Executive Summary by 60JURu


									               Annual Operating Plan 2008/09

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1 Executive Summary                                               3

2 Context                                                         3

3 Priority Areas for 2008/09 : Overview                           5

4 Priority Areas for 2008/09 : Tier 1 Vital signs,
 plus new and existing national target                            6

5 Priority Areas for 2008/09 : Tier 2 Vital signs,
 plus LAA targets                                                 10

6 Priority Areas for 2008/09 : Local PBC targets / objectives     13

7 Commissioning and Delivery arrangements                         15

8 Enablers                                                        20

9 Supporting information                                          23

10 Appendices A to E                                              24

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Brighton & Hove City PCT has set the following strategic objectives:

1. Health improvement and health outcomes
To deliver measurable and continuous improvements in the health of our population
and to reduce the gap between those communities which experience the best and
worst health outcomes.

2. Commissioning excellent health care services
To commission high quality evidence based services which offer people meaningful
choices, and to be recognised for this through the achievement and maintenance of a
rating of “excellent” in the annual health check.

3. Public confidence
To build public confidence in local health services and to ensure that people’s
experiences are used to inform and improve local delivery of services.

4. Finance, value for money and governance
To deliver a sustainable balanced financial position across the local health economy
which demonstrates value for money and effective stewardship of public funds.

5. Leadership and relationships
To develop effective relationships with organisations across health, social care and
other wider community sectors and to provide strong leadership for the delivery of
services across the city and the promotion of healthy living.

Following an integrated planning process put in place for the first time this year the
PCT has agreed a prioritisation of investments. In drawing together our plans we
have recognised where we have unavoidable pressures either cost or service
pressures that must be funded as a first call against available resources.

This has left funding available to invest in the delivery of targets and service
objectives in the following order of priority: -

1      Tier 1 Vital signs and the need to address performance against the existing
       national targets and new national targets.

2      Tier 2 Vital signs and targets within the Local Area Agreement.

3      Tier 3 Vital signs and other local plans

In concluding our plans for the year we have reviewed the savings target we have set
ourselves, the risks of non-delivery of targets and the level of contingency reserve.

2.     CONTEXT

Brighton & Hove City PCT has a registered population of 260,700. This includes
181,800 adults of working age, which is a much higher proportion than the national
profile. Further more, over the next few years it is estimated that the working age
population and the number of children aged less than 10 years will increase with a
reduction in the elderly female population. The overall population numbers are not
expected to change leading to a change to the demography of the population.

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Brighton & Hove’s health services are provided by a diverse range of providers,
including NHS Trusts, Independent Sector providers and Voluntary Sector providers.
The acute health services are predominantly provided by Brighton & Sussex
University Hospitals Trust (BSUH) operating from the Sussex County Hospital site
and the Princess Royal Hospital site at Haywards Heath. Orthopaedic elective Care
is provided by Care UK from the Sussex Orthopaedic Treatment Centre at the
Princess Royal site. Community services are predominantly provided by South
Downs Trust and Mental Health services are provided by Sussex Partnership Trust.
Children’s services are provided by the Children’s and Young Peoples Trust which
became fully operational in October 2006. The city has 150 GPs operating 47

Brighton & Hove has approximately £4m worth of Voluntary Sector contracts per
annum, covering a broad range of providers and services including Mental Health,
Sexual Health, Older People’s Services, and Children’s Services. We are currently
working with the voluntary sector to develop the sector to work more closely with the
PCT in the future.


The infrastructure of the buildings within Brighton & Hove is mixed, with a significant
part of the acute sector and community sector operating from Victorian or outdated
health care facilities. Over recent years the process of renewing this infrastructure
has begun, with significant developments on the Royal Sussex County site including
the Millennium Wing, the renal unit and now the re-provided Royal Alexandra
Children’s Hospital. At Brighton General, BSUHT have vacated the Victorian wards in
December 2007 and have reprovided those community beds in a range of community
facilities in and around the city.

The GP practice infrastructure has already considerably improved with new surgeries
in Preston Park, Mile Oak and now Patcham. There is an ambitious Primary Care
Development Plan involving ten further developments in the city that will see the
transformation of primary care facilities over the next five years. As outlined in “Best
Care, Best Place” and in “Fit for the Future”, the proposal to develop three polyclinics
remains, with an expansion of Hove Polyclinic, development of a polyclinic on the
Brighton General site and a virtual polyclinic within the central locality using existing
and additional community facilities.


The PCT received a ‘weak’ rating for the quality of services rating under the Health
Care Commission 2006/07 healthcheck whilst retaining a rating of ‘fair’ for use of
resources. This was disappointing and the PCT has set in place plans in 2007/08
and as part of the 2008/09 Operating Plan to address existing national targets and
new national targets where performance was inadequate.

