Scrutiny of Qipp

Appendix 5C

SCRUTINY OF QIPP

KEY QUESTIONS

Group 3 - Innovation & integration

3aWhat ways of working are you changing to become more efficient in the new financial context?

3bHow do you work with other partners to improve effectiveness of care and efficiencies (what has worked well, what is your current focus)?

3cWhat blocks in partnership working need to be overcometo maximise gains?

Hertfordshire Partnership Foundation Trust

3aAs part of our transformation programme,Leading by Design, we are examining our corporate services and back office functions to ensure that they exist to support frontline services and deliver value for money. The more we save in back office functions the more we can retain and develop our front line services that people will experience on a day to day basis. An example is procurement, where we are currently reviewing how we can further reduce what we pay third part suppliers of goods and services.

Alongside our focus on back office functions we are working to embed new more efficient ways of working across front line services 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.

3b How do you work with other partners to improve effectiveness of care and efficiencies (what has worked well, what is your current focus)?

Our key partners include:

-Joint Commissioners

-PCT

-County Council

-GPs

-Service users and their families

-Other providers including statutory, private and third sectors

-University of Hertfordshire

-Other agencies e.g. police, prisons

HPFT invests heavily in time and energy, working positively with key partners across all stakeholder groups. We have a strong reputation for honesty, transparency and integrity in these relationships. Involving the Board and Executive team in developing and sustaining these relationships is key in demonstrating an organisation wide commitment and this is supported locally in relationships with local managers and care staff. These strong relationships have meant that it has been possible to remain engaged even when all parties are not initially in agreement. Careful relationship management and an emphasis on open communication and feedback has enabled us to bring partners with us when facing difficult challenges. Specific examples of key successes as a result of partnership working include:

-Working in partnership with service user groups such as Viewpoint has enabled us to deliver user led aspects to major aspects of training, increasing the effectiveness of care.

-Work with Mind in Watford has supported prompt discharge and community reintegration delivering efficiencies and effective care.

-Strengthened liaison services with the acute trusts in Hertfordshire has improved effectiveness around the care of older people with mental health problems

-Partnership working with commissioners has allowed us to:

• Introduce alternatives to inpatient admission e.g. Acute Day Treatment Unit
• Increase the number of people able to access psychological
• Establish a new innovative Early Memory Diagnosis and Support Service that takes forward the national dementia strategy

In addition to these specific examples, HPFT has a long, successful track record of working on partnership with the County Council to provide fully integrated health and social care services since the Trust’s early adoption of delegated authority via a Section 75 agreement.

Key areas of current partnership working include:

-Our ‘Leading By Design’ (LBD) transformation programme:

• The programme’s Leadership Group includes commissioner, service user and carer representatives
• Individual LBD Project Boards include commissioner representatives
• As part of our work on introducing a Single Point of Access we are in dialogue with others looking at similar systems e.g. Hertfordshire Community Trust
• We are working with commissioners on rolling out personal budgets further

-We are working with third sector on new integrated service delivery models e.g. Drug and Alcohol services

-We are embarking on a pilot with GPs around a more psychological approach to long term conditions

3cTo maximise gains from partnership working we must:

• Align incentives of individual organisations to act in a way that delivers efficiencies for the local health and social care economy as a whole e.g. where one part of system needs to invest to deliver savings in another part.
• Develop pathways that cross organisational and funding boundaries. Examples of funding boundaries include those between health, social care, children schools and families and the criminal justice system.

The QIPP programme and associated transformation funding is welcome in this respect. It encourages cross organisational working and provides much need pump priming, but does not fundamentally shift the underlying incentive structure.

NHS Hertfordshire

3a The PCT and the organisations within Hertfordshire have developed an integrated plan “QIPP plan” that sets out how the how Hertfordshire system will work to deliver improved quality and effectiveness within the new financial context. HCC are also linked into the development of this plan.

The GPs and the emerging Clinical Commissioning Groups are taking a greater role in contract monitoring. There are new incentive schemes this year with practices to manage more care within primary care as part of our local commissioning schemes.

The QIPP plan is linked to the contracting with all providers.

Within the plan there are a number of workstreams which are taking forward specific projects to deliver more effective quality care. This includes areas such as the Intermediate Care Strategy and those project areas, discussed above.

3b The PCT and the Clinical commissioning groups are working with partner organisations to look at new care pathways and deliver more effective, efficient care.

