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					49d8103e-9c6d-4a26-a0be-95111ef7dcb9.xls 5 Boroughs Partnership NHS Trust Updated: 1/13/2009 Programme area: Service Improvement and Redesign Work stream :Wigan Development Plan Accountable Directors: Hilary Fenton, Louise Sutton Programme Leads: Sam Oliver, Sharon Eid Project Managers: Cheryl Forrest / Phil Bullock Progress Issues Next Steps Phase (number) Key Tasks (number) Actions (number) PID Method of Approach Risk Rating (High Medium Low) How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan Programme Board / Stakeholder Group John Marshall S Oliver / S Eid Al Thompson C Forrest / Phil Bullock Dr N Harvey Vince Jackson H McHolm / G Spratt Linda Kellie Project Group: Sam Oliver / Sharon Eid Dr Ramamurthy / Dr Harvey C Forrest / Phil Bullock Helen McColm / G Spratt Donna Griffiths / Jane Walton Chris Molyneux /Jim Thomas/ Chris Maj Linda Kellie Liz Price Jones finance ad hoc HR rep trust and LA BE/AMcC + S Gore Performance - EB / SL/ JA Staffside rep - Ann Cunliffe / C Coltman Information Governance- Dave Kelsall Neil Chillton

Agenda no. 11

PCT Commissioner Programme Leads Primary Care Leads Project Managers Medical Leads Service User Reps HOS's CAMHS

Phase/ Key Stage

Key Tasks
Set up pre meeting group

Ref

Actions to complete the key task
1.1 Compile list of representatives 1.2 Contact attendees 1.3 Send PID to all stakeholders for information and comment 1.4 Set date for pre meeting 1.5 Book venue 1.6 Send agenda to stakeholders

What are the key risks?

Initiation Completion date date
10/21/2008 10/17/2008

Person's) responsible

RAG status

Initiation :

Some representatives are unable to attend pre-meeting Medium

Ensure representatives are PCT and Local linked in discussion Authority Leads Ensure representatives are linked into discussions

Sam Oliver/ Cheryl 11/1/2008 Forrest/ Janet Heyes 11/4/2008 Cheryl Forrest On going Helen McColm 1/10/08 11/1/2008 Helen McColm 12/1/2008 Stakeholder group Cheryl Forrest/ Debbie Hayes/ Suzanne on going Kippax Cheryl Forrest/ Sam 10/15/2008 Oliver Cheryl Forrest/ Helen McColm/ Suzanne on going Kippax

Supporting engagement and communication financial baselines and monthly performance report

Establish 5 Boroughs Partnership NHS Trust representation on Some 1.7 all partnership forums. representatives are Confirm arrangements for the local GP and 5 Boroughs unable to attend 1.8 Partnership NHS Trust clinical / management forum pre-meeting Review existing performance data for data requirements of 2.1 purpose for project Quality of data being available from existing clinical systems to support dataset and local authority performance requirements High

2.2 Update performance dataset as appropriate Inform Performance to continue monthly reporting of project dataset including outcome measures and share with 2.3 stakeholders. Establish performance links in on-going development of data 2.3a set as negotiated with commissioners/stakeholders.

Support development of existing systems and develop templates with Performance Section to capture dataset manually

1/10/08

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Wigan Service Improvement Plan

49d8103e-9c6d-4a26-a0be-95111ef7dcb9.xls Risk Rating (High Medium Low)

Agenda no. 11

Phase/ Key Stage

Key Tasks

Ref

Actions to complete the key task
2.4 Use information to monitor activity and financial performance 2.5 Develop trajectories of activity and outcome measures Establish monthly performance reporting to illustrate project 2.6 progress and risk areas

What are the key risks?

How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan

Initiation Completion date date

Person's) responsible

RAG status

Cheryl Forrest/ work on going stream leads

1/10/08 Unable to undertake review with all stakeholders. Ensure that representatives are linked in discussion

10/1/2008 Cheryl Forrest

Confirm current service provision.

Maintain engagement with GP and Service User stakeholders 3.1 about developments in service provision. 4.1 Compile list of representatives 4.2 Contact attendees 4.3 Set dates for stakeholder meetings. 4.4 Book venue 4.5 Send agendas to stakeholder Review, agree and list development goals with reference to 5.1 PID using SMART objectives Present current baseline activity, financial position and 5.2 trajectories to Stakeholder and Project Group.

Medium

1/10/08

Helen McColm/ Cheryl Forrest/ Sam Oliver/ on going Robin Evans 11/27/2008 11/28/2008

Establish stakeholder project group

Ensure that Some stakeholders attendees are are unable to linked in with attend. Medium discussion

11/28/2008 PCT and Local Authority Leads 11/28/2008 1/10/08

Sam Oliver/ Cheryl Forrest/ Debbie 11/18/2008 Wilkins Cheryl Forrest/ Work 10/31/2008 Stream leads 11/1/2008 Sam Oliver

Consultation:

Stakeholder project group to review mapping exercise and develop strategy to meet goals.