Despite the weak rating for quality of services, the Local Health Economy (LHE) has
made excellent progress over the last three years improving the services it provides
to the residents of the city. Its performance across a very broad range of local and
national targets has improved significantly, however we have further work to do to not
only bring performance up to the required level but also to ensure we are achieving
optimum performance across all care areas.

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We have seen a significant fall in cardio vascular disease mortality and are improving
our recording and management of blood pressure and cholesterol and we continue to
over-achieve our targets for reducing smoking habits. During 2007/08 we have
achieved the 98% of patients seen within four hours in A & E, achieved the cancer
targets for all patients seen within two weeks and all patients treated within two
months of urgent referral. We have further work to do to ensure a reduction in
teenage conception rates, and ensure all patients are seen and treated within 18
weeks of referral for all specialties. We require further work to reduce our Delayed
Transfers of Care and we need to maintain more drug misusers in treatment.

The Quality Outcomes Framework Assessment of GPs shows that whilst we have
some excellent performing practices within the city there is too great a variation in
achieving these standards in Primary Care and we need to improve performance in
access to GP services, and across a broad range of clinical and organisational

3.       Priority Areas for 2008/09 : Overview

During the last three years, we have made significant investments in community
services, hospital and specialist services and have improved access to services
across nearly all areas. We have remained in financial balance throughout this time,
and since the formation of the PCT.

Whilst investments have improved premises and access, we now need to invest to
further improve quality of services, reduce health inequalities and improve health
outcomes. This year we will focus on the following key areas:

    Tier 1 Vital signs, plus new and existing national target
    Tier 2 Vital signs, plus LAA targets
    Local PBC targets / objectives

The Strategic Commissioning Plan (SCP) demonstrates that there is urgent attention
and investment required to:

   Reduce harmful effects of alcohol consumption and drug taking
   Improve mental health services to reduce suicide rates
   Reduce sexually transmitted diseases and teenage pregnancy
   Improve primary care services to support better prevention and health promotion
    and improve chronic disease management

Added to the above there has been additional Department of Health Guidance which
comes into force in 2008/09. An example of this is the requirement for the NHS to
ensure priority treatment for war pensioners. This guidance came into effect in the
last quarter of 2007/08 and the PCTs obligation to ensure that GPs are aware of the
extension of priority treatment for all veterans has been met.

While we will focus on these areas, we will invest and improve all services, as we aim
to develop health services that are fit for the future and are seen as best practice
example across the UK.

Appendix A of this document are the trajectories submitted to the SHA
demonstrating the performance improvements expected to be delivered against the
targets over the next three years.

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4.       Priority Areas for 2008/09 : Tier 1 Vital signs, plus new and
         existing national target

4.1. Convenience & Choice – PCT Booking: Performance in 2007/08 has
improved; by January 2008 the PCT performance had increased to 50%.
The PCT is looking to build on its performance in 08/09 through:

        Supporting and encouraging GPs through direct support and offering a
         centralised processing of Choose & Book referrals.
        Ensuring full utilisation of Choose & Book within practices.
        Enhancing hospital based system and embedding slot availability into
         the 18 week programme.
        Enabling Two Week Wait referrals via Choose & Book.
        Implementing Advice & Guidance in all specialties.

In addition, the PCT is reviewing a new Primary Care gateway management
service which, if approved, would process Choose & Book in a standard
referral method.

4.2. Delayed Transfers of Care: Progress has been made in quarter four of
2007/08 to reduce the number of patients delayed in hospital from an average
of 28 at the start of 2007/08 to the current level of 15. This improvement is
directly attributed to the implementation of a daily escalation process and
reporting against agreed thresholds.

Brighton & Hove LHE is recruiting a LHE wide coordinating role to manage the
process and to build on this improved performance.

The PCT is undertaking a short term bed capacity review and is planning to
commission an additional number of intermediate care and transitional beds in
the city.

4.3. Thrombolysis call to needle : To date (Q1-Q3) in 2007/08 63.2% of
people suffering from a heart attack receive thrombolysis within 60 minutes of
calling for professional help, falling short of the planned level of 68%.

The PCT will establish telemetry of ECGs as standard practice in the chest
pain pathway and ensure all relevant cases not meeting the target time under
the extenuating circumstances rule are excluded. In addition the PCT will
review individual case by case breeches and develop care pathway solutions
to mitigate any specific issues with local providers.

4.4. Breastfeeding initiation rate: (96.4% Q1-Q3), currently the target is
likely to be underachieved by approximately 4.5%.

The PCT will increase community breastfeeding groups in children’s centres
and deprived neighbourhoods as well as improve peer support across
localities and increase access to antenatal breastfeeding education.

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A communication campaign will be launched entitled ‘Big Debate’ aimed at
making Brighton and Hove more breastfeeding friendly (branding ‘Baby
Friendly Brighton and Hove’.

