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FOREWORD BY THE CHAIR - North of England SCG

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FOREWORD BY THE CHAIR - North of England SCG Powered By Docstoc
					NHS Barnsley
NHS Bradford and Airedale Teaching
NHS Calderdale
NHS Doncaster
NHS East Riding of Yorkshire
NHS Hull Teaching
NHS Kirklees
NHS Leeds
NHS North Lincolnshire
North East Lincolnshire Care Trust Plus
NHS North Yorkshire and York
NHS Rotherham
NHS Sheffield
NHS Wakefield District




         Yorkshire and the Humber
      Specialised Commissioning Group
       5 year Commissioning Strategy
               2010/11 – 2013/14




How the 14 PCTs of Yorkshire and the Humber will commission specialised
services.




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                                              CONTENTS

Foreword By The Chair of SCG                                                                       3


Section 1: VISION               1.1-     Purpose, Aims and Core Principles                         4
                                1.5
                                1.6      Health Needs Assessment                                    5
                                1.7      Local and National Context                                 6
                                1.8      Our Approach                                               7
Section 2: CONTEXT              2.1      Regional health profile                                    9
                                2.2      Insights from public, patients, clinicians and partners   10
                                2.3      Provider Landscape                                        11
                                2.4      Financial Context                                         12
Section 3: STRATEGY             3.1      How this section has been developed                       17
                                3.2      SCG Approach to Prioritisation                            17
                                3.3      Supporting Documents                                      18
                                3.4      Goals                                                     19
                                3.5      Initiatives                                               21
Section 4: DELIVERY             4.1      SCG Approach to Performance Monitoring                    49
                                4.2      Risk Management and Monitoring                            50
                                4.3      SCG Approach to Quality                                   53
                                4.4      Organisational Requirements and Enablers                  55
                                4.5      Provider requirements and plurality of provision          58


APPENDICES

               Appendix 1                Analysis of Population Demographics and Health            62
                                         Needs
               Appendix 2                Providers of Specialised Services in Yorkshire &          65
                                         Humber
              Appendix 3                 Out of region providers                                   66
              Appendix 4                 Services Designated 2007-2010                             67
              Appendix 5                 Financial Savings by PCT                                  69
              Appendix 6                 Designation Overview                                      70
              Appendix 7                 Financial Goals and Initiatives                           71
              Appendix 8                 Map of Goals, Initiatives & Outcomes                      75
              Appendix 9                 Equality Impact Assessment                                78
             Appendix 9a                 Y&H SCG Baseline Equality Data                            87
             Appendix 10                 SCG Acute CQUINs Scheme 2010/11                           90

ANNEXES

                 Annex 1a                Acute Contracts by Speciality
                 Annex 1b                Mental Health Contracts by Speciality




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FOREWORD BY THE CHAIR
Yorkshire and the Humber Specialised Commissioning Group (SCG) has a
reputation locally and nationally as a leading edge specialised commissioning
consortium with strong governance and decision making processes. For a
new arrangement this is an excellent position to be in and we believe this
provides us with a firm foundation for achieving much more for the people of
Yorkshire and the Humber within the resources available to us.

Change is rapid and continuous in specialised services which are, by their
nature, at the forefront of technological and drug development. These
services are often very costly and bring with them major challenges when it
comes to determining which procedures and drugs should be funded bearing
in mind the opportunity costs for the PCTs involved and the anticipated
financial situation facing the NHS. Many of the services are subject to national
standards and national decision making where very significant amounts of
money are involved or/and have a high public profile.

The PCTs in Yorkshire and the Humber are determined to provide the best
health care within the resources available applying a strong rigor to decision
making which is explicit, public and demonstrates best commissioning
practice.

The Yorkshire and the Humber Specialised Commissioning Group is a joint
subcommittee of the 14 PCTs involved and thus its decision making
processes are different to those of a PCT acting alone. The combination of
the SCG being a consortium, the nature of the services commissioned and
the financial stringencies facing the PCTs will pose real challenge over the
next few years. Recognising this, SCG has been developing a range of
decision making tools which will be subject to further refinement. This
Strategy therefore describes how the PCTs, working together, will make
decisions and the key service areas we intend to focus on in the next 5 years
subject to resources being available.

Our approach is reinforced by and actively implements the Yorkshire and the
Humber Healthy Ambitions Programme, High Quality for All and the NHS Next
Stage Review.

We judge our success as a consortium not only in terms of improved health
outcomes but also in terms of productivity, the quality of our commissioning
and the openness of our decision making. NHS Barnsley which provides
commissioning infrastructure for SCG will ensure the commissioning supports
the achievement of the constituent PCTs World Class Commissioning
standards and its specialised commissioning meets those standards.

The population of Yorkshire and the Humber deserve to be served by World
Class commissioners and SCG will continue to be a significant contribution to
this.




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                                         1. VISION
1.1 The core purpose of the SCG is to commission:-

 Those services defined as specialised
 Other services where the PCTs believe that collective commissioning, on a
    region wide basis, through the SCG will add more value than the PCTs
    operating alone.

1.2 The overall aim of the SCG is to:-

 Drive up the quality of specialised services

 Deliver improved health outcomes for patients

 Ensure fast responsive services for all who require them

 Improve access and minimize inequalities

 Deliver improved productivity and value for money

1.3 The SCG supports these aims through:-

 Enabling the PCTs to                     make      explicit     and   consistent   collective
  commissioning decisions

 Providing expert advice on best practice and clinical issues

 Influencing and interpreting national policy

 Using the collective negotiating power with the large specialist providers to
  secure service improvements

 Performance managing the delivery of the services specified

 Undertaking Equality Impact Assessments on service initiatives

1.4 The work of the SCG is underpinned by the following key principles:-

 A world-class commissioning driven approach

 Rational decision making based on balancing benefits and opportunity
  costs

 Transparency and openness around decision making

 Commissioning focused on outcomes quality and value for money

 Working towards equity
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1.5 The Strategic Vision for SCG has been developed based on:-

 An assessment of health need

 An assessment of the local and national context

 An assessment of opportunities to drive up Quality, Innovation, Productivity
  and Prevention (QIPP)

1. 6 Health Need Assessment

There has been careful analysis of the specialised health needs of the people
of Yorkshire and the Humber. In order to establish our key outcomes we have
utilized the tools available in the Joint Strategic Needs Assessments, the
World Class Commissioning data pack and the Yorkshire and the Humber
Public Health Observatory Programme Budgeting and Marginal Analysis data
set. There has also been discussion with key stakeholders around a range of
data and health informatics.

This analysis, which is appended in full at Appendix 1, shows that the key
health needs in informing SCG strategy are:-

Cardiovascular disease:
SCG commissions specialised services including cardiac surgery, implantable
defibrillators and vascular services. This links to SCG World Class
Commissioning benchmark: Coronary Artery Bypass Graft procedure rate per
million.

Cancer:
SCG commissions elements of some cancer pathways, including thoracic
surgery for lung cancer, and the majority of some pathways including for
children and young people. In addition, SCG commissions blood and marrow
transplantation. This links to SCG World Class Commissioning benchmark:
Blood and Marrow Transplantation rate per million.

Death of infants:
SCG commissions neonatal and paediatric intensive care services. In
addition, SCG commissions specialist fertility services which can have a major
impact on the use of neonatal units.

The effects of mental health problems:
SCG commissions specialized elements of several mental health care
pathways including secure services and child and adolescent mental health
services.

Improving renal services:
SCG commissions almost all of the chronic kidney disease pathway including
renal transplants and renal dialysis. This links to SCG World Class
Commissioning benchmark: Renal Transplantation rate per million.


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Based on this health needs assessment, SCGs overarching outcomes are as
follows:

    1. Fewer deaths following cardiac surgery and complex cardiac
       procedures
    2. Improved survival rates for specific cancers
    3. Minimising deaths of infants through the right level of support, in the
       right place for all neonates
    4. Treating people with specialist mental health needs in the right
       setting, improving rehabilitation and recovery rates
    5. Improving renal services through providing dialysis when required,
       and increasing kidney transplants

In a generic health needs assessment the needs of the small number of
patients who need highly specialised services would not be prioritised.
Highlighting the need for these services and ensuring that dedicated, quality
services are available is a unique role for the SCG. To reflect this there is an
additional overarching outcome.

    6. Achieving quality outcomes for highly specialised services

It is recognised that the achievement of the above outcomes is only possible
through the combined goals and initiatives of primary, secondary and tertiary
services, and for the majority of the outcomes, it will be the interventions and
preventions put in place early in the pathway that will hold the most influence.
Therefore to attach performance metrics purely to the specialised element of
the pathway would be misleading.

Instead, SCG will measure its contribution to these outcomes by ensuring
tertiary providers achieve the upper quartile of national performance in
mortality, survival, rehabilitation and transplantation rates for the relevant
conditions, and embedding this within the SCG performance management
framework (more detail provided in Section 4).

1.7 Local and National Context

Yorkshire and the Humber Specialised Commissioning Group commissions
those services that have been deemed nationally to be “specialised” (see
http://www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Commissi
oningspecialisedservices/Specialisedservicesdefinition/index.htm).

The 2008/09 Operating Framework identified that SCGs were expected to
commission all specialised services in 2009/10; reflecting the
recommendations in the Carter Report which was published in 2007.

The SCG has made good progress in achieving this national requirement but
it will be important, particularly over the next 3-5 years, to frame this within the
local strategic, clinical and financial context, and identify the priorities to
achieve the most health gain and improved productivity and value for money.

At present, the SCG formally contract for all or part of 25 of these services on
behalf of its 14 PCT members. The decision on whether the SCG formally
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contracts for the service in addition to taking the planning lead, is taken based
on the ease of identifying the service to be contracted for, and the added
value of contracting at SCG level. This may relate, for example, to the need
for risk-sharing across PCTs, or a desire to improve equity of price.

The NHS Constitution became enshrined in legislation from 19 January 2010.
This sets out patients’ rights in relation to access to treatments, choice and
waiting times. The pledges set out within the Constitution underpin and are
captured throughout this strategy.

1.8 Opportunities for Quality, Innovation, Productivity and Prevention
(QIPP)

It is recognised that given the nature of specialised services, the opportunities
to drive up quality and value for money are often synonymous with service
reconfiguration and system redesign. Where this is the case, it is explicitly
recognised that decisions must be taken by the whole system, not unilaterally
by commissioners only, in order to retain local integration and avoid
destabilisation of current provision.

SCG have defined five approaches to driving up QIPP, which will underpin the
initiatives described later in this strategy. These are:

1.   Price Control, eg:
    Lower prices
    Standardisation of tariffs
    Assessment of block agreements versus tariff where appropriate

2.   Activity Control, eg:
    Demand management
    Care/treatment thresholds
    Active management of high cost parts of the pathway
    Case management/ Repatriation

3.   Contract Terms and Conditions, eg:
    Contractual agreements on discharge and admission thresholds
    Length of stay monitoring with appropriate incentives/penalties
    Commissioning for Quality and Innovation (CQUIN) levers

4.   Service Model Redesign, eg:
    In-reach/Outreach
    Review of satellite clinics where these exist
    Shift from tertiary to secondary care
    Shift from secondary to primary/community services
    Stronger prevention focus

5.   Driving up Service Standards, eg:
    Do once and share
    Reducing duplications of care and tests
    Reducing readmissions
    Designation/accreditation of providers
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The above approaches, and ultimately the SCG Vision, will be delivered by
clearly identifying those services where SCG commissioning can add
significant value, via the commissioning “categories” as defined below.

Category 1

For some services where there is a single or very few (usually less than 5)
providers, SCG will be responsible for the whole commissioning cycle
including contracting and financial risk sharing. These services fall into
Category 1.

Category 2

For other services the SCG will be responsible only for specific elements of
the commissioning cycle which benefit from a regional approach, including:

 Agreeing common commissioning policy e.g. specialist fertility treatment
  eligibility criteria

 Implementing common service strategy e.g. renal dialysis

 Commissioning services to a common service specification and common
  service standards e.g. neonatal intensive care

These services will fall into Category 2. For Category 2 services, SCG will not
usually be the contracting body, as the number of providers will usually
exceed 5, which lessens the added value and feasibility of regional
contracting.

Category 3

There are some services where there is currently no pressing need to
undertake significant commissioning activities and maintaining the status quo
is a valid position to take. For such services, SCG will retain a “watching
brief”, in order to ensure that services move into Category 1 or 2 as it
becomes appropriate.

For all services, across all categories, the SCG will maintain an overview of
the market and lead on service designation.




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2. CONTEXT

2.1 Regional health profile

On 27 January 2009, the Department of Health published a Health Profile for
England, which summarised the local health profiles at regional and national
level. The report also includes a comparison with EU national data.1

Table 2: Selected indicators

                         Time and             Yorkshire           England   EU best
                         unit                 and the
                                              Humber
Life                     2004-06              76.6                77.3      78.6 (Sweden,
expectancy               (years)                                            2005)
(male)
Life                     2004-06              81.0                81.6      83.9 (France,
expectancy               (years)                                            2005)
female
Infant deaths            2004-06       5.8                        5.0       2.5 (Sweden,
                         (crude rate                                        2005)
                         per 1,000)
Premature                2004-06 (rate 90.5                       84.2      N/A
deaths from              per 100,000)
circulatory
diseases
Premature                2004-06 (rate 122.3                      117.1     N/A
deaths from              per 100,000)
cancer


As the above table shows, the region served by the Yorkshire and the
Humber SCG is an area of poor health. This impacts on life expectancy
across the region, but also leads to significant health inequalities. The
analysis of these is provided at Appendix 1, and the results have been used to
inform the SCG vision as described in the latter section.




1                                           th
 Health Profile of England. Published 27 January 2009.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_093
465
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      2.2 Insights from the public, patients, clinicians and partners

      The Healthy Ambitions report was the product of a regional review sponsored
      by Yorkshire and the Humber Strategic Health Authority. Recommendations
      from Clinical Reference Groups, which either have direct relevance to or
      interfaces with specialised services include:
      Table 3: Healthy Ambitions Links to SCG
Staying healthy         NICE guidance indicates that for adults who are morbidly obese, surgery
                        may be the best intervention. PCTs should proactively collaborate on setting
                        the specification and agreeing when these services should be
                        commissioned so that there is a common standard across the region
Maternity and           Where in-utero transfer does not take place, the reasons should be
newborn pathway         monitored and improvements made. If ex-utero transfer is required, there
                        needs to be appropriate equipment and up-to-date skilled staff for the
                        transport.
                        Commissioners should work with stakeholders to develop regional guiding
                        principles for transfer times when the place of birth alters during labour.
Children’s              For planned surgery, Trusts and PCTs need to create more opportunities for
pathway                 children to have surgery carried out in local hospitals by competent
                        surgeons and anaesthetists. Occasional practice should cease.
                        For the small numbers of children that may require specialised surgical care,
                        better outcomes may be achieved through concentrating care into larger
                        units.
Planned care            Clinical services should be localised when possible and centralised when
pathway                 necessary and the impact on other services properly understood.
                        The CPG recommend that a review of critical care services should be
                        commissioned across the region to ensure the NHS is delivering the very
                        best care. For similar reasons the CPG also recommend a review of
                        vascular surgery.
Long Term               The NHS should actively identify people in the community at risk from long
Conditions              term conditions and support them to reduce their risk of needing hospital
                        admission, and manage their own conditions.
                        The SCG Strategy needs to take account of this particularly in relation to
                        renal patients, and as the lead for the Y&H Renal Strategy
End of Life Care        Commissioners should put in place clear commissioning frameworks based
                        on national minimum standards to be delivered across all settings and
                        consistent end of life pathways
                        Advanced care planning needs to be undertaken for all individuals with
                        diseases acknowledged to be incurable and progressive.
                        The SCG Strategy needs to take account of this particularly in relation to
                        renal patients, and as the lead for the Y&H Renal Strategy
Acute episode           Where a decision is made that highly specialised care is needed, direct
pathway                 ambulance transfer with A&E bypass is the ideal. This would be likely to be
                        for primary angioplasty, stroke, aortic aneurysms and major trauma.
                        Y&H is already developing a network of primary angioplasty providers in
                        specialised centres. The CPG recommend that this should continue so that:
                        ST elevation acute myocardial infarction patients should be treated with
                        reperfusion (thrombolysis or primary angioplasty) within 3hrs of symptom
                        onset.
                        For appropriate patients primary angioplasty within 3hrs is preferred
                        requiring direct ambulance transfer to designated centres.


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2.3 Provider Context

Providers of specialised services can be separated into three distinct
categories: regional and sub-regional providers of specialised surgical and
medical services; regional and sub-regional providers of secure mental health
services; and out of region providers of specialised and super-specialised
services.

2.3.1 Regional and sub-regional providers

The NHS provider landscape for surgical and medical services within
Yorkshire and the Humber includes 15 acute Trusts and two ambulance
services. In addition, there are around 30 independent providers of acute
medical and surgical services.

Yorkshire and the Humber Specialised Commissioning Group contract with
most of these providers for aspects of specialised services, although much is
concentrated in the three main tertiary providers within the region, Sheffield
Teaching Hospitals NHS Foundation Trust, Leeds Teaching Hospitals NHS
Trust and Hull and East Yorkshire Hospitals Trust.

Each of these tertiary providers acts as a sub-regional hub for specialised
activity, ensuring access to specialised services within reasonable travelling
distances for patients wherever possible, whilst also ensuring sustainable and
viable service infrastructures. Where appropriate, specialised services are
provided in local hospitals or local outreach services are offered.

