHS to place greater emphasis on patients as partners in the management of long-term conditions. Hillingdon CCG has been working with Hillingdon Council in a Partnership arrangement to implement and manage the Personal Health Budgets direct payments service. It takes around 3 months to set a Direct Payment for Healthcare. Together we have developed the following: A service Specification ( in final draft) My Support Plan PHB patient agreement forms Public Leaflet Access to DASH ( voluntary organisation) Access to Pay Packet ( who run payroll services) Access to the pre-paid card service Financial Monitoring Fraud Prevention We will continue to work with our partners to ensure the effective introduction of PHBs in line with the Department of Health’s recommendations.

Hillingdon CCG Commissioning Intentions 2015/16 Page 15 Hillingdon’s Health Landscape – Demographics Hillingdon has the second largest area (116 km2) of London's 33 boroughs with the 13th largest population. The overall size of the population for the London Borough of Hillingdon is shown in the following table. National Statistics, Census-based sub-national population projections (SNPP)2015295,000 Greater London Authority(GLA) 2012 round projections (SHLAA incorporating DCLG)2015292,000 Hillingdon Clinical Commissioning Group (CCG) GP registered population2013289,000 Greater London Authority GP registered population residing in Hillingdon2013301,000 SNPP and GLA estimates are used in this report The population pyramid shows the population of Hillingdon by age band and gender and contrasts it with the population of London and the population of England as a whole. The populations for England and London are scaled so the proportion of the population in each age band can be compared with Hillingdon. The age structure of the population in Hillingdon is intermediate between that for London and that for England, with, for the most part, a distribution that is older than London as a whole but younger than England. Among teenagers and young adults, however, there is a larger proportion resident in Hillingdon than for London overall or for England as a whole.

Hillingdon CCG Commissioning Intentions 2015/16 Page 16 Hillingdon’s Health Landscape – Population Growth Projections The number of people in the following age bands are expected to increase in the next 5 years: 5-17, 25-39, 40-64. All the other age bands are expected to increase only slightly or remain flat until 2020 The population increase in Hillingdon over the next 5 years is expected to be 7.2% (around 1.4% per annum). The corresponding 5-year increase in London is 6.4% and in England overall is 4.1%. The main driving force behind the increase in the population between 2015 and 2020 is natural change, i.e. 15,000 more births than deaths. Net migration is expected to account for around 6,300 persons over the same period.

Hillingdon CCG Commissioning Intentions 2015/16 Page 17 Hillingdon’s Health Landscape – Population Growth Projections Total Population By Year AREA20122013201420152016201720182019 England 53,493,700 53,843,600 54,227,900 54,613,400 55,019,800 55,414,500 55,811,800 56,198,300 London 8,308,400 8,418,300 8,530,500 8,641,400 8,759,000 8,870,600 8,982,000 9,088,000 Brent 314,700 317,200 319,800 322,400 325,400 328,200 331,100 333,700 Ealing 340,700 344,100 347,600 351,100 355,000 358,600 362,200 365,600 Harrow 242,400 245,000 247,900 250,800 253,800 256,800 259,700 262,600 Hillingdon 281,800 286,400 291,100 295,700 300,400 304,900 309,300 313,500 Hounslow 259,100 263,400 267,800 272,000 276,500 280,600 284,600 288,400 Cumulative Percentage Population Increase From 2012 AREA20122013201420152016201720182019 England 100 101 102 103 104 105 London 100 101 103 104 105 107 108 109 Brent 100 101 102 103 104 105 106 Ealing 100 101 102 103 104 105 106 107 Harrow 100 101 102 103 105 106 107 108 Hillingdon 100 102 103 105 107 108 110 111 Hounslow 100 102 103 105 107 108 110 111 Comparatively, the population growth in Hillingdon is projected to be higher than any other North West London CCG other than Hounslow and will be above both the average for London and England. The absolute population growth projection numbers used in the graph opposite are incorporated into the table below.

Hillingdon CCG Commissioning Intentions 2015/16 Page 18 Hillingdon’s Health Landscape – Ethnic Breakdown In 2015, 29% of the population are of south Asian extraction and 10% self report as being “black African”, “black Caribbean” or “mixed black and white”. These proportions are set to rise over the next five years both because of numerical increase in these population groups and also because of a net decrease in the population who self-report as “white”. Given that several diseases (eg. diabetes, CVD, dementia) are more prevalent in the non-white population, this may have implications for future demand on health care.

Hillingdon CCG Commissioning Intentions 2015/16 Page 19 Hillingdon’s Health Landscape – Older People This graph shows the percentage of the population who are aged 60 years and over in each ward. The proportion of those people that are living in relative poverty is also shown. The graph shows that the proportion of people in Ruislip & Northwood locality who are older is high but the proportion of older people living in deprivation is higher in the other two localities. The second graph shows the actual numbers of older people living in deprivation by ward. The area with the greatest number of older people living in deprivation is Hayes & Harlington. Deprivation in older people is associated with poor health outcomes. Therefore this has implications for health and care services.

Hillingdon CCG Commissioning Intentions 2015/16 Page 20 Hillingdon’s Health Landscape – Influencing Factors There are a number of influencing factors that need to be considered in planning health services for the people of Hillingdon and these are expanded upon below. Language Barriers There are some wards where the number of people (aged 3+) who cannot speak English or cannot speak English well number more than 2000; these are Townfield (7%), Barnhill (7%), Pinkwell (6%) and Botwell (6%). The implication being that additional translation support may be required when patients from this demographic present for treatment. However, it is also likely that the younger patients in these areas will develop bilingual capabilities sooner rather than later. Infant Mortality The infant mortality rate (before the infant’s first birthday) in Hillingdon (4.0 per 1,000 live births) was slightly lower (not statistically significant) than the average for London and England (both 4.1 per 1,000 live births). TB The TB rate (2010-12) in Hillingdon is in the band 47.8 per 100,000 population, higher than the 2011 UK rate (15.1 per 100,000). Those born outside of the UK continue to account for the majority of TB cases, with India, Pakistan and Somalia the most common countries of origin. Some of this is possibly a consequence of the presence of adult immigration holding centres based within the borough and unaccompanied minors arriving at Heathrow airport without papers who become the responsibility of Hillingdon Local Authority. However, in the main many have been resident here for long periods of time prior to their TB diagnosis. Cervical Cancer Screening Cervical cancer screening coverage is lower in Hillingdon (67.1%) than either London (68.6%) or England (76.3%). This may reflect lower uptake in minority ethnic communities. Injuries Due To Falls With regard to injuries due to falls, Hillingdon performs worse than London for all but one metric among older people (the 65-79 age band). Hillingdon performs worse than England for all age gender bands among older people.

Hillingdon CCG Commissioning Intentions 2015/16 Page 21 Hillingdon’s Health Landscape – Influencing Factors Other lifestyle factors and risky behaviours contribute enormously to long-term (and short-term) health. The most significant of these in the Hillingdon area are shown below: Excess weight & obesity: In Hillingdon, 67.2 % of adult population is estimated to be overweight or obese. This is higher than London (57.3%) and England (63.8%) Physical Inactivity: In Hillingdon, among adults, 30.7% are recorded as being physically inactive. This is higher than London (28.4%) or England (28.9%) Smoking: The estimated 2012 prevalence of smoking in Hillingdon (17.5%) is lower than the estimated proportions for England (19.5.0%) and London (18.0%). Alcohol: Alcohol attributable hospital admissions are worse (higher) than the England average. Conception: Conception rates for females aged <18 years in Hillingdon are 27.7%, identical with the rate for England but higher than that in London as a whole. There are some illnesses or conditions where Hillingdon may be performing less well than other areas, these include: Communicable diseases Mortality from communicable diseases among Hillingdon residents, taking into account the age of the population is higher (76.8 per 100,000) than either London (68.1 per 100,000) or England (64.8 per 100,000). Depression and anxiety Hillingdon has the lowest standardised prescribing of antidepressants in the “Thriving London Periphery” cluster. It also has the lowest rate of people entering psychological therapies (IAPT) (187.68 per 100,000) in the “Thriving London Periphery” cluster. Dementia Epidemiological models suggest that there are around 2,500 Hillingdon residents living with dementia in 2014, while GP registers find around 1,100 people.