4.5. Patient based registers – registers of patient with risk of CVD: To
improve on 2007/08 performance the PCT will facilitate:

       An increase in the uptake of the Local Enhanced Service (LES),
        improve the level of rewards available and increase numbers of
        patients recorded on registers via a peripatetic multi-disciplined expert
       Facilitate health promotion activity in practices and develop a patient
        health promotion template for practices.

4.6. Community Equipment: Performance in 07/08 has been 91.48% against
a target of 95%. The PCT have agreed a project plan to increase the
percentage of items of equipment or minor adaptations delivered within seven
days. Key actions are:

       Rationalisation and updating of prescribing catalogue.
       The development of a database for electronic equipment referral.
       Further roll out of pilot ‘man and van scheme’ from April 2008 onwards
        to boost delivery response times.
       Establishing an exception reporting system.

4.7. CPA 7 day follow up: Year to date performance(Q1-Q3) in 2007/08 has
been 87% of 'at risk' service users have received post discharge follow-up
within 7 days, against a target of 100%.

The commissioning team will deploy a new Public Health specialist to
undertake Significant Event Audits and develop Audit Cycle. In addition the
PCT continues to review provider’s data quality to ensure that DH technical
guidance is being applied.

4.8. Cleanliness and healthcare associated infections – MRSA &
Clostridium difficile: The PCT has agreed a trajectory with providers that will
not allow for any hospital acquired MRSA infection by January 2011.

Although the final outturn data for Clostridium Difficile infection levels in
2007/08 will not be available until Q1 2008/09, the PCT has developed an
interim trajectory to deliver its share of a 55% reduction across the SHA,
ensuring the rate of infections is reduced to 8.52 per 10,000 population by

The PCT plans to recruit an Infection Control Specialist Nurse to provide
support and training to infection control champions in care homes and in
Primary Care. It is anticipated that this will be extended into other providers.

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Performance management systems established in 2007/08 will continue to be
actively managed in 200809 to ensure providers continue to develop and
improve clinical practice. In addition to this an antibiotic policy is being
developed and will be implemented in year.

4.9. Improving access – 18 week access: In partnership with provider
organisations the PCT is committed to delivering the 18 week access target,
within the operational tolerances set out in the National Operating Framework
by October 2008, ahead of the national deadline in December 08. The PCT
plans to demonstrate a commitment to the access target and show sustained
delivery in 2009, 2010 and 2011.

The PCT has a detailed project plan and governance structure for delivering
18 week target and will continue to closely monitor providers performance
against target. The PCT has purchased some additional activity in 08/09 to
ensure delivery of the target whilst alternative sustainable and new service
models/care pathways are developed, lead by Practice Based Commissioner.
The PCT is working with Primary Care clinicians in the development of a
gateway management function and system reform (Brighton Integrated Care

The PCT will be undertaking patient and public workshops to develop
appropriate communication messages and media to explain rights and

4.10. Primary Care - GP led Health Centre and Access to Primary Care:
To support the delivery of better health outcomes, the PCT is committed to
ensuring the patients are satisfied with access to primary care, when and
where they need it. Satisfaction levels are measured by a patient survey and
the PCT has planned to achieve significant improvements in levels of patient
satisfaction. The PCT plans to commission over 50% of practices to deliver
extended opening hours in 2008/09, rising to over 76% by 2010/11.

To increase capacity in primary care and access, the PCT is also procuring a
GP Led Health Centre by December 2008. This new centre will host GP
service for registered and non-registered patients and offer extended
community services.

Delivery of extended out of hours provision will be coordinated by an Access

4.11. Cancer: To deliver the new vital signs access targets investment is
needed in the following areas: -

      Two Week Wait for patients with breast systems
      31 day standard for subsequent cancer treatments
      62 day standard for patients treated for cancer following the detection
       of an abnormality by an NHS Cancer Screening programme.

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In line with the technical guidance, collaboration is required between
commissioners, providers and the Cancer Network to establish a baseline and
generate plans for achieving the target level of 100% within the required

Until this work is done it is impossible to determine exactly what further
investment is require over and above the agreed annual cancer operation
plan for 2008/09.

Therefore, an amount of £800,000 has been provided for in order to purchase
additional capacity/invest in pathway redesign so as to meet the performance
trajectories (when agreed) in year.

The target is to reduce cancer mortality rates by 2010 from cancer by at least
20% in people under 75 against a baseline from 1997 (1996-8).

The target is based on a three year rolling average using calendar years.
Therefore for this year‘s performance review the target relates to deaths
occurring in 2005, 2006 and 2007. Given the recent increase seen in the
2005 and 2006 rates it would be very unlikely that the PCT will meet this

The recent increase in cancer mortality has been highlighted in this year’s
Annual Public Health Report.

