Nhs Acute Contract 200910 by mwc16934

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									OPERATIONAL PLAN

      2009/10




   DRAFT V4 25.03.09
                             CONTENTS


                                                         Page
                                                          No:

Introduction                                              3

Achieving Local Priorities                                5

Ensuring High Quality Care                                8

Maintaining Financial Balance                             15

Ensuring Appropriate Levels of Separation with the        25
PCT’s Provider Services

Supporting Priorities

                                        Contestability    27
       Information Management and Technology (IM&T)       27
                                           Workforce      28
                                 Emergency Planning       30
                          World Class Commissioning       31
                       Practice Based Commissioning       32
                              Reputation Management       32
Appendices


Appendix 1 – PCT Vision and Values                        34

Appendix 2 – Local Strategic Milestones                   36




                                 2
                       Section 1 - Introduction

What is the 2009/10 Operating Plan?
Thank you for your interest in NHS South Gloucestershire’s annual Operating
Plan. In this Plan, the Primary Care Trust (PCT) sets out its priorities for
improving health and local services in South Gloucestershire over the next
financial year (April 2009 – March 2010).

You may wish to read the Plan alongside the PCT’s Strategic Plan, which sets
out the PCT’s vision and plans for healthcare over the next five years (2009/10 –
2013/14). Both documents can be found at www.sglos-pct.nhs.uk or can be
requested from the PCT by calling 0117 330 0213.

The Plan has been informed both by the national Operating Framework for the
NHS in England 2009/10 ‘High Quality for All’ and the Operating Framework for
the South West 2009/10, issued by the South West Strategic Health Authority.
The Plan is one of the ways in which the PCT shares how we plan to continue to
make progress towards the PCT’s vision, which is to:

 ‘Maximise the Health and Well Being of People in South Gloucestershire’

and to work within our strategic priorities, which are:

       To improve the health of people living in South Gloucestershire by
       effective partnerships with other organisations and with local people

       To reduce differences in health between people and places in South
       Gloucestershire

       To bring more health services closer to local people by delivering more
       primary and community-based services

       To improve the experience of local patients when they use health by
       making sure that health services are provided promptly, safely and
       effectively

A summary of the PCT’s vision and values can be found in Appendix 1.

How will we Measure Success?
We will measure the success of our Operating Plan in terms of:




                                          3
   •   Achieving our key local priorities – our strategic milestones for 2009/10
       (see section 2)

   •   Achieving, and where possible, exceeding national quality and service
       indicators and targets, for example as measured through the national
       annual Health Care Commission (soon to become the Care Quality
       Commission) ‘Health Check’ assessment) (please see section 3)

   •   Commissioning high quality care within the levels of funding available -
       maintaining financial balance (please see section 4)

Success will be monitored by the Board on a quarterly basis.




                                       4
                Section 2 – Achieving Local Priorities

We enjoy a good level of health and healthcare locally but the PCT is
understandably as ambitious as the people of South Gloucestershire about
continuing to improve health and the quality and accessibility of local health
services. The PCT’s draft Joint Strategic Needs Assessment (JSNA) has also
confirmed some important local inequalities in health which we want to continue
to tackle.

In addition to meeting, and where possible exceeding, the national statutory
requirements placed on Primary Care Trusts, the PCT has therefore also set out
in this Plan the 26 key local priorities or ‘milestones’ that it wishes to achieve in
2009/10. These priorities reflect the discussions we have had with, and feedback
from, people living in South Gloucestershire and other key stakeholder
organizations and sit alongside the Local Area Agreement targets jointly agreed
with South Gloucestershire Council

The priority milestones are:

Strategic Priority 1

Improve the health of people living in South Gloucestershire by effective
partnerships with other organisations and with local people

   1)      To reduce levels of obesity in reception children to 10% and in year 6
           to 14%
   2)      To contribute to achieving a national target of an adult smoking rate of
           21% or less by helping 1,332 local people to stop smoking. To reduce
           the local percentage of women who smoke during pregnancy to below
           10%
   3)      To ensure a co-ordinated multi-disciplinary team approach for long
           term conditions, to be in place by 31 March 2010 in each locality, with
           a single point of access
   4)      To achieve and maintain a maximum 6 week wait for primary care
           mental health counselling service from December 2009.
   5)      To ensure timely implementation of NICE guidance (within 4 weeks of
           implementation for Technical Appraisal Guidance) and equitable roll
           out across all healthcare sectors
   6)      To implement an agreed integration programme with South
           Gloucestershire Council to include: establishment of Single Point of
           Access to emergency support, service integration across provider
           services, and closer integration between health and social care teams
           supporting discharge from hospital by October 2009