Hillingdon CCG Commissioning Intentions 2015/16 Page 22 Hillingdon’s Health Landscape – Focus for Public Health There are a number of areas of ongoing public health work that can help to inform and also support commissioning intentions moving forward and the most important of these are listed below: In addition, Public Health have highlighted the following areas where the health landscape in Hillingdon is more than 3 standard deviations from the national average: Nurse Staffing Per Bed Patient Safety Incidents Reported In addition, our co-morbidity index is very low suggesting that across the board in both elective and emergency care Hillingdon is admitting ‘weller’ patients than the rest of the country. NEEDS ASSESSMENT Mental Health Suicide Prevention Substance Misuse Children and Young People including CAMHS Learning Disability Pharmaceutical Needs Assessment HEALTH IMPROVEMENT PLANS Mental Wellbeing Dementia Friends Early years Smoking Cessation Obesity Strategy and Action Plan Development HEALTH SERVICES CONTRACT Sexual Health Substance Misuse Local Authority Primary Care Contracts

Hillingdon CCG Commissioning Intentions 2015/16 Page 23 Feedback from Patients & Carers How we gathered patient and stakeholder feedback We ran Co-Production Workshops involving patients, carers, providers, clinicians, Healthwatch and the voluntary sector. We gathered information through the NHS’s Friends & Family Test. We reviewed the Complaints & Compliments we had received. We drew lessons and feedback from the following surveys and reports produced between June 2013 and June 2014: o Integrated Care Programme Patient & Carer Consultation report o Hayes & Harlington Outreach project report o Diabetes Self-Management Education Pilot with South Asian Communities in Hayes & Harlington o Medicines Management Team Diabetes Focus Group Report o Better Care Fund Public Meeting Q&A Summary o Carers Impact Assessment Report Write Up o Dermatology Briefing Assessment o MSK & Adult Mental Health Friends & Family Test Pilot Report o Commissioning Intentions Report o Safeguarding Engagement with Children & Younger People o Wheelchair Focus Group

Hillingdon CCG Commissioning Intentions 2015/16 Page 24 Feedback from Patients & Carers What Patients & Carers Told UsWhat We Will Do About It Patients want to take control of their health through education, involvement in decision making, better care planning and advice on what to do should a crisis arise. Care planning should also involve community and voluntary sector partners and should cover both Mental Health and Physical Health conditions We will expand our Health Champions programme. We will continue to improve the effectiveness of our Integrated Care Programme and in particular enhance Crisis Planning activities. We will look to commission MH services to support patients with Long Term Conditions. We will continue to seek better ways of educating and empowering patients to self-manage. Patients want to be made more aware of alternatives to receiving treatment other than attending A&E. We will work with public health and through our relevant programmes to provide patients and carers with information to enable them to make informed decisions about where their care is delivered. Patients are experiencing problems in accessing GP support particularly Out of Hours. This is a particular issue for ethnic minorities and travellers. We will undertake a review of Out of Hours support. We will look to develop services targeting hard to reach and disadvantaged groups to enable them to avoid having to go to A&E. Patients want consultant led community clinics and services that enable them to spend less time travelling to and from appointments. We will continue to focus on developing Out of Hospital services for planned care activities. Patients want better management of pain. We will be introducing a new pain management pathway during 2014/15 and this will be expanded during 2015/16. Patients want an overhaul of Mental Health support including better crisis planning for patients with known conditions, access to holistic services including benefits advice, a focus on both their mental and physical health needs and a continuing reduction in the stigma associated with mental health conditions. In addition, they mentioned specific concerns about the Riverside Centre’s ability to cope with demand and the need for increased access to talking therapies. We will undertake a review of Mental Health support across Hillingdon. We will continue to invest in and expand our IAPT services to provide more opportunities for talking therapies. We will undertake a review of the Riverside Centre. We will continue to look at opportunities to eliminate the stigma associated with Mental Health conditions. Patients and Carers want more involvement in the decision making processes that affect how and what services are commissioned and delivered. We will undertake Co-Production Workshops for all new pathways. We will rollout the Friends & Family Test across entire pathways.

Hillingdon CCG Commissioning Intentions 2015/16 Page 25 The Provider Market in Hillingdon in 2015/16 Primary Care We will continue to focus on supporting the emerging GP Networks to enable them to coordinate care and enhance services provided in primary care. We will strengthen our Primary Care Initiative (PCI) programme to support GP Practices to enable them to better understand the changes we are making to the health economy in Hillingdon. We will look to support more patients in primary care as outlined in our Out of Hospital Strategy. We will continue to be closely aligned with the North West London Primary Care Transformation programme that forms part of the Shaping a Healthier Future (SaHF) structure. Community Care We will seek to redesign community services to support our Out of Hospital strategy. We will look to integrate community services more closely in the empowerment of patients with Long Term Conditions and supporting children and vulnerable patients at risk of being admitted to hospital. We will work with our community nursing service to develop collaborative approaches to service delivery We will actively explore approaches to integration of nursing services. We will seek to improve overall productivity within our existing contracts and will selectively seek to test the market where productivity cannot be achieved in areas such as Community Equipment, Wheelchair Services, Tissue Viability and others.

Hillingdon CCG Commissioning Intentions 2015/16 Page 26 The Provider Market in Hillingdon in 2015/16 Mental Health We will continue to focus on ensuring that patients are treated in the most appropriate setting through our Shifting Settings of Care Programme. We will work to achieve the productivity levels identified by NHS England in regards to IAPT and to seek to reach the 15% prevalence target. We will look to shift from bed based to community based care across the contract to enable us to fund and support our Dementia Strategy based on the future needs identified for the population of Hillingdon. We will work with our partners in the North West London CCGs to procure CAMHS services (including LD CAMHS) and to define an Urgent Care Pathway. We will seek to improve care and crisis planning for patients with mental health conditions to reduce the numbers attending ED. We may seek to undertake a procurement exercise for some or all mental health services to improve overall productivity. Acute Care The Hillingdon Hospitals NHS Foundation Trust (THH) is a ‘fixed point’ within the SaHF programme and therefore will remain as an acute hospital with elective and non-elective functions although we will continue to work with our other acute providers. We will continue to focus on managing the numbers of patients attending ED through developing new pathways within the UCC, working closely with the London Ambulance Service, undertaking clinical audits to understand changes in activity and focusing on safely avoiding admissions wherever possible. We will continue to focus on reducing referrals to Outpatients and moving more activity into the community wherever this can be achieved safely without increasing risk to patients. This approach supports the delivery of our Out of Hospital Strategy. We will continue to seek to obtain value for money from all of our acute providers and will test the market where we are unable to achieve the required productivity improvements.

Hillingdon CCG Commissioning Intentions 2015/16 Page 27 The Provider Market in Hillingdon in 2015/16 Voluntary & Third Sector We will work with voluntary and community groups to support proactive early identification of people who would benefit from lifestyle coaching, care navigation and behaviour change programmes and self directed care. We will provide opportunities for voluntary and community groups as part of new provider networks, including methods to assess social value and patient motivation factors. We will ensure that the development of provider markets include voluntary and community organisations eg IAPT We will ensure effective use of the voluntary sector to support access from hard to reach or seldom heard communities.

Hillingdon CCG Commissioning Intentions 2015/16 Page 28 QIPP Requirement for 2015/16 The Quality, Innovation, Productivity and Prevention (QIPP) programme is a large-scale programme developed by the Department of Health to drive forward quality improvements in NHS care, at the same time as making efficiency savings. Hillingdon CCGs QIPP requirement for 2015/16 and beyond is determined by the assumptions stated in our Financial Recovery Plan which include: o A 2% growth in funding levels per year over the period from 2014/15 to 2018/19. o QIPP delivery is expected to be a net 4% per annum. This equates to approximately £12.7m for 2015/16. o There is no new recurrent investment from 14/15 onwards over and above any demographic and/or non-demographic growth that might be applied to any or all schemes. The delivery of QIPP efficiency targets allows Hillingdon CCG to ensure that essential services remain funded and operational and can cope with the demands placed upon them. Failure to achieve the QIPP efficiency targets means that Hillingdon CCG will not be in a position to fund specific services and will need to scale back activity. For 2015/16 we will continue to work with CNWL and THH to achieve our QIPP targets and support the costs they need to release to achieve these. Currently the CCG has not identified sufficient QIPP schemes to achieve the £12.7m target. Work is on-going and further to these commissioning intentions there will be a requirement for additional discussions with providers on new schemes. These discussions and changes will follow normal contracting processes.

