Scrutiny of Qipp

Appendix 5B

SCRUTINY OF QIPP

KEY QUESTIONS

1. Group 2 –Quality & Outcomes within the New Financial Context

2aHow are you changing the way you do things within the financial context?

2bWhat are the key challenges for you as an organisation over the next few years?

2cHow can patients judge the hospital/trust – what are the key indicators?

Hertfordshire Community NHS

2a HCT is updating a number of strategies (clinical services, market analysis, financial modelling) to consider the medium to longer-term risks and opportunities for services. Business development is being strengthened to ensure that we are well placed to complete for new work in a competitive environment.

2b Continued delivery of new models of care, care closer to home and facilitation of the transfer of services from an acute setting to community care, making us the provider of choice.

Delivery of an ambitious cost improvement programme, whilst continually improving and driving up standards of care and the patient experience.

Relationship and support from NHS Hertfordshire, as our lead commissioner and development of relationships and effective working with the clinical commissioning consortia

Lack of progress with development of a community based tariff.

2c We achieved all of the national performance standards during 10/11. We have 4 quality priorities (as set out previously) and our progress against these is monitored and reported. Key performance indicators are reported monthly to the Board in the Integrated Performance Report.

Hertfordshire Partnership Foundation Trust

2aWe are reviewing and transforming the way we work and deliver services via our bold and innovative programme – Leading by Design

This programme will deliver a structure that has critically examined our entire workforce, cutting out costly duplication and making sure that our workforce is modelled to fit the changing face of the provision of both mental health and specialist learning disability services. Examples of this include:

i) The trialling, testing and subsequent introduction of a Single Point of Access to all of our services will see the introduction of consistent, costed care packages throughout the patient journey.

The Trust receives around 30,000 routine referrals a year, approximately 100 urgent contacts a day through 34 duty systems and around 4000 crisis referrals. This system can lead to inefficiencies and inconsistencies in how services are delivered across the Trust. It also limits the Trust’s ability to flex resources to meet changes in the volume of demand. The Single Point of Access will provide consistent high quality information, advice and access, including assessment, across all HPFT services. It will operate 24 hrs a day, 7 days a week, 365 days a year. In addition to being more efficient, this system will help ensure that people needing services will receive them when needed from the person best placed to provide them.

ii) The Trust is introducing Recovery Care Pathways that will reduce variation in practice and ensure that we deliver consistently high quality effective care based on need. They will also reduce duplication and handovers resulting in more efficient delivery of care.

iii) Alongside the introduction of new care pathways we are working to embed new more efficient ways of working as part to of our ‘Working As One’project. This builds on previous work e.g. the introduction of parts of the NHS Institute for Innovation’s ‘Productive Series’. As part of this we are looking at best practice that already exists both within and outside of the Trust.

2bThere are key external and internal challenges facing HPFT over the next few years. They include:

External

-Working with our commissioners and partners to manage rising demand for mental health services. This is expected to be exacerbated by cuts in other areas of public expenditure disproportionately impacting the most vulnerable in society.

-Ensuring Mental Health and Learning disabilities get fair and equitable access to the available growth money. History tells us that this has not typically been the case.

-Working with Clinical Commissioning Groups to ensure that joined up commissioning and delivery of health and social care services is not put at risk

-Managing the uncertainty and potential volatility in income as a result of the introduction of Payment By Results to Mental Health services

-Maintaining the support of all our stakeholders (including service users, carers, GPs and provider partners) for the planned changes

We are working closely with commissioners (current and future) to mitigate against these risks.

Internal

-Delivering the efficiency savings required by commissioners (incl. social care savings) whilst maintaining and improving the quality of services.

-Delivering our transformation programme ‘Leading By Design’ safely and on time.

-Maintaining high levels of staff engagement and motivation through a period of significant change

-Developing our workforce to ensure we have the right number of people with the right skills and attitude to deliver our a new model of care

We are investing significant resources (financial and people) into Leading By Design to ensure it is well planned, communicated and that the expected benefits are tracked and delivered.

2cService users and carers are able to access a range of information to judge the quality of the services provided by HPFT. This includes:

• Our Quality Account which we publish every year and is also available through the NHS Choices website
• The results of the National Inpatient Mental Health Survey
• The results of the National Community Mental Health Survey
• The results of CQC inspection reports
• An Independent Survey of Care and Treatment conducted in April 2009 (published on our website)

The key indicators are set out in our Quality Account (attached)

We encourage service users and carers are to pass judgement on our services through several ways including:

• Participation in national surveys (see above)
• Participation in ‘Having Your Say’
• Participation in the care council and the service user councils
• Their roles as a Governor or Member of the Trust
• Their work as part of the Trust’s Involvement Team either as a volunteer or paid service user or carer representative
• Their role as a paid member of staff (peer support worker) or as a “peer listener” recruited and trained to carry out surveys of service user and carer views under supervision
• Their links with other user and carer involvement groups such as View point and Carers in Herts
• Their membership of the Service User and carer Engagement Group which forms part of the Trust’s formal Integrated Governance committee structure

NHS Hertfordshire

2aAs the commissioning organisation we have been very clear in our contracting arrangements to set out the quality and outcomes that we expect from providers. This not only is the explicit CQUIN but they are also set out within our commissioning intentions letters that we send out to trusts in October each year.

