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					                                                                          AGENDA ITEM NO. 9 (ii)

               TRUST BOARD MEETING – WEDNESDAY 25 NOVEMBER 2009

                 SCHEDULED CARE COMMISSIONING INTENTIONS UPDATE

1. Introduction

In July 2008, the PCT Board approved the Scheduled Care Commissioning Intentions document
which set out the scope of the area covered, the national and local policy context, and
performance to date, a vision of services for 2013 and started to describe actions which would
take place in order to achieve the vision.

This update describes the progress achieved to date and identifies immediate priorities in the
Scheduled Care work programme. Following the approach in the initial Commissioning Intentions
document to the Board, Cancer Services are included in a separate section in this update. Work
in year has concentrated on achievement and maintenance of national access targets, promoting
choice and choose and book, service redesign and progressing the Cancer agenda as outlined in
the Cancer Reform Strategy and North West Cancer Plan. The Scheduled Care key work streams
are summarized in the appendix to this paper.

2. National Access Targets (Non-Cancer)

NHS North Lancashire has attained and maintained achievement of the national 18 weeks
referral to treatment target (RTT) in respect of consultant led services. Global performance is
presently measured across all specialties and requires 95% of non-admitted and 90% of admitted
treatments to have commenced by 18 weeks. Over 70% of inpatient and over 85% of all out
patient treatments are now commencing between 11 and 12 weeks from referral. The 2009/10
Operating Framework raised the bar and required improvements in access so that 18 weeks
should be the maximum wait at individual specialty level by the end of March 2010. Whilst both of
the PCT’s two main providers of Scheduled Care, University hospitals of Morecambe bay (UHMB)
and Blackpool Fylde and Wyre Hospitals Foundation Trust (BFW FT), consistently achieve the
overall 18 weeks target there is variation in performance at individual specialty level with a small
number of specialties, for a variety of reasons, continuing to fail the 18 week target. Specialties
where performance has been poor and areas coming under increased pressure have been
identified as a priority for service review and redesign.

In the previous report to the Board long waiting times for Audiology services were identified as a
particular challenge for Scheduled Care commissioning – especially within the PCT’s own
Provider Arm (Pediatric Services) and BFW FT (Adult services). As a result of waiting list initiative
funding and service redesign both services have now transformed performance and continue to
achieve national targets for assessment and treatment.

3. Choice and Choose and Book

3.1 National Context

Patient Choice has been enshrined in the NHS Constitution and national initiatives are being
rolled out to increase the range of referrers on Choose and Book and the range of services that
may be booked in this way.

3.2 Provider Review

NHS North Lancashire inherited several providers of Choose and Book support services and a
key piece of work in year has been to review these providers and re-let the Choose and Book

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             contract. The outcome of the review was to award the contract for Booking and Choice advice
             and services to the NHS Blackpool Booking and Choice Centre (BCC) and to award the contract
             for project support to the Blackpool Booking and Choice Team. Previously these providers had
             been contracted to provide services to Wyre and Fylde GP practices. The Project Team provide
             practices with support and training on Choose & Book (CAB) issues and work with the NHS North
             Lancashire Provider Services to inform, advise, project manage and train provider staff on
             services suitable for migration to Choose and Book.

             The change in service provider has provided a cost effective solution that has resulted in very
             positive feedback from North Lancashire practices and from the PCT Provider Arm.

             3.3 Performance

             The North Lancashire Choose and Book Focus Group continues to meet to agree strategy and
             has been supplemented by an Operational Group comprising the Blackpool Booking and Choice
             Centre Manager, PCT Commissioning Manager and Provider Managers as well as local Acute
             Trusts and Information representation. This group has updated an Action Plan for increasing
             utilisation of Choose and Book and promoting patient choice and meets regularly.

             Chart 1
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% T IS T N
 U IL A IO




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                                                                                              NATIONAL
                                                                                              NLPCT
                       54

                       52

                       50

                       48
                            JAN   FEB    MAR     APR        MAY          JUN   JUL      AUG
               NATIONAL     55    53     59       60            60       57    54       53
               NLPCT        58    60     56       61            59       58    56       56
                                                       MONTHS




             Chart 1 shows the national utilisation of C&B by practices year to date (w/e 4/1/09-18/10/09)
             stands at an average of 58%, based on utilisation of the system by 36 of the 39 NHS North Lancs
             practices.

             Two of the three remaining North Lancashire GP practices that resisted using Choose and Book
             since its introduction in 2005 have now agreed to move to Choose and Book and are being
             supported by the Booking & Choice Centre with training, process redesign and general advice.

C&B Utilisation
PBC Area        Monthly Average
                April              May                               June            July        Aug
Fylde           64.4%              66.0%                             66.6%           64.9%       62.0%
Wyre            73.9%              76.9%                             78.8%           73.2%       73.4%
L& M            48.4%              53.2%                             60.6%           51.1%       54.0%
Lo Local utilisation varies across the locality areas


             The main Fylde and Wyre local provider only accepts paper referrals via the Booking and Choice
             Centre where opportunities for referral by CAB are immediately investigated. Any referrals which
             are found to be suitable for CAB are reported to the practice concerned and put on CAB. The
             main Lancaster and Morecambe local provider is now monitoring paper referrals and reporting
             any which should have gone via CAB to the B&CC who then follow up with the practice(s)
             concerned.