As for 2008/9 because of the rolling three year average the PCT can only
influence the data for 2008. Given the long lead in time to developing cancers
to have any short term impact on the rates will really depend on increasing
access to treatment and the treatments provided.

It has been estimated by American researchers in 2003 that:
     reducing smoking could reduce cancer mortality by 15%
     modifications in diet could reduce cancer mortality by 8%
     screening programmes could reduce cancer mortality by 3%
     treatments could reduce cancer by 10-26%.

Relevant actions to meet this target therefore include:
    further investigation of the underlying type of cancers
    continuing to promote and develop the local smoking cessation service
    continuing to work on reducing obesity, improving healthy eating and
      promoting exercise.
    increasing the coverage of local cancer screening services. The
      cervical screening coverage is low at present. A new health promotion
      post specifically aimed at increasing the coverage of cancer screening
      programmes has recently been appointed to. Their priority will be the
      cervical screening programme. Breast screening has acceptable
      coverage and a new bowel cancer screening programme will be
      introduced in 2008.
    Raising awareness amongst the local population of the signs and
      symptoms of cancer

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          Improving access to services
          Improving treatment services

Achieving this target therefore cuts across different teams and directorates
within the PCT. Currently a proposal for a virtual cancer team is being

4.12. Stroke: The PCT has already funded a TIA Stroke Prevention Service
delivering rapid assessment and treatment. The nurse led triage service
provides a single point of access for GPs/Primary Care. Future plans may
require consideration of more flexible patient transport to ensure that targets
are met. BSUHT are currently looking at their contract to see how this can be
accommodated. Also a capacity review later in the year may be required
depending on actual usage.

The national stroke strategy 2007 outlines a quality framework against which
local stroke services are to be developed. Stroke is given national priority due
to the significant impact stroke has on the nations health, economy and on
individual lives, the fact that many strokes are preventable and treatable and
that post stroke recovery can be enhanced specialist rehab and wider support
so reducing the incidence and level of disability.

Local objectives for delivery of the national stroke strategy are compliance
with vital signs and improved service provision through :

          Development of primary and secondary care prevention
          Development of thrombolysis service to provide hyper – acute stroke
           care at RSCH
          Improved access to longer term support including strengthening early
           supported discharge and support to patients

5.         Priority Areas for 2008/09 : Tier 2 Vital signs, plus LAA targets

5.1.       Local Area Agreement/Choosing Health: Within our plans for
           2008/09 the PCT is increasing the ‘Choosing Health’ funds that were in
           growth allocations in previous years. The total amount being made
           available for inequalities and health promotion initiatives is c£1000k.
           The funding covers a range of schemes in a number of areas, e.g.:-

          Encouraging sensible drinking £195k
          Improving Mental Health and well being £127k
          Improving sexual health £128k
          Self management skills of those with long term conditions £36k
          Reducing the number of people who smoke £43k
          Tackling health inequalities £404k
          Tackling obesity £100k
          Reducing teenage pregnancy £50k

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These link in part to both national targets and to local targets that will be
contained within the Local Area Agreement (LAA).

5.2       Patient Engagement:

The obligation to involve patients and the public in all levels of healthcare is
outlined in the Health and Social Care Act 2000. In the White Paper “Our
Health, Our care, Our say” , a central theme was the need to develop services
in line with people’s “opinion, preferences and views”.

Engaging the public and patients needs to be incorporated into all aspects of
the PCTs business and indeed the Health Care Commission development in
World Class Commissioning and Vital Signs have a set of targets that the
PCT needs to meet.

The development of commissioning plans and decisions, including Practice
Based Commissioning (PbC) needs to demonstrate that robust methods of
engagement have been used to ascertain the publics views.

Although the PCT is required to engage people the benefits of are clearly
demonstrated by:
       Improved care pathways- through good quality feedback and use of
          relevant patient experience
       Achieving “buy in” from patients
       Improved the publics perception of the NHS
       Enhancement of “choice”- those who have been involved are more
          likely to have ownership and spread the message. This may also
          improve public perception of how services are commissioned and
       Increased understanding of systems and processes
       Involvement of individuals and groups who may otherwise have
          been marginalised
       Development of different solutions

What the PCT does now

The PCT has a range of ways in which it engages with the public:

         Citizen’s Panel: The Citizen’s Panel is made up of between 1300 and
          1500 people from across the city, who are prepared to answer a series
          of questions about the public sector. Funded equally by the City
          Council, Police and PCT the Panel receive 3 ‘regular questionnaires’
          and where on of the organisations wants to ask specific questions they
          can use the Citizen’s Panel data base.
         Clinical Reference Groups: These are groups of managers, health
          professionals and service users who discuss services and
          commissioning intentions for a particular disease area.
         Patient satisfaction: The PCT has recently contracted with the Picker
          Institute and Dr Fosters to provide hand held ‘patient tracker systems’.