Appendix 2 provides a breakdown of the regional providers with whom the
Specialised Commissioning Group contract, and the 2009/10 contract values.
Annex 1a shows the breakdown of SCG contracts by specialty.

Yorkshire and the Humber SCG acts as an Associate to the majority of these
contracts, working closely with the coordinating commissioner to deliver
quality and value for money.

2.3.2 Mental Health Providers

The NHS provider landscape for mental health includes four mental health
trusts and two care trusts. In addition to these NHS providers there are 16
independent mental health providers. The breakdown of these providers and
the indicative contract values are provided in Appendix 2.

2.3.3 Out of region providers

A range of contracts and service level agreements have been negotiated and
agreed between the SCG and numerous out of region providers. In some
cases, this is to cover planned movement of patients from within Yorkshire
and the Humber to super-specialist centres, such as highly specialised
services for children provided nationally from Great Ormond Street Hospital.

In other cases, there may be an existing provider within Yorkshire and the
Humber, but it may be more convenient for some patients within the region to
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travel to an out of region centre. An example of this would be the cochlear
implant service at Nottingham University Hospitals.

Finally, there are also contracts in place where patients from Yorkshire and
the Humber regularly choose to be treated outside the region, or regularly
require emergency treatment in a particular area.

Appendix 3 shows a breakdown of the out of region providers with whom the
Specialised Commissioning Group contract, and the 2009/10 contract values.

2.4 Financial Context

The SCG has been in operation for just over 2 years and has a history of
strong financial and managerial governance. Recent external audit reports
have highlighted the sound governance structures that have been operating
within SCG across the Yorkshire and the Humber.

Over the last few years there have seen significant increases in the number of
specialties and breadth of financial responsibility commissioned through SCG
moving to over £600 million in 2010/2011 from £323 million in 2008/2009.
The risk share arrangements have evolved and now cover a greater
proportion of spend through SCG commissioned services with the intention
that these are extended as far as possible over more services in the next few
years.

For 2009/2010 the resources commissioned by SCG on behalf of the PCTs
within the Yorkshire and the Humber patch are less than the national average
national formulae for the PCTs with a weighted capitation size the same as
the Yorkshire and the Humber patch. In addition the national picture across
all SCGs shows that the Yorkshire and the Humber SCG commission less
spend on services per head of population. Across all national SCGs the
services commissioned vary according to national and local need.

In order to achieve fair use of the resource allocation SCG takes into account
the following when making decisions about investments:
        -    Health outcomes – greatest benefit for all
        -    Clinical effectiveness – use of a sound evidence base
        -    Cost effectiveness - greatest benefits for resource committed
        -    Access - to support the delivery of Care Closer to Home
        -    Quality – use of quality standards in all commissioning decisions
        -    Affordability – within available resources

The resources managed by SCG on behalf of the PCTs are either managed
on a host arrangement and costs charged directly back to PCTs or are part of
a risk share agreement to enable costs to be managed across all 14
organisations. Commissioning of these services is undertaken on behalf of
the PCTs to ensure from a financial perspective that services provided are
cost effective and that there is best use of scarce resources.

2.4.1 The Financial Strategy
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The financial strategy going forward is based on three overarching principles:

        Maintaining a balance between investment, affordability, risk and
         quality;
        Sustaining financial stability by either only investing in services
         recurrently where recurrent resources exist or changing services
         commissioned to within affordable financial envelopes ; and
        Commissioning services according to need based on a range of health
         indicators

As with all strategies, the financial strategy will continue to develop as the
overall commissioning strategy evolves. Documents supporting the strategy
describe the required level of investment and disinvestment plans for SCG
which includes the use of the resource available via the constituent PCTs.
This is against the background of the overall financial context of the NHS and
the requirement to combine everything we do with the QIPP agenda. The
supporting Medium Term Financial Plan is available to commissioners at the
members’ section of the SCG website.

Funding decisions have been, and will continue to be made, using all
available intelligence. A focus has been on the use of information from
programme budgeting and benchmarking against NICE criteria to determine
appropriate levels of investment over and above our baselines.

A range of health economic indicators have been used to ensure resource is
invested to improve the overall health and well being of the population. It is
our intention to strengthen health economic analysis and further develop
programme budgeting to support World Class Commissioning in the context
of SCG. Our aim is to achieve the greatest health gain by investing in an
ethical manner.

The SCG continues to analyse the total investment, through its internal
mapping exercises to achieve maximum value for money, benchmark
expenditure and matching expenditure to changing health need.

The financial context in which the SCG currently operates is summarised as
follows.

         Table 4: Growth Context
                                                  2009/10         2010/ 11
        Average Growth Y & H                      5.7%            5.6%
        Highest PCT Growth                        7.8%            6.9%
        Lowest PCT Growth                         5.3%            5.2%

The growth uplift, tariff uplift and efficiency for 2010/2011 are in line with the
2010/2011 Operating Framework. This is based on an uplift of 3.5% and a
cash releasing efficiency target of 3.5%. In addition to this a CQUINS scheme
for Specialised Services is being developed which will equate to 1.5%
(including the 0.5% paid in 2009/2010). Locally the national element of the
CQUINS scheme is not being applied to SCG contracts.

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For 2011/2012 until 2013/14 the planning assumptions are the same as those
issued by the Yorkshire and the Humber SHA. These will continue to be used
until the Operating Framework for the future respective financial years is
issued by the Department of Health. There are three planning assumptions
for 2011/2012 until 2013/2014 for each of the respective financial years which
are as follows.

        Table 5: Planning Assumptions
                                  Best                            Downside   Upside
       PCT allocation Growth      0.0%                            0.0%       2.5%
       Tariff Uplift              2.5%                            2.5%       2.5%
       Efficiency Target          (4.5)%                          (4.0)%     (3.5)%
       Net uplift                 (2.0)%                          (1.5)%     (1.0)%

Given the change in the financial climate from 2011/12 onwards and the
planning assumptions of little or no growth given to PCTs the focus will move
into what efficiencies can be made across all of commissioned services linked
heavily to the QIPP programme.

The SCG will need to make financial decisions that are congruent with
individual PCTs financial positions and also work within the financial climate
within which the whole of the NHS is working. Prioritisation of investments,
funding and expenditure profiling must also take account of local need.

In each of the financial scenarios on the net uplift above there is an
assumption that if all things stayed equal then the value of individual contracts
would decrease. However, decisions have already been made by the SCG
on further investments for 2010/11 onwards which will need to be taken into
account. In addition to this the financial plan has looked at the current
contract values, balance to full year effect of service changes made in
2009/10 and the impact of the forecast out-turn for 2009/10 for the 2010/2011
plan.

If the financial plan for the SCG dictates that further efficiencies are to be
made due to the current plans being unaffordable then based on the current
levels of commissioned services of £600 million each 1% of further efficiency
would equate to the following:

         Table 6: Cost Efficiency Values
                                       Value of Efficiencies
          1% cost efficiencies         £ 6,000,000
          2% cost efficiencies         £12,000,000
          3% cost efficiencies         £18,000,000
          4% cost efficiencies         £24,000,000
          5% cost efficiencies         £30,000,000

For each 1% of efficiency this would equate to £1.10 per head of population
required to be saved (based on a Yorkshire and the Humber population total
of 5,455,655). The split by PCT per 1% of efficiency is shown at Appendix 5.


2.4.2 Risk Shares
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To help the management of financial risk, risk shares are currently in place on
a number of commissioned services across the Yorkshire and the Humber.
The following criteria has been agreed with the SCG Board against which
services are confirmed.

    - Where the service or treatment has low incidence and/or high cost per
      patient and there is likely to be small number random variation in patient
      numbers per PCT e.g. Blood and Marrow Transplants

    - There is a new service – usually a specialised service - for which initial
      activity levels are difficult to predict and a critical mass of investment is
      needed to start up and initially maintain the service

    - A critical mass of service infrastructure is required to meet national
      standards. The designated service providers and the clinical networks
      they serve are nationally recognised. Immediate/urgent access is more
      important than equity of access e.g. Burn Care

    - Where the commissioner is unable to influence the care pathway or
      activity levels through local service development or demand
      management in respect of a specialised service e.g. Spinal Injuries
      services

The actual methodology used depends on whether or not historic activity
information is available however the different methodologies used are either
served population, weighted population, prior year use, x years moving
average or births.

The Carter report recommended that SCGs should develop robust, long-term
commissioning arrangements and manage financial risk, and that each SCG
should have a budget pooled from PCT allocations to cover both the cost of
specialised services that it commissions on behalf of PCTs and its
management costs.         Within the Yorkshire and the Humber SCG
approximately £95million of commissioned services are risk shared to enable
the management of financial risk. Going forward into 2010/2011 the SCG
Board has agreed to extend the list of services risk shared to ensure that for
the following categories the same risk share arrangements are in place for
every PCT within the Yorkshire and the Humber.

         -   Spinal Injuries
         -   Blood and Marrow Transplants
         -   Blood and Marrow Transplant database
         -   Pulmonary Hypertension Drugs
         -   Stereotactic Radiosurgery
         -   Paediatric Critical Care transport

The aim should be for all specialised services to be risk shared across all
PCTs within the Yorkshire and Humber with the appropriate pace of change if
required.

2.4.3 Financial Goals
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Professional financial advice is seen as critical to the commissioning process
of SCG, offering additional challenge to decision making, as well as providing
the financial analytical support.

It is recognised though that the SCG needs to continue to develop the
professional financial support infrastructure. The financial strategy goal and
initiatives outlined in Appendix 7 will ensure that the SCG moves forward in its
aim to be a World Class Commissioner.

2.5.4 Host PCT arrangements

The commissioning of specialised services is an integrated function of NHS
Barnsley and the scale and scope of the PCT’s infrastructure reflects this
position. The dedicated senior commissioning team is employed by NHS
Barnsley and there are other staff in the PCT who provide support to the
Team.

All financial and governance arrangements are subject to the same scrutiny
as any other NHS organisation. Audit reviews of SCG business are
undertaken periodically to not only give assurance to NHS Barnsley but to
give assurance to every PCT within Yorkshire and the Humber in terms of the
SCG commissioning services and expenditure on behalf of its patients.

External assessments of NHS Barnsley as manager of their money also point
to strong financial governance within the organisation. The Use of Resources
score for 2008/2009 has been published indicating an overall score of ‘3’
performing well across the majority of categories.




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3. STRATEGY
3.1 How this section has been developed

This section sets out the high level goals of the SCG, against the specific
initiatives that will deliver these goals.

As a joint sub-committee of the Boards of the PCTs the SCG supports the
constituent PCTs in their achievement of World Class Commissioning, and
the SCG Strategy reflects the common values iterated in each PCT’s
individual strategy with respect to specialised services as follows:

        Where services need to be centralised, outreach and a network
         approach (hub and spoke) are favoured for other elements of care
        Where few centres are needed for the region these should be
         geographically spread to meet need
        Where there are multiple providers, they must meet common quality
         standards
        Where the evidence is supportive, innovation should be encouraged as
         a natural part of safe and effective services

3.2 SCG approach to Prioritisation

In order to deliver the desired outcomes within the challenges of the financial
context outlined above, and in developing the initiatives within the strategy,
the SCG will use a common decision-making framework within which to
commission services and prioritise focus and resource.

This framework was considered by SCG board in February 2010, and
essentially covers the three elements shown in Table 7 below, which are

    a) consideration of the discretion and powers held by SCG relating to the
       services;
    b) how the advice to SCG has been developed and who has input; and
       lastly,
    c) an overarching assessment of whether the service “works”, in terms of
       effectiveness, equity, value for money, and configuration.




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    Table 7 – SCG Decision Making Framework
Stage          Step                   Elements                              Factors/ Evidence/ Advisory body
1              Discretion and         Does the decision relate to a         National Specialised Services
               powers                 specialised service, or a service     Definition Set
                                      included in the SCG work by           SCG Board minutes
                                      agreement?
                                      Does the decision have                Financial Network Group
                                      significant budgetary or service      Designation Standards Sub Group
                                      reconfiguration consequences          Strategic Commissioning Board
                                      (SCG would then recommend
                                      rather than decide)
                                      Is there sufficient information       Advice from SCT
                                      available to make the decision        Checked against decision
                                                                            framework
                                      What would be the added value         Consistency and Equity
                                      of regional decision making,          Efficiency of commissioning
                                      commissioning or planning?            Current decision makers
2              Development of         a. Clinicians and providers           Clinical Standards Sub Group
               advice                 b. PCT commissioners                  Direct consultation
                                      c. Patients and the public            PPI and consultation
3:             Does it work?          - The condition- severity, level of   - Public health and clinical
Four                                    need, effects                         evidence
Questions                             - Clinical effectiveness and          - Evidence review
                                        potential for health gain           - Clinical Standards Sub Group
                                      - Clinical safety and risk
               Is it fair?            - Needs of patients                   - Evidence review and patient
                                      - Impact of decision (positive or       views
                                        negative)                           - Risk assessment
                                      - Reducing inequalities               - Equality Impact assessment
               Is it a reasonable     - Affordability including             - Evidence review, comparison to
               return for the           opportunity cost                      NICE benchmark
               public?                - Cost of not agreeing to fund        - Fair return based on health gain
                                        intervention
                                      - Cost versus health gain
               Is it the best way     - Established Clinical Standards      -   Clinical Standards Sub Group
               of delivering the        and Guidance                        -   Finance Network Group
               service?               - Does the service model              -   Risk Assessment
                                        maximise productivity               -   Market analysis
                                      - Sustainable
                                      - Accessible

    The draft Framework has been sent to individual PCTs for discussion and
    advice with a view to finalisation later in 2010.

    3.3 Supporting Documents

    Maximising health and well-being cannot be achieved by health organisations
    alone. Although the Strategy reflects the actions the SCG will undertake it
    should be seen in the context of a wider strategic context of the constituent
    PCTs and agreement with staff, clinicians and providers as well as with the
    public.

    Commissioning is a live and dynamic process and thus the Strategy will be
    refreshed each year and re-written every three years. It is underpinned by:

            The Operational Plan which describes the financial and activity
             implications of the strategic approach in any one year;
             The PCTs’ Strategic Needs Assessments;
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        The SCG Communications and Participation Strategy which ensures
         public, partnership and clinical engagement.
        The SCG Organisational Development Strategy which describes how
         the SCT and NHS Barnsley will acquire the appropriate skills, systems
         and processes to deliver highly effective commissioning on the SCG’s
         behalf
        The SCG 5-year financial plan
        The SCG Business Plan

3.4 Goals

For services within the National Definition Set, with small numbers of patient
and, usually, small numbers of providers in the region, SCG will improve
outcomes through regional commissioning and regional level engagement.

Goal 1 – Highly Specialised Services
Ensuring equitable access to highly specialised services across the region,
which meet defined quality standards in the most cost effective way to
contribute to the reduction in premature deaths and reduce the impact of
specific conditions.

For services within the National Definition Set and services identified by the
SCG where a regional approach to planning, standard setting, policy and
pricing brings benefits of quality and cost improvement; SCG will establish a
framework for collaboration which may, in time, include contracting at
regional, sub-regional and PCT level.

Goal 2 – Priority Pathways
Improving quality and maximising the efficiency of specialist elements of
priority pathways to contribute to the reduction in premature deaths and
reduce burden of ill health across the region.

In addition, as the only regional commissioner decision making body, SCG
can add value by co-ordinating the development of consistent commissioning
policy and leading the design of a coherent pattern of specialised service
provision where supra-PCT level decision making is required.

Goal 3 – Regional Consistency
To support PCTs and Providers in the region to deliver safe, efficient and
sustainable specialised services through consistent commissioning, intelligent
market management and robust decision making.

3.5 Initiatives
The following initiatives have been developed to deliver the above goals,
within the QIPP context outlined earlier in the document, and also linking back
to the overarching SCG outcomes. A high level map of the links between the
above goals, initiatives, and overarching SCG outcomes is provided at
Appendix 8.

Each initiative describes the productivity potential to be gained by
implementing the various elements. The delivery of these initiatives is key to

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the delivery of the financial strategy in this regard, in ensuring the affordability
of specialised services going forward into the future.