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3.4 Local Appointments Line

A further benefit of the migration to the Blackpool Booking and Choice Service has been that calls
from Lancaster & Morecambe patients to the national Choose and Book Appointments Line
number are now redirected to the Booking & Choice Centre (BCC). This has enabled BCC staff to
book, rebook or cancel appointments on behalf of patients, as well as to provide information and
discuss appointment options, advise patients when booking online and any local issues. This
provides a single service provision for all North Lancashire GP practices and registered patients
(Fylde and Wyre patient calls were already re-routed). BCC staff also liaise with providers and
practices on behalf of patients when issues arise.

3.5 Training and Awareness Raising Events

A series of events were arranged this year to raise awareness of Choice and Choose and Book.
These included:
• Workshops to inform GP practice staff of a planned upgrade to CAB software as well as to
raise awareness of Choice, the NHS Constitution and NHS Choices
• Demonstrations to the Board, an evening of clinical engagement for GPs, practice staff and
providers with speakers from NHSNW, NHS Choices and Commissioning designed to raise
awareness of Choice and CAB
• Presentations to the GP Practice Managers meetings.

Choose and Book is also included as a topic in the Health Fast Forward initiative and a Patient
Focus Group has been held to gain insight into patient experience. Representation was drawn
from North Lancashire Affiliates and facilitated by representatives of the Blackpool Booking and
Choice Team using voting software. This was well received and it has been decided to repeat the
sessions at a further date.

3.6    Incentives to promote the use of Choose and Book

NHS North Lancashire has continued to incentivise GP practices to use Choose and Book since
the Directly Enhanced Service ended in April 2008. A Locally Enhanced Service (LES) rewards
practices for their achievement against the percentage of utilisation achieved.

3.7   Introduction of Referral To Treatment (RTT) Monitoring for Allied Health Professionals
(AHP) Led Services.

NHS North Lancashire is committed to support benchmarking of AHP services in relation to RTT
Performance in keeping with national guidance and is working with its providers to collect referral
to treatment data. Local plans are in line with the implementation of mandatory collection from
April 2010.

Scheduled Care Commissioning Intentions are to make the 18 week RTT the maximum wait for
all elective care, not just referrals to consultant led services. As Choose and Book coverage
extends it is a natural progression to migrate AHP services onto Choose and Book and the PCT
is working with its main providers to move therapy services on to Choose and Book.

Action plans are being developed to progress this by the North Lancashire Choose and Book
Operational Group.

3.8    Patient Experience

Choose and Book is integral to the achievement and maintenance of 18 weeks. Patients’
experience with booking and choice is also a key element in patient satisfaction. This was
reflected in the national survey of the 18 week patient experience that was commissioned from


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    Mori by the Department of Health and took place in the last quarter of 2009. Key results from the
    survey relating to NHS North Lancashire patients experience with booking and choice were:



                     • 90% of patients felt the date of appointment offered was
                     convenient
                     • 95% of patients were able to get their first choice of appointment
                     • 84% of patients felt the time offered was convenient
                     • 85% of patients felt it was easy to arrange their first appointment
Areas of Success     • 94% of patients found it easy to rearrange their appointments
                     • Less than 50% of patients discussed choice at the time of referral
                     • A greater proportion of patients seen at BFWHT discussed choice
Areas            for than UHMB
improvement          • Only 29% of UHMB patients and 48% of BFWHT patients used
                     Choose and Book.
                     • A GP letter to the hospital was still the predominate method of
                     booking (43%)
                     • 65% of patients were not offered a choice of dates
                     • 69% of patients were not offered a choice of time
                     • 13% of patients had appointments cancelled by the provider
                     •



    NHS North Lancashire has developed an Action Plan in response to the 18 week Patient
    Experience survey results, to understand and improve the experiences of our residents. These
    includes running Patient Focus Groups and Patient Choice surveys, linking with local voluntary
    organisations and the library service to increase public awareness and ability to access Choose
    and Book, and retaining Affiliate representation on the NHS North Lancashire Choose and Book
    Focus Group

    3.9 Future Commissioning Intentions

    3.9.1 Utilisation

    The PCT has a local target to achieve 70% Choose and Book utilisation by the end of December
    2009, against a national target of 90% utilisation to be achieved by the end of March 2009. These
    targets all relate to referrals from a GP to a first consultant outpatient appointment. Achievement
    of these will require:

    • Extension of the range of specialties included on Choose and Book – most significantly
    inclusion of Cancer Two Week Wait referrals.
    • Enhancing Choose and Book slot availability at UHMB/ BFWFT via requirements within the
    formal contracting mechanism. Problems with slot availability, especially at UHMB, have been a
    major impediment to progress with Choose and Book utilisation in the Lancaster and Morecambe
    area. It is therefore intended to attach financial penalties to limited slot availability in the 2010/11
    contracts.
    • Focused supports to practices with low levels of Choose and Book utilisation.
    • Increasing Peer scrutiny of Practice Based referral practice
    • Mandating electronic referral to Choose and Book in the 20010/11 contract
    • Increasing Public awareness of Choose and Book.