Hillingdon CCG Commissioning Intentions 2015/16 Page 29 Commissioning Principles Hillingdon CCG’s Commissioning Principles for 2015/16 remain to: Commission high quality, clinically effective care with a robust evidence base. Demonstrate and evidence equality and consistency in access to services and health outcomes within Hillingdon that continues to reduce health inequalities. Work with other commissioners where integrated commissioning will deliver innovative and effective healthcare solutions in line with the commissioning strategy. Work with providers, patients and carers to co-design an affordable integrated care system with an increased focus on Out of Hospital care. Develop patient and public engagement that ensures meaningful public involvement in commissioning. Achieve financial balance and a viable local health economy within existing and future resources with particular emphasis on robust contract monitoring across the entire contract portfolio. Commission care in line with health needs as identified within the JSNA and in line with the Joint Health & Wellbeing Strategy. Commission services that continue to move toward outcome-focused care, driven by the NHS Outcomes Framework with a key quality focus on the care and treatment of vulnerable adults.

Hillingdon CCG Commissioning Intentions 2015/16 Page 30 Commissioning Priorities Hillingdon CCG’s Commissioning Priorities for 2015/16 are: In line with NHS England’s priorities we will progressively introduce the ten clinical standards in hospital contracts with sanctions for non-compliance and also publish information on how the clinical standards are being implemented over 7 days. We will empower patients to self-manage their conditions and involve them in developing robust care plans with detailed crisis plans for patients with both physical and mental health conditions. We will develop integrated care pathways for patients with Long Term Conditions focusing especially on Cardiology, Respiratory, Diabetes and Stroke. We will continue to improve the effectiveness of Mental Health support and create integrated care pathways to support and empower patients and carers and reduce the number of emergency attendances. We will enable GPs and Community Providers to manage more patients in primary care without the need to refer to secondary care and reduce overall referral rates to Outpatients. We will undertake a thorough review of Out of Hours services across Hillingdon. We will work to manage the growing demand for Urgent Care services and focus on admission avoidance schemes where appropriate and the establishment of a 24/7 Single Point of Access for professionals. We will look to develop more community based services including the possibility of a consultant led Care of the Elderly service. We will deliver the Better Care Fund programme and enhance our integration with social care in the support of patient needs in Hillingdon. We will undertake a review of all smaller contracts with the aim of ensuring they offer value for money. We will directly involve providers in achieving the 2015/16 QIPP efficiency targets.

Hillingdon CCG Commissioning Intentions 2015/16 Page 31 Commissioning Intentions The majority of health needs in Hillingdon are covered by 5 major health care systems: Unplanned Care, Planned Care, Long Term Conditions, Mental Health and Integrated Care. In addition, there are a further 11 cross cutting systems that can be seen in the diagram above. Hillingdon CCG are not directly involved in managing or commissioning two of these systems (Public Health & Social Care). The following slides contain the strategies and projects associated with the 5 major health care systems and the 9 cross cutting systems that the CCG has direct input into.

Hillingdon CCG Commissioning Intentions 2015/16 Page 32 Commissioning Intentions: Unplanned Care Scope Although unplanned care is one of the five major health care systems addressed in these Commissioning Intentions, there are several cross-cutting service settings and themes that are vital to delivery of the whole systems approach to unplanned care, for example: primary and community care, secondary care, admission avoidance, services for children, services provided by the London Ambulance Service and also those commissioned by NHS England and Public Health England. These commissioning intentions for Urgent Care cover: NHS 111 Service. Primary Care – UCC and services ‘Out of Hours’. Admission Avoidance including services provided by the LAS and support to Care Homes. Acute service provision through The Hillingdon Hospital (THH) Emergency Department (ED), Ambulatory Emergency Care Centre (AECC) and the Minor Injuries Unit (MIU). Our commissioning intentions are consistent with the Urgent and Emergency Care Review (2014 Update) and also the North West London 5 year Strategic Plan and link with the wider agenda on raising public awareness of what services are available and how the public should be accessing them. What is the need in Hillingdon? The number of patients attending THH for unplanned care is increasing and there is an increase in the number of admissions. In 2014/15, the CCG commissioned a review of A&E activity to understand the drivers for these changes in patterns of demand, the review findings are expected to be complete by the end of September 2014 and will further inform the development of our commissioning intentions in the area of Urgent Care.

Hillingdon CCG Commissioning Intentions 2015/16 Page 33 Commissioning Intentions: Unplanned Care Assumptions, Risks & Issues & Fixed Points Assumptions The CCG will continue to commission the 24/7 Urgent Care Centre service co-located with Hillingdon Hospital ED and will continue to invest in developing new pathways for the UCC to increase the ~60% of patients they support without needing to onward refer to ED. Risks & Issues Continued increase in the number of patients presenting at Hillingdon Hospital with urgent care needs Fixed Points Achievement of All Type 4 hour A&E Standard Commissioning Priorities for 2015/16 We will continue to focus on admission avoidance through expanding the ambulatory emergency care pathways, investing in intermediate care services, continuing to work with the London Ambulance Service and the on-going development of support to care homes. As part of this work we will seek to improve the integration between the various service elements involved in admission avoidance and safe discharge including looking at the restructuring of the Home Safe Programme including reviewing how it is funded and how it is aligned with the BCF Programme. We will seek to more effectively manage patients with Long Term Conditions by empowering them to self-manage and reduce the number of times they develop an unplanned care need. This will also include improving links between the UCC/ED and the Integrated Care Programme so that patients with care plans can be better supported. We will seek to improve the effectiveness of other urgent care services that reduce the demand on ED such as participating in the NWL Procurement of the NHS 111 Service (new service to start from 1 st Oct 2015) and a review of the longer term options for such schemes as the Minor Ailment Pilot. To support this, we will continue to work with Public Health colleagues to raise public awareness of the options available other than attending ED. We will continue to explore opportunities to commission services from the voluntary sector building on the example provided by Age UK. We will look to commission GP networks to provide admission avoidance schemes to their over 75’s population and those most at risk of admission or readmission. We will seek to implement the recommendations arising from the clinical audit, review of NEL activity at Hillingdon Hospital. Expected Impact Although the CCG would like to see a reduction in unplanned attendances and admissions at Hillingdon Hospital, this has to be set in the context of closure of Hayes Walk In Service in October 2014 and the closure of the A&E units at Central Middlesex and Hammersmith Hospitals in September 2014 as well as the overall growth in Hillingdon population, particularly in the under 5’s age group which may all contribute to a continued pattern of high demand for services.

Hillingdon CCG Commissioning Intentions 2015/16 Page 34 Commissioning Intentions: Planned Care Scope The commissioning intentions for Planned Care cover the extended scope and stretch of CATs programmes for Dermatology, ENT, Gastroenterology, Gynaecology, Ophthalmology, Neurology and Urology. What is the need in Hillingdon? There is a growing number of referrals from GP requiring an improved usage of existing capacity across primary and secondary care. To manage a growth in demand requires efficient pathways which enable a more streamlined journey for the patient, and in doing so improve patient experience and ensure care is delivered within the most appropriate settings. Assumptions, Risks & Issues & Fixed Points Assumptions Following a Procurement process for some of the contract variation CATS currently provided at Hillingdon Hospital will require notice periods to contract. In addition there is likely to be a minimum six/nine month procurement period before new providers are mobilised. Risks & Issues Incomplete evaluation of current CATS. Delays to delivery of data. Contract management if contract or variation KPIs breached. Fixed Points Contract for Ophthalmology with fixed activity and cost levels. Contract for Dermatology (to be awarded Quarter 3 2014/15) with fixed activity and cost levels. Commissioning Priorities 2015/16 We will implement consistent KPIs across Planned Care CATS and the consistent application of the Referral Return Policy. We will strengthen links between secondary care and our PCI programme. We will seek to increase delivery of activity within the community and reduce the demand for Outpatient attendances. We will increase the use of IT Templates to support triage, referral and education to make referring patients easier for GPs. We will continue to deliver our 3 year plans and seek stretch where possible including exploring procurement of services (ie ENT) as well as seeking to identify how to reduce both the number and costs associated with diagnostic testing. We will cooperate with our colleagues at Brent and Harrow CCGs to explore changing the plastics service currently delivered at Mount Vernon Hospital that may result in this service being moved to NWLHT. Expected Impact Through work in Planned Care we hope to secure the expected QIPP savings and to achieve any stretch where possible whilst increasing access for patients and maintaining quality and safety for the services delivered.