5.3 Discuss and agree project group's work streams 5.4 Discuss further monitoring criteria as required. Engage clinical team managers regarding project development 5.5 goals and review as appropriate Establish regular engagement with GPs and User Groups 5.6 regarding project development goals. Project team sign off of project development goals and 5.7 communicate to all stakeholders

10/21/2008 Work Stream leads on going Project group Helen McColm/ Service Managers/ 12/1/2008 Cheryl Forrest Helen McColm/ Cheryl 10/1/2008 Forrest/ Robin Evans

Ensure that Some stakeholders attendees are are unable to linked in with attend. Medium discussion

1/10/08

11/4/2008 Project Group

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Wigan Service Improvement Plan

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Agenda no. 11

Phase/ Key Stage

Key Tasks

Ref

Actions to complete the key task

What are the key risks?

How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan

Initiation Completion date date

Person's) responsible

RAG status

Developmental: Work stream 1 - Redesign CMHT Resources to respond to Caseload Audit and Personalisation Agenda - Donna Griffiths/Jane Walton
a) Continued recording of previously agreed performance measures b) Agreement reached on performance measure of the minimum number of people over 65 who should be managed within adult services. c) Development of service description and operational policy (acceptable to commissioners) of redesigned CMHTs d) Repeat of Case Load Audit to measure impact of changes. e) Fully agreed pathways/ protocols between LES practices and 5 Boroughs agreed, in place and rolled out for both Dementia and Recovery/ Depot LES’s Establish monthly reporting of data set figures to Project 1.1 Manager by 10 th of every month. Identify current numbers of over 65s open to 'Adult' CMHTs: numbers of over 65s, complex/non-complex functional mental illness; referred to 'OP' CMHTs over last 12 months and provide 1.2 service managers with figures. Agree minimum numbers of over 65s to be accommodated 1.3 within redesigned 'ageless' CMHTs Commence preparation of draft proposal/operational policy for 1.4 redesign of CMHTs and identify pilot site. 1.5 Commence role out of service redesign in pilot site. Repeat Case Load Audit and provide completed audit papers to 1.6 Service Managers. Identify cases suitable for transfer of care back to LES for 1.7 'Dementia' and/or 'Recovery & Depot'. Set up meeting with Consultant medical staff, GPSI and 5BP service leads to agree local protocols around Service 1.8 Specification for LES Review activity from pilot site and make necessary adjustments 1.9 to pathways and protocols. 1.10 Begin borough wide roll out of service. Elicit service user and carer views via quarterly standard 1.11 satisfaction questionnaires. 1/5/08 on going Ward/Team managers

1/10/08 1/10/08

11/18/2008 Team managers Jane Walton/ Donna 12/1/2009 Griffiths Jane Walton/ Donna 11/1/2008 Griffiths Jane Walton/ Donna 12/1/2008 Griffiths 3/31/2009 Team Managers Donna Griffiths/ Jane 7/1/2009 Walton/ Chris Maj

1/10/08 1/10/08 30/3/09

1/10/08

1/10/08 01/12/08 01/04/09

12/1/2008 Louise Buffey DG/ JW/ CF/Cmaj/ 4/1/2009 GPSI 9/1/2009 DG/ JW/ CMaj

Dec 08 and 3 DG/ JW/ SU & Carer 01/09/08 monthly on going reps

Work stream 2 - Develop referral pathways into community mental health service - Donna Griffiths/Jane Walton
a) 6 monthly review of pathways with commissioners and other relevant stakeholders. b) Submission of report on the above for the Wigan Joint Mental Health Commissioning forum. c) Development of contingency plans to maintain service provision at times of staff shortages or other significant disruption. Review and agree arrangements to maintain Gateway and 2.1 Advice Service in the event of staff shortages/sickness. 1/10/08 Donna Griffiths/ Jane 12/1/2008 Walton

Review, compare and interpret Gateway and Advice Team data - including waiting times, GP, SU and Carer satisfaction 2.2 surveys, feedback from Practise visits - and prepare report.

1/10/08

Donna Griffiths/ Jane 3/1/2009 Walton

2.3 Present report to Stakeholders/Commissioning Forum

1/10/08

4/1/2009 HOS

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Wigan Service Improvement Plan

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Agenda no. 11

Phase/ Key Stage

Key Tasks
a) Conformity to relevant NICE guidance is evidenced and Audited on an annual basis. b) Commissioners will be provided with an annual audit report.

Ref

Actions to complete the key task
Compile index of relevant NICE guidelines and make available 3.1 to workstream leads. 3.2 Agree audit framework for NICE adherence.

What are the key risks?