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       These devices enable the LHE to ask patients in a range of settings
       (BSUH; SDNHST; primary care settings) for their views (about
       cleanliness; food; attitudes of staff; treatment regimes etc).

       Patients are asked to complete a short questionnaire (either with help
       or by themselves). The Dr Fosters programme can ask five questions
       and results are downloaded immediately. Ward or clinic get real time
       information about what patients think of the services provided.

       The Picker system will provide the opportunity of asking up to 30
       questions, which enable clinicians and managers to obtain a rich
       picture of services. The PCT is currently working with other Trusts to
       develop an integrated approach to this and early discussions are a
       proposal for using this system in primary care is being developed.

      Gateway organisations: The PCT funds a number of organisations to
       consult on behalf of the PCT and help the PCT engage with mainly
       marginalised groups. Current funding includes:

       -Black & Ethnic Minority Community Partnership
       -Spectrum (LGBT Community organisation)
       -Federation of Disabled People

Review of engagement: In order to ensure that the PCT is a world class
commissioning organisation it needs to ensure that it has developed robust
engagement mechanisms. In order to do this effectively a review of
engagement is currently taking place. This has included two events, one
focussed on members of the public, voluntary sector organisations and the
communities of interest and the other on organisations the PCT commissions
services from. Both events have provided the PCT with a rich picture of how
stakeholders would like to be engaged. An independent review of
engagement is also taking place as part of the actions agreed with the SHA as
part of the FFP review.

Proposed new patient engagement activity: Although we do not want to
pre-empt the results of the independent review, there are a number of
initiatives that would enhance how the PCT ensures that patient engagement:

      Gateway organisations - further funding to ensure that communities of
       interest , particularly those who are ‘seldom heard from’ . Areas for
       further funding include:


      Funding to support involvement - this would include travel and caring
       expenses and where patients are specially helping to develop care
       pathways or policies a payment/voucher system.

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         The possible development of a patient group, who could function in a
          similar way to patient Board being set up as part of Foundation Trusts.
          Supporting practice based commissioners to develop patient groups.

5.3       Children

The Operating Framework sets out a target for the improvement for services
for disabled children making specific reference to respite care. As part of the
Joint Strategic Needs Assessment (JSNA) process, the Children and Young
Persons Trust (CYPT) has identified a need for investment in this service to
improve the quality of respite care across the city.

The CYPT is working on a JSNA with Brighton and Hove City Council, aimed
at delivering a robust action plan for key targets across health and local
government. This is expected to be completed in May/ June 2008, and will
lead to the development of a detailed action plan for the delivery of key
targets, including the Vital Signs indicators.

5.4       Maternity

The PCT is working with BSUH to deliver a vita sign (Tier 2 National priority
for local delivery): Percentage of women who have seen a midwife or a
maternity healthcare professional, for assessment of health and social care
needs, risks and choices by 12 completed weeks of pregnancy

 improving data recording systems so that robust access data is available
    including the ability to identify late bookers by postcode, ethnicity, age
 developing initiatives to encourage women to access a maternity care
    professional early in pregnancy (eg developing a card to be given out by
    pharmacies to all women purchasing pregnancy tests, ovulation kits, or
    folic acid)
 developing systems to enable women to access their midwife directly
 developing local initiatives (eg outreach in disadvantaged areas/with
    particular target groups) to reduce the numbers of late-bookers
 establishing a part-time midwifery post to work with black and minority
    ethnic groups of women and families; particularly recent immigrants from
    Eastern Europe

6.        Priority Areas for 2008/09 : Local PBC targets / objectives

6.1.   Primary Care Estates: The PCT has led on producing a Local Health
Economy Estates Strategy. This identifies the existing building stock and
included the requirements to deliver the PCTs strategic commissioning plan.

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It has been recognised that we need to improve primary care estate in
particular and this is seen as essential investment to both improve access to
primary care and to deliver a number of service changes.

The schemes progressing in 2008/09 are:-

      Opening Patcham Health Centre
      Surgery in central Brighton
      177 Preston Road (space for commissioned services)
      Additionally work towards developments in
          o Whitehawk
          o Kemptown
          o West Hove

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7.     Commissioning and Delivery arrangements

7.1.   Source and application of funds

08/09 SOURCE AND APPLICATION OF FUNDS                                                     £'000's
Note           08/09 Recurrent Resource Increase                                          20863
           1   Additional resource from budget roll-forward                               15984
           2   Return of 07/08 Surplus                                                     3000
           2   Non Recurrent funds for Mental Health investment                            1291

TOTAL RESOURCES AVAILABLE                                                                 41138

           3   Inflationary Pressures                                                     -7857
           4   BSUHT increase in contract value (net of savings)                         -13500
           5   Other Unavoidable Cost Pressures                                           -9925
           6   Costs required to deliver savings - including reprovision costs            -3504