In 2011/12 the PCT created a Transformation Fund worth £32.3m. Just under £18m has been approved by the PCT from across the organisation in Hertfordshire. The Transformation Fund has£14.5m left uncommitted in 2011/12.

The key workstreams are outlined in the QIPP plan. There is a QIPP Programme Board, currently chaired by the Finance Director of ENHT with senior Executive representatives of the Hertfordshire organisations.

Progress on QIPP schemes is monitored and discussed here.

Clinical pathway changes are discussed and agreed at the two Clinical Committees that have been established between GP and Consultant colleagues.

Managing demand and working within the financial resources available are key priorities that underpin the QIPP plan.

3c There is a very strong record of partnership working across Hertfordshire that was developed and enhanced through the DQHH consultation process. This has continued through the development of the QIPP plan. The pressures of managing day to day situations can sometimes have an impact on effective partnership working and the resources needed to plan for future changes.

The SHA has recognised the positive way that the system works together across Hertfordshire.

WestHertfordshireHospital Trust

3a Transformation funds are supporting changes in the way we assess patients with the development of a Clinical Decisions Unit (CDU) which will divert the need to admit some patients entering A&E and the Acute Admissions Unit.

The introduction of the Older People Assessment and Liaison model to ensure a full care needs assessment is completed at the beginning of the care pathway for older patients. This will identify the specific interventions required at the beginning of the pathway to ensure care is delivered more efficiently resulting in a better patient experience and a reduction in unnecessary delays to discharge and on-going care planning.

Work-streams are underway to support admission avoidance, including better GP signposting to more appropriate care (ie urgent care centres or disease specific care pathways).

We have initiated a programme of specialty reviews to support the development of integrated service planning, potentially to re-align secondary care as appropriate. We are currently looking at internal issues which will inform future collaboration with health and social care partners.

CEO led group focusing on ‘making things work better’. The initial focus is on communication with patients, staff, GPs and other external partners. The focus is to improve efficiency to improve the patient experience.

3b We have set up a number of processes/systems to try and ensure this:

1. Primary Care set up via Conclave/Clinical Quality Sub-Group/Clinical Partnership Group. We meet with General Practitioners to discuss and resolve these issues.
2. There is considerable and ongoing dialogue with health and social care partners at senior level to address whole systems challenges in relation to the Trust’s access to community and social care.
3. PCT directly through the Clinical Quality Group, but also more specifically with sub groups such as the Infection Control Group that
   is working closely with the PCT, and between primary and secondary care.
4. Networks such as the Herts & Beds Cardiac and Stroke Networks, have already achieved significant improvement in outcome for both.
5. Finally, at regional level through the Medical Directors’ Network to tackle particular issues including revalidation.
6. The Trust participates in a number of whole system groups to improve issues across the system such as the management of falls, infection control and more recently it has established a neo natal capacity group involving NHS Hertfordshire and the Specialist Commissioning Group for neo natal care. More recently a work stream has started to review the extent to which acute and mental health services fully meet the needs of patients admitted to A & E who have mental health issues.

3c We need the incentives to be much better aligned and to develop mechanisms to ensure implementation in primary care. Recommendations are not always followed at a practice level.

There continue to be issues in relation to clarity of purpose across the system. The organisational demarcations that continue to exist, although being loosened, are not conducive to really addressing the need to develop integrated care across health and social care providers. Similarly, the lack of continuity and consistency in the way services are funded and their susceptibility to current financial challenges will continue to impede progress in achieving consistently smooth care pathways.

East and North Hertfordshire NHS Trust

3a We have progressed our plans for the consolidation of acute services in a programme called Our Changing Hospitals (or OCH). In addressing a number of clinical and financial challenges, it will:

 allow us to achieve the highest standards of clinical practice and improve outcomes and productivity across the organisation

 create a critical mass of clinical and specialist staff to allow us to sustain a wider range of high quality services than would otherwise be possible and introduce new technologies

 enable us to maintain viable 24/7 medical staffing rotas for all our services

 facilitate the modernisation of our facilities, improving their attractiveness to patients

 improve our ability to attract and retain high quality staff

 Allow us to prepare for a future in which more acute care is provided in the community

 enable reductions in estate and related costs from the reshaping of the QEII site to offset the income loss and support the revenue consequences of the capital investment on the Lister site.