                                         5
   7)      To commission comprehensive primary care based brief intervention
           support to help at risk individuals to reduce their alcohol consumption,
           in at least half of local practices by March 2010

Strategic Priority 2
Reduce differences      in   health   between   people   and   places   in   South
Gloucestershire

   8)      To target smoking cessation services at communities with the highest
           prevalence, ensuring 50% more successful quitters / 1000 population
           from the most deprived quintile compared with the least
   9)      To reduce the level of teenage pregnancies from 30.8 (2006 levels) to
           21.9 per thousand females aged 15 – 17 by March 2010
   10)     To improve by one third the cervical and breast screening rates in
           women with learning difficulties towards the overall rate of women in
           South Gloucestershire
   11)     To reduce levels of self harm within the 3 local prisons to national
           average benchmarks, with a particular focus in Eastwood Park Prison
   12)     To contest prison primary care service (Leyhill), prison nursing
           services (Eastwood Park and Leyhill) and pharmacy services
           (Eastwood Park and Leyhill) to achieve improvements in accessibility,
           quality, integration and safety.

Strategic Priority 3

Bring more health services closer to local people by delivering more primary and
community-based services

   13)     To achieve timely assessment and review of patients for Continuing
           Health Care funding, with the current backlog of cases cleared by
           December 2009 and regular reviews undertaken in line with national
           recommendations
   14)     Responding to individual preferences, to reduce by 10% year-on-year
           the number of adult deaths in acute hospitals, supporting individuals
           who wish to be supported to die at home
   15)     To agree the model of rehabilitation services and complete the outline
           brief for the services to be commissioned from the Frenchay site form
           2013/14, including consideration of further public engagement or
           consultation, as appropriate
   16)     To approve Cossham service developments and capital Full Business
           Case by May 2009
   17)     To progress the review of community facilities in Thornbury – with the
           Strategic Outline Case produced by May 09, and Outline Business
           Case achieved by Nov 09
   18)     To open the new community health centre in Yate in November 2009
   19)     To achieve more efficient use of healthcare resources
           - reducing unnecessary pre-operative stays in hospital


                                         6
           - reducing unnecessary follow ups in secondary care
           - reducing lengths of stay avoiding unnecessary delays
           - avoiding unnecessary admissions to hospital
   20)     To commission new primary care based services, including:
           - expansion of GP with Special Interest services
           - community respiratory services
           - palliative care support infrastructure
   21)     To improve access, including:
           - 13 weeks referral to treatment times delivered at specialty level for
              hospital services
           - maximum six week waits from referral to assessment in community
              mental health services
           - extended opening hours in general practice available to all patients
              by March 2010
           - year-on-year improvements in numbers of people accessing NHS
              dental services

Strategic Priority 4

Improve the experience of local patients when they use health by making sure
that health services are provided promptly, safely and effectively

   22)     To deliver local Commissioning for Quality and Innovation (CQUIN)
           targets for improvements in quality of services across commissioned
           services
   23)     To achieve all NHS targets within national requirements
   24)     To implement new pathways for acute myocardial infarction and acute
           stroke during 2009
   25)     To implementation of the Primary Care Trust's "Maternity Matters"
           action plan within agreed timescales
   26)     To implement the new AGW NHS Treatment Centre on time
           (November 2009), and planned capacity utilised

Appendix 2 summarises how these milestones contribute to the achievement of
the PCT’s overall strategic priorities and link to the achievement of the agreed
World Class Commissioning outcomes and Local Area Agreement targets.




                                        7
         Section 3 – Ensuring High Quality Care
Improving Quality

‘High Quality Care for All’, published nationally in June 2008, emphasised the
need to ensure quality is at the heart of the NHS reforms, including:

   o Safety so that there are no needless deaths or incidents
   o Effectiveness so that clinical outcomes including patient reported outcome
     measures (PROMs) are maximized, and people are helped to stay healthy
   o Patient experience, so that there is fast access to high quality and
     personalized care

PCTs will be required to publish quality accounts, alongside annual financial
accounts, for the first time in 2009/10 and will be supported by the establishment
of a new Quality Observatory for the South West. The PCT has submitted
indicators for potential inclusion in the quality accounts for further discussion with
the Strategic Health Authority. An additional 0.3% has been set aside within the
Operational Planning process to make targeted improvements in quality based
on local priorities.