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3.5 GOAL 1 INITIATIVES

Initiative                 Elements                       Outcomes                 Timescale                   Dependencies           Productivity
Description                                                                                                                           Potential
Improve the                Development of Y&H             Patients receive         Baseline assessment of      Development of         Potential benefit
quality and ensure         service strategy for           optimal care and         services against            national designation   from national
equitable access           Intestinal Failure             treatment that           standards outlined in       pack                   procurement
to highly                  services, in line with         reflects the level of    national strategy and                              process
specialised                the national strategy          case complexity          scope local issues          Co-ordinated
services for                                                                       2010/11                     response to            Common thresholds
Intestinal Failure         Effective                      Assurance of                                         designation process    for all levels of care
                           participation in the           consistent, effective,                               by SCGs
                           national IF                    high quality             Designation of ‘sector 2’                          Reduced length of
                           Commissioning                  specialist IF            service in line with        Provider capacity      stay for IF patients
                           Group (responsible             services, with clear     national timescale          and capability
                           for co-ordinating the          links to local service
                           designation process            provision                                            Effective clinical
                           for ‘sector 3’                                                                      engagement
                           services)                      Assurance that
                                                          commissioned
                           Implementation                 services meet
                           within Y&H of the              national quality
                           national strategy and          standards
                           designation of
                           ‘sector 2’ services




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3.5 GOAL 1 INITIATIVES

Initiative         Elements                 Outcomes                                Timescale                            Dependencies              Productivity
Description                                                                                                                                        Potential
Ensuring           Agreed common            Equitable access to new                              Ongoing                 Clinical advice and       Avoidance of
the                approaches to            technologies that are introduced                                             leadership of the         unplanned
availability       new technologies         through a managed process                                                    process                   development/growth
of highly                                                                                                                                          in high cost
specialised                                                                                                                                        interventions
cardiac
                   Adult congenital         Equitable access to services            Designation of providers 2010/11 National ‘sign off’ of
services           cardiac services                                                                                  designation pack
across the         designated and           Assurance of standards of service
region to          commissioned to          delivery
contribute to      agreed standards
the
reduction in       Children to be           Equitable access to specialist          Designation’ of ‘level 2’ services   Timely access to          Potential reduction
premature          appropriately            children’s cardiac services              in 20010/11. In line with the       specialist paediatric     in demand for
deaths and         assessed prior to        Assurance of quality of provision for     Congenital Cardiac Service         cardiac services is       specialist (level 3)
reduce the         referral to a            paediatric cardiac outpatient                      Strategy                  dependent on high         paediatric
impact of          paediatric cardiac       services                                                                     quality and appropriate   congenital cardiac
specific           specialist (level 2)                                                                                  referral from             outpatient
                   in line with i)          Reduction in morbidity and mortality                                         paediatricians.           appointments as
conditions.        agreed clinical          associated with congenital cardiac                                           Implementation of         children ‘assessed
                   guidelines ii) care      conditions                                                                   changes needed to meet    by paediatrician
                   pathway.                                                                                              agreed standards.
                   Services for             Equitable access to services for        Consultation on strategy in          Clinical engagement and   Potential increase in
                   people with              people with inherited cardiac           2010/11.                             support.                  the number of
                   inherited cardiac        conditions.                                                                                            patients managed in
                                                                                    Agreement of the strategy
                   conditions to be         Assurance of quality of service                                              Stakeholder support for   secondary/primary
                   commissioned in          provision for people with inherited     Inclusion of the service             the strategy              care resulting from
                   line with agreed         cardiac conditions.                     specification into contracts in                                clear discharge
                   service                  Reduction in morbidity and mortality    2010/11 with associate                                         criteria from
                   specification.           associated with inherited cardiac       monitoring arrangements.                                       specialist services.
                                            conditions                              Designation 2011-12


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3.5 GOAL 1 INITIATIVES

Initiative                  Elements                       Outcomes                  Timescale                   Dependencies             Productivity
Description                                                                                                                               Potential
Ensuring availability        Access to cochlear            Equitable access to      Establish consistent       Timely access to          Get best value
of and equitable              implantation to be in          timely, responsive,       approach to sequential      specialised ear            tariffs for
access to high                line with agreed care          high quality cochlear     cochlear implantation –     surgery dependent          assessment and
quality specialised           pathways and                   implantation services     December 2009               on high quality,           maintenance
ear surgery                   protocols                                                                            appropriate referral      Implement clear
                             Commission                                                                           from primary and           treatment
                              cochlear implant                                                                     secondary care.            thresholds for
                              capacity to meet                                                                                                sequential
                              national capacity                                                                                               implants
                              targets and in line
                              with identified need.
                             Agreed common
                              approaches to new
                              technologies such as
                              middle ear
                              implantation.




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3.5 GOAL 1 INITIATIVES
.
Initiative   Elements                                             Outcomes                Timescale                    Dependencies             Productivity
Description                                                                                                                                     Potential
Ensure early        Long-term service strategy and                Patients have          Early 2010 –                Provider capacity       Standardised
referral and         planning for Spinal Cord Injury                the best                Formal launch of             and capability.          commissioning
admission to         Services across the region.                    possible                the new National            Provider income.         framework and
a Spinal            Full and effective participation as            chance of               Strategy Board.             Continued                currencies.
Cord Injury          SCG member of the new National                 recovery.              2010/11 – Publication of     development of the      Additional
Centre for all       Spinal Cord Injury Strategy                   Patients do not         new National Guidelines      new National Spinal      investment may
patients             Board.                                         develop further         and Standards.               Cord Injury Strategy     be required in
requiring           Full implementation of new                     complications.         2010/11 –                    Board.                   order to meet
specialist           National Guidelines and                       Significant             Plans to run shadow                                   new national
care.                Standards for the identification               improvements            contracts, monitoring                                 standards.
                     and management of spinal cord                  in quality of life,     proposed new
                     injured patients.                              not just in the         currencies.
                    Implementation of standardised                 immediate
                     information management                         aftermath of an
                     requirements.                                  accident, but in
                    Implementation of a standardised               the long term.
                     commissioning framework and                   Improved
                     commissioning currencies.                      patient
                                                                    experience,
                    Reductions in health inequalities.             year on year.
                    Assurance of consistent, clinically
                     effective, high quality, cost
                     effective specialised Spinal Cord
                     Injury Services across the region.
                    Patients and their representatives
                     are fully engaged and involved in
                     the planning and development of
                     these services.




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3.5 GOAL 1 INITIATIVES

Initiative                  Elements                          Outcomes                  Timescale                 Dependencies             Productivity
Description                                                                                                                                Potential
Ensuring equitable           Development of long-             Blood & Marrow           Revised local tariffs    Revised local tariff    Introductions of
access to highly              term service strategy             Transplant services       agreed – March 2010       dependent on             national tariff
quality Blood &               for blood and marrow              capacity is available                               pending the             Cost and volume
Marrow Transplant             transplantation.                  to meet the health       Full designation          introduction of          contracts
services                     Development and                   needs of the              complete – March          indicative
                              implementation of local           population                2010                      /mandatory national
                              and national tariffs, and        Blood & Marrow           Service strategy in       tariffs.
                              elimination of                                                                       Clinical, managerial
                                                                Transplant services       place – April 2010
                              significant differences           are commissioned to                                 and patient
                              in tariffs.
                             Provider compliance
                                                                in a way that            Annual assessment         engagement.
                                                                considers patient         and report available     National lead to
                              with contractual
                                                                views and is              for the contractual       develop database
                              information
                              requirements, and                 consistent with           year ended 31March        reporting
                              access to national                patient needs.            2010
                              reports.                         Assurance that
                             Improved access to                commissioned
                              services and reductions           services meet
                              in health inequalities.           national quality
                             Assurance of clinically           standards services
                              effective, high quality,         Services
                              cost effective blood and          commissioned in a
                              marrow transplant                 consistent manner
                              services across the               and demonstrate
                              region.                           value for money
                             Patients and their
                              representatives fully
                              engaged and involved
                              in the planning and
                              development of these
                              services




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3.5 GOAL 1 INITIATIVES

Initiative                   Elements                      Outcomes                   Timescale                   Dependencies             Productivity
Description                                                                                                                                Potential
Ensure availability of        Equal access across          Improved access to        Implement regional         Engagement of           Standardise pricing
Gender Dysphoria               PCTs to a complete            treatment for              commissioning policy        primary care             for surgery and
services based on              pathway of care for           patients with gender       – October 2009              practitioners, in        GICs
need                           gender dysphoria,             dysphoria                                              ensuring timely,        Consider
                               for those meeting            Improved quality of       Establish Expert Panel      equitable and            narrowing the
                               eligibility criteria in       life for patients with     – December 2009             appropriate referral     range of
                               line with best                gender dysphoria                                       to specialist gender     procedures
                               evidence                     Reduction in gender       Pilot shared care,          dysphoria services       contracted for. Set
                              Services we                   dysphoria associated       community based                                      up contracts with
                               commission meet               morbidity                  pathways                                             surgical providers
                               national waiting time        Improvements in            – December 2009                                     Increase care
                               and clinical                  patient experience        Implement regional                                   closer to home,
                               standards and                 measures, year on          service specification –                              better use of local
                               deliver care closer           year                       April 2010                                           services
                               to patient’s homes           Patient choice of
                               wherever                      provider                  Designation of
                               appropriate                                              providers of gender
                                                                                        dysphoria services –
                                                                                        March 2011




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3.5 GOAL 1 INITIATIVES

Initiative                 Elements                       Outcomes               Timescale                Dependencies         Productivity
Description                                                                                                                    Potential
Ensuring equitable         Access to targeted             Equitable access to    National commissioning   National policy      Control/common
access to high             high cost therapies            appropriate services   policy reviewed on an    requires agreement   decision making for
quality services for       in line with                   and therapies          annual basis             of all 10 SCGs       high cost
Pulmonary                  commissioning                                                                                       treatments
Hypertension               policy                         Improvements in                                 Implications for
                                                          quality of life        Standards for shared     congenital heart     Reduced activity in
                           Provider compliance                                   care agreed December     disease services     specialist centres
                           with national service          Improved patient       2010-05-21
                           standards                      experience             Formal designation of
                                                                                 shared care providers
                           Development of                                        2011/12
                           formal shared care
                           arrangements




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3.5 GOAL 1 INITIATIVES

Initiative                Elements                        Outcomes                  Timescale               Dependencies            Productivity
Description                                                                                                                         Potential
Ensuring                  Reorganisation of               Patients have the    Referral criteria and        National work           Effective utilisation
availability and          burn care services to           best possible chance pathways implemented         programme on            of highly specialised
equitable access          meet the nationally             of recovery          January 2011                 service standards       service capacity
to specialist             recommended three
                                                                                    Service configuration
Burn Care                 tier model (burn                Patients do not                                   Engagement and          Reducing
                                                                                    agreed 2011/12
services which            centres, burn units,            develop further                                   education of            inappropriate
meet the national         burn facilities)                complications             Commissioning           clinicians in primary   referrals
standards                                                                           framework agreed        care and secondary
                          Provider compliance             Significant               2011/12                 care                    Standardisation of
                          with service standards          improvements in                                                           local prices
                          associated with each            quality of life, in the
                          tier                            long term –
                                                          particularly for the
                          Designation of                  complex cases
                          relevant service
                          providers                       Improved patient
                                                          experience
                          Full implementation of
                          referral criteria and
                          care pathways

                          Implementation of
                          standardised
                          commissioning
                          framework,
                          commissioning
                          currencies and tariff
                          based payment
                          system


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3.5 GOAL 1 INITIATIVES

Initiative                Elements                         Outcomes                    Timescale            Dependencies            Productivity
Description                                                                                                                         Potential
Ensuring the              Identify capacity and            Internal review of the      Work ongoing         Robust interface        More effective
availability of a         demand issues within             Genetics Service at         throughout 2010-11   between Trust, Host     resource utilization
high quality,             the two Genetics                 LTHT with regard to                              PCT and SCT
consistent and            Services to ensure               existing practices
appropriate               compliance to 18 week            leading to a more
medical                   requirements                     streamlined service
genetics
services for              Development of                   Develop a framework         Regional             Robust collaborative    Effective utilization of
patients who              Genetics Expert Panel            agreement consisting of     documentation to     and partnership         resources
need to access                                             agreed regional             be agreed by         working between the
the service.                                               documentation including     Autumn 2010          two existing services   Equity of access
                                                           service specification,                           in Leeds and
                                                           pathways policies and                            Sheffield               Robust regional
                                                           protocols                                                                commissioning

                                                           Advise SCG of               On-going                                     Tighter contract
                                                           appropriate and effective                                                controls,
                                                           new treatments, utilizing                                                specifications and
                                                           local, regional, national                                                accountability.
                                                           and international
                                                           guidance

                          Designation of                   Designation Team to                                                      Quality assurance
                          Genetics Services in             assess whether the two      By end of 2011                               and quality standards.
                          Y&H                              services meet
                                                           designation standards




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3.5 GOAL 1 INITIATIVES

Initiative                  Elements                          Outcomes                  Timescale                 Dependencies            Productivity
Description                                                                                                                               Potential
Ensuring equitable              Agree model for               Haemophilia                 Full designation      National               Impact of national
access to high                   delivering services            services are                based on agreed         procurement of          blood products
quality Haemophilia              that provides                  available to meet the       model by April 2011     blood products runs     and home delivery
services                         assurance of clinically        health needs of the                                 according to            procurement will
                                 effective, high quality,       population               Commissioning Policy      planned timescales      realise cost
                                 cost effective services       Assurance that            be developed April                                efficiencies
                                 across the region              commissioned              2011
                                Designate                      services are
                                 Comprehensive care             coordinated and
                                 centres and                    meet national quality
                                 supporting units
                                                                standards
                                Expert regional
                                                               Haemophilia
                                 clinical panel to
                                                                services
                                 advise on local
                                                                commissioned in a
                                 interpretation of
                                                                consistent manner
                                 evidence to support
                                                                and demonstrate
                                 evidence based
                                                                value for money
                                 commissioning




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3.5 GOAL 2 Initiatives

Initiative                   Elements                      Outcomes                      Timescale                Dependencies             Productivity
Description                                                                                                                                Potential
Ensuring equitable              To lead the                     1 and 5 year              Improving Outcomes    Close collaboration     Admissions
access to high quality           implementation of                survival rates show        Guidance               with                     avoidance
specialised cancer               the NICE                         year on year               implemented            commissioners of        Reduction in bed
services                         Improving                        improvement                 o Brain/central       non specialised          days through
(highly specialised)             Outcomes                        Access to                     nervous system      elements of patient      enhanced recovery
                                 Guidance for                     specialised cancer            April 2011          pathways across a        programmes
                                 Hepato                           services meets all          o Specialist skin     wider range of          Reductions in out-
                                 Pancreato-biliary                national waiting              cancer services     providers                patient
                                 services,                        time targets               o Sarcoma April       Providers                appointments
                                 Sarcoma,                        Patient reported              2011                effectively             Commissioning
                                 Brain/central                    outcomes show              o Children & Young     managing capacity        policy setting out
                                 nervous system,                  year on year                  People December     to meet access           explicit treatment
                                 Children & Young                 improvement                   2010                targets                  criteria
                                 People, Skin                    Health equity audits                             Early detection and
                                 Lymphoma and                     show reducing                                     referral by primary
                                 the extracorporeal               inequality in all                                 care
                                 photopheresis                    specialised services                             Close collaboration
                                 component of                                                                       with the three
                                 specialist skin                                                                    cancer networks
                                 cancer services                                                                    on implementing
                                To ensure                                                                          referral guidelines,
                                 capacity for                                                                       treatment protocols
                                 thoracic surgery to                                                                and improved
                                 treat patients with                                                                patient pathways
                                 lung cancer is                                                                    Joint working with
                                 maintained                                                                         other SCGs and
                                                                                                                    possibly the NCG
                                                                                                                    where there is
                                                                                                                    supra SCG service
                                                                                                                    provision




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3.5 GOAL 2 INITIATIVES

Initiative                 Elements                        Outcomes                   Timescale          Dependencies                             Productivity
Description                                                                                                                                       Potential
Ensuring equitable         Assess specialist               Interventions used are     Scoping phase      Executive leadership                     Option of less
access, and                interventions against           underpinned by robust      20010/11                                                    expensive
improving                  clinical evidence               clinical evidence base                    Clinical engagement                          treatment
clinical/cost                                                                         Implementation                                              modalities for same
effectiveness of the                                                                  phase 2011/14 Political acceptability of e.g. changing      clinical outcome
specialised                                                                                          options for treatment modalities
elements of the
overall cardiac            Develop consistent              Improved equity of         Rolling                                                     Improved quality
patient pathway            commissioning policy            access to specialist       programme                                                   through
                           and service                     interventional             2010/15                                                     consistently applied
So that specialist         specifications for              cardiology procedures                                                                  service
interventions are          specialised cardiac                                                                                                    specifications
provided maximum           interventions
health gain thereby
contributing to the        Commission sufficient           Ensuring equitable         Annual to fit in   Achievement of equitable access          Reduced variation
reduction in               capacity for CABG               access to services of a    with LOP           dependent on robust commissioning        across the region,
premature deaths           surgery to meet                 consistently high          timetable          and provision of DGH cardiology          leading to
.                          identified need and             standard within national                      services (i.e. identification and        increased efficiency
                           access targets                  waiting time targets                          appropriate referral)                    and productivity

                                                           Revascularisation                             Identifying capacity needs is
                                                           activity to meet demand                       dependent on clinical networks
                                                                                                         identifying health need and
                                                                                                         coordinating capacity planning for all
                                                                                                         treatment modalities.