How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan

Initiation Completion date date

Person's) responsible

RAG status

Work stream 3 - Ensure NICE Guidance is fully implemented - Cheryl Forrest
1/10/08 1/12/08 12/1/2008 MM 3/1/2009 MM/HOS

3.3 Audit adherence to NICE guidelines 3.4 Prepare and present report to Commissioners

1/6/09 1/7/09

MM/ team managers/ 7/1/2009 Ward Managers 8/1/2009 MM

Work stream 4 - Support Development of integrated Personality Disorder Service - Jim Thomas
a) Participation in PCT commissioned development of exemplar PD service. b) Adjustment of pathways to reflect model when implemented. c) Participation in training programmes for staff. d) 5 boroughs utilisation of PD services commissioned from a range of providers. Attend PCT meetings re development of PD services and 4.1 feedback to Project Group. Liaison with Gateway and Advice Services in order to 4.2 accommodate pathways in to developed PD Services. Jim Thomas/ Joe Johnson/ John on-going Marshall Jim Thomas/ Donna TBA Griffiths/ Jane Walton Jim Thomas/ Julie Chadwick/ Team and TBA Ward Managers Jim Thomas/ Julie TBA Chadwick Jim Thomas/ Team 10/1/2008 and Ward Managers

1/10/08

1/10/08

Identify current numbers of appropriately trained staff and 4.3 current provision of training. Identify any gaps in training provision and produce a plan to 4.4 address these gaps.

1/10/08 1/10/08

4.5 Identify current uptake of commissioned services.

1/10/08

Work stream 5 - Implement Strategy for GP engagement and communication - Helen McColm
a) All practices are offered the opportunity of a visit by a 5 Boroughs representative to talk through service provision, job roles and pathways, and subsequent visits are offered on a 6 monthly basis b) Recording of practice visits. c) Establishment of GP / 5 Borough clinical forum d) Production of a communication strategy for engaging with GP’s 5.1 Produce draft communication strategy Arrange first GP forum and issue invitations to relevant 5BP, GPSIs, LA and PCT representatives to discuss proposed communication strategy, care pathways and information 5.2 recording/distribution Send out letter to offer GP visits and follow up with telephone 5.3 call. 1/10/08 11/1/2008 Helen McColm

1/10/08 1/10/08

12/1/2008 Helen McColm 12/1/2008 Helen McColm Helen McColm/Robin 11/1/2008 Evans

5.4 Commence practice visits Produce record of practice visits and timetable for continued/6 5.5 monthly contact.

1/10/08

1/10/08

2/1/2009 Helen McColm

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Wigan Service Improvement Plan

49d8103e-9c6d-4a26-a0be-95111ef7dcb9.xls Risk Rating (High Medium Low)

Agenda no. 11

Phase/ Key Stage

Key Tasks
a) The relevant recommendations of the Sir Jonathan Michael report. “Healthcare for all” are fully implemented. b) Evidence of implementation of the recommendations is reported to commissioners on a 6 monthly basis. c) 5 Boroughs participate in the Commissioner led working group being established to monitor implementation d) Revised protocols are in place between Mental Health and local Learning disability services concerning access to mental health services.

Ref

Actions to complete the key task

What are the key risks?

How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan

Initiation Completion date date

Person's) responsible

RAG status

Work stream 6 - Implement Recommendations of Sir Jonathon Michael Report - Liz Price-Jones
DG/ JW/ Karen Green/ Stephanie McComb/ 1/1/2009 Peter Harrison DG/ JW/ Karen Green/ 4/1/2009 Stephanie McComb/

Liaise with PCT and LD lead to identify relevant 6.1 recommendations in Health Care for All.

01/10/08

6.2 Implement relevant recommendations of 'Healthcare For All'. Provide report to commissioners to show evidence of 6.3 implementation. Identify local representatives to participate in monitoring 6.4 implementation via Commissioner-led working group.

01/10/08

01/10/08

4/1/2009 DG/ JW DG / JW/ Liz Price 12/1/2008 Jones DG/ JW/ Karen Green/ 2/1/2009 Stephanie McComb

01/10/08

6.5 Agree revised LD/Mental Health referral protocols.

01/10/08

Work stream 7 - CAMHs developments - Tarnia Woods
a) Full implementation of out of hours practitioner and 24 hour medical cover. b) Implementation of the commissioned practitioner cover for weekends and bank holidays. c) Agreement of maximum waiting times for access to a CAMHS practitioner or medic i.e. urgent and routine) d) Delivery of minimum service requirements for provision of services to RAEI, in line with the expectations of “Making it Better” e) To work collaboratively within the above arrangements. f) The development of a CAMHS Borough wide workforce plan in line CSIP/ SHA guidance and the identification of a relevant lead.

CAMHs practitioner available for weekend and bank holiday 7.1 cover.

01/10/08

Linda Kellie/ Barbara 10/1/2008 Costello

Implement plan to provide 24hr availability of CAMHS practitioner and specialist medical cover to inpatient units and 7.2 A&E department in line with 'Making It Better'.

01/10/08

Linda Kelli/ Barbara 12/1/2008 Costello/ Tessa Myatt

Identify and agree maximum urgent and routine waiting times 7.3 for access to CAHMs services.