    3.9.2 Increasing the Range of Services on Choose and Book


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Actions to increase the range of services on Choose and Book include:
• Working with NHS and Independent Sector Providers to extend services on the Primary Care
Choose and Book Directory of services – with especial emphasis on Allied Health Professional
Services
• All new intermediate care services to be advertised on and bookable through the Primary Care
Choose and Book menu.

4. Progress in Cancer

4.1 Increasing effective prevention as evidenced by a reduction in the incidence of cancer.

Within its Strategic Plan, NHS North Lancashire made a commitment to tackle the cancer
prevention and early detection agenda. The Public Health team has undertaken to work closely
with Primary Care teams and the general public on cancer awareness raising. Particular efforts
have been made for the cancer screening programmes:

•      A dedicated cervical screening nurse works closely with practices with low coverage rates
and supports advice and training for staff.
•      The NHS North Lancashire Bowel Screening group has been set up to raise awareness of
the new screening programme which targets both men and women
•      Targeted health promotion activity to improve coverage for breast screening in Fleetwood
was undertaken in the summer 2009.

A cross–directorate lifestyle development group has also been set up to pick up cross cutting
themes to support prevention and awareness issues across Cancer services, Long Term
Conditions, Mental Health and Sexual Health. A strategic approach across the PCT has been
taken to support interventions on alcohol, obesity and smoking, which supports the cancer
agenda.

It is the intention of the PCT to undertake social marketing interventions to support the early
intervention and detection of cancer, and commissioners are working closely with public health
colleagues to develop a social marketing framework to support this agenda.

4.2 Breast Screening

As Lead Commissioner, NHS Lancashire coordinated a collaborative approach to support the
recovery of the North Lancashire and South Cumbria Breast Screening programme. In July 2007,
the Breast Screening QA reported that only 6.2% of women were being screened within 36
months of their previous offered appointment and 7% were being screened within 38 months. In
June 2009, the Breast screening service achieved full recovery of the breast screening round
length ( 90% of eligible population offered screening within 36 months) ten months ahead of
schedule.

With the turnaround in the performance of the screening unit the service now fulfils all the
performance prerequisites for the age expansion as set by the NHSBSP guidelines which are:-

•      Achievement of breast screening round length of 36 months
•      Screen to assessment results within 3 weeks
•      14 day turnaround time for results.

4.3 Breast Family History Service

This service has been commissioned from Blackpool Fylde and Wyre Hospitals Foundation NHS
Trust to support women with risk of breast familial cancer. Any women requiring ongoing
mammography will receive this through the BMI hospital in Lancaster. The breast family history
service will be included within the expansion of the breast screening programme in line with

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national guidance. NHS North Lancashire and Blackpool are the only two PCTs in Cumbria and
Lancashire to currently offer a comprehensive Breast Family History Service.


4.4 Bowel Screening

NHS North Lancashire achieved full roll out of the bowel screening programme in 2008 as part of
the second phase of the national roll out.

The bowel screening uptake rate for the population of North Lancashire to May 2009 is 59.1%
which is extremely encouraging and well on target to meet the PCT’s ambitious target of 60% set
out within the Strategic Plan. This is above the national average of 51.74%. Preparation for local
roll out of the programme included a patient Focus Group that advised on publicity.

From April 2010 the responsibility for commissioning bowel screening will be the responsibility of
the PCTs and funding will go into PCT baselines. NHS Blackpool will be the lead commissioner
for the Lancashire Bowel Screening programme. NHS Cumbria will be the lead commissioner for
the Cumbria and Morecambe Bay Programme. The age expansion to the 70 to 75 year age
group is expected to commence in 2010.It has been indicated that the age expansion costs will
be picked up by the Department of Health in the first year.

4.5 Earlier Diagnosis

In May 2009 a GP audit was piloted within 5 practices across North Lancashire to review the last
30 new cancer referrals and to understand the delays in presentation within Primary Care. The
audit was based on the National Scottish Audit. The initial analysis has identified areas for service
development at the front end of the pathway which demonstrated both patient and doctor delays
within different tumour sites and it is the intention to roll the audit out across all GP practices. The
audit also showed that awareness raising in the signs and symptoms for lung, urological and
breast cancers should be undertaken. This audit will link into the national audit being undertaken
by the National Awareness and Early Intervention Initiative (NAEDI) being led by the National
Cancer Action Team.