Hillingdon CCG Commissioning Intentions 2015/16 Page 35 Commissioning Intentions: Long Term Conditions Scope In supporting adults with Long Term Conditions we will focus on the ‘Big 6’ conditions: CHD, CHF, Stroke, Diabetes, COPD and Asthma. What is the need in Hillingdon? Hillingdon has a higher than average number of patients with LTCs and in addition spends more per patient than equivalent areas. Variations in the quality of care provided and a lack of ‘joined up’ activity is leading to the quality indicators for Hillingdon based patients being lower than equivalent areas and this is especially the case for the management of diabetes which is a particular problem given that the increasing prevalence of this disease. In tackling this issue, we need to focus on integrated care for patients with LTCs has been shown to deliver better outcomes for patients and result in fewer complications and reduced non-elective activity. Assumptions, Risks & Issues & Fixed Points Assumptions None Risks & Issues Empowering patients will generate more need for support within primary care and we will need to review capacity. Integrated care brings the need for providers to work more closely together and this may raise issues. Integration also creates risks around the sharing of data between providers. Fixed Points Bariatric surgery services will need to be provided within an Acute setting The financial envelope for the CCG remains fixed. Commissioning Priorities 2015/16 We will seek to empower patients to self-manage their conditions including expanding our Health Champions pilot programme to include more conditions and to cover more patients. We will also look to integrate health coaching into the package of services provided. We will seek to commission integrated care pathways and services for cardiology and diabetes and may also look to develop integrated pathways for stroke and respiratory. This may include the option of commissioning a Tier 3 diabetes service (including bariatric surgery). We will seek to expand the number of patients with LTCs that have a care plan under the Integrated Care Programme (ICP) and to improve both the effectiveness of the care plans and the engagement of patients and their carers in using them. We will work to reduce the number of patients with Long Term Conditions that attend urgent care facilities where we can support them to effectively self- manage their condition and avoid unnecessary complications. Expected Impact Through our work we will expect to reduce variation in the care provided and improve the quality of services available to patients with LTCs. We will also seek to remove the duplication of care between providers and through this improve the overall outcome for patients. We would expect to see more patients managing their conditions effectively with the support from primary and secondary care clinicians and through this reduce non-elective activity.

Hillingdon CCG Commissioning Intentions 2015/16 Page 36 Commissioning Intentions: Mental Health Scope This system covers adults and older adults mental health services in Hillingdon. It includes health, social care, 3 rd sector, Primary and secondary care mental health services, GP networks, jointly commissioned and jointly funded services. It excludes services commissioned by NHS England (eg Forensic services, mother and baby, Tier 4 CAMHs). Public Health, Drug and Alcohol Services, and CAMHs services except in relation to transition. What is the need in Hillingdon? 55.000 people in Hillingdon are known to have a mental health condition, with significant numbers experiencing more than one condition. The most recent JSNA highlights the fact that there is a concentration of mental health morbidity in the South of the Borough. Most admissions into secondary care inpatient mental health services come from these areas. This fits with the patterns of deprivation across the Borough and supports the well documented link between deprivation and the incidence of mental illness. The level of need in relation to the incidence of mental health need is expected to rise to 20% by 2021.National data indicates a comparative under diagnosis of anxiety and depression and relatively low use of ante depressants. Locally there is a high incidence of mental health attendances at Accident and Emergency Departments, but a gradual reduction of the total number of admissions into inpatient mental health facilities. With regard to Dementia, population estimates suggest an increase in prevalence with a figure of 2,694 expected by 2015, 67% 0f whom will be over the age of 85. Although the majority of people who develop dementia are older people there is a growing number of younger people developing the illness. This is mostly related to other long term conditions eg Parkinson’s disease, AIDS, Korsakoffs syndrome and diabetes. Assumptions, Risks & Issues & Fixed Points Assumptions No additional funding into services except potentially IAPT following the development of a Business Case. Risks & Issues Need to ensure GP ownership of the SSOC initiative. Contract still unsigned, so risk still remains regarding the funding stream for the SSOC. CCG faces NHSE penalties if it does not meet the national IAPT target by March 2016 Fixed Points  Section 75 Agreement.  Commitments made under the Better Care Fund.  Shifting Settings of Care Initiative, WISIC Pilot Scheme & IAPT (key CCG target mandated nationally).

Hillingdon CCG Commissioning Intentions 2015/16 Page 37 Commissioning Intentions: Mental Health Commissioning Priorities 2015/16 We will seek to respond to the national commitment to expand the “Improving Access to Psychological Therapies “(IAPT) programme to reach a wider audience including more from ethnic minorities and those with long term health conditions with the aim of achieving the 15% of prevalence national target. We will seek to transform mental health services within Hillingdon including: o Exploring development of a single point of entry to advice, assessment and/or treatment to improve urgent access to mental health services and meet standards around access times and crisis response. o Developing an enhanced primary care mental health service to facilitate the transfer of care from secondary to primary care and further reduce the rate of referrals into secondary mental health services. o Improving the effectiveness and productivity of the money we spend on mental health services (including selective procurement activities where appropriate). o Improving the integration between mental health and community health services. o Further development of memory services and enhanced diagnostic skills of primary care staff in the early detection of dementia in line with national targets and ensure that patients, once diagnosed and stabilised are supported to return for as long as possible to daily life under the care of their GP. o Improving the physical healthcare of people with mental health problems, in both secondary and primary care settings in line with expectations around “Parity of Esteem o Reducing out of district placements. We will commit to the continuing implementation of the recommendations stated in Winterbourne View paper. We will carry out a full evaluation of the impact of the Liaison Psychiatry services in conjunction with providers, and achieve greater core standardisation of services in terms of workforce skill mix,costs,activity and productivity. We will seek to improve the transition arrangements from children’s services into adult mental health services and from adults into older peoples services. Expected Impact Key impacts are expected to be as follows:  Improved access for the general population and for disadvantaged and vulnerable groups  Improved dementia diagnosis rates  A shift from bed and secondary care based to community and primary care assessment, treatment and support  Inequalities for black and minority ethnic communities and disadvantages/vulnerable people being addressed.  Improved access to crisis support  A focus on recovery and outcomes and personalised approaches for assessment, treatment and support  Service users empowered through the promotion of choice and control and provision of easy access to information and advice  Carers supported, having choice and control and being empowered through easy access to information and advice.  Best use of available resources being made to achieve value for money.

Hillingdon CCG Commissioning Intentions 2015/16 Page 38 Commissioning Intentions: Integrated Care Scope This system covers integration of services for Adults over age 18 years, with specific focus on over 65 years. It covers the following programmes: Better Care Fund (model of care and enablers to promote integration across health and social care for people age 75years and over with 2 or more long term conditions and frailty risk factors ). Whole system Integration ( Hillingdon Early adopter pilot for NWL WSIC programme) Hillingdon Integrated Care programme ( care planning, case management and review ). It also includes health, social care, 3 rd sector, Primary, community and secondary care services. It excludes integration programmes that are covered in other sections eg GP provider networks, children, mental health and Learning Disability. What is the need in Hillingdon? There are 36,200 people aged over 65 living in the Borough. The number of over 65 living in the Borough is projected to increase by 13.3% in 2020 to 38,600. In addition, there are people over 75 years living with one or more long-term condition including: COPD, Stroke, CDV, Dementia, Diabetes, mobility issues and the socially isolated. For this population segment our services are not as joined up as they should be, and care is more focused on crisis management than anticipatory care. To improve both outcomes and experience of care, and manage demographic pressures, the model of care and workforce will need to enable care to be delivered in a way that is predictive, integrated, and seamless from a service user point of view. People will be able to plan their own care working together with key professionals across a range of agencies. Assumptions, Risks & Issues & Fixed Points Assumptions BCF programmes will utilise existing resources across HCCG and LBH. WSIC model of care will be a pilot in 15/16 in one locality with services participating being part of a capitated payment arrangement. Further development or roll out of integrated services models will be subject to business case. Risks & Issues Integration programmes fail to deliver expected benefits for service users or achieved planned reduction in unscheduled care activity Engagement and culture change required in front line services, and achieving outcomes is dependant on coproduction approach Time scale to realise benefits of integration and ongoing Impact of demographic growth on affordability Fixed Points  Section 75 Agreement for BCF and embedding of ICP programme into GP Networks.  WSIC is a pilot programme and signals a major transformation of the way that care is commissioned, planned and delivered. This will be driven by Hillingdon CCG and partners and supported at a NWL level where appropriate to ensure consistency and a system-wide approach..