01/10/08

Linda Kelli/ Barbara 12/1/2008 Costello/ Tessa Myatt

7.4 Agree CAHMs lead for the Wigan Borough

01/10/08

Linda Kelli/ Barbara 12/1/2008 Costello/ Tessa Myatt

7.5 Develop a workforce plan in line with CSIP/SHA Guidance.

01/10/08

Linda Kelli/ Barbara 1/1/2009 Costello/Tessa Myatt

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Wigan Service Improvement Plan

49d8103e-9c6d-4a26-a0be-95111ef7dcb9.xls Risk Rating (High Medium Low)

Agenda no. 11

Phase/ Key Stage

Key Tasks

Ref

Actions to complete the key task

What are the key risks?

How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan

Initiation Completion date date

Person's) responsible

RAG status

Work stream objective 8 - Carers Strategy - Cheryl Forrest
a) Participation in the Wigan Borough carers strategy group. b) Action plan developed outlining Implementation of appropriate elements of the Wigan carer’s strategy. c) All carers should be offered a carers assessment focusing on their health and emotional well being. d) All carers declining a carer’s assessment should have this recorded on case files and reported as a KPI. e) Carers who decline an assessment should be offered another within a 6-month period. f) One recording system should be developed between the Trust and DAS to record activity and level of intervention. unable to attend meetings due to other work commitments

Attend and particpate in locality Carers Strategy Group 8.1 meetings (first meeting 20.10.08).

medium

diary ahead and nominate deputy to attend.

01/10/08

11/1/2008 Cheryl Forrest

Identify specific actions relevant to 5BP within local carers 8.2 strategy and produce implementation plan.

01/10/08

Cheryl Forrest/ Carers 12/1/2008 Social workers

Agree local 5BP protocol to ensure all identified carers are offered a carer's assessment ( and reoffered at specified 6 8.3 monthly interval if declined). Failure to reach agreement with all parties within agreed time scales medium ensure regular liaison with relevant parties. Members of local Carers Strategy Group.

01/10/08

Cheryl Forrest/ Carers 11/1/2008 Social workers

Design and agree shared LA/5BP recording system to ensure 8.4 carer's activity is recorded accurately.

01/10/08

Cheryl Forrest/ Carers 2/1/2009 Social Workers

Work stream objective 9 - Annual needs assessment based on schedule of demographic info - Cheryl Forrest
a) Agreement reached on a schedule of demographic and other information that will enable commissioners and providers to assess service usage and need. Examples of information would include, Age, gender, Ethnicity data, Accommodation and employment status, carer status, diagnosis etc; cross referenced with LOS, readmission rates, type of service etc b) The production of such information should be delivered within an annual report.

Identify and agree with Commissioners, Performance and other Stakeholders, demographic information for collection, 9.1 comparison and cross referencing.

01/10/08

Cheryl Forrest/ HOS/ 5/1/2009 John Marshall

Agree/adjust reporting format for annual delivery to 9.2 commissioners.

Cheryl Forrest/ HOS/ Informatics

Agree systematic sharing of demographic information (with operational managers) in order to inform and influence future 9.3 service development, training and resource allocation.

Failure to access accurate demographic information within agreed timescales. low

ensure regular liaison with relevant parties.

01/10/08

9/1/2009 Cheryl Forrest/ HOS

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Agenda no. 11

Phase/ Key Stage

Key Tasks

Ref

Actions to complete the key task

What are the key risks?

How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan

Initiation Completion date date

Person's) responsible

RAG status

Work stream 10 - Ensure statutory requirements regarding SUI are met - Cheryl Forrest
a) Continued delivery of previously agreed performance measures. b) Implementation of SUI action plan. c) Development of an agreement between the Borough Chair of the Suicide Audit Group and the 5 Boroughs as to what information should be provided to the group. d) Protocol to be developed for the process of GP engagement in SUI processes and for the provision of feedback. Establish monthly recording of SUI data and provide quarterly 10.1 reports. 10.2 Continue participation in PCT Suicide Audit Group Establishment of local 5bp SUI Oversight Group to respond and 10.3 implement actions indicated by completed SUI reviews. 01/10/08 01/10/08 on going Governance dept 01/06/08 01/06/08 on going Cheryl Forrest/ C Maj Cheryl Forrest/ Helen 11/1/2008 McColm/ C Maj

14/10/08

Agree revised data/information to be providied to PCT Suicide 10.6 Audit group

14/10/08 on going monthly HOS/ MM/ C Maj

Agree with GPSI, local protocol for GP engagement in local SUI 10.8 processes and feedback.