4.6 National Chemotherapy Action Group (NCAG) / National Confidential Enquiry into Patient
Outcomes and Deaths (NCEPOD) reports and recommendations

The publication of the NCEPOD Report, (2008) and NCAG Report (2009,) highlighted areas of
inequity of provision of chemotherapy services in England and the poor experience and outcomes
for some patients in receipt of chemotherapy. NHS North Lancashire is working closely with the
Lancashire and South Cumbria Cancer Network (LSCCN) and local acute providers to respond to
key recommendations in these reports . Three key work streams have been identified in response
to these important reports

•       A review of resources to implement the recommendations (Network wide and led by the
Lancashire and Cumbria PCTs Commissioning Business Service);
•       A review of current financial regimes and recommendations for future chemotherapy
funding (as above); and
•       A review of urgent care pathways within organisations which is being progressed locally
by lead commissioners linking Scheduled and Unscheduled Care work streams. National data
has highlighted that poor management leads to high levels of patient readmission and local work
will identify the enhanced patient outcomes and potential cost savings to result from enhanced
management.




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4.7 Radiotherapy Expansions

The expansion is a tier one vital sign and PCTs will require plans for 2010 – 2011 to implement
the National Radiotherapy Advisory Group NRAG (2007) recommendations which for this area
implies an almost doubling of fractions.

The Lancashire and Cumbria PCTs Commissioning Business Service, on behalf of the Cumbria
and Lancashire PCTS, has produced a business case to define the level of radiotherapy
expansion required to comply with utlisation recommended by the National Radiotherapy
Advisory Group (NRAG). Evidence has shown that radiotherapy utilisation in Lancashire and
South Cumbria is considerably less than recommended by the National Radiotherapy Advisory
Group (NRAG). Future demand for radiotherapy fractionation rates has been predicted to enable
PCTs to plan for future expansion.
The fractionation rate currently commissioned is 28,000 fractions per million. The Business
Service has proposed two levels of service to commission:-

•       Level 1 (silver)=40,000 fractions per million in 2010 to 54,000 by 2016
•       Level 2 (gold) – Fractions based on NRAG recommendations of ‘optimal utilisation’
projections.

Radiotherapy plays a crucial role in the treatment of cancer and narrowing the gap is essential in
order to achieve ‘world class radiotherapy practice’ and improved survival rates/reduced mortality
rates for cancer patients.

NHS Blackburn with Darwen and NHS North Lancashire has confirmed their support for the
business case recommendations but has declared that due to the current economic climate, the
financial element is a constraint. They have requested that facilitated discussions are held with
the current provider to achieve an increase in productivity at lower unit cost.

NHS East Lancashire and NHS Central Lancashire have confirmed that they are unable to
commit to the business case at this stage.

4.8 Improving Outcomes Guidance (IOG) Compliance

IOG compliance has been included within the quality indicators within the acute contracts. As
lead commissioner within the Morecambe Bay Cancer Local Implementation Group, NHS North
Lancashire has facilitated a work programme across the locality which will work towards IOG
compliant pathways where currently the standards are not being achieved, i.e Skin and Head and
Neck cancers. As part of the cancer skin peer review process, NHS North Lancashire undertook
an audit to review skin cancers removed within Primary Care. Following the findings, a robust
system has been set up to monitor skin pathology and feedback any untoward findings to Primary
Care.

4.9 Integrated Cancer Care Programme

The PCT will encourage extension of the Integrated Cancer Care Programme (ICCP) Initiative.
The PCT in partnership with Blackpool, Fylde and Wyre NHS Foundation Trust (BFWFT) has
identified funding from the Lancashire and South Cumbria Cancer Network to pilot an ICCP
coordinator based within Fleetwood Mount View Practice working with colorectal cancer patients
initially. The benefits of the Integrated Cancer Care Programme include the co-ordination of
patient care with less frequent visits to hospital and fewer admissions. Care Co-coordinators can
work as ‘navigators’ to assist patients as they are receiving active treatment and beyond
treatment. ICCP nurses, can be District Nurses with extended skills beyond cancer who can offer
holistic assessments to patients who may have other comorbidities such as heart disease or
chest disease. These teams will work closely with Clinical Nurse Specialists (CNS) whom have


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tumor specific expertise. Research locally and nationally reports that patients’ experience of such
programmes is positive.

4.10 Signposting

There is a great need for patients to access high quality information on both their disease and
social factors such as benefits advice. As a minimum the PCT has a responsibility to signpost this
advice and to commission good information services.

The PCT has recently secured funding from the Rosemere Cancer Foundation to develop a
Morecambe Bay Cancer Services Directory and is supporting the BFW Trust in developing a
directory for Blackpool, Fylde and Wyre patients and carers.

4:11 Contract Migration

In 2009/10, Cumbria and Lancashire non-specialised Cancer Services have migrated from the
responsibility of the North West Specialised Commissioning Team to local PCTs and the Cumbria
and Lancashire PCTs Commissioning Business Service.

This has increased the local commissioning workload, but has afforded an opportunity to
undertake a detailed review and revise commissioning intentions.

Initial scrutiny has identified apparent financial anomalies that are likely to be to the net financial
benefit to this PCT. These can be summarised as identification of cross subsidisation in
historical arrangements for commissioning Oncology services at Lancashire Teaching Hospital
and apparent double payment for some service development that have received collaborative
pump-priming funding whist being charged out at tariff. The PCT is working with the
Commissioning Business Service to realise the associated savings. The value of the cross
subsidisation is in excess of £350,000.