Hillingdon CCG Commissioning Intentions 2015/16 Page 39 Commissioning Intentions: Integrated Care Commissioning Priorities 2015/16 BCF (frail elderly over 75 years) We will expand intermediate care programmes, including alignment of the role of rapid response and reablement to support people in crisis to enable them to remain in their normal setting of care as part of an improved and better integrated urgent care pathway. This will include embedding social care into the current team, enhanced use of third sector and 7 day working. We will improve support to people to manage their own care, including access to information, use of technology, early individualised prevention plans, support and coaching for people with identified risk factors. We will develop early supported discharge programmes with proactive in reach /outreach support to manage the transition from hospital to home. This will include risk protocols to support transfer of care between hospital, primary/community and social care. We will develop shared and personalised care plans with active care management and care coordination for people with risk factor. We will support the development of a multidisciplinary team of primary, community and social care support in each locality to support care homes, supported living and end of life care, including improved support for people who wish to die at home. WSIC (over 75s with long term health conditions, mobility issues,social isolation) We will pilot a model of care including GP as lead professional with one holistic assessment and one care plan which is owned by patients and accessed by all professionals. We will develop a capitated payment model based on budgets currently spent on target population group. This resource will form part of a capitated budget with which will be used to commission providers to deliver specified outcomes to ensure that care is truly person-centred. We will develop models for accountable care partnerships to enable the system to support provider integration. Rather than holding contracts with a number of providers, care for this population segment will be commissioned through a single contract held by a partnership of providers with ongoing assurance and monitoring against the specified outcomes. ICP (over 65 years) We will review the model for ICP and seek to identify how we can obtain the best value for money from this programme.. We will then embed the revised model for ICP, moving from a condition specific pathway approach, to one ased on a risk-stratified approach. We will embed ICP case management and care planning in primary care with care plans as a living document which are managed and reviewed. We will improve the measurable outcomes from the ICP programme including reduction in use of unscheduled care and optimising independence and self directed care. We will align support for delivering case management from the care navigator, coordinator and community matron roles, based on the care actions required across the spectrum of need. We will develop a risk stratification tool to support predictive care and shared records (CMC) aligned with Hillingdon's wider IT plan. Expected impact Key impacts are expected to be as follows: Improved patient experience outcomes (less duplication carers and users understand and know how to access services available to them, and coordinated care across different agencies). Shift from crisis to predictive care - including care plans that that can be accessed by the service users and the professionals who look after them. Appropriate response for people every day of the week. Support for carers having choice and control and being empowered through easy access to information and advice. Reduction in unscheduled care activity including readmissions.

Hillingdon CCG Commissioning Intentions 2015/16 Page 40 Commissioning Intentions: Primary Care Scope These intentions covers all activities that the CCG is involved in relating to primary care including the commissioning of Community Health services. What is the need in Hillingdon? Demographic changes, increasing demands on healthcare services and fewer resources mean that services provided in primary care, and particularly those offered by GPs are under severe pressure. To ensure that local people can continue to receive the same (or better) level of service, the CCG needs to support GPs to transform primary care. 2015/16 will be year 2 of the CCG’s primary care development plan – see the Plan for further details. At the same time, the CCG is keen to promote integrated working between primary and community care services, not only to provide a sustainable solution to the issues surrounding workforce, but also to ensure the patient receives a better experience and improved outcomes. This also aligns with the Hillingdon GP networks involved in the early adopter pilot for Whole Systems Integrated Care and the work the borough is leading on to deliver Better Care Fund objectives. Assumptions, Risks & Issues & Fixed Points Assumptions IT strategies continue to support the delivery of primary and community care and facilitate integration. CCG will support the development of the primary care workforce. GP Networks will flourish and start bidding to provide services. A nursing conference will be held in Hillingdon to agree workforce planning, education requirements and future supervision needs. Risks & Issues NHS England investment in primary care premises and out of hospital hub strategy. Sustainability of primary and community services during period of change. Possible changes to Department of Health/NHS England strategy stemming from general election in 2015. Fixed Points Number of healthcare professionals and difficulty attracting professionals to work in Hillingdon. Commissioning intentions have to align with Operating Plan and 5 year strategic plan. One year notice period to vary existing contract with CNWL.

Hillingdon CCG Commissioning Intentions 2015/16 Page 41 Commissioning Intentions: Primary Care Commissioning Priorities 2015/16 We will aim to commission more “Out of Hospital “services from GP Networks. We will seek to: o Increase the number of patients with mental health issues that are capable of being managed in general practice. o Provide better co-ordinated services for the elderly with co-morbidities including dementia. o Enable children to access appropriate services closer to home. o Integrate community nursing services, linking primary care nursing, community nursing services and acute services providing nursing input in community setting. o Establish a community phlebotomy service. o Establish a paediatric rapid response service. o Work with BHH CCG colleagues to procure a new wheelchair service. We will continue to focus on to ensuring that patients, carers and healthcare professionals are involved in decisions that affect their care. We will work with organisations to revise specifications for community services to deliver services that provide continuity across care settings and therefore improve quality and cost effective delivery. Expected Impact Through these commissioning intentions we aim to provide sustainable primary care services that retain the GP as central to patient care.

Hillingdon CCG Commissioning Intentions 2015/16 Page 42 Commissioning Intentions: Patient & Public Engagement Scope The aim of this strategy is to ensure that communications and engagement activities to support the CCGs 2015/16 commissioning intentions also complies with all relevant standards. What is the need in Hillingdon? Services can no longer be designed without the input of patients, carers and representative groups. Hillingdon has a history of involving patients in joint decision and will continue to listen to the voice of the ‘customer’. Assumptions, Risks & Issues & Fixed Points Assumptions Established channels for engaging with HCCG membership (where engagement with the public overlap) will continue. Whatever replaces the NWL CSU will continue to support and manage the CCGs media reputation, social media presence and the public facing website Integrated PPE with CNWL and THH will continue into the 2015/16 contracts. Risks & Issues Co-commissioning will increase need for integrated care and membership engagement that current communications and engagement support is not aligned to. Clear allocation of funding for joint PPE and coproduction. Carers impact analysis. Process needs strengthening and adopting by all commissioning staff. Fixed Points Statutory reports (e.g. PSED, Objectives, FFT (not currently applicable directly to Comms team), NHSE PPE Report, Annual report). Statutory requirements such as: GB Public Meetings, PPI&E Committee and other governance arrangements that impact decision making. Commissioning Priorities 2015/16 We will roll out the Friends and Family Test across primary and secondary care We will improved access and support for both patients with adult mental health problems and their carers. We will seek to improve self-management / education opportunities for patients with LTCs. We will embed a culture of co –production / co-design workshops within both providers and the CCG measurable outcomes from joint engagement activities and initiatives. Expected Impact Through our work we expect to have the following impacts: Patients, Carers and members of the public will feel more confident in the CCG as a commissioning organisation. They will also be confident that the CCG has the mechanisms in place for commissioning healthcare services and operates in the interests of people in Hillingdon. Registered patients, carers and members of the public in Hillingdon will know and understand what changes are being made and what challenges exist within Hillingdon and the wider NHS and social care system.

Hillingdon CCG Commissioning Intentions 2015/16 Page 43 Commissioning Intentions: Patient Empowerment Scope This strategy is focused on supporting patients predominantly with LTCs (including Mental Health) to enable them to remain independent and healthier for longer. This strategy covers self-care, education programmes and health coaching. What is the need in Hillingdon? Patients with LTCs (including enduring Mental Health conditions) represent a large percentage of the number of people accessing urgent care services. Empowering and supporting patients and carers has been shown to reduce the number of exacerbations experienced by patients and overall to improve their quality of life and health outcomes. Assumptions, Risks & Issues & Fixed Points Assumptions None Risks & Issues Empowering patients will generate more need for support within primary care and we will need to review capacity. We will need to manage the expectations of patients who previously relied heavily on urgent care services. Fixed Points Public Health are responsible for activities related to prevention of long term conditions. The financial envelope for the CCG remains fixed. Commissioning Priorities 2015/16 We will seek to commission and integrated patient empowerment programme that brings together the existing elements of our Health Champions programme, the Integrated Care Programme and additional elements such as health coaching and educational assets for patients. We will seek to develop a package of care for patients with enduring mental health conditions that empowers them to self-manage their conditions more effectively. Expected Impact Through this work we will improve the health outcomes for patients and reduce the demands placed upon Urgent Care services.