There is a formal performance monitoring element of the contract management process.We have been explicit where there is national guidance on outcomes and quality that Trusts are commissioned to deliver the most effective pathways for patients. We have formal prior approvals processes for some treatments. The PCT may have decided not to fund the treatment because it does not provide sufficient clinical benefit and/ or does not provide value for money, an example of this would be tonsillectomy.Quality schedules are part of our contracts with each organisation. These are tailored to each Trust and will focus on the issues or areas that have been agreed as priorities.

2b Financial
We recognise that, as the White Paper sets out, we will be working within a system where there will be significantly less growth in funding than received in previous years. Although the Government has agreed year on year real terms increases, there are a great number of pressures on NHS resources that we need to manage. Health inflation often far exceeds the Government’s inflation indicator (GDP deflator) as, for example drug and equipment cost increases can be higher. A growing and ageing population, increased public expectation and the continuous drive to improve services will lead to increased costs in excess of the real terms growth in funding made available. In addition, the resilience of emergency demand vividly illustrated by the pressures seen during December 2010 and January 2011 means some of our previous assumptions about demand need to be revisited. Taken together these mean that even with the growth in funding, the health system is facing the prospect of significantly increased cost above the level of funding received.

With very limited growth monies but continued demand, quality and inflationary pressures, the health economy in Hertfordshire faces the challenge of releasing £276m in productivity and cost efficiencies as demonstrated in the table below.
It should be noted that in addition to this, other NHS providers that are not based in Hertfordshire, but from which the PCT commissions services, will also need to find £70m of savings relating to their services for Hertfordshire, in order to remain in financial balance. Although included here for completeness, the actions they take will be included within the QIPP plans of the relevant health systems.

£ millions / 2010/11 / 2011/12 / 2012/13 / 2013/14 / 2014/15 / Total
Benefit from PCT allocation increase / 1651.6 / -36.7 / -38.4 / -43.3 / -48.2 / -166.7
Pay and price pressure on 2010/11 base / 33.0 / 31.5 / 31.2 / 31.1 / 126.8
Demand and quality pressure on 2010/11 base PCT / 76.7 / 55.8 / 60.4 / 59.6 / 252.4
Demand and quality pressure on 2010/11 base providers / 14.4 / 13.3 / 20.2 / 7.7 / 55.5
Debt repayment / 0.0 / 0.0 / 0.0 / 0.0 / 0.0
Residual challenge from 2010/11 / 33.4 / 0.0 / 0.0 / 0.0 / 33.4
Total size of challenge net of tariff / 120.8 / 62.1 / 68.4 / 50.1 / 301.5
Benefit of tariff reduction outside Herts / -6.1 / -6.0 / -6.4 / -6.6 / -25.2
Overall System Challenge / 114.6 / 56.1 / 62.0 / 43.5 / 276.2

The challenge for the PCT is set out below:

£ millions / 2010/11 / 2011/12 / 2012/13 / 2013/14 / 2014/15 / Total
Assumed PCT allocation / 1651.6 / 1688.3 / 1726.7 / 1770.1 / 1818.3
Pay and price pressure on 2010/11 base / 12.0 / 12.4 / 12.8 / 13.2 / 50.5
Demand and quality pressure on 2010/11 base / 76.7 / 55.8 / 60.4 / 59.6 / 252.4
Less tariff benefit derived from NHS providers * / -17.5 / -16.8 / -16.6 / -16.4 / -67.4
Debt repayment / 0.0
Underlying 2010/11 pressure c/fwd / 32.3 / 32.3
Size of challenge / 66.8 / 12.9 / 13.2 / 8.2 / 101.2
Memorandum
Non system provider challenge / 30.3 / 10.5 / 14.5 / 14.5 / 69.8
*Note - the tariff benefit is the benefit to the PCT from all its NHS contracts

Quality

The PCT strategy remains based upon three strategic goals:

• Keeping Hertfordshire healthy
• Enhancing the patient experience
• Commissioning high quality care.

Underpinning these goals is a series of work streams each of which has specific outcomes and action plans. This means that we can monitor and measure achievement and progress. These include the key clinical priorities in Towards the Best Together, the East of England’s strategic vision. Through Herts Forward each LSP has a sustainable communities strategy which tackles issues such as smoking, teenage pregnancies and health inequalities.

Quality outcomes

The PCT’s strategic plans set out key quality outcomes and these remain our high priorities.

1.Health inequalities

There is still too great a variation in health outcomes within Hertfordshire and the trend is increasing. We aim to reverse this trend and reduce health inequalities. One of the indicators of health inequalities is life expectancy. Our aim is to reduce the difference in life expectancy between the poorest 20% of our population and the average. Overall we also aim to increase life expectancy for all women and all men.

2.Birth - Caesarean birth rates

Current rates of caesarean births in Hertfordshire are above the national average. For 2011/12 we aim to have reduced rates to 26% in west Hertfordshire and 24% in east and north Hertfordshire with particular focus on planned (non emergency) caesarean births. We are working with colleagues to develop pathways to help deliver this objective and to agree future targets.