14/10/08

Cheryl Forrest/ Helen McColm/ Alex 4/1/2009 Turnbull/ C Maj

Work stream 11 - Prescribing practices - Norman Harvey TBC (supported by Lorraine Prescott )
a) Shared care protocols in place for all “Amber” drugs. b) Written notification to GP’s of non – urgent changes in medication, dose or frequency within 2 working days. Any urgent notifications must take place within the working day. c) All prescribing will be in line with jointly agreed protocols. d) Clinicians will not deviate from the agreements made between the PCT and the 5 Boroughs. e) Annual audit of compliance with the above requirements. f) 5 Boroughs contract will be amended to reflect the above requirements. All medical staff will demonstrate adherence to current prescribing PCT/5Boroughs Partnership agreements in their 11.1 practise. Medical staff will provide clear, written notification of changes to 11.2 non-urgent prescriptions within 2 working days. Notification of urgent changes to medication will take place 11.3 within the working day. All proposed changes to current Shared Care arrangements to be fully costed, including further resource costs re storage, 11.4 dispensing, delivery e.t.c. Shared Care' protocols to be agreed for all 'Amber' drugs. disseminated to all medical staff for immediate implementation 11.5 in prescribing practice. Shared Care' protocols disseminated to all medical staff for 11.6 immediate implementation in prescribing practice. 11.7 Plan for annual audit of compliance to be designed. Norman Harvey/ Lorraine Prescott/ Neil Chilton

01/10/08 on going

01/10/08 01/10/08

1/1/2009 Norman Harvey 1/1/2009 Norman Harvey

01/10/08

12/1/2008 Lorraine Prescott Norman Harvey/ 1/1/2009 Lorraine Prescott

01/10/08

07/11/08 01/10/08

1/1/2009 Norman Harvey 6/1/2009 Lorraine Prescott

11.8 Annual audit of compliance to be completed.

01/10/08

7/1/2009 Lorraine Prescott

Work stream 12 - Mental Health Act / Mental capacity Act Training and Business Plan - Peter Acton / Ann Cunliffe / LPJ

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Agenda no. 11

Phase/ Key Stage

Key Tasks
a) Production of an implementation plan, including training and development, to support these requirements within the borough. b) The development of a business plan outlining any additional resource requirements.

Ref

Actions to complete the key task
Identify current numbers of appropriately trained staff and 12.1 current provision of training.

What are the key risks?

How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan

Initiation Completion date date
01/10/08

Person's) responsible

RAG status

Ann Cunlife/ Peter 12/1/2008 Acton Ann Cunlife/ Peter 12/1/2008 Acton

12.2 Identify any gaps in training provision.

01/10/08

Develop a business case to identify any additional resource 12.3 requirements.

01/10/08

Ann Cunlife/ Peter 1/1/2009 Acton

N/A

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Agenda no. 11

Phase/ Key Stage

Key Tasks

Ref

Actions to complete the key task

What are the key risks?

How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan

Initiation Completion date date

Person's) responsible

RAG status

Work stream 13 - Conduct MDO service review and implement improvement plan - Sharon Eid
a) Participate in the Greater Manchester Review of Mentally Disordered Offenders services. b) Review Borough wide MDO services. 13.1 Identify baseline current activity and capacity Partcipate in meetings re Greater Manchester review of 13.2 Mentally Disordered Offenders services. 13.3 Identify any gaps in service provision. 01/10/09 01/10/09 01/10/09 01/10/09 11/1/2008 S.Eid/ Pat Smith 11/1/2008 S.Eid/ Pat Smith 4/1/2009 S.Eid/ Pat Smith 4/1/2009 S.Eid/ Pat Smith

13.4 Present report to project Stakeholder Group

Work stream 14 - Improve performance of In-Patient Services and write a business case for redesign - Chris Molyneux
a) Demonstrate a sustained reduction in the number of admissions, length of stay, occupancy and readmissions to inpatient mental health services over a 12-month period. b) Develop a costed business case (to the satisfaction of commissioners) which will be publicly consulted upon, to propose improvements to inpatient services that focus upon improved quality and an appropriate reduction in bed numbers to national benchmarks. The business case must reflect the commissioners’ specification and be in line with best practice. c) The proposal will be revenue neutral for commissioners and if savings are identified they will be declared to commissioners, who will determine their usage.

Identify number of admissions, length of stay, occupancy and readmissions to inpatient unit for two consecutive 12 month 14.1 periods (Apr 07 to 08, and Apr 08 to 09)

01/10/08

5/1/2009 IP Service manager

Elicit service user and carer views via quarterly standard 14.2 satisfaction questionnaires.

Jan 09 and 3 IP Service manager/ 01/09/08 monthly on going SU & Carer reps

Develop costed business case to propose improvements to in 14.3 patient services.

01/10/08

IP Service Manager/ 10/1/2009 HOS/ Ben Nuttall

Report any cost savings to commissioners to enable service 14.5 need/demographically appropriate reallocation of resources

01/10/08

10/1/2009 HOS

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Agenda no. 11

Phase/ Key Stage

Key Tasks

Ref

Actions to complete the key task

What are the key risks?