Hillingdon CCG Commissioning Intentions 2015/16 Page 44 Commissioning Intentions: Children & Young People Scope In the context of an increasing population in Hillingdon, the expansion of numbers of 0-19 year olds reflects the recent and continuing higher than usual birth rate both nationally and locally. The increases present pressures on services and systems in the context of reduced resources across all children’s services. The scope therefore includes the review of funding streams focused on children aged 0-19 and up to 25 for those with SEN and complex needs along with maternity services. It includes health, social care, therapies provision commissioned by LBH, 3rd sector, Primary and secondary care health services, GP networks, jointly commissioned and jointly funded services. Adult mental health services are also in scope with regards to the perinatal period, preparing for adulthood services provision up to age 25 and similarly for adult community health services as required by the Children and Families Act 2014. Out of scope are those services commissioned by NHSE such as Tier 4 CAMHS and Mother and Baby units. What is the need in Hillingdon? The proportion of the population in Hillingdon is higher than the proportion in London and England for the age groups 5-10 and 19-22. Within Hillingdon borough the number of people in the following age bands are expected to increase in the next 5 years: 5-17, 25-39, 40-64. All the other age bands are expected to increase only slightly or remain flat until 2020. JSNA 2014. There are estimated to be around 4,000 children and young people aged 5-16 with a MH disorder in Hillingdon. Furthermore there are around 2000 16-19 year olds with emotional disorders. Additionally with medical advances more children with disabilities and special needs are surviving. Poverty and social inequalities in childhood have profound effects on the long term health of children that carry through into late adulthood. The rapidly growing and developing foetus and child seem to be particularly vulnerable to the adverse effects of poverty providing a further powerful argument for policy initiatives designed to protect children from its worst effects. There is evidence in Hillingdon of higher prevalence of poor outcomes for children living in poorer households e.g. number of accidents, infant and child deaths, rates of illnesses, hospital admissions, poor oral health.Across borough about 17,500 children in poverty; most in Hayes and Harlington locality. Other issues include: Increasing rates of asthma. Increasing demand for CAMHS that outstrips supply. Increasing attendances at A&E. Lack of Perinatal Mental Health provision.

Hillingdon CCG Commissioning Intentions 2015/16 Page 45 Commissioning Intentions: Children & Young People Assumptions, Risks & Issues & Fixed Points Assumptions Alignment of NWL MH transformation priorities and HCCG priorities for 15/16 including Perinatal and CAMHS out of hours provision Full roll out of service changes commissioned in 14/15 into contracts (LD CAMHs). Children’s services available to 18 th birthday and up to 25 for those with special education needs and complex care (Children and Families Act 2014) Risks & Issues Increasing demand on urgent care for children Partnership approach required to commission services for children across LBH (incl public health), schools and health commissioners. Existing service capcity in children's services eg psychiatric specialist provision. Fixed Points There is a target date of the 1 st Sept 2014 for implementation of SEND reforms that continues into 15/16. SaHF assumptions for maternity and paediatric acute care reconfiguration commencing March 2015. Commissioning Priorities 2015/16 We will seek to: o Develop PNMH for specialist services (possibly with three borough focus across BHH). o Develop an integrated CAMHS service with LBH and progress phase two of our LD CAMHS development. o Develop an urgent care programme with primary care for children and families, informed by accurate needs assessment. o Review Children’s Community Child Health Services and Community Children’s Nursing Services o Review care for children with epilepsy and those with asthma ensuring effective management o Explore with BHH potential to combine specialist CAMHS provision o Review and possibly re-develop our maternity specification and service We will seek to establish the joint commissioning programme with LBH re SEND and other development areas such as CAMHS (inc LD) We will establish children young people and families’ involvement in service commissioning and development We will prioritise pathways for vulnerable groups accessing health provision including looked after children, children with long term conditions, children with disabilities including those with learning disabilities and young people who offend and those at risk of offending We will seek to establish a knowledge hub in our primary care networks and provide training and consultation across all practices Expected Impact Through our commissioning intentions we would expect the impact to be: Improved access to services for local children, young people and families and more effective transition services Slowing down in escalation of complex condition with earlier identification and treatment of children with mental health and LD, disabilities, young people who offend, children with disabilities and looked after children Improved response by adult mental health teams and IAPT for women in the perinatal period Improved pathway management in primary care and decreased unnecessary urgent care attendance Appropriate primary care management of asthma, and epilepsy resulting in decreased incidence of unplanned admissions./attendances

Hillingdon CCG Commissioning Intentions 2015/16 Page 46 Commissioning Intentions: Hubs & Out of Hospital Scope Hillingdon has already published its Out of Hospital Strategy and Strategic Services Delivery Plan (SSDP). Both documents work on the assumption that more planned care will be delivered in out of hospital settings in the three localities within Hillingdon: North Hillingdon, Uxbridge & West Drayton and Hayes & Harlington. The first hub to be developed is the Hesa Centre in Hayes where there will be some space available for the delivery of planned care starting in 2015. The second planned hub to be developed will be in Uxbridge and West Drayton, followed by the North Hillingdon hub. What is the need in Hillingdon? Available space in existing primary care premises in Hillingdon is extremely limited. In line with the SSDP, the CCG has modelled their need for additional space to ensure that the Out of Hospital Strategy can be delivered and that primary care services are sustainable. Assumptions, Risks & Issues & Fixed Points Assumptions: Providers will be willing to locate to community settings and patients will be happy to use services that are not based in the hospital setting. Establishing out of hospital services is cost-neutral to the CCG. Risks and Issues: Some additional costs associated with developing Hubs may need to be borne by the CCG. Although the CCG has identified the first hub in the Hayes area, it is struggling to find suitable premises in Uxbridge and West Drayton, despite extensive land searches. If suitable premises cannot be found in 2014/15 in Uxbridge and West Drayton, then the CCG needs to explore the concept of a virtual hub. Fixed Points: Service redesign around a number of planned care specialties is already underway. Limited capacity within existing primary care estate. Commissioning Priorities 2015/16 We will seek to develop a strategy so that the following specialties can be commissioned out of hospital: Pain management as part of the MSK provision, Ophthalmology (currently available in the community in Uxbridge and West Drayton and North Hillingdon, but needs to be commissioned in Hayes and Harlington as well), Dermatology (expected to come on stream in 2014/15), ENT, Urology, Neurology, Gynaecology, Spirometry, Diabetes and a potential for minor surgery suite in each hub. Expected Impact By having more planned care being delivered in the community, closer to people’s homes it will avoid the need for patients to travel to secondary care service settings and reduce the overall financial burden in Hillingdon.

Hillingdon CCG Commissioning Intentions 2015/16 Page 47 Commissioning Intentions: Medication Scope To support effective medicines optimisation for Hillingdon residents so that they get the most out of their medicines. This requires health and social care professionals, patients and carers working together in an integrated way. The primary care prescribing budget efficiency savings will be delivered through a Local Incentive Scheme that will incorporate NICE, National and local QIPP indicators, and focussed practice-based prescribing projects. What is the need in Hillingdon? A RAG-rating dashboard developed by the London Procurement Project (LPP) comparing CCG performance on numerous prescribing indicators shows that Hillingdon CCG needs to reduce the volume of prescribing is specific areas such as Dressings, Blood Glucose Testing strips and LA Insulin analogues. Some practices need more support than others to prescribe more cost-effectively, and the pharmaceutical advisors ensure resources are directed to the appropriate practices. Evidence-based advice is provided so that patient receive high quality, safe, effective and rational medicines. Assumptions, Risks & Issues & Fixed Points Assumptions Prescribers are willing to follow advice and recommendations from the pharmaceutical advisors District nurses from CNWL prescribe wound care products listed in the local formulary Clinicians from Hillingdon Hospital link in with CCG prescribing messages, particularly with managed entry of new drugs. Risks & Issues Insufficient GP engagement & conformance to guidelines & processes Individual practices do not engage with the QIPP programme Patients may not wish to have medication changes Community pharmacists not engaging with HCCG prescribing agenda Pathway redesign projects and out of hospital care Insufficient joint working with providers- THH & CNWL Fixed Points There is no fixed formulary of drugs in primary care so GPs and nurses can prescribe any medication they deem necessary for their patients. There are no penalties for prescribing outside guidelines, though there are incentives to prescribe as recommended by pharmaceutical advisors.

Hillingdon CCG Commissioning Intentions 2015/16 Page 48 Commissioning Intentions: Medication Commissioning Priorities 2015/16  We will further improve prescribing efficiencies and uptake of medicines optimisation initiatives through investment in a local incentive scheme as well as supporting our on-going care homes programme and undertaking joint care working with community teams in medicines optimisation.  We will provide on-site support for improved prescribing processes and advice on cost-effective prescribing by spending time in practices that are outliers in terms of prescribing expenditure and quality prescribing.  We will continue with the promotion of ScriptSwitch at a practice level to support cost effective prescribing and enable CCG preferred choices to be highlighted as well as continue to review prescribing trends and further support the reduction of inappropriate GP prescribing variation. We will also continue to work with practices and community pharmacists to address repeat prescribing issues and medicines wastage.  We will identify improvement in medicines management in priorities areas such as diabetes and respiratory.  We will use primary care rebate schemes approved by LPP and improve the implementation of the NWL formulary with THH to support our QIPP agenda.  We will aim to improve shared decision making so patients do not get medicines they will not take.  We will implement processes to improve optimisation of secondary care medicines excluded from payment by results (PBR) through CSU.  We will support providers to improve systems for safe transfer of information on patient medication at admission and discharge. Expected Impact Realisation of the QIPP savings whilst maintaining quality prescribing. Implementation of cost-effective evidence based medicine. Improvements in the practice repeat prescribing systems / processes with a view to reducing medicines wastage.