3.Children - Childhood Obesity

Improving the health of children has clinical, social and resource benefits that can be life long. This is a national issue as rates are increasing and although we have made some improvements already we want to ensure that there is a not only a halt to the increase but obesity rates fall to 14.2% by 2013/14 from the 2009/10 rate of 17.0% for year 6 pupils (10-11 year olds). The target for Reception Class children (4-5 year olds) is to reduce obesity to below 9.0%. The 2009/10 result showed obesity prevalence in this age group of 9.1%, the rate having increased from the year before.

4.Stopping smoking

A key element of our strategy to reduce major illness is to reduce smoking. We have made good progress in terms of the number of residents that have stopped smoking but there is more to be done to reach the target of reduced smoking prevalence. We are aiming to support over 15,000 people to quit between 2011/12 and 2012/13.

5.Patient and User experience

Patients who are well informed about their condition and engaged by their clinicians are more likely to have a better clinical outcome. And when we deal well with patients and increase their understanding they are also more likely to use their medicines most effectively and so reduce the chance of wasting expensive resources. We have included patient experience in all our CQUIN schemes for 2010/11 and will continue to do so to enable effective monitoring of patient experience rates which differ for each provider.

We recognise that improved access to, and awareness of, primary care services can prevent unnecessary demands on other services including acute hospitals and A&E. in the recently published national GP access survey, the Hertfordshire average score across the 5 domains was 75.3%[1] a small decline on the previous survey and ranking NHS Hertfordshire 10th out of 13 in the east of England. 15 NHS Hertfordshire practices feature in the lowest 10% nationally. To improve this performance the PCT Clinical Executive Committee has developed a GP Practice “Performance Management” process specifically focusing on practices with particular areas of poor performance.

On GP Patient Experience Indicators within east of England, NHS Hertfordshire is ranked 7th out of 13 for overall satisfaction at 90% and 5th out of 13 for willingness to recommend GP surgeries at 85%. 6 Hertfordshire practices feature in the lowest 10% nationally for both these indicators. We recognise that there are opportunities to improve the quality of access to primary care and we are working with GP practices to do this.

Each year the Care Quality Commission undertakes a number of surveys for all NHS Trusts in England. These outpatient/inpatient survey results benchmark local provider organisations. Dr Foster publishes a Good Hospital Guide and Quality Reports for Trusts and the findings of these reports are also used to recognise areas where the patient experience and patient safety are good and to highlight areas for further improvement.

Patient Safety

Maintaining and improving patient safety are key focus of our strategy regarding patient experience. Across organisations in Hertfordshire there are robust quality schedules which are part of contracting between commissioners and providers and these set out the standards of care and safety expected for patients and users of services. All organisations publish data on serious incidents, hospital associated infections and other indicators such as mortality rates.

We recognise that we need to look after our more vulnerable patients, both adults and children and ensure that they receive safe and appropriate care and support. There are countywide groups specifically set up to safeguard adults and children. The CQC undertakes inspections across the county and actions plans and recommendations are reported to the NHS Hertfordshire Board.

6.Stroke

Stroke is one of the major causes of disability and death. Evidence shows that patients admitted to a stroke unit have better outcomes, and Hertfordshire has achieved the vital sign target of more than 80% of patients spending 90% of their time on a stroke unit. We know that continued effort will be required to maintain this.

We also know that eligible patients receiving thrombolysis within 3 hours of onset of a stroke have reduced disability. Hertfordshire trusts have delivered thrombolysis to 24 patients by the end of December 2010. This represents only 5% of all patients. We are working towards the national target of 12% of all patients by the end of 2010/11. We expect to achieve this from March 2011 onwards through further staff thrombolysis training, improving access to imaging and delivery of thrombolysis 24/7 across Hertfordshire.

Fast identification and treatment of people presenting with Transient Ischaemic Attacks (TIAs) or 'mini-strokes', can prevent the onset of a major stroke. Our initial target (2010/11) is to see more than 60% of these patients within 24hours, and latest data (end December 2010) shows we are achieving 38%. Targets for future years have yet to be agreed. Our acute trusts are redesigning pathways and are setting up new clinics in order to see patients more quickly.

After patients have had a stroke, good quality rehabilitation has been shown to reduce longer term dependence. Hertfordshire’s 'Life after Stroke' group is reviewing patient pathways from the acute trusts through the community services to ensure that we meet the 'Accelerating Stroke Improvement' recommendations.

7.End of Life

We recognise that we need to do more so that patients reaching the end of their lives can choose to die in their preferred place of care. To achieve this there is close working between GPs, the acute trusts, local hospices and the voluntary sector to ensure that patients and their families have access to the information and the support they need. We also plan to do further work to raise the profile of end of life services and to implement the national strategy for end of life care.

8.Access to GP services

We recognise that good quality access to GP and primary care services is important to ensure that patients are able to be looked after in the community and do not make use of A&E and other services unnecessarily. We have identified those practices where access needs to be improved and we are working closely with these practices to deliver better access arrangements.

9.Cancer services