4.12   Cancer Performance

Over the past 12 months an interactive cancer dashboard has been developed by the Scheduled
Care and Performances Team to monitor cancer performance. The dashboard includes
performance monitoring information on all the access targets and information is broken down to
tumour level. The dashboard supports the national targets and those set out within the PCT’s
strategic plan including screening uptake by practice for breast and cervical, and coverage rates
for bowel and breast screening and cancer mortality. In 2008/09 all cancer targets were achieved
as demonstrated in the Care Quality Commission report.

In 2009, alongside the introduction of the new commitments from the Cancer Reform Strategy, a
decision was taken to align the monitoring of cancer waiting times with the existing 18 weeks data
collection. Operational standards were previously set for the existing commitments from the NHS
Cancer Plan. However, the change of reporting methodology means that the operational
standards used previously for the assessment of the 31-day and 62-day commitments (98% and
95% respectively) were no longer suitable for use within the NHS. The Department made a
commitment to produce revised operational standards to take account of these developments.
This has proved challenging in 2009 and continues to do so with the following targets: - 14 day
breast and further stretch targets on the 62 day pathway:- screen detected and consultant
upgrade.

Cancer Reform Strategy Commitments:

In order to ensure that more people benefit from better access to cancer services the Cancer
Reform Strategy, 2007, gave extended cancer waiting times commitments and these new
commitments are within the vital signs targets which mainly focus on the extension of screening

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targets and cancer mortality. Within the world class commissioning assurance framework the PCT
has also signed up to the following outcome measures:-

•       Cancer mortality rates

•       Proportion of women aged 53- 70 screened for breast cancer within the last 3 year

4.13 Future Plans for Cancer Services

4.13.1 Chemotherapy closer to home with the development of an Outreach chemotherapy service
for the Fleetwood population.

This is planned to support the closer to home agenda and improve the quality of patient care for
patients in Fleetwood. Initial discussions between Fleetwood PBC, BFWHFT and NHS North
Lancashire have commenced. This service will enable patients to receive second line and
subsequent chemotherapy treatments for an agreed list of drug indications and disease group
such as breast and colorectal patients and drugs such as oral and single agent carboplatins. The
Fleetwood service will also help to address the shortfall in capacity within secondary care. This
service will be used as a pilot for community based chemotherapy services in other areas and an
evaluation will be undertaken to include patient satisfaction and cost effectiveness. At minimum
this initiative is expected to be revenue neutral and to enhance the patient experience.

4.13.2 Implementation of Breast Lymph Node technology to improve quality of patient care and
reduce numbers of breast surgeries.

NHS North Lancashire has been working closely with the breast cancer team at UHMB which has
been part of the national pilot in the development and implementation of breast lymph node assay
technology to improve the quality of patient care for women with breast cancer. The assay
technology will allow patients’ lymph nodes to be assessed within theatres allowing the surgeons
to make an immediate clinical decision on the surgical treatment options for the patient. Within
North Lancashire, it has been estimated that this new service will benefit 20 women per annum
within the Lancaster and Morecambe population and reduce the need from two surgical
procedures to one with an estimated cost saving of £50,000. The PCT will be working closely with
the Trust on the development of a local tariff for the service with an expectation that the service
will commence from April 2010. North Lancashire will encourage BFW FT to also adopt this
technology.

4.13.3 Age Expansion of the National Breast Screening programme

The Government has directed the NHS to extend the age range of breast screening to 47-73
years of age while still keeping the requirement to invite 90% of women within 36 months. The
proposed extension of the programme will increase the breast screening population by an initial
32%. The National Guidance dictates that the extension of the programme must have started by
2012.

The expansion will require an initial investment envelope of some £2.5 million for digital
mammography equipment and a Picture Archiving System (PACs) across the whole footprint plus
additional revenue costs.

Due to the current financial situation, it has been difficult to reach a decision between
commissioners on the start of the expansion of the programme. Realistically, the programme
needs to commence expansion by April 2010 to ensure full expansion by 2012, however until a
collaborative decision is made this service development cannot be taken forward. The age
expansion is included in vital signs.




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4.13.4 Age Expansion of the National Bowel Screening Programme

From April 2010, the commissioning of the local bowel screening programmes will become the
responsibility of the local PCTs. NHS North Lancashire will work closely with NHS Cumbria and
NHS Blackpool on the commissioning arrangement with the two main Acute providers, UHMB
and BFW HFT. The expansion of the age range from 60 to 69 years to the 70 to 75 age group is
expected to commence by December 2010.

4.13.5 GP Engagement

The importance of the role of Primary Care in the cancer patient journey is well recognised. A GP
Cancer Newsletter is currently in development with support from the PCT’s two GP Cancer Leads
and it is the intention to launch this communication in the Winter, 2009.