Hillingdon CCG Commissioning Intentions 2015/16 Page 49 Commissioning Intentions: Technology/IT Scope The CCGs of North West London are committed to achieve greater integration of care through greater integration of information about patients between GPs and providers, and across the provider network. What is the need in Hillingdon? IT is a key enabler of Hillingdon CCG’s clinical strategies for 2015/16 and therefore the CCG intends to place a heavy emphasis on IT in the CQUINs for the year, as for 2014/15. The objective is to implement three layers of clinical information exchange where at least one of the following is in place in any setting of care: Level 1 - Access to and two way information exchange within a common clinical IT system and a shared record between the GP and the care provider. Level 2 – Where Level 1 is not possible, ensuring systems are interoperable and in full conformance with the current Interoperability Toolkit (ITK) standards Level 3 - Where neither of the above is relevant or feasible then the Summary Care Record is enabled, available and accessible. The minimum achievement to meet CQUIN targets in 2015/16 between providers and the CCG will be implementation of Level 2, with a longer term plan to achieve Level 1. Achievement of Level 3 will be sufficient between providers and out-of-area CCGs. Assumptions, Risks & Issues & Fixed Points Risks & Issues Ability of providers to deliver integration capabilities due to the immaturity of their existing IT systems Ability of providers to change obsolete clinical business processes which introduce unnecessary delays and are dependent on unsafe technologies such as fax Some GP practices are slow to adopt changes such as automation of clinical information flows, with the result that paper-based flows have to be retained (some providers are to adopt automated Commissioning Priorities 2015/16 We will improve access to diagnostic Information: electronic ordering of diagnostic tests and reporting results through the provider’s order communication system, for pathology and radiology diagnostics. We will improve referral processes: elimination of unsafe fax referrals to providers and replacement with electronic communication (e.g. through NHS e- Referrals system) We will improve access to details of Clinical Episodes: electronic transmission, via either Level 1 or Level 2 mechanisms, in a timely way (as close to “real time” as possible given standard clinical processes) – e.g. the information currently contained in inpatient discharge summaries, outpatient letters, A&E/urgent care letters. We will improve integration of clinical systems between providers to enable multidisciplinary teams to function effectively with the information required to make safe, timely and properly informed clinical decisions. Expected Impact We expect the commissioning intentions in relation to IT systems 2015/16 should have the following impact: Live information flows from and to primary care clinical information systems (as close to “real time” as possible) A standardised repository of diverse clinical information on the patient within the primary care record, so that the primary care record is the single comprehensive source of medical history on the patient Technology solutions that will allow multidisciplinary teams across different settings of care to function as one integrated team Patients to have access to their own medical records and participate in monitoring and reporting on their care

Hillingdon CCG Commissioning Intentions 2015/16 Page 50 Commissioning Intentions: Continuing Health Care (CHC) Scope The scope of this system covers all adults and children that meet the criteria for either fully or partially funded healthcare under the Continuing Healthcare criteria. What is the need in Hillingdon? Due to improvements in healthcare more children with complex disabilities are surviving and are in need of care. Hillingdon, along with many other London boroughs, has an aging population complicated by a higher rate than average of patients with disabilities due to the diverse nature of the population. Hillingdon also has a higher rate of adults with complex Mental Health and Dementia related challenging behaviour. The Children’s Act places greater emphasis on Children who meet the SEND criteria (Special Education Needs and Disabilities). There are an increasing number of complex patients with mental health issues that require 1-2-1 support. New guidance is suggesting that CHC Assessments are started whilst the patient is still in hospital. Assumptions, Risks & Issues & Fixed Points Assumptions It is assumed that the current pilot being run at The Hillingdon Hospitals (THH) will continue and be mainstreamed. Risks & Issues Not undertaking reviews due to staffing shortages could lead to patients not receiving the appropriate packages of care with associated cost and quality issues then arising. Fixed Points We must work in accordance with the Department of Health (DH) framework on Continuing Healthcare and meet our obligations under the Children’s Act. Commissioning Priorities 2015/16 We will fully establish our team. We will improve links with the Local Authority (London Borough of Hillingdon). We will develop specialist capabilities in LD. We will engage acute partners in starting the CHC Assessment process. Expected Impact Our aim is to meet our statutory obligations and deliver appropriate packages of care to patients that meet the criteria for Continuing Healthcare.

Hillingdon CCG Commissioning Intentions 2015/16 Page 51 Commissioning Intentions: Palliative Care Scope The End of Life Care system includes all adults, irrespective of diagnosis, who are in the end of life phase of their life / disease process. What is the need in Hillingdon? Only 50% of those who may need a plan have one identified on the Coordinate My Care (CMC) system. The London Ambulance Service (LAS) is not making best use of CMC and is conveying patients to ED. Assumptions, Risks & Issues & Fixed Points Assumptions The current performance will not fall below the 50% of patients currently maintained within the community and dying outside of hospital. Collaborative processes with THH, LBH, CNWL and Primary Care will be enhanced and maintained. Appropriate patients with ICP plans are moved to an end of life plan as soon as is appropriate. Risks & Issues  The introduction of personalised budgets following the publication of the palliative care funding review.  Lack of Primary Care Engagement Fixed Points Criteria for Continuing Care Existing capacity in the provider is maintained. 10 step down beds are maintained at Hayes Cottage hospital Commissioning Priorities 2015/16 We will maintain the standard to support 50% patients dying outside of hospital. We will continue to work with Care Homes to improve the knowledge of staff to enable them to deal with the needs of a dying patient including seeking to achieve adequate GP cover for Nursing Homes. We will undertake a workforce planning review to determine the needs of the system. We will agree a local policy, informed by the London policy due March 2015, for documenting and managing DNACPR directives. We will seek to develop a fast track palliative care pathway to link health with social care and the Better Care Fund. Expected Impact The system will aim to reduce dependence on secondary care for services to support them in this phase and therefore the result will be for fewer patients to be admitted as emergency to hospital. Services will be adequately commissioned within the community to support patients to be cared for in their preferred place of care, this is usually in their usual place of residence.

Hillingdon CCG Commissioning Intentions 2015/16 Page 52 15/16 QIPP Projects UNPLANNED CARE TitleDescriptionActivity Changes Ambulatory Emergency Care Expand existing scheme to include additional conditions and improve utilisation of existing resources. Remainder of 2014/15 Activity + 10% Additional Intermediate Care Revisit existing assumptions and expand remit of service. Review possible medical input and closer links with Home Safe and other services. 6/Day Admissions Avoided from April 2015 Care Homes Programme Improve access to medical advice to Care Homes and improve effectiveness of Community Matrons. Undertake Frail/Elderly assessment in Care Homes and combine with targeted polypharmacy reviews undertaken by the Medicines Management Team. ~350 Admissions Avoided Falls & Falls Prevention ServiceIntegrate falls prevention into community rehab service.~20 #NOF Avoided. Fracture Liaison Assumes £105k in 14/15. The business case indicates £90k cost to deliver £91k saving in its first year. Will this have already been counted in the falls service ~250 Patients Per Annum Home Safe Directly commission service and have a cross-provider CQUIN for Joint Assessment to run alongside programme. 1 st Year Cost Neutral. UCCNo further savings expected.None Walk in CentreSix months of full year effect rolled forward. Reduced cost following WiC Closure.