           7   TIER 1 VITAL SIGNS +Existing National Targets/New National Targets         -2849
           8   TIER 2 VITAL SIGNS + Local Area Agreement                                  -2166

               Primary care estates development                                             -597
               World Class Commissioning Reserve                                               0

          10   Prescribing Savings                                                         1035
               Contingency & Reserves
          11     Contingency reserve                                                      -4028
          11     SHA lodgment                                                                  0

               ADDITIONAL SAVINGS TARGET                                                 2253

TOTAL RESOURCES EXPENDED                                                                 -41138

          12   Planned Surplus                                                                 0

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Notes supporting the source and application of funds are as follows:-

1.    The additional resource from budget roll-forward represents the
      underlying surplus built up over the last 2 years as a result of financial
      recovery and turnaround. We had set ourselves a target to maintain
      this level of underlying surplus but currently savings fall below that

2.    Both the return of the 2007/08 surplus (£3,000k) and the funds for
      Mental Health investment (£1291k) are technically both non-recurrent
      items in 2008/09.

3.    Inflationary pressures are the tariff uplifts to providers and this takes
      over 1/3 of the growth uplift for the PCT.

4.    The increase in the contract value for BSUHT is above the inflation
      increase mentioned in 3 above and is mainly due to the purchase of
      outturn activity from 2007/08 including a higher level of short stay
      emergency activity at full tariff. The additional services commissioned

         HIV services additional outpatient and drugs treatments
         An additional 2500 new GUM attendances
         8% additional support to patients following kidney transplant
         108,000 additional pathology tests
         3 additional intensive care cots and 1 additional ITU bed

5.    Other unavoidable cost pressures are made up of the following:-

         Continuing Care £2250k
         Prescribing inflationary increase (8%) £2760k
         Specialist Commissioning (inc SECAMB) service pressures £2613k
         MH – SPT released funds re-invested in MH £1291k
         SDH support to cover Integrated Community Equipment Store
          (ICES) service pressure £400k
         Various other service pressures £611k

6.    These are the costs to deliver savings and they include the costs of re-
      providing services which have been taken out of a secondary care

      The costs also include:-
       Services to be delivered by Brighton and Hove Integrated Care
         Services (BHICS); referral management £750k, Service Redesign
         £250k and Choose and Book £250k.

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         Extension of Urgent Care Centre £500k
         Palliative Care Beds £120k

7.    Tier 1 investments :-

         GP led Health Centre £500k
         Access to Primary Care £250k
         Cancer £1073k
         Intermediate Care Beds £557k
         Various other £469k

8.    Tier 2 investments :-

         Choosing Health £1000k
         Alcohol Harm £440k
         CAMHS £265k
         Various other £461k

9     Local PbC targets/objectives:-

         Primary Care Estates Development £597k

10.   Savings – these relate to prescribing savings and result in reducing the
      prescribing uplift (8% gross) to a 5% increase in funding to reflect both
      cost and volume increases forecast for 2008/09.

11.   As part of the SEC Operating framework we are required to plan for a
      1% contingency and lodging a voluntary 1% with SEC. Following the
      conclusion of the plan we have not been able to lodge 1% with the SHA
      but we have set a contingency reserve of £4028k (1%).

12.   Surplus – The PCT plan is to breakeven in 2008/09.

Through an integrated planning process the PCT has identified the proposed
investments we wish to make from the additional resources it has available for
investment in 2008/09. These additional resources include an underlying
surplus built up over the last 2 years and non-recurrent funds some of which
may be only available in 2008/09. This together with there being no funds
available for Tier 3 priorities means that the PCT is looking to generate
savings in year to fund further investments both in 2008/09 and 2009/10.

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In arriving at these funded priorities for investment we have deferred a
number of investments until next year or until further in-year savings have
been identified. We have also identified projects which whilst not saving
money are designed to change the care pathway within the existing

7.2.      Link to vital signs trajectories

The integrated planning process has been designed to ensure a read across
between vital signs trajectories and financial investment. In many instances
the trajectories are to be achieved without changing resource utilisation.

7.3       Implications for contract values

The implications to our three main local providers is set out in the table below
showing the 2008/09 contract value compared to the initial 2007/08 figure.

                                                       2008/09       2007/08

         BSUHT        main Acute provider (*)         £136m         £123m
         SPT          main Mental Health provider     £ 41m         £ 39m
         SDH          main Community provider         £ 43m         £ 40m

      * - excluding transitional support of £6m

Other increases are within the portfolio of contracts commissioned on our
behalf by Sussex Acute Commissioning Team (SACs) and Specialist

7.4   Summary description of commissioning projects with summary of
investments and disinvestments is attached to this document as Appendix B.