The OCH programme takes a phased approach to change, testing deliverability and flexibility at each stage. To date:

 Phase One (Surgicentre): construction of the Surgicentre development is progressing. The service becomes operational in September 2011

 Phase Two (Women’s and Children’s): construction commenced in September 2009 with the service due to become operational in October 2011. This project remains on plan and in budget, and the unit opened as part of our decanting plan in December 2010

 Phase Three (Car Park): construction commenced in August 2010, and the car park opened in September 2011

 Phase Four (Full consolidation of acute services): the centralisation of emergency services, including A&E, on the Lister site during 2014 and full acute service consolidation later that year. The Trust Board approved the outline business case in September 2010 and the PCT and SHA Boards approved the case at their respective Board meetings in September 2010. It was approved by both the DH and HMT in August 2011.

The economic downturn and its consequent impact on PCT commissioning has informed our plans to deliver these improvements. These are fully consistent with our Commissioners’ intentions. This strategic framework provides an opportunity for us to extend service provision into community settings (for example, through the provision of minor injury services and community based services), and also to develop more specialist local services, reducing the need for the people of Hertfordshire to travel long distances.

The Mount Vernon Cancer Centre (MVCC) is a key component of our portfolio. Since 2005 we have invested heavily in the centre, with £25.5m combined NHS and charitable investment made in developing its services. Whilst many of the centre’s facilities have been transformed, there remains a need for further investment. Mindful of this, the Cancer Services Division are working with partners to develop plans to maintain MVCC ‘at the top table’ of cancer centres nationally, having delivered new research facilities, chemotherapy capacity and robotic treatment technology in 2010.

This strategic direction is fully aligned with the commissioning intentions of our local PCTs, which are reflected throughout this Integrated Business Plan in our objectives, development plans, and financial modelling.

3b The health strategy for Hertfordshire (DQHH) has been agreed with NHS Hertfordshire and local authorities. The Trust has a positive relationship with local authorities and the Trust’s Involvement Committee (future Ft Council of Governors) includes appointed governors in shadow from local authorities including the county council.

The Trust consulted widely on its intention to apply for NHS foundation trust status and local authorities supported this proposal.

The Trust is an active member of several local strategic partnerships.

We have also developed an innovative partnership with Assura Lea Valley LLP, a limited liability partnership between local GPs in the Hertford/Ware/Cheshunt area and Assura Group, a national health provider organisation, which partners with GPs to deliver high quality patient care in the community. We have successfully delivered urgent care centres (UCC) at HertfordCountyHospital and CheshuntCommunityHospital. Following the end of the UCC pilot and the decision by NHS Hertfordshire to not continue commissioning the UCC at Hertford from October 2011, the Trust is working with AssuraLeaValley and NHS Hertfordshire to develop a nurse-led Minor Injuries service at CheshuntCommunityHospital.

Delivery of the Hertfordshire QIPP plan is managed through a joint programme board including representation from all organisations within the health system and social services. The programme board is chaired by the Trust’s Director of Finance, Paul Traynor. The current focus remains on delivering the agreed strategy for east & north Hertfordshire regarding consolidation of acute services.

3c There are no significant blocks to partnership working which we perceive as risks to delivery. Maintaining focus and corporate attention on delivery through periods of potential structural instability and system change represent key risks in the forthcoming period

Hertfordshire Community NHS Trust

3a We are reviewing the estate, to ensure that clinical areas are fit for service delivery and that the most cost effective buildings are used for the location of our clinical teams and services. Where possible we look to co-locate staff, building on successful co-location already in place across parts of the county.

A number of service redesign projects are underway to increase efficiency and improve service delivery. These include:

-Single point of contact for people accessing and contacting services

-Children’s occupational therapy integration

-Hertsmere project

-Diabetes service

-Redesign of podiatry services

-Focus on reduction in length of stay and associated work which ensures patients are treated in the right place for the right amount of time

-Pilot of mobile working and increasing use of teleconferencing

-Integration and closer working with other agencies e.g. ‘Think Family and children’s centres’

-Specifying the ‘sub acute’ model of care and potential for service developments

Services are being supported to review their service delivery using LEAN methodology, internal benchmarking and the Productive Series.

3b HCT takes part in the NHS National Community benchmarking club, which enable us to review our performance on a number of quality, financial and activity based measures in comparison with other aspirant community foundation trusts.