                                                                                                         Meeting access targets dependent on
                                                                                                         providers managing commissioned
                                                                                                         capacity




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3.5 GOAL 2 INITIATIVES

Initiative                   Elements                      Outcomes       Timescale                   Dependencies         Productivity
Description                                                                                                                Potential
To commission            Setting KPIs for PIC  Paediatric intensive                                  Clinical            Common/clear
effective critical care  Reviewing and          care and high             KPIs for Paediatric         engagement           thresholds for all
paediatric intensive      monitoring PIC         dependency services        Intensive care agreed      Development of       levels of care
care services across      activity across the    delivered in line with     April 2010                  tools to monitor    Introduction of a
the region to reduce      region                 agreed quality                                         service delivery     national tariff
premature deaths,        Complete a gap         standards                 Agreed action plans for     against quality     Reduction in out of
reduce the health         analysis of                                       Paediatric high             standards            area transfers
burden and                paediatric high                                   dependency                                      Reducing/eliminating
contribute to the         dependency                                        services April 2010                              delayed discharges
reduction in infant       services against the                                                                               – particularly
mortality                 specification and                                                                                  patients with long
                          agree local action                                                                                 term ventilation
                          plans                                                                                              needs
                         Designate all NIC &
                          PIC units to provide
                          clarity on the level
                          and standard of care
                          they can provide




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3.5 GOAL 2 INITIATIVES

Initiative                   Elements                      Outcomes                Timescale                 Dependencies             Productivity
Description                                                                                                                           Potential
To support neonatal           Map the current              Neonatal services      CQUIN indicators for     Clinical engagement     Common/clear
services to ensure               neonatal services           configured to meet      NIC services agreed      Identifying neonatal     thresholds for all
the availability of              against the                 National Taskforce      by April 2010             investment to meet       levels of care
neonatal care across             principles in the           recommendations        Development of action     taskforce               Introduction of a
the region to reduce             National Taskforce         No babies               plan to implement the     recommendations          standard local
premature deaths,                recommendations             transferred out of      neonatal taskforce       Development of tools     tariff, in advance of
reduce the health                (published Dec              region unless on a      recommendations, to       to monitor service       a national
burden and                       2009) and develop           clinical need basis     be signed off by SCG      delivery against         approach
contribute to the                an implementation                                   Board by December         quality standards,      Reduction in out of
reduction in infant              plan to achieve the                                 2010                      including required       area transfers
mortality                        principles including:                              NIC designation 2011-     data and information
                             - Implementing the                                      12, within context of     flows
                               limits of NIC that can                                wider action plan        Effective
                               be delivered in local                                Implementation of         implementation of
                               neonatal units and                                    action plan 2011-14,      Y&H Infant Retrieval
                               local special care                                    including addressing      Service in 2010-11
                               units                                                 the workforce deficit
                             - Increasing the                                        and managing any
                               availability of                                       required system
                               Neonatal intensive                                    redesign to achieve
                               care cots in the                                      desired outcomes
                               Network neonatal
                               intensive care units
                             - Agreeing the
                               medical and nursing
                               workforce standards
                               within each unit
                              Designate NIC units
                                to provide clarity on
                                the level of care
                                they can provide



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3.5 GOAL 2 INITIATIVES

Initiative           Elements                                     Outcomes              Timescale                      Dependencies          Productivity
Description                                                                                                                                  Potential
To commission         Develop a framework                         Greater equity of    Transfer current contract     Robust interfaces    Reduced costs
Tier 4                 agreement consisting of an                   provision             management to SCG              between macro-        through common day
Children &             agreed specification including              Centralised           2010-2011                      management by         rate tariff and single
Adolescent             quality standards and single                 data/information     Develop agreed service         SCG and micro-        contracting
Mental Health          Yorkshire & Humber                           flows                 model and standard             management by         framework
services               contractual arrangements                    Reduction in          service specification          PCTs                 More effective
(CAMHS) to             utilising the national Mental                costs in single       Sept 2010                     Effective             resource utilisation
ensure the             Health Contract                              contracting          Agree commissioning            commissioning
availability of       Lead the implementation of                   framework, ie.        and accreditation              case management
high quality,          the service model and the                    through single        framework, aligned to          in PCTs
consistent and         process of accreditation of                  day rates across      national principles of co-
appropriate            existing and new providers,                  providers for         operation and
care for               managing new market                          each PCT              competition
children who           entrants where required, and                Drives down          Implement agreed
require                working with existing                        under-utilisation     framework, from April
specialised            providers to enable                          of resource and       2011- March 2012
mental health          achievement of the standards                 reduce out-of-       Monitor outcomes 2012-
as an inpatient       Develop a database of                        area and spot-        13, review and refresh
                       accredited providers and                     purchased             from 2013 onwards
                       maintain this for use by in-                 placements
                       district commissioners and
                       providers to guide placement
                       decisions
                      Work with all providers on the
                       approved framework to
                       negotiate an agreed day rate
                       tariff to develop a cost per
                       case model of commissioning




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3.5 GOAL 2 INITIATIVES

Initiative             Elements                                   Outcomes                     Timescale                      Dependencies               Productivity
Description                                                                                                                                              Potential
Ensure the                  A managed network approach            Reduced ‘late diagnosis’    Designation timescales        Clinical Culture shift    Some
availability of              will ensure local access to            measured by CD4 count        planned for PTCs and          strengthening of           control/common
specialised                  specialised support, while             at presentation              networks – April 2010          monitoring and             decision-making
services based               networks will be encouraged           Reduced emergency                                           audit,                     for new (high
around Principle             to work collaboratively across         admissions for HIV and                                      available                  cost) treatments
Treatment                                                                                       SCG commissioning of
                             the region on standards, audit         AIDS related causes                                         mechanisms for             would avoid
                                                                                                 all PTC services – April
Centres to                   and training                          Improved patient             2010
                                                                                                                                delivery uncertain         inconsistent
support patients            Designated Principle                   experience and outcomes                                                                access to
with HIV and                 Treatment Centres (PTC) will                                       Timescale for move to                                     therapies across
AIDS on the                  support local Units to provide                                      year of care tariff agreed                                region
basis of need                ongoing support for patients                                        – April 2010
                             requiring care
                          The long-term conditions model
                           will be applied, with funding for
                           patients on highly active
                           antiretroviral therapy (HAART)
                           being based on a year-of-care
                           tariff
                          Where possible in-patient care
                           will be provided locally with
                           support from 24/7 on call
                           specialists at the PTC.
                          An MDT approach will be
                           encouraged for the oversight of
                           all patients
                          Expert regional clinical panel to
                           advise on local interpretation of
                           evidence to support evidence
                           based commissioning




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3.5 GOAL 2 INITIATIVES

Initiative                  Elements                       Outcomes                   Timescale                   Dependencies             Productivity
Description                                                                                                                                Potential
A strategic plan for         Personality Disorder          Improved mental           Strategy agreed – April    infrastructure and      Negotiate
personality                   consultation process           health and social          2010                        workforce                benchmarked tariffs;
disorder services             with key                       care outcomes for                                      implications;           implement
to draw together              stakeholders agreed            patients                  Knowledge and skills       lack of control over     procurement
population need,              and implemented                                           framework implemented       growth (Criminal         framework;
identify current             Draft strategy                Improved cost              – April 2010                Justice system)         reduce IS activity
service provision,            discussed and                  effective range of        Procurement                                          increase NHS
and outline future            agreed                         services                   frameworks agreed -                                  activity;
service configuration        Knowledge and                                             January 2010                                        standardise
                              Skills framework              Increase in range of                                                            contracts;
                              implemented across             services closer to        Evaluation of services                              focus case
                              workforce in Y&H               patients home areas        and pilots - 2010/11                                 management;
                             Evaluation of                                                                                                 enhance gate
                              dedicated services            Swifter access to                                                               keeping;
                              and pilot projects             secure services                                                                commission local
                              undertaken                                                                                                     services to reduce
                             Procurement                   Higher quality of                                                               referrals to secure
                              frameworks agreed              clinical service                                                                services;
                              for service                    provision                                                                      maximise levers
                              developments with                                                                                              within CQUINs
                              local PCT’s                   Increase in level and
                             Five year service              quality of service and
                                configuration plan           patient information
                                developed and
                                agreed                      Enhanced liaison
                             Detailed service               and integration with
                                specifications and           social, criminal
                                outcome                      justice and third
                                frameworks agreed            sector agencies




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3.5 GOAL 2 INITIATIVES

Initiative                     Elements                           Outcomes                    Timescale           Dependencies             Productivity
Description                                                                                                                                Potential
Develop and             Undertake a review of                     Improved cost              Undertake          infrastructure and      Negotiate
Implement low secure     services using new 10/11                   effective range of          review process      workforce                benchmarked tariffs;
services                 standards                                  services                    – 2010/11           implications;           implement
commissioning strategy  Agree and monitor action                  Higher quality of                              lack of control over     procurement
                         plan with each provider                    clinical service           Monitor action      growth (Criminal         framework;
                         which outlines the areas                   provision                   plans- 2010/11      Justice system)         reduce IS activity
                         for improvement                           Increase in level and      Agree low                                    increase NHS
                        Ensure any derogation                      quality of service and      secure strategy                              activity;
                         from the standards are                     patient information         Q1 2010                                     standardise
                         understood and there are                  Improved health and        Implement                                    contracts;
                         contingency plans in                       social care outcomes        strategy                                    focus case
                         place                                      for patients                2010/15                                      management;
                        Low secure strategy                       Reduced risk to the                                                     enhance gate
                         framework developed and                    public                                                                   keeping;
                         stakeholder engagement                    Enhanced levels of                                                      commission local
                         via consultation process                   safety for patients                                                      services to reduce
                        Draft strategy discussed                  Minimum level of care                                                    referrals to secure
                         and agreed                                 provided across all low                                                  services;
                        Procurement framework                      secure services                                                         maximise levers
                         agreed and tender                         Increase in range of                                                     within CQUINs
                         process implemented                        services closer to
                        Detailed service                           patients home areas
                         specifications and                        Swifter access to
                         outcome frameworks                         secure services
                         agreed
                        Finalise remaining
                         collaborative
                         commissioning
                         arrangements with PCT’s




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3.5 GOAL 2 INITIATIVES

Initiative                     Elements                           Outcomes                  Timescale   Dependencies         Productivity
Description                                                                                                                  Potential
High, medium and low              Introduce enhanced                Improved quality of   2010-2011    PCT Ownership of      Potential for
secure service                     case management                    service provision                   lead PCT model         significant savings
pathways QIPP                      procedures to improve             Improved cost                                              during 2010 - 15
programme                          Patient Pathway                    effectiveness                        Case
                                   management across                 Cash releasing                        management
                                   High, Medium and Low               savings
                                   secure services                   Improved range of                    Provider
                                                                      provision                             engagement
                                  Develop commissioning             Reduced lengths of
                                   plans for new secure               stay
                                   services due to open
                                   during 2010/11/12

                                  Review High secure
                                   patient population to
                                   accelerate transfer to
                                   lower levels of security

                                  Implement pilot
                                   development
                                   programme for secure
                                   services as agreed with
                                   DH

                               Review benchmarking
                               information from all secure
                               services and develop
                               procurement plan




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3.5 GOAL 2 INITIATIVES

Initiative                     Elements                    Outcomes                   Timescale                 Dependencies         Productivity
Description                                                                                                                          Potential
Co-Ordinated                    Implementation             Improved cost             Implementation plan      PCT Ownership of    more efficient
Commissioning of non-            plan agreed which           effective range of         agreed – December         lead PCT model       planning and
secure specialised               outline changes to          services                   2009                                           procurement; more
mental health                    current                                               Stakeholder              Case management      equitable services,
services, leading to             arrangements               Integrated regional        involvement and                                standard Y&H
more efficient planning         Stakeholder                 and local planning         engagement – June                              service
and procurement; more            engagement with             arrangements               2010/11                                        specifications and
equitable services,              plans                                                                                                 agreed, closely
standard Y&H service            Establishment of           Greater clarity of        Establishment of                               monitored quality
specifications and               expert reference            patient pathways           expert reference                               standards
agreed, closely                  groups and                                             groups – 2010/11
monitored quality                networks as                Higher quality of
standards                        appropriate to              clinical service          New standard
                                 steer service               provision                  contracts agreed – Q4
                                 changes                                                2010/11
                                Agreement of new           Increase in level and
                                 standard contracts          quality of service and    New case
                                 with providers              patient information        management
                                Agreement on                                           arrangements in place
                                 underpinning case                                      – 2010/11
                                 management
                                 arrangements




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3.5 GOAL 2 INITIATIVES
Initiative           Elements                             Outcomes                 Timescale                   Dependencies             Productivity
Description                                                                                                                               Potential
Ensure                Long-term service                   Prevention of the       November 2009 – Draft      Continued               Reduction in the
equitable              strategy and planning for            occurrence of renal      Service Strategy out to     development of           number of patients
access to high         renal services.                      disease, through         consultation.               more sophisticated       presenting with end
quality               Full implementation of the           systematic              April 2010 –                planning tool, in        stage renal failure.
specialised            National Service                     identification of at     Service Strategy            conjunction with DH.    Reduction in the
and non-               Framework and NICE                   risk groups, and         published.                 Full engagement          number of patients
specialised            Guidance.                            reduction of risk       June 2010 - Annual          and commitment of        presenting with
renal services        Provider compliance with             factors.                 assessment and report       primary care and the     acute kidney injury
in line with the       contractual information             Improvements in the      published.                  local implementation    Increase in home-
National               requirements, and access             presentation of         September 2010 - Data       groups of the renal      based therapies
Service                to robust national reports,          kidney function.         submission and              network.                 and self-care.
Framework              for planning and                    Delayed                  reporting requirements     Provider income,        Increase scale of
                       benchmarking.                        progression of renal     fulfilled.                  cultural shift, and      conservative and
                      Improved access to                   disease, through                                     short-term               palliative care.
                       services and choice of               ensuring high                                        investment in           Increase number
                       treatment modality.                  coverage of disease                                  transplantation.         of transplants,
                      Reductions in health                 management                                                                    including live donor
                       inequalities.                        interventions across                                                          transplants.
                      Assurance of consistent,             primary and                                                                  Standardisation of
                       clinically effective, high           secondary care.                                                               local prices.
                       quality, cost effective             Reduced                                                                      Introduction of
                       specialised renal services           progression and                                                               national tariff.
                       across the region.                   complications of                                                             Greater utilisation
                      Patients and their                   renal failure,                                                                of existing
                       representatives are fully            including reduced                                                             haemodialysis
                       engaged and involved in              incidence of acute                                                            facilities, through
                       the planning and                     kidney injury.                                                                the
                       development of these                                                                                               introduction/extensi
                       services.                                                                                                          on of
                                                                                                                                          twilight/weekend
                                                                                                                                          shifts.



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3.5 GOAL 2 INITIATIVES

Initiative           Elements                                 Outcomes                 Timescale                    Dependencies             Productivity
Description                                                                                                                                  Potential
Ensuring        Access to neurosurgery to                     Equitable access to     Establish consistent        Timely access to        Compare local
equitable        be in line with agreed care                    timely, responsive,      arrangements for             specialised              tariff
access to high   pathways and protocols                         high quality             neurosciences                neurosurgery             arrangements
quality         Commission neurosurgery                        neurosurgery             commissioning at a           services dependent       across Y&H and
specialised      capacity to meet national                      services                 regional and sub             on high quality,         across SCGs to
neurosciences    capacity targets and in line                  Reduction in             regional level – October     appropriate referral     drive down costs;
services         with identified need.                          mortality and            20010                        from primary and        Reduce routine
                Specialised neurosurgical                      morbidity from          Review capacity for          secondary care.          spinal referrals,
                 services commissioned in                       neurological disease     neurosurgery – annually     Clinical engagement      through
                 line with good practice.                      Equitable access to     Complete service review                               implementing
                Agreed common                                  timely, responsive,      for neuro-rehabilitation                              new guidelines.;
                 approaches to new                              high quality             to identify the care                                 Potential to look
                 technologies such as                           specialist neurology     pathway and appropriate                               at thresholds for
                 stereotactic radiosurgery                      services                 service model linking to                              routine spinal;
                Equitable access to                           Effective                other rehabilitation                                 Reduce wastage
                 Intravenous immunoglobulin                     management of IVIg       services – April 2011                                 through
                 (IVIg) for use in neurology                    supply (nb IVIg have                                                           cancellations;
                 and neurological conditions                    a wider than                                                                  Identify clear
                 is in line with the IVIg                       neurosciences)                                                                 thresholds for
                 demand management                             Reduction in                                                                   Neuro ITU and
                 strategy.                                      mortality and                                                                  ensure balance
                Access to high quality                         morbidity from                                                                 between Neuro &
                 neuro-rehabilitation services                  neurological disease                                                           General ITU
                 to meet identified need and
                 consistent with good
                 practice
                Agreed common
                 approaches to new
                 technologies such as deep
                 brain stimulation

C:\Docstoc\Working\pdf\36c951a4-2ddf-45e0-ae14-837a7501e39e.doc                                                                                             42
3.5 GOAL 2 INITIATIVES

Initiative                   Elements                      Outcomes                  Timescale                  Dependencies             Productivity
Description                                                                                                                              Potential
Ensure availability of        Equal access across          Improvements in live     Implement regional        Long term value for     Implement new
sub-fertility                  all PCTs to three full        singleton birth rate      commissioning policy       money dependent on       pricing structure for
services based on              cycles for those              by service                July 2010                  development of           fertility;
need                           meeting eligibility          Appropriate cycles                                   national tariff,        Introduce clear
                               criteria in line with         delivered per million    Implement regional         planned                  thresholds for
                               best evidence                 population by PCT         service specification      implementation           fertility treatments
                              Services we                  Improvements in           during 2010/11             2011/2012                through eligibility
                               commission meet               patient experience                                  Equitable access         criteria and
                               national standards            measures, year on        Incorporate value for      dependent on             number of cycles
                               and perform in line           year                      money in contracts         appropriate referral    Implement new
                               with the most                Equitable travelling      April 2010 and April       from primary and         service
                               successful and safe           distance for patients     2011                       secondary care.          specification with
                               services                     Assurance that                                      Clinical and patient     KPIs to drive up
                                                             commissioned             Agree standardised         engagement               pregnancy rates
                                                             services meet             patient pathway                                     and reduce
                                                             national quality          Jan 2011                                            multiple births
                                                             standards services
                                                            Services                 Designation of
                                                             commissioned in a         providers of fertility
                                                             consistent manner         services
                                                             and demonstrate
                                                             value for money