The PCT is currently finalising its Quality Framework, setting out priorities and
action plans across each of the above domains, and will be driving and re-
emphasising performance across a range of quality indicators through its
contracts with commissioned providers. Quality is increasingly a core driver in
practice based commissioning and in the PCT’s engagement programme with
local people and other stakeholders. Local clinical leaders will oversee progress
against each of the three quality domains, reporting via the Integrated
Governance Committee to the Board

An additional payment of up to 0.5% will be available to key commissioned
providers in 2009/10 if additional ‘stretch’ quality targets are achieved beyond
national / statutory requirements, as part of the national Commissioning for
Quality and Innovation (CQUIN) initiative. A parallel penalty programme is in
place to support the delivery of existing national / local targets.

CQUIN payments are being developed to support the delivery of the following
priorities, and will be monitored via existing contractual fora. These include:

                Provider                   Proposed CQUIN Incentives /
                                                Contract Penalties
Acute Hospital Providers (North Bristol Gateway requirements for CQUIN
NHS Trust, University Hospitals Bristol payments:
NHS Foundation Trust)
                                             o A&E 4 hour waits at or below
                                                 98%


                                          8
          o Meeting expanded 31 / 62
            day cancer targets
          o Meeting 13/26 week waiting
            time targets (no more than
            0.3% breaches)
          o Meeting 6 week national
            diagnostic target (no more
            than 0.3% breaches)
          o Slot availability for choose
            and book at or above 96%
          o MRSA (no more than 2008/9
            out-turn)
          o No more than 1% elective
            surgery cancelled by the
            provider   for     non-clinical
            reasons

    Available CQUIN rewards:

       o Achieving SHA local MRSA / C
         Diff targets (NBT)
       o 90% of patients undergoing
         primary angioplasty to achieve a
         door to balloon time of less than
         40 minutes (UHB)
       o Level B        GRS endoscopy
         standards in all areas (excluding
         paediatrics) and level A in 50%
         of areas) (UHB)
       o 90% compliance with standard
         for discharge communications
         received by GPs within 48 hours
       o Timely     reporting    of   SUIs
         (including never events)
       o 95%      adult     patients   risk
         assessed for VTE
       o 90% of mothers to be non-
         smokers at the point of delivery
       o 80% of mothers initiating breast
         feeding in hospital
       o 90% of people with a stroke to
         receive brain imaging within 30
         minutes of arrival
       o 90% of stroke patients spend
         90% of their inpatient stay in a
         stroke unit



9
                                        o 98% of women booking within
                                          12 weeks and 6 days (Maternity
                                          services standards)
                                        o 75% of individuals known to
                                          have a learning difficulty staying
                                          over 48 hours to have a
                                          completed risk / dependency
                                          assessment and care plan
                                          completed
                                        o Disability monitoring to be
                                          completed in 70% of cases
                                        o Achieve 50% green and no red
                                          ratings using 2007 Picker ‘The
                                          Hospital and Ward’ survey
                                        o Demonstrate improved patient
                                          experience (measures to be
                                          confirmed)
                                        o 90% of patients to be booked in
                                          the month before they would
                                          have breached
                                        o 70% of all major A&E attendees
                                          to be assessed within 30
                                          minutes
                                        o Staff or patient smoking quitters
                                        o Brief interventions provided to
                                          patients identified with a harmful
                                          or hazardous alcohol intake
                                          pattern

                                     Contract     penalties   /    financial
                                     adjustments:

                                        •
                                        Non delivery of Clostridium
                                        Difficule target reductions (NBT
                                        only)
                                      • Cancelled operations (S22’s)
                                        above national average of 2.3%
                                      • Consultant to consultant referral
                                        growth above 2008/9 ratios
                                      • New to follow up outpatient
                                        ratios above agreed plan
                                      • Non delivery of agreed Trust led
                                        actions to manage within agreed
                                        contract plan
Avon and Wiltshire Partnership NHS Gateway requirements for CQUIN
Trust (Mental Health Services)     payments (pre-qualifying requirements


                                   10
 to be met before CQUIN rewards are
 made available):

         o Meeting all 4 national access
           targets across all PCTs
           (crisis resolution, 7 day CPA,
           early intervention, assertive
           outreach)
         o Meeting agreed trajectory for
           improvements in staff survey
         o Meeting agreed trajectory for
           improvements in national
           patient survey

 Potential CQUIN rewards:

     o Undertaking 90% of mental
       health assessments in acute
       hospital settings within 48 hours
       for urgent requests and 5 days
       for routine requests made to the
       Trust
     o Meeting agreed timescales for
       roll out of improved data
       collection and reporting systems
       (RIO) in 2009/10
     o Shadow monitoring of 2010/11
       mental health tariff activity
       against the 21 national care
       clusters from month 9
     o Achievement        of      agreed
       productivity      gains      (e.g.
       reductions in length of hospital
       length of stay)
     o Every patient admitted screened
       for a learning difficulty in line
       with the green light toolkit and,
       where identified, agreement of
       admission and discharge care
       planning with liaison nurse and
       carer, from month 4