Hillingdon CCG Commissioning Intentions 2015/16 Page 53 15/16 QIPP Projects PLANNED CARE TitleDescriptionActivity Changes MSK (Spinal) To review current Hillingdon activity and reduce variation in referral rate. Agree an end to end pathway with corresponding development of specialist surgical capacity Commission services to deliver new pathway Reduction of 400 elective procedures in 2015/16 MSK (Pain) Pain pathways distributed to primary care for implementation. Development of a community service model has been agreed. In the process of agreeing a community tariff and identifying cost related. Reduction of 776 First and 832 Follow Up MSK (Rheumatology) To implement the agreed pathways in primary care. Specification and direction of travel to be agreed with the development of a community tariff. Savings may be generated following agreement of the service model from the reduction in secondary care procedures with more taking place in the community with a community tariff. Most of these procedures relate to the giving of injections. Reduction of ~400 procedures. GastroenterologyExtend number of conditions available for community treatment including Bowel Disorders.~200 appointments DermatologyContinuation of programme from 2014/15 implemented in last 3 months of the year.Procurement Saving ENT75% of 427 First Appointments and 482 Follow Ups. Possible reprocurement of service. ~320 First and ~360 Follow Up Appointments. TalleyFull year effect of contractProcurement Saving GynaecologyDelayed start means 4 months of existing scheme slip into 2015/16 ~1,560 Appointments and procedures. UrologyHydro-Distention project plus 240 First Appointments and 369 Follow Ups.As per description. OphthalmologyIncrease number of patients moved into community. ~750 Follow Ups and balance of 14/15 target. Rectal BleedingAssumed not introduced until Mar 2015 and therefore full year effect.~£200 Procedures NeurologyNot introduced till November 2014/15 therefore 8 months carried forward.TBD

Hillingdon CCG Commissioning Intentions 2015/16 Page 54 15/16 QIPP Projects LONG TERM CONDITIONS TitleDescriptionActivity Changes Cardiology Phase 1 (THH)Direct access diagnostics~600 New/FUPs Avoided Integrated Cardiology Model Implementation of a consultant led integrated service model that spans acute, community and primary care settings To be defined with Clinical Working Group during Q3 and Q4 of 2014/15 Diabetes Phase 1~450 Follow Ups Avoided Integrated Diabetes Model Diabetes community services and DESMOND and DAFNE education programmes plus Tier 3 Weight Management Service. Re-commission primary and community diabetes services to deliver an integrated service model across primary, community and acute care settings To be defined during 3 rd quarter of 2014/15 Improved Monitoring of Community Diabetes Contract Ensuring we obtain best value.Contract Productivity Respiratory (14/15 Scheme)~15 Procedures Enhanced ICP for Care/Crisis Planning Covered under ICP Programme in Primary Care.-- Respiratory Breathlessness ClinicsReduced diagnostic costs and outpatient costs.~35 Admissions Avoided Additional Programmes to close QIPP gap Yet TBD

Hillingdon CCG Commissioning Intentions 2015/16 Page 55 15/16 QIPP Projects MENTAL HEALTH TitleDescriptionActivity Changes Shifting Settings of Care Continue the programme of transferring service users from secondary to primary care with the support of the Primary Care Plus Service. Currently the service is supporting 59 Service Users and it is expected that this will rise to at least 334 by 31th March 2016, probably significantly more. To date £238k savings have been identified leaving the sum of £300k in 2914/15. A minimum of 284 Service Users supported under the PCP Initiative. CNWL Block Productivity on total Contract Value 2% efficiency saving required from the Block Contract, in line with Recommendations from the Review of Transformation Readiness and the “ Deep Dive Review” into Provider Services. Efficiency saving only. Review of Rehabilitation Beds. A full review of the Rehabilitation Facility at Colham Green to be undertaken in 2014/15 to inform QIPP requirement in 2015/16. Will involve discussions with London Borough of Hillingdon as part of the Review. Potential reduction in Health funded overnight bed days. Merger of Adults and Older Adults Home Treatment Teams This initiative will reduce both management costs and Estate/Premises. Provider has indicated that the would expect any such savings to contribute to their CIPs, not HCCG QIPP,could signal our intention to split the savings 50/50. Efficiency saving. Rationalise treatment options currently provided in the Community. Work with the Provider to have some services, for example Psychology more focussed on assessment only. Would need to identify Posts as they become vacant to avoid the possibility of Redundancy Costs. Marginal reduction in treatment options which may lead to increased waiting times. See description. Centralisation of inpatient services on key sites over a 2 year period. Work with the Provider and colleagues in neighbouring CCGs and Local Authorities to reduce the number of in-patient sites over a longer strategic period to free up the level of savings required to underpin both HCCG and CNWL financial imperatives No activity changes expected as no overall reduction in bed numbers IAPT Rationalisation Work with colleagues in Harrow and Brent to overall reduce the number of sites from which IAPT Services are delivered.Pro rata savings across the 3 CCGs Reduction in the number of bases. Reduce the scope of Early Intervention and Home Treatment Services Following the implementation of the Single Point of Access and Urgent Care Initiative, reduce the staffing across both services by 4 WTE, the balance to be agreed jointly with the Provider following a Quality Impact Assessment Marginal impact on activity. IAPT Continue to develop Increased Access to Psychological Therapies in line with national policy initiatives. At the end of July 2014 1011 Hillingdon Service Users had accessed IAPT, to meet national targets this will need to increase to 4345 by March 2016 (15% of those with a common mental illness in Hillingdon). Business Case under development. 3,334 additional Service Users receiving IAPT Graduate Mental Health Workers. These are currently outside the main Contract and from 2014/15 should be absorbed into mainstream services within the Trust as part of the Block Contract not separate invoicing arrangements. Formalising new funding arrangements

Hillingdon CCG Commissioning Intentions 2015/16 Page 56 15/16 QIPP Projects INTEGRATED CARE TitleDescriptionActivity Changes Better Care Fund (BCF)Savings and activity changes included in other schemes.As per plan. Whole Systems Integrated Care (WSIC) Anticipatory model of care for older people with 1 or more LTC to be piloted in north locality in first instance. As per plan. Integrated Care Programme (ICP)See Primary Care Section. PRIMARY CARE TitleDescriptionActivity Changes Practice Commissioning Initiative (PCI) Focus on non-QIPP Pathways.Balance of 14/15 Under-Achievement. Integrated Care ProgrammeRole within primary care networks being defined with GP networks Net Saving on Urgent Care costs of patient cohort. Community & Mental Health Bed Review Approximately reduction of 5 beds. Integrated Nursing Service Better coordination between District Nurses, Community Matrons, Practice Nurses, Continence Team, Community Paediatric Nursing, the Complex Wound Service and specialist nursing such as Tissue Viability, Palliative Care and Rapid Response. Reduced duplication or gaps in care. Impact to be defined. Community Diagnostics Developing community access to phlebotomy, spirometry and 24 hour blood pressure monitoring. ~2000 diagnostics. Community Consultant Team Developing a consultant led team for Care of the Elderly and Palliative Care. Linked to integration initiatives. ~125 admissions avoided. Additional Community SchemesProductivity as per 2012 Financial Recovery PlanTBA with community provider

Hillingdon CCG Commissioning Intentions 2015/16 Page 57 15/16 QIPP Projects PATIENT EMPOWERMENT TitleDescriptionActivity Changes Health ChampionsExpanding the existing programme.~200 Patients Engaged. CHILDREN & YOUNG PEOPLE TitleDescriptionActivity Changes Development of a paediatric rapid response team /review urgent care pathway. Based on accurate needs assessment. Pilot in place Jan – March 2015 and will inform viability Reduction of ~200 non- elective admissions. Explore potential community provision for CYP requiring ventilation. This will require a joint approach with children's continuing careTo be identified Wheezy Child Programme Dependent on assumption that there is a significant cohort of paediatric admission for respiratory disorders. Reduction of ~100 non elective admissions. MEDICATION TitleDescriptionActivity Changes Reduction in Medication Expenditure Wastage Reduction: £600k Medicines Optimisation: ~£100k Anti-Coag: ~£100k High Cost Drugs: ~£100k Care Home Pharmacist Admissions Avoided: ~£50k Targeted Polypharmacy Reviews: ~£100k Targeted Cost Reductions: ~£550k To be specified for each scheme. PALLIATIVE CARE TitleDescriptionActivity Changes Health and Social Care integrated Rapid Access Programme As a work stream of the BCF the London Borough of Hillingdon, Hillingdon CCG, The Hillingdon Hospital, CNWL and the Voluntary sector will work together to develop a combined pathway to enable speedy discharge from A&E to the patients preferred place of care.

Hillingdon CCG Commissioning Intentions 2015/16 Page 1 Finance Report Month 3 2012-13 Commissioning Intentions 2015/16 Ian Goodman, Chair of the CCG Ceri.

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Hillingdon CCG Commissioning Intentions 2015/16 Page 1 Finance Report Month 3 2012-13 Commissioning Intentions 2015/16 Ian Goodman, Chair of the CCG Ceri.

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Presentation on theme: "Hillingdon CCG Commissioning Intentions 2015/16 Page 1 Finance Report Month 3 2012-13 Commissioning Intentions 2015/16 Ian Goodman, Chair of the CCG Ceri."— Presentation transcript:

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