C:\Docstoc\Working\pdf\36c951a4-2ddf-45e0-ae14-837a7501e39e.doc                                                                                              43
3.5 GOAL 2 INITIATIVES

Initiative                   Elements                      Outcomes                   Timescale                 Dependencies              Productivity
Description                                                                                                                               Potential
Ensure equal access           Ensure availability of       Centres meet              Full capacity and        Local Weight             Reduction in unit
to surgical obesity            obesity surgical              national designation       demand review –           Management                price
services based on              services for all              standards                  October 2009              Services are crucial     Introduce
need, and develop              patients meeting the         Improved patient                                     in ensuring equitable     consistent
centres of excellence                                                                  Develop expert panel
                               NICE eligibility              experience                                           access to services        treatment
in the provision of                                                                     – June 2010
                               criteria.                     measures, year on                                    for patients and          thresholds for
obesity surgery to            Reduction in                  year                      Review regional           choice of provider.       obesity surgery
deliver safe and               mortality following          Demonstrable choice        commissioning policy                               Improve
effective services             surgery for obesity           of providers for local     – April 2011                                        effectiveness and
                              Contribute to a               weight management                                                              efficiency of pre-
                                                                                       Implement any willing
                               regional reduction in         services to refer into                                                         surgical pathways
                                                                                        provider model – June
                               obesity levels               Reduced mortality          2011
                                                                                                                                            to manage
                                                             rates following                                                                demand and
                                                             obesity surgery           Full Designation of                                 maximize
                                                            Sustained reduction        providers – June 2011                               outcomes
                                                             in BMI following
                                                             weight loss surgery




C:\Docstoc\Working\pdf\36c951a4-2ddf-45e0-ae14-837a7501e39e.doc                                                                                              44
3.5 GOAL 2 INITIATIVE

Initiative                  Elements                       Outcomes                  Timescale                 Dependencies               Productivity
Description                                                                                                                                Potential
Ensure equitable            Establish resilient             Improve outcomes         Complete regional        Timescales                Increased
access to high              vascular services                from vascular surgery     review of vascular        dependent on               efficiencies through
quality vascular            across the region.                                         services July 2010        external factors, such     high quality
services                                                    Improved cost            Implement outcomes of     as purdah,                 services.
                            Establish standards for          effectiveness of          regional review by        consultation and          Establishing the
                            vascular services                services                  2012.                     service change             correct number of
                            across the region.                                                                   assurance processes        providers should
                                                            Greater clarity of                                                             maximise efficiency
                                                             patient pathways




C:\Docstoc\Working\pdf\36c951a4-2ddf-45e0-ae14-837a7501e39e.doc                                                                                               45
3.5 GOAL 3 INITIATIVES

Initiative                   Elements                      Outcomes                 Timescale                   Dependencies            Productivity
Description                                                                                                                             Potential
 Ensuring                     Reductions in               1 and 5 year            Decision making            Close collaboration    Rationalisation of
equitable access to            health inequalities.        survival rates show        process for new             between all           treatment regimens
high quality                  Assurance of                year on year               technologies                commissioners of      through audit/review
specialised services,          consistent,                 improvement                established April 2010      services to ensure     Active
through supporting             clinically effective,        Health equity audits    Establish links between     coherent policy       collaboration around
robust decision                high quality, cost          show reducing              PCTs, networks and          across the patient    decision making for
making, agreeing               effective                   inequality in all          Regional Policy             pathway               non NICE treatments
common service                 interventions.              specialised services       Gateway September          Collaboration with     Reduction in
access and treatment                                        Patient reported         2010                        the PCT’s,            individual funding
criteria                                                   outcomes show year                                     networks on           requests through the
& agreeing common                                          on year improvement                                    implementation of     development of
approaches to the                                           New treatments/                                      policy                commissioning
introduction of new                                        technologies                                          Joint working with    policies
technologies and                                           introduced through a                                   other SCGs and         Support for PCT
drugs                                                      managed process                                        possibly the NCG      decisions not to fund
                                                                                                                  where the             treatments that are
                                                                                                                  treatment/ service    considered to be not
                                                                                                                  has supra SCG         cost effective
                                                                                                                  implications




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3.5 GOAL 3 INITIATIVES

Initiative                   Elements                      Outcomes                 Timescale   Dependencies             Productivity
Description                                                                                                              Potential
Ensuring equitable            Availability of              1 and 5 year                       o Close collaboration     Rationalisation of
access to high quality         consistent,                 survival rates show                    with the three         treatment regimens
specialised services,          clinically effective,       year on year                           cancer networks        through audit/review
through co-                    high quality                improvement                            on implementing         Maximising value
ordination and                 radiotherapy                 Health equity audits                 referral guidelines,   of existing contracts
oversight of a range           services.                   show reducing                          treatment protocols
of services                   Availability of and         inequality in all                      and improved
                               equitable access            specialised services                   patient pathways
                               to consistent,
                               clinically effective
                               PET/CT services
                              Availability of and
                               equitable access
                               to high quality
                               screening
                               programmes




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3.5 GOAL 3 INITIATIVES

Initiative                   Elements                      Outcomes                  Timescale   Dependencies            Productivity
Description                                                                                                              Potential
Ensuring                      Horizon scanning             Needs relating to all               o Close collaboration    Opportunities for
responsiveness to              of national                 specialised services                    with PCTs to          productivity are
areas of need for              priorities                  are identified and                      identify issues and   identified and acted
specialised services,         Alerting the SCG            responded to.                           opportunities         upon
through maintaining a          to new                       SCG are seen as                       relating to
watching brief over            opportunities for           the leaders of                          specialised
all specialised                SCG                         specialised services.                   services
services, including            commissioning                Health equity audits
those not                      where these will            show reducing
commissioned by                respond to national         inequality in all
SCG                            priorities; or offer        specialised services
                               significant QIPP
                               potential




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4. DELIVERY
This section of the strategy should be read in conjunction with the SCG
Organisational Development Strategy, which is integral to delivery of the
commissioning goals and initiatives.

4.1 SCG approach to Performance Monitoring

The Performance Management Subgroup of the SCG Board monitors monthly
finance and the activity and quality about the main providers of SCG
commissioned services.     An integrated monthly performance report is
prepared by the subgroup for the SCG Board.

Diagram A sets out this performance management structure. It illustrates
performance information flows to the SCG Board and via minutes to the
Boards of the 14 member PCTs. The right hand side of the diagram shows
the relevant part of NHS Barnsley’s governance system which will provide to
SCG additional scrutiny and assurance. This includes the following:

        NHS Barnsley’s Commissioner Governance Committee receives
         quarterly governance/quality reports. These reports will include a
         review of performance against the key clinical quality performance
         indicators by provider and any other issues that have been discussed
         with providers at their clinical quality review meetings.

        NHS Barnsley’s Performance and Finance Committee receives
         quarterly reports on SCG finance and performance and ad hoc reports
         on request on particular issues that require additional attention and
         scrutiny.

        NHS Barnsley’s Audit Committee provides overall scrutiny of the
         system. The Audit Committee receives minutes of the Commissioner
         Governance Committee routinely and may request specific reports to
         be able to provide assurance to the SCG Board and 14 PCTs. The
         Audit Committee also receives Audit reports from Internal and District
         Auditors about SCG (as well as from the perspective of NHS Barnsley
         as one of the 14 members of SCG). Feedback from the Audit
         Committee in relation to its assurance role for SCG is provided to the
         SCG Board.

These arrangements will be monitored and reviewed on an annual basis to
ensure ongoing fitness for purpose.

4.1.1 In-year monitoring of Strategy

SCG has identified the need to develop a rigorous and systematic approach to
managing the complex range of inter related work streams which will deliver
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the key outcomes of the Strategy whilst at the same time ensuring that core
business can also be delivered. SCG will therefore adopt a programme
management approach which will provide a consistent and transparent
approach with clear reporting and accountability arrangements in order to
ensure that the initiatives identified in the strategic plan can be delivered
effectively and to provide assurance to the SCG Board on implementation.

Through the use of structured framework of Programme Management SCG
will be able to:

         Co-ordinate and align the activities and projects involved.
         Reduce the risk of failure
         Resolve competing priorities
         Breakdown the programme outcomes into manageable and
          achievable outputs.
         Provide a communication framework and provide shared values and
          collaboration
         Realise early benefits

Each agreed initiative is managed as a project and each of these has a
responsible commissioning manager who has overall responsibility for
reporting current achievement/progress on a monthly basis. A balanced
scorecard approach is being developed to incorporate performance against
the outcomes, reporting on finance and using patient feedback to develop
outcome focused metrics.

If progress against achieving the metric/outcome is behind expectation,
remedial plans will be requested from the identified lead and these will be
monitored to ensure that the metrics are to be achieved.

4.1.2 QIPP Programme Management

Each QIPP initiative will have a CEO sponsor. The formal sub-groups of SCG
Board (ie Clinical Standards, Performance Monitoring, and Designation) will
be used to performance manage the initiatives where appropriate, without
having to set up additional tiers of groups. Dedicated programme
management resource will be identified to support delivery of the schemes,
and the SCG QIPP programme will be part of the SHA QIPP monitoring
processes alongside the PCTs.

4.2 Risk Management and Monitoring

It is one of the responsibilities of NHS Barnsley Board to ensure that risks to
the achievement of the SCGs objectives are effectively managed.

The principal risks to the non-achievement of SCG strategic objectives and
goals will be recorded in the assurance framework / risk register. This
document identifies the current and planned controls in place to manage each
risk and assurance that the risk is being effectively managed. This will be
reported to SCG on a quarterly basis.


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Each initiative within this strategy has been risk assessed and the strategy as
a whole is being risk assessed to inform the assurance framework. The initial
assessment has highlighted the following key risks:

   Funding pressures
   Infrastructure and workforce implications (provider & commissioner);
   Lack of control over growth (technological, drugs, population)
   Availability of evidence and guidance to support commissioning intentions

This risk analysis will be documented with NHS Barnsley’s assurance
framework and risk register and form part of the organisations overall
governance process.

The risks will be mitigated through the activities detailed in each initiative and
via supporting activities set out in the Financial Plan, the Communication and
Participation Strategy and the Organisational Development Strategy.




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                                                                                                                                                   Diagram A
                                  4.1.2 Commissioning Governance Structures and Performance Information Flows




                                   13 PCT Boards                                                 NHS Barnsley Board

                                                                           Minutes
                                         Minutes                                                           Minutes                 Minutes
                                                                                          Minutes
                                                        Reports on    NHS Barnsley
                                SCG Board                 SCG        Audit Committee            NHS Barnsley                  NHS Barnsley
                                                        Assurance                           Commissioner Governance         Performance and
                                                                                                  Committee                Finance Committee
                                                                     Minutes
                                                                                                       Quarterly                    Quarterly performance
                                                                            Monthly                    governance/quality report    report
                                                                       Performance
                                                                             report
Designation              Clinical Reference              Regional Policy
Sub- Group                   Sub-Group                   Gateway Group           Performance Monitoring Sub-Group


                                 Expert Panels
                                                                                     Monthly reports on:
                                                                                       - finance
                                                                                       - activity
                                                                                       - quality

                SCG Performance Management                                                                               BPCT Assurance




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4.3 SCG Approach to Quality

The final report of Lord Darzi’s NHS Next Stage review ‘High Quality Care for
All’ sets out a vision for an NHS with quality at its heart. How this vision is to
be implemented is set out in the document ‘Measuring for Quality
Improvement: The Approach’.

The principles for delivering effective systemic change were outlined in High
Quality Care for All:
    Co-production
    Subsidiary
    Clinical Ownership and leadership
    System alignment

In developing a quality improvement system for SCG one further principle
must be added:

      Proportionality

4.3.1 Role of designation toolkits/processes

Providers of specialised services must be designated against clear standards
to assure patients that the required level of service will be available. The
designation standards are the foundation of quality for SCG. The designation
process, overseen by the Service Designation Sub-Group of SCG, will use
designation standards developed regionally or nationally which have been
agreed by the Clinical Standards Sub-Group and the expert clinicians for that
service.

The SCG has identified 3 levels of designation:-

    Preliminary designation – this level relates to a new provider of a
     service and is conditional on the provider demonstrating that all
     appropriate actions have been taken to enable the new service to start.

    Interim designation - this level requires the service provider to meet all
     the core standards to enable the provision of a safe and effective
     service.

    Full designation – this level requires the service provider to meet all the
     core standards and all the development standards.

The process map which sets out the key steps of designation is attached in
Appendix 6.

Compliance with standards may be reviewed through self assessment or peer
review and will be further assessed on a 5 yearly rolling programme.

The designation process will ensure:-

 A minimum standard of delivery, quality and service in all specialised
    providers
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 A robust process for managing entry into the market of new providers
  where this is desirable

4.3.2 Contracting for Quality

Along with the standards developed for designation, contract monitoring of
specialised services needs to link performance and activity monitoring with
review of quality.

Using the Commissioning for Quality and Innovation (CQUIN) payment
framework, SCG have agreed a CQUIN scheme with each provider of
specialised services in their area, related to the contract value associated with
those services.

In line with SCG’s approach to quality outlined above, the SCG CQUINS
scheme, to take effect in 2010/11, is based on the following steps.

    1.   Reflecting priorities
    2.   Linked to service improvement
    3.   Link to QIPP agenda
    4.   Aim for Invest to Save

Therefore indicators have been developed in line with the following priorities
outlined previously in this strategy, which are:
   - Specialised Cancer Services
   - Specialised Children’s Services
   - Specialised Cardiac Services
   - Secure Mental Health Services
   - Specialised elements of Chronic Disease Management (HIV,
       neurosciences, renal, genetics)

The indicators are attached at Appendix 10, and have been developed with
input from clinicians around the region and ultimately signed off by the Clinical
Standards Sub-Group. The rationale for each indicator has been underpinned
by the need to improve the service, within the QIPP context of improving
productivity and efficiency.

4.3.3 Improvement and Innovation

Specialised services cannot stand still. As new developments arise the best
practice standards will change. Service developments will need to be
considered within the context of the QIPP agenda, and will be assessed using
the SCG Decision-Making Framework.

Service reviews will seek to identify the improvements to patient care which
could result from changes to the commissioned service. Any such changes
will need to be reflected in changes to Designation standards and Quality
monitoring.

This will ensure:
 Greater health gain for a given investment
 First class services kept up to date
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4.4 Organisational Requirements and Enablers

4.4.1 World Class Commissioning

The population of Yorkshire and the Humber deserve to be served by World
Class Commissioners and SCG will continue to be a significant contribution to
this. Therefore, the world-class commissioning framework will be applied to
the Specialised Commissioning Team (SCT) and SCG Board, and used as a
development tool, to ensure the skills, infrastructure, systems, culture and
resource are fit for purpose in delivering the commissioning strategy. The
SCG Organisational Development Strategy outlines the results of the self-
assessment of SCG/SCT against the WCC competencies, and describes the
action plans that will address the identified gaps over the coming months and
years. The ensuing section of this strategy should therefore be considered in
conjunction with the OD Strategy.

4.4.2 Clinical Engagement and Links with Clinical Networks

The SCG seeks to engage expert clinicians from commissioning and provider
organisations within the region and beyond to improve the quality of services
in all specialised services.

The SCG has agreed to the formation of a Clinical Standards Sub-Group with
clinical representatives from PCTs and providers, to support the SCG in
making clinically appropriate decisions. This will include work related to
designation standards, quality indicators and commissioning policies.

In addition, where formal clinical networks exist, the SCG engages directly
with them. In general, the network approach is most appropriate where the
care pathway is commissioned at primary, secondary and tertiary levels. If
there is more than one network (as with Cancer and Cardiac networks) the
SCG seeks to work with representatives from all of the networks in a
coordinated way. Where one network covers the whole region, this is hosted
by the SCG (Renal, Congenital Cardiac) with links to local sub-regional
collaborative commissioning arrangements.

In some instances, parts of the commissioning process are delivered via the
networks. All networks include primary care and PCT clinicians. The
commissioning process for secure mental health services also includes a
range of key clinicians. Where there are clinical networks the relevant service
strategy and work programme need to be aligned with the SCG Strategy to
ensure effective delivery across the patient pathway. PCTs will need to
ensure that the SCG activities and the activities of the clinical networks are
complimentary and achieve optimum productivity.

Where no network exists, the SCG can establish Expert Panels to advise on
clinical aspects of specialised services. This approach is favoured when there
are a small number of expert clinicians responsible for the specialised aspects
of patient care, sometimes linked to a wider group of clinicians. The recently
proposed Regional Policy Gateway is being established with strong clinical
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representation to support the production of robust regional commissioning
policies.

4.4.3 SCG Contracting Arrangements

For all acute contracts within Yorkshire & the Humber contracting consortia
are in place with the co-ordinating PCT taking the lead on the negotiations
with their respective local provider. These arrangements are underpinned by
appropriate accountability and governance statements set out in a formal
contract consortia agreement.