4.13.6 Review of Tariffs

A review of chemotherapy tariffs and currencies in collaboration with the Cumbria and Lancashire
PCTs Business Service is currently in progress as part of a wider review of collaboratively funded
Cancer initiatives.

4.13.6 Streamlining the Patient Journey.

Work is planned with the main acute providers to identify opportunities to increase ‘one stop’
clinics for patients with a suspected diagnosis of cancer and to increase the cost-effectiveness of
referral via increasing access to key diagnostic tests.

4.13.7 Introduction of Helicobacter screening for Upper GI Cancer.

The NICE commissioning tool for upper GI Cancer services suggests that if H-Pylori test and treat
services and strict referral criteria for access to Upper GI Endoscopy are introduced and
managed appropriately then the endoscopy referral rate should drop to 750 per 100,000 i.e
prevalence rate of 0.75%. This development will reduce the number of invasive procedures for
patients and will lead to a potential reduction of 660 endoscopies (21%) per annum. An outline
business case has been developed to take this service forward across the PCT. This should
enhance the patient experience whilst releasing revenue.

5. Other Service Developments and Reviews Undertaken

Acknowledging that effective clinical engagement is a critical success factor in service review and
redesign, initial work has focused on areas that were included as PBC scheduled care
commissioning priorities and/or related to high risk areas for 18 weeks and hence priorities on
Acute providers’ agendas.

Beyond the work to support service redesign in Audiology services noted above efforts have
focused on Musculoskeletal services, Dermatology, Gynaecology, Ophthalmology and, GP direct
access to diagnostics.

5.1 Musculoskeletal Services

There is a common vision for Musculoskeletal (MSK) services across the PCT to

• Enhance the management of patients within the community, and actively manage the demand
for secondary care services ensuring patients have timely access to the most appropriate course
of treatment
• Deliver care within a single pathway, and reduce any unnecessary delays in the patient’s
journey

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• Achieve a reduction year on year in inappropriate referrals to secondary care
• Improve patient experience by reducing waiting times for patients and assisting in maintaining
the target of a maximum 18 week period from referral to treatment
• Also to, improve patient experience by reducing waiting times for patients and assisting in
maintaining the target of a maximum 18 week period from referral to treatment
• Ensure patients are seen closer to home in an environment most appropriate to their needs
• Support the development of agreed care pathways for common musculoskeletal services
• Offer patient choice
• Promote secondary prevention by providing patients with information regarding their
musculoskeletal condition, promoting self care and management

All three PBC areas have signalled a desire to achieve this, but there is a difference in approach
across the North and South.

For Lancaster and Morecambe there is an emphasis on practice based support and training and
in the Wylde and Fleetwood areas the priority for practices has been to establish an electronic
MSK triage system and at the same time enhance the capacity of the existing community Medical
Orthopaedics service.

5.1.1 Practice Based Physiotherapy

In year there has been an extension to the Lancaster and Morecambe PBC Practice Based
Physiotherapy scheme. The scheme was designed to incorporate practice based physiotherapy
triage for the registered population of Lancaster and Morecambe with practices being allocated a
fair share number of slots. The scheme has put into practice an understanding of demand
management in primary care, and a prioritisation of referrals to secondary care to ensure only the
most appropriate patients are referred for treatment.

Through this initiative the following objectives were achieved:

•      Reduction in waiting times for physiotherapy from 20 weeks to an average 4 week wait
•      Patients are seen and treated closer to home when appropriate
•      Increased patient management of their condition, promoting self care
•      Reduction in DNAs – did not attends
•      Improving the efficiency of the available Physiotherapy resource
•      Achievement of a high level of patient satisfaction

Quarterly meeting are held with stakeholders to review the scheme and flex the system to deal
with differences/ fluctuations in referral volumes.

Referral data shows that 45% of all patients triaged were deemed clinically suitable for onward
referral for further Physiotherapy treatment. The scheme requires the patient to ‘opt in’ to further
treatment and of those triaged only 35% opted for this- 65% of patients were either managed in
Primary Care by their GP/ HCP, encouraged to self manage their condition, or required referral to
an orthopaedic consultant. Further work is planned audit patient outcomes.

By working collaboratively with the Physiotherapists and jointly assessing patients, GPs have
developed enhanced skills for treatment and management of musculoskeletal conditions

5.1.2 Pathway Redesign to Incorporate Electronic Triage (Wylde and Fleetwood)

Two priority areas have been identified for development: on behalf of the Wylde and Fleetwood
PBCs




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1.      Implementation of a Musculoskeletal Clinical Assessment and Electronic Triage Service
(CAS)
2.      Enhancing the existing community Medical Orthopaedic/ Physiotherapy service to deal
with the demand following the redesign of the pathway

The Musculoskeletal Framework explains that many patients with musculoskeletal problems do
not need to be treated in hospital and indeed can receive faster and more appropriate care in a
community setting (The Musculoskeletal Services Framework – Department of Health 2006). In
developing a Clinical Assessment and Electronic Triage Service, better orthopaedic services with
shorter waits and fewer delays can be achieved. By developing a system that reduces referrals to
hospital whilst ensuring that patients are directed towards the most appropriate services and
clinicians enhances patient satisfaction and achieves better value for money for the Trust. A well
designed CAS working at the interface between primary and secondary care will provide effective
rapid assessment of patients with a variety of musculoskeletal conditions. Site visits have been
made to different CAS models within the North West to identify best practice and a business case
is being completed for the Wylde and Fylde areas to introduce a CAS and increase Medical
Orthopaedics capacity.