How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan

Initiation Completion date date

Person's) responsible

RAG status

Investments: Work stream 1 - Illustrate PTS Service capacity v activity and develop business plan to address gaps - Graham Spratt
a) The Psychological Therapies Service will be in a position to submit the IAPT Vital Signs Monitoring (VSM) data lines 3a, 3b and 4, 5,6 and 7 as outlined in the detailed technical definition b)The 5 Boroughs will have developed a plan to market Psychological services as a 'Health service' and not as a'mental health' service c) Locally based psychological treatment for people with a mild to moderate learning disability will be present in each of the three localities supported by robust arrangements for the delivery of that function of the service. Tha activity for the people that access this service will be identifiable from the IAPT dtat set. d) the Psychological Therapies Service will have identified the resource required to deliver the provision of step two and three clinics to all general practices in the ALW area. 1.1 Agree with informatics to develop appropriate recording system. Liaise with PCT IT Dept to establish capacity of CORE NET to 1.2 collect Vital Sign Data. Establish 'best fit' of non-mental health PTS to data recording 1.3 requirements. Service managers to ensure data collection is delivered to 1.4 acceptable quality and standards Produce a policy/ philosophy statement to communicate the 1.5 concept of 'health' service. Produce a business plan to demonstrate locality based 1.6 psychological treatment for LD service users. 01/10/08 01/10/08 01/10/08 11/30/2008 Graham Spratt 11/30/2008 Graham Spratt 11/30/2008 Liz Price Jones Janet Winstanley/ Jane Kenny/ Liz Price 11/30/2008 Jones

01/10/08

01/10/08

12/31/2008 Graham Spratt

01/10/08

3/31/2009 Liz Price Jones

1.7 Prepare for IAPT Data collection for LD Service users.

01/10/08

6/1/2009 Liz Price Jones

Produce a business plan to identify resource requirements which includes current service capacity and additional 1.8 investments required to reflect local needs. e) The 5 boroughs Psychological Therapies Service will be participating in a Psychological Therapies hub along with other provider designed to assist in the development of psychological services for health in Wigan f) The PTS will have developed an outline plan to deliver clinical supervision and developmental support for third sector providers of psychological therapies

01/10/08

3/31/2009 Jane Kenny

Liaise with PCT and other providers to establish mechanisms for a psychological therapies hub and write service 1.9 specification.

01/10/08

4/30/2009 Janet Winstanley

Map third sector PTS delivery in order to identify supervision/support requirements. Produce a plan to meet 1.10 identified supervision/support requirements.

01/10/08

7/1/2009 Mike Valentine

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Agenda no. 11

Phase/ Key Stage

Key Tasks

Ref

Actions to complete the key task

What are the key risks?

How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan

Initiation Completion date date

Person's) responsible

RAG status

Work stream 2 - Develop Business case and implementation plan "Mental Health Hospital Liaison Service" for Adults and Older People - Jim Thomas
a) Review of Older persons A and E Liaison service to ensure compliance with recent policy guidance b) Production of a business case to provide hospital and A and E Liaison services, including training, consultation and assessment services. c) Production of an Implementation plan for the development of the service. d) Agreement on access to psychological services where appropriate. e) Protocol developed with neighbouring A and E departments regarding access and transfer to local services for individuals registered with ALW GP’s. f) Arrangements should be made for the provision of liaison services to Leigh Walk in centre. Identify baseline activity of A&E Liaison Services Apr 07 to Apr 2.1 08, including out of hours referrals to CRHT. Review current A&E Liaison Service (OP), identify gaps in 2.2 service that do not comply with recent policy guidance. Produce business case for provision of comprehensive A&E 2.3 Liaison Service to include training costs. 01/10/08 Jim Thomas/ Robin 11/1/2008 Evans Jim Thomas/ Mandy 1/1/2009 Hanson

01/10/08

01/10/08

11/1/2008 Jim Thomas

2.4 Produce service implementation plan

01/10/08

11/1/2008 Jim Thomas Jim Thomas/ Graham 11/1/2008 Spratt.

2.5 Agree appropriate access to Psychological Services. Liaise with neighbouring A&E departments to develop transfer 2.6 protocols for ALW service users. Design and agree provision of liaison services to Leigh 2.7 Infirmary Walk In centre.

01/10/08

01/10/08

2/1/2009 Jim Thomas

01/10/08 01/10/08

1/1/2009 Jim Thomas. 2/1/2009 HOS/ Sam Oliver

2.8 Present business case to commissioners.

Work stream 3 - Medical cover developments - Norman Harvey / Jim Thomas
a) A developed plan to provide medical cover in A and E, when it is appropriate. b) Development of protocol between RAEI, commissioners and 5 Boroughs to define ' a '. c) Reporting of waiting times to access all medical staff out of hours and for A and E attendance (grouped into relevant grades i.e. SHO, SPR, Consultant) Include provision of appropriate medical input to RAE Infirmary 3.1 A&E department in A&E development proposal. 01/10/08 Norman Harvey/ Jim 12/1/2008 Thomas

3.2 Develop protocols to support appropriate medical input to A&E.

01/10/08

Norman Harvey/ Jim 12/1/2008 Thomas

Agree recording and reporting system to identify out-of-hours and A&E waiting times for access to appropriate grade of face 3.3 to face medical support.