The SCG is an associate member of all the relevant consortia and therefore
attends the appropriate contracting committee and contract performance
review groups. For each of the contracts to which SCG is associate, SCG
Contract Leads:

        Act as the main link to the contract for any queries raised by Provider,
         Lead PCT or Service Lead. (This does not include informal service
         queries, which should be raised directly between Service Lead and
         provider)

        Ensure information on activity, performance and quality for all services
         contracted for is routinely provided to the YHSCG nhs.net address, for
         finance staff to include within the ‘Contracts’ folder on G Drive

        Regularly attend the Contract Review and Clinical Quality Review
         meetings

        Play an active role in contract negotiations each year, attending
         contract negotiation meetings where appropriate

        Ensure all relevant Key Performance Indicators, Service Specifications
         and Standards are included within the contract, as advised by Service
         Leads or the SCG, through agreement with the Lead PCT

        Raise with Service Leads any queries generated through contract
         meetings, for them to identify reasons for under/overperformance

        Performance manage the Trust on any contracted activity that does not
         fall under the remit of an identified Service Lead, such activity to be
         formally identified within personal objectives




4.4.4 Sub regional commissioning arrangements

As a result of the network review and the further development of the SCG, the
need for coherent sub-regional forums was agreed by Chief Executives in
September 2008.

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        The cluster level commissioning fora will enable the insights and
        recommendations of networks for specialised and non-specialised issues to
        be addressed within one coherent and consistent forum.
        The sub-regional commissioning consortia will provide a coherent forum for:-

                Discussion and working up issues to take to SCG
                Implementation of SCG decisions
                Gaining clinical insight and network views
                Gaining coherent view of non-specialised commissioning views and
                 intentions
                Co-coordinating commissioning intentions to take forward into Contract
                 Consortia

        There are three sub-regional commissioning groups, shown at Table 8,
        focused on the populations of North Eastern Yorkshire and Northern
        Lincolnshire, South Yorkshire and North Derbyshire and West Yorkshire.
        These groups align PCTs in a way that reflects existing patient referral
        pathways and geographic links.

        Table 8 – Sub-Regional Commissioning Collaboratives
  Sub Regional Commissioning Cluster                                      Membership

North East Yorkshire And Humberside                       NHS East Riding of Yorkshire
Commissioning Forum (NEYHCOM)                             NHS North East Lincolnshire Care Trust Plus
                                                          NHS Hull
                                                          NHS North Lincolnshire
                                                          NHS North Yorkshire and York
South Yorkshire and North Derbyshire                      NHS Barnsley
Commissioning Forum                                       NHS Doncaster
(NORCOM)
                                                          NHS
                                                          NHS Rotherham
                                                          NHS Sheffield
                                                          NHS Bassetlaw
                                                          NHS Derbyshire County
West Yorkshire Commissioning Forum                        NHS Bradford and Airedale
(WYCOM)                                                   NHS Calderdale
                                                          NHS Kirklees
                                                          NHS Leeds
                                                          NHS North Yorkshire and York
                                                          NHS Wakefield



        The accountability and governance of the three sub regional commissioning
        arrangements are currently being strengthened to appropriately support
        transparent decision making. There will be further work required to ensure
        there is clarity about the scope and remit of the SCG and the sub regional
        commissioning fora.



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4.5 Provider Requirements and Plurality of provision

4.5.1 Developing the Provider Landscape

Yorkshire and the Humber SCG has identified service areas where a review of
models of provision, or total capacity is required. It is recognised that major
service change may be required as a result of these reviews, which may
significantly affect the provider landscape. These include:

        Obesity surgery
        Cancer services
        Cardiac services
        Children’s services
        Fertility services
        Renal services
        Neurosurgery and long term neurological conditions
        Specialist mental health services
        Vascular services

Where significant service change is needed, this will be subject to the SHA’s
Service Change Assurance Process and national review if appropriate.
Formal consultation with patients, public and Overview and Scrutiny
committees would also be carried out.

In some areas the SCG will need to manage and restrict entry into the
provider market, in order to balance the tension between providing specialised
services as close to people’s homes as possible, with the need for sustainable
services, often requiring a critical mass of patients per service.

In other instances, the SCG will need to stimulate the provider market to
ensure that sufficient capacity is in place to deliver planned improvements in
access and availability of services to patients, and to be able to offer patients
a genuine choice of provider.

SCG is an active member of the Yorkshire and Humber Commercial
Professional Network, and through this vehicle, members of the Specialised
Commissioning Team will access market analysis and management tools, and
build capacity and capability in market analysis and procurement, in order to
ensure that all decisions in respect of commissioning of specialised services
will be made via a rigorous and transparent process.




4.5.2 Market Analysis

The following issues will be taken into consideration when deciding on the
definition of the provider market, including whether or not it is appropriate to
support the designation of a new service provider. Broadly the issues fall into
three categories.


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The first category of issues relates primarily to whether or not there is a need
for a fundamental change to the market by introducing a new service provider.
These issues include:-

   Is there a need to significantly increase service capacity to meet a growth
    in demand and to ensure compliance with national and local targets can be
    sustained
   Are the current services delivering key national and local targets
   Is the current service model consistent with ‘best practice’ and local and
    national strategy
   Do existing services offer good value for money
   Is there a need to increase patient choice
   Are there serious shortcomings in the services provided in respect of
    service quality?
   Is there a risk of significant clinical or financial un-sustainability with
    existing services?

The second category relates to secondary issues which also need to be taken
into account when considering the scope and potential for working with
existing providers relative to the potential to introduce a new provider.

   Is there potential and a willingness for the existing providers to change the
    service provision to be consistent with local national strategy?
   Are there potential market entrants either established locally or able to
    establish themselves effectively?
   Are there performance issues which need to be addressed?
   Would the introduction of a new provider significantly impact on the
    existing providers’ opportunity to implement service improvements
   Is the service concerned a specialised service with a limited number of
    potential providers able to sustain the require standards
   Is the service protected by monopoly rights in accordance with legal or
    administrative arrangement?
   Is the existing service covered by an existing contract?
   Is the potential cost of supporting a new provider into the market,
    proportionate to the value of the contract?

Finally there is the need to consider the impact of any market action to be
taken.
 Will the introduction of new providers have a detrimental impact on the
   provision of services to patients e.g. reduction of critical mass in a service
   leading to it becoming unviable?
 Will the action taken in this SCG have a detrimental impact on patients
   from other SCGs?
 Are there strong linkages with other existing clinical services and removal
   of the service could destabilise other services?

4.5.3 Provider Economics

When answering some of the questions above, SCG will follow the common
guide to understanding provider economics, developed by Frontier Economics
on behalf of the Y&H Commercial Professional Network. This identifies five
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stages of analysis to provide the understanding of the likely impact on a
provider of a specific service change, outlined in Table 9.


Table 9 – Practical Guide to Provider Economics (Frontier Economics
December 2009)
Stage of Analysis Elements
Context               Nature of providers – location, current activity, quality,
                       financial health.
                      Nature of population – density, demographics and
                       expected future demand.
Costs                 Costs vary with volume but also time – both dimensions
                       are important.
                      Costs structures – to what extent are costs fixed?
Revenues              Sources of income – healthcare services, training, R&D,
                       charity, private activity.
                      Viability – how do revenues compare to costs?
Behaviours            Constraints – workforce and investment plans, PFIs,
                       PCT working relationship.
                      Nature of constraints – how flexible/inflexible are the
                       constraints facing providers?
System                Capacity – how much will be required (and where) under
                       service change?
                      Pathway – will patient care remain integrated? Will
                       access be affected?

The rest of this Guide considers each of these stages in turn. Each stage
provides a summary of key issues, the evidence base that can be collected by
PCTs and the analysis that is required to gain the required insights. SCG will
work alongside PCTs within the Y&H Commercial Professional Network to
adopt common approaches to these issues.

4.5.4 Procurement

The role of SCG as a commissioner is to secure services to meet the health
needs of their local populations, which deliver the best combination of quality
to patients and value for taxpayers. Procurement enables this by securing
services through transparent engagement with providers, normally culminating
in an award of new contract(s) albeit that this may be a new Contract awarded
to an existing provider. Procurement is therefore an integral part of the
commissioning cycle.

There will need to be careful consideration of the circumstances under which
procurement is undertaken, to ensure that the level of outlay of investment
and resources in conducting the procurement is clearly matched to the level of
expected gain to the system. Decisions to undertake procurement exercises
will be underpinned by robust market analysis, conducted along the principles
outlined above.

SCG will comply with the overarching obligation of transparency, and note the
wider competition policy of the Department of Health reflected in Principle 1 of
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the Principles and Rules for Cooperation and Competition that makes clear
that commissioners should seek to secure services from the best placed
provider whilst adopting proportionate practices, reflected in Diagram B.

Diagram B: The Procurement Balance (PRCC principle 1, DH)




SCG will demonstrate consistency with the overarching principles of public
procurement in relation to all procurement activities, including a decision to
provide services itself. These principles are as follows;

            Transparency
            Proportionality
            Non-discrimination
            Equality of Treatment

SCT will develop the required capacity and capability in procurement skills as
described in the SCG Organisational Development Strategy, working within
the Commercial Professional Network to maximise advantage of the tools and
training modules being developed within the region.

4.5.5 Designation of providers

The quality of specialised care provision across Yorkshire and the Humber is
in many cases variable, as indicated within Yorkshire and the Humber’s
strategic vision: Healthy Ambitions..

To counter this, providers of specialised services must be designated as such
by the Specialised Commissioning Group. This involves assessing potential
providers against a set of designation standards to ensure that they are able
to deliver services in line with agreed service specifications. It is envisaged
that designation will be for a maximum of 5 years, with a view to developing a
rolling programme of designation to ensure continual service improvement.

The intention is that through this process the provider landscape for
specialised services becomes very clearly defined and is closely managed

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and monitored. Yorkshire and the Humber SCG is currently at the beginning
of this process, and has awarded interim designation for a number of services.

Appendix 4 shows the breakdown of services/providers designated.




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                                                                    APPENDIX 1


Analysis of population demographics and
health needs
The health needs of people in Yorkshire and the Humber have been recently
identified in the JSNAs of each of the PCTs. The JSNAs have been produced
in conjunction with key partners and reflect the key health issues experienced
by the population.

Population
   The UK statistics authority estimates the population of the Yorkshire
     and the Humber region will be 5,327,500 in 2010. Based on current
     trends the regional population in 2015 will increase to 5,572,000.
   The projections suggest a 13.2% increase in residents over the age of
     65 and a 5.6% increase in children under 15.
   For this region the largest minority ethnic group is Asian with an
     estimated 177,600 residents from a Pakistani ethnic origin, 76,400 from
     an Indian ethnic origin and 42,800 from other Asian ethnicities.


SCG must:
   Commission for an increasing population, especially for older people
   Be mindful of the diverse population served


Births
    There were 66,353 live births to women registered in the region in
       2008. The number of live births has been increasing gradually over
       recent years.
    On average the age of women at the time of their child’s birth is lower
       in the region than in England as a whole. There are consequently a
       lower proportion of older mothers than nationally.
    Data on prematurity are not collected centrally. As a proxy, birth weight
       can be used to compare communities. Percentage of live births below
       2500g in 2008 in the region was 7.4 compared to an England figure of
       7.1


SCG must:
   Commission for an increase in neonates, infant and children’s services
   Commission for an increase in infertility treatments, though not
     necessarily at as high a rate as elsewhere in the UK

Health and health behaviours
   Smoking prevalence in the region has fallen in men by almost a third in
      the past ten years. In women the prevalence has fallen less sharply
      and women are now more likely than men to smoke for the first time in
      history.
   The most recent estimates suggest that the region has slightly less
      overweight men (41.9%) and slightly more overweight women (34.1%)
      than the average for England (43.7 and 33.1 respectively).
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SCG must:
   Expect some slowing in the growth in smoking related diseases,
     mindful that this will be countered by growth in the older population
   Expect growth in diseases associated with overweight, lack of exercise
     and poor nutrition, at about the same rate as forecast nationally



Tackling regional health inequalities

In June 2007, the Yorkshire and the Humber Public health Observatory
published a review of which causes of death had the greatest impact on life
expectancy in the region.

Main causes of death in Yorkshire and the Humber (2001-05), average
number per year by broad cause

                     Males                                           Females
        Cause                        Number                       Cause         Number
CHD                                   5555           CHD                         4595
Other cancers                         3824           Stroke                      3414
Stroke                                2136           Other cancers               3202
Lung cancer                           1877           Pneumonia                   1832
Other cardiovascular                  1397           Other cardiovascular        1695
disease                                              disease
COPD                                   1396          Lung Cancer                 1329
Pneumonia                              1154          COPD                        1261
Other                                  7253          Other                       9838

In the same report, the causes of death having the greatest impact on years of
life lost, compared to if the life experience was the same as England as a
whole were identified.

Top ten causes of death contributing to gap between Yorkshire and the
Humber and England years of life lost (by gender, 2001-05)

Males                                              Females
Coronary heart disease                             Coronary Heart Disease
Lung cancer                                        Lung cancer
Mental and behavioural disorders                   Chronic obstructive airways disease
Chronic obstructive airways disease                Deaths under 1 year
Stroke                                             Ill defined conditions
Deaths under 1 year                                Stroke
Road traffic accidents                             Congenital anomalies
Other respiratory disease                          Mental and behavioural disorders
Other cancers                                      Other respiratory disease
Stomach cancer                                     Road traffic accidents

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When comparing the most deprived fifth of the region with the region as a
whole, a similar list was drawn up.

Top ten causes of death contributing to gap between most deprived
quintile and Yorkshire and the Humber life expectancy (by gender, 2001-
05)

Males                                              Females
Coronary heart disease                             Coronary Heart Disease
Lung cancer                                        Chronic obstructive airways disease
Deaths under 1 year                                Lung cancer
Suicide and undetermined injury                    Deaths under 1 year
Chronic obstructive airways disease                Other cancers
Mental and behavioural disorders                   Perinatal conditions
Chronic cirrhosis of the liver                     Pneumonia
Other accidents                                    Chronic cirrhosis of the liver
Other cardiovascular disease                       Other cardiovascular disease
Stroke                                             Other accidents


SCG must:
   Support PCTs in tackling health inequalities in
        o Cardiac surgery
        o Lung cancer treatment
        o Neonatal care
        o Specialised mental health services


Summary
The region served by the Yorkshire and the Humber SCG is an area of poor
health. This impacts on life expectancy across the region, but also leads to
significant health inequalities.


SCG must:
   Ensure access to services which will have the greatest impact on the
     overall health of the population
   Target measures to increase use of treatment services where activity
     does not meet expected need
   Plan for changes in the population including a growth in older adults,
     and the consequent rise in chronic diseases




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                                                                                                    APPENDIX 2


                                       Y&H Providers

 Provider                                                   2009/10 Indicative Value (£ million)
 Leeds Teaching Hospitals                                                                  164.0
 Sheffield Teaching Hospitals                                                              146.0
 Hull and East Yorkshire Hospitals                                                           72.7
 Bradford Hospitals                                                                          23.1
 York Hospital                                                                                9.6
 Mid Yorkshire Hospitals                                                                      9.4
 Doncaster & Bassetlaw Hospitals                                                              7.6
 Sheffield Childrens Hospital                                                                 6.0
 Hull IVF Unit                                                                                1.4
 Calderdale and Huddersfield Hospitals                                                        1.1
 Leeds Partnership                                                                            0.5
 Care Fertility Sheffield                                                                     0.5
 Scarborough & North East Yorks Hospital                                                      0.4
 Nova Healthcare                                                                              0.4
 Northern Lincs & Goole Hospitals                                                             0.4
 Airedale Hospital                                                                            0.3
 Sheffield Care Trust                                                                         0.2
 Rotherham Hospital                                                                           0.2
                                                TOTAL                                      437.1

                                Mental Health Providers

 Provider                                                   2010/11 Indicative Value (£ million)
 Rampton Hospital (Nottinghamshire Healthcare)                                               24.6
 South West Yorkshire Partnership NHS                                                        23.8
 Partnerships In Care                                                                        14.8
 Humber NHS                                                                                  12.8
 Nottinghamshire Healthcare NHS                                                               7.9
 Riverside Healthcare                                                                         7.4
 Alpha Hospitals                                                                              5.2
 Bradford District Care NHS                                                                   4.5
 InMind Healthcare                                                                            3.6
 Sheffield Heatlh and Social Care NHS                                                         3.4
 Calderstones NHS                                                                             3.2
 Cygnet Healthcare                                                                            3.1
 Rotherham Doncaster and South Humber NHS                                                     3.1
 Tees Esk and Wear Valleys NHS                                                                2.2
 St Andrews Hospital                                                                          2.1
 Healthlinc Individual Care                                                                   2.1
 Northern Pathways                                                                            2.0
 Raphael Healthcare                                                                           2.0
 Care Principles                                                                              1.5
 Priory Healthcare                                                                            1.3
 Leeds Partnership NHS                                                                        1.1
 Ashworth Hospital (Mersey Mental Health NHS)                                                 0.9
 Optima Care                                                                                  0.6
 North Yorkshire and York CMHS                                                                0.4
 Broadmoor Hospital (West London MH NHS)                                                      0.3
 Other                                                                                        0.1
                                          TOTAL                                            134.0

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                                                                                          APPENDIX 3

                               Out of Region Providers

 Provider                                                 2010/11 Indicative Value (£ thousand)
 Guys and St Thomas                                                                      1,666.7
 UCLH                                                                                    1,459.9
 Nottingham University Hospitals                                                         1,000.0
 University Hospital Birmingham                                                          1,040.0
 Great Ormond St Hospital                                                                  979.1
 Birmingham Children's                                                                     809.2
 Imperial College Healthcare                                                               776.4
 United Lincolnshire Hospitals                                                             655.0
 Oxford Radcliffe                                                                          654.2
 Alder Hey Children’s Hospital                                                             529.9
 Royal Orthopaedic                                                                         468.5
 Cambridge University Hospitals (Addenbrookes)                                             453.2
 Royal Brompton & Harefield                                                                437.4
 Barts & the London                                                                        435.2
 Kings College London                                                                      423.6
 Walton Centre for Neurology & Neurosugery                                                 356.7
 Manchester Children's Hospital                                                            320.0
 Royal National Orthopaedic                                                                342.3
 Papworth Hospital                                                                         319.7
 Blackpool, Fylde & Wyre                                                                   238.4
 Moorfields Eye Hospital                                                                   224.4
 North West London                                                                         200.0
 Wrightington, Wigan & Leigh                                                               134.0
 Southampton University Hospitals                                                          120.4
 Betsy Cadwallader                                                                         116.9
 Royal Free Hampstead                                                                       76.0
 St George's                                                                                74.2
 Birmingham Women's                                                                         28.0
                                        TOTAL                                           14,339.3



                             OVERALL TOTAL                                      £585,439,300




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                                                                                                                                   APPENDIX 4

                                                            SERVICES DESIGNATED DURING 2007-2010

Service                                              Provider                          Interim Designation   Review Date   Full Designation

HIV (Principal Treatment Centre                      Leeds                             03/09
                                                     Hull                              03/09
                                                     Sheffield                         03/09                     12/10
                                                     Bradford                          03/09

Childrens Cancer (Principal Treatment Leeds                                            09/07                 12/10
Centre)                               Sheffield                                        09/07                 12/10

Teenage & Young People’s Cancer Leeds                                                  09/08                 12/10
(Principal Treatment Centre)    Sheffield                                              09/08                 12/10


Pancreatic Services                                  Hull                              01/09                 06/12

Liver & Pancreatic Services                          Leeds                             03/10                 06/12
                                                     Sheffield                         03/10                 06/12

Stereotactic Radiosurgery                            Nova Healthcare                   09/09                 08/10


Cochlear Implants                                    Bradford                          -                     -             10/08
                                                     Royal Infirmary




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Service                                              Provider                             Interim Designation   Review Date   Full Designation

Obesity Surgery                                      Sheffield                            04/09
                                                     Doncaster                            11/09
                                                     Leeds                                04/09
                                                     Hull                                 04/09
                                                     Mid Yorkshire                        04/09
                                                     Calderdale & Huddersfield            04/09                    07/11
                                                     Bradford                             04/09
                                                     York                                 04/09
                                                     SPIRE Leeds                          04/09
                                                     SPIRE Hull                           04/09

Sarcoma                                              Leeds                                ?
                                                     Sheffield                            ?