5.1.3 Direct Access to Diagnostic Services

In October 2009 a pilot scheme was launched for the Lancaster and Morecambe practices that
refer into UHMB to trial direct access to musculoskeletal diagnostic ultrasound for shoulder
problems. The pilot was designed to:

•      Test the benefits of direct access to diagnostic ultrasound
•      See whether patients could be managed differently based on the results of the ultrasound
•      Quantify efficiency gains

All GPs who utilise the Musculoskeletal Direct Access Ultrasound Pilot will be required to
complete an evaluation form for each person referred.

Throughout this process general principles were agreed to ensure the most appropriate use of
direct access to diagnostic services
•       Educational/ clinical launch event
•       Clear eligibility criteria
•       Pilot evaluation
•       Roll out determined by efficiency

5.2 Ophthalmology

The end of the national Net care cataract contract combined with new NICE guidelines lowering
the threshold for consultant referrals for suspected glaucoma have increased pressure on hospital
Ophthalmology Departments. This has provided an opportunity to drive forward work to divert
activity closer to home.

In year an Optometrist cataract LES was developed and rolled out to the BFW FT catchments. It
is planned to roll-out the scheme across the PCT.
There is clear scope to develop clinically appropriate out of hospital Ophthalmology services in a
way that will promote the closer to home agenda and thus enhance patient experience, reduce
waiting times and increase cost-effectiveness. Future developments for which planning has
commenced in year include. extension and roll-out of the current Glaucoma LES and the
intermediate eye care service model that presently applies to Wyre and Fleetwood.




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5.3 Dermatology

A review of referrals into BFW FT has identified that some 60% of these do not require a
consultant led service. This replicates results of similar reviews in other areas and experience
with a GPwSI intermediate Dermatology pilot in Fleetwood has proved very successful and cost
efficient.

The PBCs are keen to work with the PCT and providers to identify opportunities to rebalance
work from secondary to primary care and to undertake specific service reviews that include a
review of current pathways. Service redesign within Dermatology services provides a real
opportunity to affect change in service delivery.

Dermatology services must meet the needs of large numbers of patients, a significant proportion
of who will have long term conditions needing different types of care at different times throughout
the pathway when redesigning the pathways the following objectives will be key.

•       Easy access to the right level of service at the right time and in the right setting to meet
        the patients changing needs throughout their lives
•       Rapid access to diagnostic services
•       A high quality of clinical care
•       Treatment appropriate to the patient’s condition
•       Informed choice for all patients and the flexibility to meet their needs
•       Cost efficiency

5.4 Gynaecology

A Lancaster and Morecambe PBC led Gynaecology pilot, that harnessed the skills of its
Gynaecology GPwSI to provide a range of intermediate Gynaecology services, was demonstrated
to be cost effective and to increase patient satisfaction. The pilot was restricted to the GPwSI’s
practice population and options are being explored with the PBC to maximise benefits from that
clinician’s skills.

5.5 Neurosciences

Neurosciences (Neurology and Neurosurgery) are one of the most challenging areas for
achievement of 18 weeks across the North West. Current commissioning arrangements are that
the PCT commissions the service within the block contract with UHMB and BFW FT, who in turn
subcontract for clinical capacity from LTH FT as the Cumbria and Lancashire Tertiary Centre. The
PCT commissioned a review of Neurology services that has led to the establishment of a task and
finish group on the UHMB/BFWFT footprint (including representation from NHS Blackpool and
NHS Cumbria) with the aim of enhancing the patient experience and reducing waiting times.

5.6 Assisted Fertility

There is an increasing demand on the provision of Assisted Fertility Services within the North
West. Nice Guidance reports that 1 in 7 couples are expected to experience fertility problems
and may require assisted fertility treatment after trying to conceive unsuccessfully for a period of 3
years or more.

The provision of Assisted Fertility is presently contracted through the North West Specialist
Commissioning Team (NWSCT) and provided by St Mary’s in Manchester who are a tertiary care
provider. It is anticipated that in 2010/11 the contract management of Assisted Fertility will return
to Primary Care Trusts.

Assisted Fertility services have been associated with long waiting times, with patients waiting up
to 2 years for their treatment to commence. Assisted Fertility is included in the 18 week target,

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requiring that all patients’ treatment starts within 18 weeks from their referral date to the start of
their first definitive treatment.