01/10/08

Norman Harvey/ Jim 2/1/2009 Thomas/ Informatics

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Agenda no. 11

Phase/ Key Stage

Key Tasks

Ref

Actions to complete the key task

What are the key risks?

How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan

Initiation Completion date date

Person's) responsible

RAG status

Work stream 4 - Fully implement ATC business case (Organic and Complex MH Services) - Chris Maj
a) Implementation plan developed for the commencement of this service. b) Development of service description for complex CMHT element of service c) Development of operational policies. Establish Implementation Working Group (to develop service 4.1 description and operational policies) 4.2 Manage transition of existing staff (Beacon Day Hosp) 4.3 Agree increased consultant input to Phase 1 Site (Wigan) 4.4 Begin recruitment of staff Phase 1 (Wigan) 4.5 Agree Shared Care arrangements with PCT 4.6 Produce plan to engage with GPs to promote new service 4.7 Phase 2 Service roll out to Ashton and Leigh localities. 01/09/08 01/09/08 01/09/08 01/09/08 01/09/08 01/09/08 01/03/09 12/1/2008 C.Maj 11/1/2008 C.Maj 12/1/2008 C.Maj/Glynn Thomas 12/1/2008 C.Maj 12/1/2008 C.Maj 12/1/2008 C.Maj 9/1/2009 C.Maj

Work stream 5 - Develop Dual Diagnosis Service based upon agreed business case - Jim Thomas
a) Continued reporting of agreed performance measures in this area. b) Development of a business case, acceptable to commissioners, for the expansion of the Dual Diagnosis service. c) Implementation plan developed. Review baseline numbers of service users with dual diagnosis 5.1 open to CMHTs. Set up separate function for Dual Diagnosis activity on IT 5.2 system. Record caseload and co working activity for Dual Diagnosis 5.3 Practitioners. Jim Thomas/ Dual 11/18/2008 Diagnosis Practitioners 18/11/08 monthly Jim Thomas/ on going Informatics 18/11/08 monthly Jim Thomas/ Dual on going Diagnosis Practitioners 18/11/08 monthly Jim Thomas/ Dual on going Diagnosis Practitioners 12/1/2008 Jim Thomas 12/1/2008 Jim Thomas

01/10/08

01/10/08

01/10/08

5.4 Record consultation activity for Dual Diagnosis practitioners. Produce a business case for the expansion of Dual Diagnosis 5.5 Services. Produce implementation plan for expanded Dual Diagnosis 5.6 Service

01/10/08 01/10/08 01/10/08

Information: Work stream 1- Ensure that the reporting of PTS performance outcomes/outputs meets expectations of the PCT / LA - Graham Spratt
a) Provision of financial and activity data requested by the PCT. b) Agreed baseline of finance and activity. c) Agreement of performance targets. Provide information re finances and activity as requested by 1.1 PCT. 1.2 Agree baseline finance and activity Graham Spratt/ Ben Nuttall/ Performance 12/1/2008 Team Sam Oliver/ John 12/1/2008 Marshall

01/10/08 01/10/08

1.3 Agree performance targets.

01/10/08

Graham Spratt/ John 12/1/2008 Marshall

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Agenda no. 11

Phase/ Key Stage

Key Tasks

Ref

Actions to complete the key task

What are the key risks?

How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan

Initiation Completion date date

Person's) responsible

RAG status

Work stream 1a - Ensure that the reporting of service performance MH outcomes/outputs meets expectations of the PCT / LA - Helen McColm
a) Provision of financial and activity data requested by the PCT. b) Agreed baseline of finance and activity. c) Agreement of performance targets. Provide information re finances and activity as requested by 1.1 PCT. 1.2 Agree baseline finance and activity 1.3 Agree performance targets. Helen McColm/Ben Nuttall/ Informatics 12/1/2008 team Sam Oliver/ John 12/1/2008 Marshall Helen McColm/ John 12/1/2008 Marshall

01/10/08 01/10/08 01/10/08

Work stream 2 - GP Data Set - Cheryl Forrest
a) Issue practices with agreed financial and activity data. b) Agreed SLAs between practice consortiums and the 5 Boroughs that outline the level of service they can expect. Meet with GPSI to agree content and presentation of GP data 2.1 set. Agree outline expected level of service and Service Level 2.2 Agreements with GP Practice Consortiums. Cheryl Forrest/ Al 4/1/2009 Thompson HOS/ Cheryl Forrest/ 4/1/2009 Al Thompson

01/09/08

01/09/08

Work stream 3 - Outcome Measures - Cheryl Forrest
a) To agree with the PCT a full set of outcome measures. b) To set targets against current outcome measures e.g. User, carer and GP satisfaction. c) To develop appropriate systems to monitor and report those outcomes at a PCT and practice level. Agree targeted areas of service improvement based on current Service User, Carer and GP experience/areas of 3.1 dissatisfaction.. Identify and agree an appropriate set of outcome measures with 3.2 commissioners. Donna Griffiths/ Jane 12/1/2008 Walton/ Cheryl Forrest Cheryl Forrest/ John 3/1/2009 Marshall

01/10/08 01/10/08

Develop effective reporting systems to enable feedback to PCT 3.3 and GP consortia.