Specialist (rare) Skin Cancer                        Leeds

Medium Secure                                        Wakefield (Newton Lodge)             04/10                 03/11
                                                     Hull (The Humber Centre)             04/10                 03/11
                                                     Rotherham (Wathwood Hospital)                                            04/10
                                                     York (Stockton Hall)                                                     04/10
                                                     East Yorkshire (Lindon House)                                            04/10
                                                     Doncaster (Cheswold Park Hospital)                                       04/10




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                                                                                                                      APPENDIX 5

                                     Financial Savings by PCT
Efficiencies to be saved by 1% of total SCG spend as at 2010/2011

Total spend                             600,000,000

                                                                               Efficiencies per head of population
                                             Unified
                                           weighted
PCT                                       population               1%                2%             3%               4%           5%

Barnsley PCT                                285,173           313,627            627,254       940,881       1,254,508      1,568,135
Bradford and Airedale Teaching PCT          535,017           588,399          1,176,798     1,765,197       2,353,596      2,941,995
Calderdale PCT                              202,783           223,015            446,031       669,046         892,062      1,115,077
Doncaster PCT                               343,837           378,144            756,288     1,134,432       1,512,576      1,890,719
East Riding of Yorkshire PCT                300,119           330,064            660,128       990,191       1,320,255      1,650,319
Hull Teaching PCT                           316,634           348,227            696,454     1,044,681       1,392,908      1,741,135
Kirklees PCT                                398,257           437,994            875,988     1,313,982       1,751,976      2,189,970
Leeds PCT                                   775,785           853,189          1,706,379     2,559,568       3,412,758      4,265,947
North East Lincolnshire Care Trust
Plus                                        172,505           189,717            379,434       569,151         758,867        948,584
North Lincolnshire PCT                      165,373           181,873            363,747       545,620         727,494        909,367
North Yorkshire and York PCT                718,558           790,254          1,580,507     2,370,761       3,161,014      3,951,268
Rotherham PCT                               282,620           310,819            621,637       932,456       1,243,275      1,554,093
Sheffield PCT                               568,641           625,378          1,250,756     1,876,134       2,501,512      3,126,890
Wakefield District PCT                      390,352           429,300            858,600     1,287,899       1,717,199      2,146,499

                                          5,455,655          6,000,000     12,000,000       18,000,000      24,000,000     30,000,000




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                                                                                APPENDIX 6

                                      DESIGNATION OVERVIEW
      1        Stakeholder Analysis
      2        Risk Assessment (including competition/contestability issues)
      3        Service Specific Work programme/timetable
      4        Designation brief produced and shared
      5        Communication plan produced & shared
                                                       G1

      1        Review services against designation criteria and standards
      2        Produce Interim Designation Report covering:-
                Compliance with standards (gap analysis)
                Service model/capacity issues
                Development plan (where appropriate)
      3        Identify where adopting preferred model/s will involve significant service
               change
                                                       G2

                            Interim Designation granted (with action plan)


          No Significant                                               Significant Service
          Change                                                       Change possible

                  1        Log with service change assurance process
                  2        Develop case for change
                  3        Develop consultation plan
                  4        Establish lead officers and change management structure


                  1        Following SHA quality assurance conduct consultation
                  2        Ensure engagement with Health overview and Scrutiny
                           committees


                  1        Post consultation analysis and decision making
                  2        Consider procurement options


                  1        Following SHA quality assurance progress implementation
                  2        Action agreed procurement route



Final Designation Report including development plan

     G3

Designation Outcome Report circulated to all stakeholders



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                                                                                   APPENDIX 7

                                                FINANCIAL GOALS

      The three initiatives to deliver this goal are as follows:

                                                 INITIATIVE 1

      Excellence against Use of Resources indicators

      OWNERSHIP

      Initiative Sponsor           Steve Hackett                 Initiative Lead     Frances Carey,
      (Accountable)                Director of Finance           (Responsible)       Deputy Director of
                                                                                     Finance

      DESCRIPTION

      This initiative aims to help constituent PCTs to perform well against the
      following range of indicators.

              Managing Finances
              Governing the Business
              Managing Resources

      OUTCOMES

      The successful delivery of this initiative will impact on all our key outcomes.

              Full understanding of recurrent and non recurrent baselines and
               financial impact of SCG strategic decision making for the next 5 years;
              Forward planning and prioritisation of the impact of new services being
               managed by SCG;
              Risk share agreements in place to manage financial risk within PCTs


      The effective use of resources will allow for greater health investment and
      more efficient delivery of service.

      Key milestones

Milestone            Milestone Description                                           Date Due
Assessment of         Evaluate criteria for SCG impact                               March 2010
new criteria          Audit Commission feedback

Internal              Internal evaluation of current performance of SCG              July 2010
Evaluation


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Action Planning         Findings discussed with Directorate Team Leads                   July 2010
                        Action plan initiated where appropriate

External                External reporting to PCTs giving evidence                       July 2010
Assessment             Wider communication as required



        MONITORING ARRANGEMENTS

        Monitoring arrangements will be through feedback to the Performance
        Monitoring Group and through the SCG finance network group.

        DEPENDENCIES

        The following operational dependencies have been highlighted:

                Dependency: The delivery of this initiative is dependent on availability
                 of data to support improvements in health gain / health inequalities.

        INITIATIVE RISKS

        The key risks identified for this initiative are as follows:

Description                       Impact         Likeli-       Over-all   Mitigation Actions
                                                 hood
 Lack of clarity about          M              M             M            Continued communication
  scoring criteria                                                          with Audit Commission
 Failure of staff to            H              L             L            Presentation to all key Team
  embrace initiative                                                        Leaders




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                                                 INITIATIVE 2

      Analysis to support QIPP

      OWNERSHIP

      Initiative Sponsor           Steve Hackett                 Initiative Lead   Frances Carey,
      (Accountable)                Director of Finance           (Responsible)     Deputy Director of
                                                                                   Finance

      DESCRIPTION

      This initiative will look at how the QIPP agenda is supported by financial and
      activity analysis on which to take forward agreed priorities by the SCG Board.

      OUTCOMES

      The successful delivery of this initiative will impact on the following key
      outcomes.

              Assist PCTs to commission services that optimise health gain and
               reduce health inequalities;
              Contribute to more efficient use of resources in line with the QIPP
               agenda;
              Ensure clinical and financial engagement are included in all decision
               making;
              Understand current and future health need;

      The support to the QIPP agenda will contribute towards greater health
      investment and more efficient use of resources.

      Key milestones

Milestone            Milestone Description                                         Date Due
Reconfiguration       Secure appropriate support                                  
Programme             Outputs discussed with Directorate Teams                    
Budgeting             Triangulate the findings with health need
                      Re-evaluate future years expenditure priorities

Health Gain           Use financial, economic and health data to                  
                       understand the greatest health gain from
                       investment
                     




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        MONITORING ARRANGEMENTS

        Monitoring arrangements will be through feedback to the Performance
        Monitoring Sub Group and the SCG Board.

        DEPENDENCIES

        The following operational dependencies have been highlighted:

                Dependency: The delivery of this initiative is dependent on the
                 successful working between the SCT and PCTs


        INITIATIVE RISKS

        The key risks identified for this initiative are as follows:

Description                       Impact         Likeli-       Over-all   Mitigation Actions
                                                 hood
 Ability to secure              H              M             M            Ongoing discussions
  required support




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APPENDIX 8 – HIGH LEVEL MAP OF GOALS, INITIATIVES, AND OUTCOMES

Goal 1               Initiative                                                                      Overarching Health Outcome
Highly               Improve quality & ensure equitable access to intestinal failure services        Improved quality of high cost, low volume specialised services
Specialised                                                                                          prioritised by the SCG Decision-Making Framework
Services             Ensure availability of highly specialised cardiac services                      Fewer deaths following cardiac surgery
Ensuring             Ensuring availability of and equitable access to high quality specialised ear   Improved quality of high cost, low volume specialised services
equitable            surgery                                                                         prioritised by the SCG Decision-Making Framework
access to            Ensure early referral and admission to a Spinal Cord Injury Centre for all      Improved quality of high cost, low volume specialised services
highly               patients requiring specialist care                                              prioritised by the SCG Decision-Making Framework
specialised          Ensuring equitable access to highly quality Blood & Marrow Transplant           Improved quality of high cost, low volume specialised services
services across      services                                                                        prioritised by the SCG Decision-Making Framework
the region,          Ensure availability of Gender Dysphoria services based on need                  Improved quality of high cost, low volume specialised services
which meet                                                                                           prioritised by the SCG Decision-Making Framework
defined quality      Ensuring equitable access to high quality services for Pulmonary                Improved quality of high cost, low volume specialised services
standards in         hypertension                                                                    prioritised by the SCG Decision-Making Framework
the most cost        Ensuring availability and equitable access to specialist Burn care which meet   Improved quality of high cost, low volume specialised services
effective way to     the national standards                                                          prioritised by the SCG Decision-Making Framework
contribute to        Ensuring availability of high quality, consistent and appropriate medical       Improved quality of high cost, low volume specialised services
the reduction in     genetics services for patients who need them                                    prioritised by the SCG Decision-Making Framework
premature            Ensuring equitable access to high quality haemophilia services                  Improved quality of high cost, low volume specialised services
deaths and                                                                                           prioritised by the SCG Decision-Making Framework
reduce the
impact of
specific
conditions.




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APPENDIX 8 – HIGH LEVEL MAP OF GOALS, INITIATIVES, AND OUTCOMES
Goal 2           Initiative                                                                             Overarching Health Outcome
Priority         Ensuing equitable access to high quality specialised cancer services (highly           Improving survival rates for specific cancers
Pathways         specialised)
Improving        Ensuring equitable access and improving clinical & cost effectiveness of the           Fewer deaths following cardiac surgery
quality and      specialised elements of the overall cardiac patient pathway
maximising       Ensure availability of high quality, consistent and appropriate paediatric intensive   Reducing infant deaths
the              care services
efficiency       Ensure availability of high quality, consistent and appropriate neonatal intensive     Reducing infant deaths
of specialist    care services
elements of      Ensure availability of high quality, consistent and appropriate Tier 4 Child and       Treatment of people with mental health needs in the right setting,
priority         Adolescent Mental Health services                                                      improving rehabilitation and recovery rates
pathways         Ensure the availability of specialised services based around Principle Treatment       Improved quality of high cost, low volume specialised services
to               centres to support patients with HIV and AIDS on the basis of need                     prioritised by the SCG Decision-Making Framework
contribute       A strategic plan for personality disorder services to draw together population         Treatment of people with mental health needs in the right setting,
to the           need, identify current service provision, and outline future service configuration     improving rehabilitation and recovery rates
reduction in     Develop and implement low secure services commissioning strategy                       Treatment of people with mental health needs in the right setting,
premature                                                                                               improving rehabilitation and recovery rates
deaths and       High, medium and low secure service pathways QIPP programme                            Treatment of people with mental health needs in the right setting,
reduce                                                                                                  improving rehabilitation and recovery rates
burden of ill    Co-ordinated commissioning of non-secure specialised mental health services            Treatment of people with mental health needs in the right setting,
health                                                                                                  improving rehabilitation and recovery rates
across the       Ensure equitable access to high quality specialised and non-specialised renal          Improving renal services through providing dialysis and
region           services in line with National Service Framework                                       increasing kidney transplantation rates
                 Ensure equitable access to high quality specialised neurosciences services             Improved quality of high cost, low volume specialised services
                                                                                                        prioritised by the SCG Decision-Making Framework
                 Ensure availability of sub-fertility services based on need                            Improved quality of high cost, low volume specialised services
                                                                                                        prioritised by the SCG Decision-Making Framework
                 Ensure equal access to surgical obesity services based on need, and develop            Improved quality of high cost, low volume specialised services
                 centres of excellence to deliver safe and effective services                           prioritised by the SCG Decision-Making Framework
                 Ensure equitable access to high quality vascular services                              Fewer deaths following cardiac surgery




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APPENDIX 8 – HIGH LEVEL MAP OF GOALS, INITIATIVES, AND OUTCOMES

Goal 3                                                                                                 Overarching Health Outcome
Regional             Ensuring equitable access to high quality specialised services, through           Improved quality of high cost, low volume specialised services
Consistency          supporting robust decision making, agreeing common service access and             prioritised by the SCG Decision-Making Framework
To support           treatment criteria & agreeing common approaches to the introduction of new
PCTs and             technologies and drugs
Providers in         Ensuring equitable access to high quality specialised services through co-        Improved quality of high cost, low volume specialised services
the region to        ordination and oversight of a range of services                                   prioritised by the SCG Decision-Making Framework
deliver safe,        Ensuring responsiveness to areas of need for specialised services, through        Improved quality of high cost, low volume specialised services
efficient and        maintaining a watching brief over all specialised services, including those not   prioritised by the SCG Decision-Making Framework
sustainable          commissioned by SCG
specialised
services
through
consistent
commissioning,
intelligent
market
management
and robust
decision
making




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Equality Impact Assessment for:                                                                                                         Appendix 9
Y&H SCG 5 YEAR COMMISSIONING STRATEGY

Step 1: About your piece of work
               1.     Directorate / Business Unit:                         Yorkshire & Humber Specialised Commissioning Group

               2.     Policy / Strategy / Service to be assessed:          Y&H SCG Commissioning Strategy 2010- 2014



               3.     Lead Officer:                                        Cathy Edwards

               4.     Equality Impact Assessment Person / Team:            Laura Sherburn


               5.     Date of Assessment:                                  April 2010
                      Review Date:                                         March 2011

               6.     The main purpose and outcomes of policy/strategy /    Drive up the quality of specialised services
                                                                            Deliver improved health outcomes for patients
                      service to be assessed                                Ensure fast responsive services for all who require them
                                                                            Improve access and minimize inequalities
                                                                            Deliver improved productivity and value for money
               7.     Groups who the piece of work should benefit or       Users of specialised services & their carers
                                                                           Y&H PCTs (x 14)
                      apply to, for example:                               Providers of specialised services in Y&H

                      - Service users




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                      - Staff

                      - Other internal or external stakeholder

                      (Will the piece of work be delivered in partnership

                      with another agency?)

               8.     Any associated strategies, guidelines, frameworks     SCG Communications and Participations Strategy
                                                                            SCG Organisational Development Strategy
                                                                            SCG Financial Plan
                                                                            SCG Business Plan




Step 2: Gathering Information
1.   Who should be served by the policy / strategy / piece of work?

                 Users of specialised service in Yorkshire & Humber and their carers
                 Delivery partners, specifically providers of specialised services in Yorkshire & Humber
                 PCT stakeholders
2.   What relevant information do you have about the people who this piece of work is aimed at?
     (Baseline information is given in the guidance notes, please refer to these and then add further information relevant to your area of work).
     Refer to guidance notes for further demographic information.
                                   Information (research / data)               Known or potential inequalities
     Race
     Gender (including
     transgender)
                                                                             PROVIDED AT APPENDIX 9A
     Disability
     Age
     Faith



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     Sexual Orientation
     Human Rights
     Do you have enough information about the different groups to inform an equality impact assessment?    No
     If not, this area should be addressed in your action plan.
3.   Do you have monitoring data or consultation findings specific to your area of work? If yes list the sources of evidence here & go to Step 3, if
     No list the actions required to get more data.