NHS North Lancashire has a Commissioning Policy for Assisted Fertility Services. This is not
currently compliant with NICE Guidance and will be included in a pan Cumbria and Lancashire
review of Commissioning policies to start later this year. There is national and local evidence that
demonstrates that Assisted Fertility Services pathways are poorly understood, leading to patients
following inappropriate pathways and incurring delays in treatment and unnecessary costs. Work
has commenced to review the current pathways into assisted fertility and to enhance the start of
the patient journey, providing an opportunity for a greater role for Primary Care clinicians to
ensure patients have had the appropriate work up and counselling before being referred to the
Fertility providers.

The objectives of this work are to promote
•      Equity of Access
•      Increased cost effectiveness of the patient pathway
•      Reduced patient waiting times
•      Enhanced patient experience
•      Informed Choice

5.7 Closer to Home

The official opening of the Lytham Primary Care Centre has enabled repatriation of services from
the former Lytham Hospital. For Scheduled Care, this relates mainly to BFW FT and the PCT
Provider Arm services. The public and staff feedback from the new premised has been extremely
positive and it is planned to use the Centre as a base for intermediate care developments.

6.     Future Commissioning Priorities

The main drivers for change in the forthcoming contracting round will be increasing financial
pressures coupled with increasing pressures on key access targets, with the expectation that
current ‘entitlements’ to care within a certain time are set to be enshrined in law. Following on
from commitments made in Building Britain’s Future, which was published in June, within the new
Parliament the government has advised there will be a legal entitlement to a maximum two week
wait for a patient with a suspected malignancy to see a Consultant, and a maximum waiting time
of 18 weeks from referral to treatment for all patients.

Responding to the dual pressure of heightened access targets and reduced finance requires a
mixture of short term and longer term responses with the common aims of reducing inappropriate
demand and increasing the efficiency of supply.

Demand management will include a mixture of:

• Supporting referral management with initiatives including
• Establishment of Clinical Assessment Services (CAS)
• Increasing referrer understanding of appropriate referral routes and thresholds with targeted
educational initiatives.
• Development of referrer’s access to expert clinical opinion via e-advice/telephone support.
• Provision of regular peer performance feedback on referral behaviour and surgical intervention
rates for key procedures.
• Review and revision of Commissioning Policies relating to interventions of low clinical benefit.
• Increasing the Efficiency of Supply by commissioning.
• Evidence based innovations that increase cost-effectiveness of service delivery e.g. Enhanced
Recovery Programme for key surgical procedures with introduction of local prices as appropriate.



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• Better care better value pathways’ e.g. reducing new to follow up ratios, and substituting
clinically appropriate cost effective alternatives to secondary care.
• Increasing use of ‘one-stop’ clinics
• Increasing direct access to diagnostics where clinically and financially indicated.

The findings of the Teamwork report commissioned earlier in the year, ‘Better Care, Better Value’
and the ‘Opportunities Locator’ all confirm that the PCT has scope to improve the cost
effectiveness of the services commissioned. Initiatives and developments will continue in the
areas of Dermatology, MSK and Ophthalmology. In addition, work is planned to enhance acute
Oncology services to reduce emergency admissions. Contracts will incentives lean pathways,
including Enhanced Recovery Programme (ERP) techniques and reduction in new to: follow-up
ratios. The appendix to this paper summarises key initiatives. The list will be extended with the
completion of more detailed work on pathways and programme budgets to clarify current patterns
of expenditure and opportunities for disinvestment. Initial Programme Budgeting work will
concentrate on MSK.

All plans to streamline the patient pathway will be formalised in contracts with the relevant
providers.

Clinical engagement is of paramount importance. GPs, as Practice Based Commissioners, are
able to limit acute demand by only referring patients genuinely in need of acute care, as
alternative providers they are able to compete for existing acute work and they impact
significantly on the patient’s understanding of the pathway. For demand for acute services to
drop (or at least for demand growth to reduce), GPs will need to genuinely feel that demand
management benefits them and improves the service for patients and is therefore not an
unnecessary, managerially-imposed requirement. This requires strong clinical leadership and
ultimately, successful demand management requires GP champions and real secondary care
engagement and involvement in the work-up and implementation of new pathways.

In order to ensure innovations do not compromise the quality and safety of patient care, a whole
systems approach to designing and implementing more efficient and productive services is
required. Engagement with key stakeholders from Primary/ Community/ Secondary Care
providers, PBC Leads and PCT Commissioners will ensure the focus remains on sustainable
quality improvements, innovation, productivity and prevention (QIPP)

Engagement is being facilitated via two service redesign Groups – one on the Wylde/Fleetwood
PBC/BFW FT footprint and the other on the Lancaster and Morecambe PBC/UHMB footprint.
These are overseeing various clinically led and PCT facilitated task and finish groups in respect of
the initiatives in the appendix.

Within all service redesign, quality of patient care and the productivity of health care services are
paramount and in all future intentions we strive to bring equity of access to services and
consistently high standards of patient care and patient satisfaction across North Lancashire.

The recent NHS preferred provider statements have been noted and future commissioning will
consider this along with the full range of current system management guidance and regulations.
Scheduled Care is working closely with the Estates team to model community based service
requirements.

Ann Steele
Head of Scheduled Care

12.11.09




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Appendix 1 – Commissioning Intentions
            Key Initiatives




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