7.5       High risk projects (project template in appendices)

All projects listed within Appendix B carry risk at this stage. This is because,
for the majority of these projects we have not yet detailed business cases that
have been reviewed through our integrated planning process. The aim is to
have business cases developed and agreed by end March 08. Once they
have gone through that process they will become part of our Delivery Plan for
2008/09. In these circumstances Appendix C attached to this document
contains the one page summary of all projects we intend progressing this

The main high risk projects are :-

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      Brighton Integrated care Services
      Additional Intermediate Care Beds
      Extension of Urgent Care Centre – Phase 4
      Community Adult Hearing Aid Service
      GP led Health Care and GP Access
      Breast Screening

7.6. Performance management, showing milestones to be achieved and
contract management arrangements

In 2008/09 we are maintaining the PMO methodology put in place to oversee
Turnaround and from the Operational Plans we will produce a Delivery Plan
which will be used to oversee delivery of the key projects.

This methodology uses a milestone tracker, and the monitoring of KPIs and
finance which will be drawn from the detailed project plans.

We will continue to develop a data base to monitor not only the contract
monitoring information but also referral information.

The 2008/9 contract contains levers to ensure delivery of key targets and the
management of secondary care activity as per PCT plans.

   (i) There is an explicit and robust performance review process with
         monthly performance and clinical review of activity and key
         performance indicators. If performance is below a planned level for
         information quality, activity levels, clinical quality, financial
         reconciliation, referral management, or 18 weeks, then the contractual
         process is explicit about serving performance notices, warning notices,
         construction of remedial action plans, and potential consequences.
   (ii) There are specific mandatory indicators for MRSA and Cdiff, access
         targets for cancer, cardiac care, and 18 weeks, and provision of timely
         accurate data.
   (iii) Locally agreed indicators that incentivise improved performance for the
         Trust include (not exhaustive list):
             a. New: Follow Up ratios – improvement towards national upper
                quartile performance
             b. Conversion rates from A&E to admissions
             c. Pre-operative bed-days
             d. Vital signs indicators
             e. Serious untoward incidents
             f. Complaints
             g. Patient and staff surveys

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8.     Enablers

Below is a brief summary of the PCTs proposed actions and progress in the
following enabling areas.

8.1. Commissioning : Practice Based Commissioners (PBC) have been
more involved in the integrated planning process and have shaped some of
our proposals. It is clear we have more work to do to fully embed PBC into
our planning and monitoring processes but we are developing a detailed
project plan to achieve this over the next year and beyond. We will continue
to develop PBC localities as being the most effective route to fully engage

Within our 2008/09 plan we are seeking to hold a ‘World Class
Commissioning’ reserve and have set ourselves a target of £750k recognising
the importance of this national initiative and the likely costs of implementation.
At present this reserve is only available if we generate in-year savings. The
PCT will be reviewing all it’s budgets within Q1 of 08/09 to identify potential

8.2. System Management : The PCT takes it’s role as LHE system manager
very seriously.

We are a financially challenged LHE with the main Acute Trust (BSUHT)
coming out of Turnaround with a significant working capital debt to repay.

8.2.1 Brighton and Sussex University Hospitals Trust (BSUHT): In
2007/08 and again in 2008/09 we have been working with BSUHT and our
partner PCTs in West and East Sussex to provide transitional support. There
are issues still to be resolved in relation to the new Children’s Hospital and the
conclusion of a review that will set robust ‘local prices’. The level of this
support in 2008/09 is £12665k (£6472k from Brighton and Hove). For
2007/08 this was £10,300k (£7490k from Brighton and Hove). The reasons
why £12665k is needed having taken account of the £8558k additional
income the Trust is to receive from Sussex PCTs in 2008/09 are as follows:-

          Non recurrent savings in 2007/08
          First year debt repayment (£4888k)
          An affordability gap for the new Childrens Hospital
          Residual issues relating to ‘local prices’

8.2.2 Sussex Partnership Trust (SPT): In 2008/09 we will see the creation of
a pan-Sussex Mental Health Foundation Trust, (assuming Sussex Partnership
Trust (SPT) are successful following the assessment process). We have
good working relationships with the Trust and we account for about 22% of
their business. One area that continues to be a challenge for the Trust is the
provision of robust contract monitoring information.       We have jointly
undertaken an ABC (Activity Based Costing) project which will result in

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devising better contract currencies in 2008/09 and determining the level of
investment we currently make in mental health as compared to the service we
wish to commission. Until that work is completed we are proceeding at risk in
reinvesting (potential) non-recurrent funds estimated to be freed up through
this review. If the review identifies further savings that can be released we will
discuss with SPT how best to reinvest these funds in mental health.