      - Implementation of SCG Communications and Participation Strategy, which includes the commitment to embed collection of service user data
        within specialised commissioning and contracting processes
      - Inclusion of EIA monitoring within service specifications for all specialised services
      - Each service to undertake a dedicated EIA as part of the commissioning process; this to be signed off as a common approach to developing
        specialised services per se
4.   What consultation activity has taken place / will be taking place on this piece of work and the equality impact assessment?
      - Commissioning Strategy has been through 3 stages of consultation with PCTs, the final one currently being discussion at PCT Board level, due to
        culminate in comments by 30th April
      - SCG Board in May to advise on further consultation required
      - Each service initiative will be considered by the Y&H SCG PPI Steering Group as the gateway to further consultation and engagement in 2010-11



Step 3: Assessing Impact
      1.          What does your monitoring data on your staff or service users tell you?
                  Are any groups under or over represented compared to what you would expect to see from the baseline data in Step 2. What
                  are the potential access issues or barriers for people in each of the equality groups?

                  Race                                            This information will be collected on at service level, not strategic level, given the diversity
                  Gender (including transgender)                  of specialised services and the complexity across the 14 PCT areas.
                  Disability                                      At strategic level, the intention is explicit within the Commissioning Strategy to improve
                  Age                                             equality and equity, and furthermore the supporting Communications and Participations
                  Faith                                           Strategy has the clear objective of establishing PPI as a standing item and element of the
                  Sexual Orientation                              work programme for all commissioning groups for specialised services, with the PPI
                  Human Rights                                    Steering Group overseeing this process. Collectively, the above aims will provide the
                                                                  overarching direction for service level monitoring and scrutiny of access issues/barriers.




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      2.          Based on the evidence gathered have you identified any potential differential impact for any of the equality groups?
                  The issues flagged below are those that are known at this stage, and relate to more than one specialised service. The detailed
                  differential impact of the various initiatives within the Commissioning Strategy will be undertaken at service level, and a full
                  EIA completed for each service.

                                                 Positive                                           Negative
                  Specific impacts on services will be defined within service strategy EqIA. The section below captures some overarching or highlight
                  impacts.
                  Race                            Dedicated commissioning of HIV services, known    Some issues related to scarcity of organ donation for
                                                  in Y&H to be most prevalent amongst the African   specialised services amongst some cultures; higher risk of
                                                  immigrant population;                             haemophilia amongst some groups; shortage of sperm
                                                                                                    donation for sub-fertility services in some races; higher
                                                                                                    risk in some groups of cleft lip & palate, cystic fibrosis,
                                                                                                    renal failure, genetic disorders, metabolic disorders, &
                                                                                                    haemoglobinopathy needs
                  Gender (including               Commissioning and prioritization of gender        Fertility services generally are more focused on women;
                  transgender)                    dysphoria services                                need to consider impact on men and families; some



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                                                                                                          cancers are more predominant in one gender; higher risks
                                                                                                          in some males of some metabolic disorders, some
                                                                                                          specialised mental health conditions, and haemophilia.
                                                                                                          Higher risks in some females of some specialised Child &
                                                                                                          Adolescent mental health conditions such as eating
                                                                                                          disorders
                  Disability                      To be part of the consultation process; as there are
                                                  risks of disability arising from numerous specialised
                                                  conditions (including for example haemophilia,
                                                  spinal surgery, neurosciences, burn care,
                                                  children’s specialised services, vascular, and
                                                  mental health services), then all service initiatives
                                                  need to consider the impact on this group.
                  Age                             Commissioning of specialised services dedicated         Fertility services not available to women over 39 years
                                                  to children, ie paediatric intensive care, neonatal     old; numerous specialised conditions/diseases carry an
                                                  intensive care, child and adolescent mental health      increased risk with age
                  Faith                                                                                   Promotion of organ donation, ie renal; pro-life groups are
                                                                                                          impacted upon with regard to IVF & medical genetic
                                                                                                          services; some invasive procedures and devices may
                                                                                                          have an impact on some faith groups such as Jehovah’s
                                                                                                          Witnesses
                  Sexual Orientation              LGB groups are now eligible for fertility services,
                                                  previously ineligible
                                                  Dedicated commissioning of HIV services
                  Human Rights                                                                          Fertility services are not available to single people (ie not
                                                                                                        in a relationship).
                  Is the differential impact as a result of indirect or direct discrimination? Yes…… / No…….
                  (Please refer to the glossary in the guidelines for explanation of these terms, if necessary).
                  If the differential impact is a result of indirect discrimination, is this Criteria for fertility treatment has been designed with significant
                  objectively justifiable or proportionate in meeting a legitimate           levels of public engagement, is based on clinical evidence and legal
                  aim? If yes, provide details here:                                         advice, and is seen as representing best use of limited public funds.




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Step 4: Promoting Equality
  1.          What has been done to promote equality in this piece of work?
              This includes any measures you’ve put in place to:
                   Improve the accessibility of your service
                   Improve the quality of outcomes for people from different groups
                   Make your service/policy/strategy more inclusive
                   Ensure staff are trained appropriately
                   Promote community cohesion or good relationships between different groups of people.
              (Think about physical access, communications needs, staff awareness, partnership working)

              Race                                                The Commissioning Strategy promotes equality and equity as explicit aims in the overarching
              Gender (including transgender)                      front section, and each specific commissioning initiative includes the need to undertake EIA as
              Disability                                          part of the agreed process.
              Age                                                 There are a number of EIAs that have already been done within the SCG and have therefore
              Faith                                               informed the development of the strategy and the initiatives; these include Fertility, Gender
              Sexual Orientation                                  Dysphoria, and Blood & Marrow Transplantation (BMT).
              Human Rights

  2.          What further actions are required?
                Implementation and governance of EIAs at service level (see action plan)
                Strengthened equality monitoring within contracts and service specifications (see action plan)

  3.          Have any changes been made to this piece of work as a result of doing the Equality Impact Assessment?
              - Updated the strategic documents (Comms & Participation Strategy, OD Strategy etc) to include cross-reference to the explicit actions within
                this EIA

  4.          How have you consulted on this piece of work?
              Members of Specialised Commissioning Team input into the EIA
              PCTs input into the Commissioning Strategy Sept 09 – April 2010
              Further guidance due from SCG Board May 2010

  5.          How will the outcomes from this EIA be managed and reviewed?
              SCG Business Manager has the role of monitoring implementation of action plans within SCG Strategies, and will establish monitoring
              systems such as those reflected in the action plan below to ensure this EIA is systematically reviewed


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Step 5: Equality Impact Assessment Action Plan
         Issues                    Action required to be taken                                  Lead                  By When      Progress
         identified

         Governance                Reflect duty to conduct an EIA in SCG Approach to           Deputy Director Y&H    April 2010
         mechanisms to             Service Strategies (to be signed off by SCG Board           SCG
         ensure EIAs are           April 2010)
         done at service
         level at early
         stage in                  Each service initiative to complete a full EIA as the       Y&H SCT Service        March
         commissioning             work is progressed in 2010-11                               Leads                  2011
         process                   Monitor the number of EIAs conducted for each service       Y&H SCG Business       2010-2011
                                   initiative within Commissioning Strategy                    Manager

         Equality                  All service specifications to include requirement to        Y&H SCT Contract       March
         monitoring                monitor equality and access to services; incorporate        Leads                  2011
                                   standard NHS Barnsley template in SCG contracts; to
                                   be in contracts for 2011-12 or as variations to contracts
                                   for 2010-11 where appropriate
                                   PPI Steering Group to fulfil the role of overseeing the     SCG Lead for PPI       March
                                   collection of service user data from all sources outwith    within NHS Barnsley    2011
                                   contracts; ie clinical networks, PPI groups, hospitals,
                                   etc.
                                   SCG Performance Monitoring Report to develop                SCG Lead for Quality   Sept 2010
                                   Quality Section to extent that EIA monitoring data is       within NHS Barnsley
                                   submitted at agreed intervals




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APPENDIX 9a – Y&H SCG Baseline Equality Data
   Equality
   Strand             Data Available (JSNA/other data)                         Needs/Known inequalities
                      The estimated proportions (2007) for each major ethnic       Each service initiative will incorporate a full EIA as part of the
                      group in Yorkshire & Humber are:                               commissioning process. Due to the diversity of specialised
                                                                                     services, each service will have a differential impact on
                      White – 90.6%                                                  respective race and ethnic groups.
                      Mixed Race – 1.3%                                            However it is known from the JSNAs of Yorkshire and Humber
                      Asian or Asian British – 5.7%                                  PCTs that some people from BME backgrounds experience
                      Black or Black British – 1.3%                                  poorer health and have unequal access to health services
                      Chinese or other – 1.1%                                        compared to the general population. Key health issues for
                                                                                     BME children are Sickle Cell disease and Thalassaemia.
                                                                                     Hospital admissions for mental illness are higher in people
                                                                                     from BME backgrounds. Clearly this has relevance for the
                                                                                     commissioning of specialised services, which include mental
                                                                                     health services, clinical genetic services, and children’s
   Race /                                                                            services.
   Ethnicity                                                                       Asylum seekers and refugees are often vulnerable as a result
                                                                                     of persecution within communities. A British Medical
                                                                                     Association report on asylum seekers’ health in 2002 showed
                                                                                     that a significant number of asylum seekers are prone to
                                                                                     particular health problems, including HIV – this has particular
                                                                                     implications for the commissioning of this specialised service
                                                                                   Health inequality for Gypsies and Travellers is even more
                                                                                     pronounced than other socially deprived or excluded groups.
                                                                                     Access to services is limited by difficulty in registering for a
                                                                                     GP. It should be noted that population figures from the
                                                                                     National Office for Statistics do not currently identify the Gypsy
                                                                                     Traveller Community.
                                                                                   Migrant workers are likely to experience greater deprivation
                                                                                     than the rest of the population. They are likely to have poorer



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                                                                                                      access to and knowledge of local services than other people.

                                                                                              Department of Health have identified:
                                                                                                 Black people are six more likely to be detained under the
                                                                                                   Mental Health Act
                                                                                                 Perinatal mortality in England and Wales amongst babies
                                                                                                   born to mothers born in Pakistan is nearly 2x the average of
                                                                                                   all births in England & Wales; particular relevance to the
                                                                                                   commissioning of neonatal services
                      7.8% of people in Yorkshire and the Humber receive Incapacity               Each service initiative will incorporate a full EIA as part of the
                      Benefit and Severe Disability Allowance (IBSDA), compared to 7%              commissioning process. Due to the diversity of specialised
                      nationally.                                                                  services, each service will have a differential impact on disability.
   Disability                                                                                     However it is known at this stage that this equality strand will
                      The number of people with a long-term Limiting Illness in Y&H is 19%,        have particular significance when considering the commissioning
                      compared to 18% nationally.                                                  of specialised mental health services, and also long-term
                                                                                                   specialised conditions such as renal failure and HIV.
                                                                                              The PCTs’ JSNAs highlight health inequalities that exist between men
                      50.4% of Y&H’s population is female and 49.6% is male                   and women, including access to primary care services and uptake of
                                                                                              prevention services such as the smoking cessation service.
                      (http://www.statistics.gov.uk/STATBASE/Product.asp?vlnk=997
                                                                                              Each specialised service initiative will incorporate a full EIA as part of
                                                                                              the commissioning process. Due to the diversity of specialised
                                                                                              services, each service will have a differential impact on gender groups.

                                                                                              However DoH data, relevant to specialised commissioning identifies
   Gender                                                                                     that:
   (including                                                                                   Men are twice as likely as women to both develop, and die from,
   Gender                                                                                           the ten most common cancers affecting both sexes
   Identity                                                                                     Incidence and mortality for heart disease are much higher in men
                                                                                                60% of sudden infant deaths occur in boys
                                                                                                Men are 3 times more likely to take their own lives
                                                                                                Conditions such as anorexia and bulimia are more prevalent in
                                                                                                    women.
                                                                                                Women are between two and three times more likely than men to
                                                                                                    be affected by depression or anxiety.

                                                                                              Transgender:
                                                                                                  Some transgender people have reported difficulties in



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                                                                                                        accessing gender reassignment services.
                                                                                                       There is also evidence suggesting significantly higher
                                                                                                        rates of self-harm and attempted suicide among
                                                                                                        transgender groups.
                                                                                                    A full EIA relating to the development of Y&H criteria for
                                                                                                        gender dysphoria services has been conducted by the
                                                                                                        SCG
                      We have little more than Census 2001 data on religion. We aim to find    DoH identifies that:
                      out more about the needs of people with different faiths and religions   The Muslim population have the highest levels of ill health among faith
                      through our future equality impact assessment work, to ensure that we    groups once the age structures of the different faith groups have been
                      provide an appropriate service to people of all faiths, as far as        taken into account. Although Muslims are represented in a wide range
                      possible.                                                                of ethnic groups, including many of African origin, the majority are of
                                                                                               Pakistani and Bangladeshi origin – a group of whom it is clear there is
                      2001 Census Data for Y&H                                                 clear evidence of health inequality, including higher smoking
                                                                                               rates amongst man and higher rates of coronary heart disease and
                                                                                               diabetes.
                                Religion
                          Description               %                                          Each specialised service initiative will incorporate a full EIA as part of
                                                                                               the commissioning process. Due to the diversity of specialised
                       Any other                                                               services, each service will have a differential impact on respective
                                                 0.2
   Religion or         religion                                                                religious groups.
   Belief              Buddhist                  0.1
                                                                                               There may be particular issues to address within commissioning of
                       Christian                 73.1                                          renal transplant services and increasing numbers of donors, as certain
                       Hindu                     0.3                                           cultures and religions do not allow organ donation. This will be a
                                                                                               particular issue for this service.
                       Jewish                    0.2
                       Muslim                    3.8
                       No religion               14.1
                       Religion not
                                                 7.8
                       stated
                       Sikh                      0.4




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                      We have no quantitative data on sexual orientation, however              Each specialised service initiative will incorporate a full EIA as part of
                      Stonewall research indicates that around 6% of the UK’s population is    the commissioning process. Due to the diversity of specialised
                      lesbian, gay or bisexual (LGB). It is important that we develop our      services, each service will have a differential impact on sexual
                      knowledge of the health needs of LGB people and ensure that the          orientation.
                      services we provide are appropriate to people of any sexual              However currently, the information we know includes:
                      orientation.                                                             • Gay and bisexual men are 7 times more likely to attempt suicide
                                                                                               • By 2006, men having sex with men accounted for up to three-
                                                                                                   quarters of UK acquired HIV infections and they remain the
   Sexual
                                                                                                   behaviour group at greatest risk of acquiring HIV in the UK. An
   Orientation
                                                                                                   estimated 31% of men having sex with men aged 15-59 were
                                                                                                   aware of their infection in 2006. Among HIV-infected men having
                                                                                                   sex with men, who are diagnosed late are 14 times more likely to
                                                                                                   die within one year of diagnosis than those diagnosed earlier.
                                                                                               • Consideration must be given to LGB groups when defining criteria
                                                                                                   for sub-fertility services, and specific engagement work is required
                                                                                                   to explore this within the fertility service initiative within the
                                                                                                   Commissioning Strategy
                      The UK statistics authority estimates the population of the Yorkshire    Each specialised service initiative will incorporate a full EIA as part of
                      and the Humber region will be 5,327,500 in 2010. Based on current        the commissioning process. Due to the diversity of specialised
                      trends the regional population in 2015 will increase to 5,572,000.       services, each service will have a differential impact on respective age
                      The projections suggest a 13.2% increase in residents over the age of    groups.
                      65 and a 5.6% increase in children under 15.                             However in general, the DoH identifies that:
                      This has a significant impact on how we plan and deliver our services.   The number of people aged over 60 is forecast to rise by 40%
                                                                                               over the next 30yrs.
                                                                                               There is a great deal of anecdotal evidence of negative attitudes from
                                                                                               healthcare providers towards older people that affect the quality of
                                                                                               service they receive. Specific examples of inequalities experienced by
   Age                                                                                         older people include:
                                                                                                     More people report experiencing age discrimination than any
                                                                                                        other form of discrimination.
                                                                                                     Those aged 65 and over constitute one-sixth of the population
                                                                                                        and yet occupy two-thirds of general and acute beds.
                                                                                               Workforce Issues to consider:
                                                                                                     In 2007 the number of people older than 65 became
                                                                                                        greater than the number of people under 16
                                                                                                     In past 10yrs employment of over 50’s has risen by 25%




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Appendix 10

The SCG Acute CQUINs Scheme 2010-11

    Description of goal




                                                            Bradford


                                                                       DBHFT




                                                                                                  STHFT
                                                                                     LTHT


                                                                                            SCH
                                                                               HEY
    To increase survival in patients with       1a
    lung cancer
                                                1b

    To increase survival following bone         2
    marrow transplantation (BMT)

    To maximise survival and quality of         3a
    life for children admitted to neonatal
    units                                       3b

                                                3c

                                                3d

    To maximise survival and quality of         4a
    life for children admitted to paediatric
    ICU                                         4b

    To improve the care of patients             5
    needing cardiac surgery




    To improve the care of people with          6a
    HIV and AIDS




                                                6b

    To improve the care of people               7a
    requiring renal replacement therapy

                                                7b

                                                7c

                                                7d

                                                7e




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