01/10/08

Cheryl Forrest/ Informatics/ Debbie Hayes/ Nigel 4/1/2009 O'Gorman

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Agenda no. 11

Phase/ Key Stage

Key Tasks

Ref

Actions to complete the key task

What are the key risks?

How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan

Initiation Completion date date

Person's) responsible

RAG status

Target performance: Work stream 1 - Ensure design & performance of LDP services develop to meet all expectations of PCT & national targets - Jim Thomas
a) A minimum of 54 people per year are admitted to EI services. b) A minimum of 721 people receive Crisis Resolution services per year c) 144 people in contact with the Assertive outreach service. d) Teams are staffed in line with PIG requirements. e) Production of a monthly report demonstrating d). f) Weekly reporting of progress against a) and b) g) Production of action plan to ensure achievement of a) and b). Monitor numbers of accepted referrals to Early Intervention Team and take appropriate actions to meet required annual 1.1 number of 54 Monitor numbers of accepted referrals to Crisis Resolution/Home Treatment Team and take appropriate actions 1.2 to meet required number of 721. Monitor Assertive Outreach Team caseload to ensure target 1.3 figure of 144 is met. Jim Thomas/ Chris 3/31/2009 Kelly Jim Thomas/ Shirley 3/31/2009 Myers Jim Thomas/ Anthony 3/1/2009 Critchley

01/04/08

01/04/08 01/04/08

1.4 Weekly reporting of progress towards target figures. Produce Action Plan to ensure target figures for LDP services 1.5 are achieved. Monitor numbers of service users open to Assertive Outreach Team and take appropriate actions to meet required number of 1.6 144

Jim Thomas/ Shirley 01/12/08 weekly, Myers/ Chris Kelly/ 01/04/08 on going Anthony Critchley 01/10/08 12/1/2008 Jim Thomas. Jim Thomas/ Anthony 3/31/2009 Critchley 12/1/2008 Jim Thomas 01/12/08 monthly, on going Jim Thomas

01/04/08 01/04/08

1.7 LDP Teams are staffed as per Policy Implementation Guidance
Monthly report to Project Development Group and commissioners to demonstrate appropriate staffing levels are achieved.

1.8

01/04/08

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Agenda no. 11

Phase/ Key Stage

Key Tasks
a) Reporting of waiting times for all services for first assessment and first treatment. b) With the exception of psychological therapy services and the ATC, all non-urgent services should have a maximum waiting time, which includes, 1st treatment, within 18 weeks. c) An agreement will be in place with commissioners for acceptable waiting times for the steps of the psychological therapies pathways, which will be expected to be significantly shorter than the 18week target, however there will be a cap on the maximum waiting time of 18 weeks including first treatment.

Ref

Actions to complete the key task

What are the key risks?

How do you intend to Engagement mitigate these 3rd party Strategy / risks? involvement Comms Plan

Initiation Completion date date

Person's) responsible

RAG status

Work stream 2 - Reporting and Achievement of Waiting time targets - Helen McColm / Graham Spratt
Establish and report current baseline waiting times for all 2.1 elements of service. Identify areas in 'non-urgent' services where 18 week target is 2.2 not being met. Identify causes/contributing factors around failure to meet 18 week target and develop draft action plan to address these 2.3 issues. (MH Services) 2.4 Agree and implement action plan. (MH Services) 2.5 Review and report waiting times to project group (MH Services) 01/10/08 Helen McColm / 11/18/2008 Graham Spratt Helen McColm / 1/13/2008 Graham Spratt Helen McColm/ Donna 1/27/2009 Griffiths/ Jane Walton 2/10/2008 Helen McColm 4/1/2008 Helen McColm Graham Spratt/ Peter 7/1/2009 Harrison

01/10/08

01/10/08 01/10/08 01/10/08

2.6 Agree specific acceptable waiting times for PTS service.

01/10/08

2.7 Report waiting times to Commissioners

16/12/08

Helen McColm/ 10/1/2009 Graham Spratt

Review
12.1 Contact attendees Send report of mapped service to all stakeholders for 12.2 information and comment 12.3 Set dates for project meeting Project Group reconvene to review performance 12.4 Book venue 12.5 Send agendas to stakeholder 13.1 Compare current activity and financial information with baseline. Project group to review performance 13.2 Agree measures that can initiate improvement if required 13.3 Agree action plan to implement measures. 14.1 Compare current activity and financial information with baseline. 14.2 Review any outstanding audit issues Project group to review performance 14.3 Agree measures that can initiate improvement if required 14.4 Agree action plan to implement measures. Risk apportionment. Risk apportionment. Not all attendees are able to attend Medium

Ensure that they are engaged in the discussion.

Quality of data

Medium

Quality of data

Medium

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