8.2.3 South Downs Health (SDH): We are not a provider of community
services as in Brighton and Hove these are provided through South Downs
Health (SDH). We continue to work closely with the Trust and have jointly
embarked on releasing efficiency savings following service reviews and an
efficiency review. These changes present challenges to SDH and we continue
to support them through this process.

8.2.4 Sussex Orthopaedic Treatment Centre (SOTC): We have a major
contract (or project agreement) with Care UK who are the providers of elective
orthopaedic services from the Sussex Orthopaedic Treatment Centre (SOTC)
located in Haywards Heath. Delivery of the activity we have commissioned
from the centre has been problematic during 2007/08. We are hopeful that
moving forward we will not need to commission capacity from outside of the
centre but this is seen within the PCT as a potential risk and therefore a
potential draw on our contingency reserve.

The PCT considers there is a risk that a number of patients will wait longer
than 18 weeks for their procedure, partly because the nationally agreed
contracts for Wave 1 Independent Sector Treatment Centre's were written in
advance of 18 week policy and partly because of performance issues with the
provider. The PCT is currently working closely with Care UK and the
Department of Health to re-negotiate the terms and conditions of the
contract and to rapidly improve performance.

Although the PCT is hopeful that no patient will be waiting more than 18
weeks for the first stage of their orthopaedic treatment by December 2008
there is a risk that some patients may wait longer.

8.3. Workforce/Leadership: The PCT has secured external support to
develop its approach and initial plans for local health economy workforce
planning.    Crucially this will focus on the implication of strategic
commissioning intentions and the Fit for the Future consultation.

The PCT has conducted an initial self assessment against the World Class
Commissioning competencies and will be working on an Organisational
Development Strategy and plan in the light of this, designed to build the
capacity and capability to deliver progress in becoming a World Class
Commissioning organisation.

Linked areas of focus identified are:
   (i)    Driving for continuous innovation and improvement
   (ii)   Partnership with patients and communication

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8.4. Knowledge management and information

Better knowledge and information management is central to the drive to
improve the NHS. Primary Care Trusts and Acute Trusts operate in an
increasing complex environment which requires robust systems to be put in
place to support delivery of what is required today as well as planning
effectively for the future.

The PCT has put in place a number of measures for 2008/09, including:

   To receive from providers for our responsible population all commissioning
    and clinical data sets as listed in Schedule 5 of the NHS National Contract.

   To ensure that providers have robust plans to work towards monthly flex
    and freeze dates and deliver fully clinically coded commissioning datasets
    within five working days of month end.

   To ensure that submissions received via Secondary Users Service are fit
    for purpose, being the definitive source of activity information to support
    payment by results.

   Continue to develop plans to improve the quantity and quality of data to
    support the commissioning and performance management of provider

   Continue to develop a data quality improvement strategy, action plans and
    robust monitoring arrangements, supported by an investment plan, to
    improve data quality.

As well as these improved processes, the PCT is working to ensure a step
change in working practices and culture regarding the effective use of data,
information and knowledge. We are working to ensure that staff at all levels
understand their information needs and have these needs met, to ensure that
evidence based decisions are made. We understand that it is critical that
knowledge and information management is seen as an integral part of the
organisation’s approach to both performance and service improvement.

In 2008/09 the PCT intends to pilot an approach to information management
that aims to improve the outcomes and care for patients with Chronic Disease
through systematic collation and sharing of data between clinicians across the
care pathway. We are proposing to start with Renal care and particularly on
those patients requiring dialysis. Similar schemes in the US have
demonstrated significant system and patient benefits.

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8.5. Information Management and Technology

The PCT will be embarking on a programme of investment (funding already
agreed in 2007/08) to improve its I.T. infrastructure and to continue with its
refresh programme. This includes investment in a new server to support the
requirement for improved electronic storage and archiving and business

In GP practices sufficient funding is available to continue investments to
ensure practices have hardware and software upgrades to enable them to
meet all the requirements of the National Programme for I.T.

The PCT continues to work with local Trusts via the Deployment Board to
ensure the deployment of Case Records Service (CRS) in accordance with
the southern programme. The Chief Executive and OLIT (organisational lead
for I.T.) attend the HIS (Health Informatics Service) Board and the Domain
Board to ensure there is appropriate leadership and delivery of the SRO role.

9.       Supporting information

Attached as appendices is the following supporting information :-

        PCT three year financial planning framework (Appendix D)
        Accountablity agreement between SHA and PCT (Appendix E) (to be

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10.      Appendices

The following appendices are attached in support of the Operating Plans of
the PCT.

      A ‘Vital Signs’ Trajectories together with other locally agreed trajectories

      B Summary of all projects to deliver operational plans (attached)

      C One page summaries of projects which have been assessed as high
        risk (attached)

      D For reference - PCT 3-year Financial Planning Framework (attached)

      E Accountability Agreement between SHA and PCT (to be developed)

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