     Contract penalties apply to:

     •   Late reporting of SUIs and
         homicides



11
                             •   NPSA ‘never events’
                             •   Non achievement of maximum
                                 6 week wait from referral to
                                 assessment from end Jan 2010
                             •   HCC Adult Inpatient Survey
                                 results if within bottom 25% of
                                 Trusts nationally
                             •   Falling below agreed standards
                                 in adult inpatient review repeat
                                 audit
                             •   Non achievement of HCAI
                                 targets

PCT Provider Services        o Roll out of improved data
                               collection and reporting systems
                               (RIO) in 2009/10 (incentive
                               applies)
                             o Achievement       of    maximum
                               waiting times (penalty applies)
                             o Reductions        in     delayed
                               discharges from acute beds
                               (incentive applies)
                             o Supporting the achievement of
                               redesign and RUM schemes
                               including      reductions       in
                               unnecessary           emergency
                               admissions to hospital where
                               community alternatives could be
                               provided (incentive applies)
                             o Supporting the achievement of
                               community        Health      Care
                               Acquired Infections targets
                             o Supporting the establishment of
                               a single point of access from
                               April 2009
                             o Productivity gains – support for
                               CHC        assessments        and
                               community based IV therapy

General Practice         Enhanced delivery of national priorities
                         via the Local Enhanced Services
                         contracts including:
                            o Chlamydia screening
                            o Smoking cessation
                            o Uptake of diabetic retinopathy
                            o Provision of palliative care


                        12
                                                 support in line with the Gold
                                                 Standards Framework
                                              o Medication reviews in nursing
                                                 homes to reduce unnecessary
                                                 emergency admissions
                                              o Incentives linked to the delivery
                                                 of       Practice        Based
                                                 Commissioning            (PBC)
                                                 commissioning plans
Great Western Ambulance Services          To be confirmed – pending agreement
                                          with Gloucestershire PCT as lead
                                          commissioner.       Local suggestions
                                          include:

                                             o Ambulance turn around times in
                                               A&E
                                             o Achievement of response time
                                               targets at PCT level
                                             o Achievement of a maximum
                                               emergency response time

Revised targets are currently being finalised in relation to acute and community
Health Care Acquired Infections respectively, following a national validation
exercise and recording change to better capture and monitor progress in respect
of infections that have arisen in community settings. Actions to reduce and
manage community infections will be included in the contract with the PCT
provider arm. Targets will apply to AWP for the first time in 2009/10. Pre-
operative MRSA screening is already in place for elective surgery and will be
extended to cover day cases in 2009.

As part of the Operational Plan, an additional investment is being made in
support of engagement work with local residents to better understand patient
experience and local perceptions on the quality of service provision, particularly
in areas where information or feedback is not routinely available to the PCT. The
PCT will continue to build an effective relationship with the newly established
South Gloucestershire LINK (Local Involvement Network, replacing PPI Fora),
with local third sector organizations (jointly with the Local Authority where
appropriate) and ensure that good practice models developed locally are
consistently applied across the PCT’s work programme (e.g. Planning for Real,
working through steering groups with majority membership from outside of the
NHS for major service / capital developments).

Nationally Patient Reported Outcome Measures (PROMs) are being brought in
from April 2009 to measure and report the perceptions of patients on the impact
of hip or knee replacement, hernia and varicose vein treatments on quality of life.




                                        13
A local pilot is also planned to establish PROMs for local stroke patients
receiving hospital care.

The PCT will be working with all local providers (including the PCT provider
service and AWP in a lead commissioner role) to finalise plans for individual
clinical teams to set quality standards against which they will monitor
performance.

The PCT is continuing with a programme of service redesign focused on
improving the quality and accessibility of local services, further details of which
can be found at www.sglos-pct.nhs.uk.

Reducing Variation

The PCT recognises that patients expect equitable access to high quality
services, particularly where there are national targets or standards set.
Improvements have been seen in a number of key areas of performance in
2008/9. Particular focus will be given in 2009/10 to

      Achieving currently unmet / at risk national targets including: emergency
      ambulance response times, ambulance turn around times into A&E
      departments, reductions in teenage pregnancy, smoking cessation
      targets, uptake of diabetic retinopathy, reductions in childhood obesity,
      and breast feeding uptake. For 2009/10 the PCT is putting in place
      strengthened contract terms, and where applicable, performance penalties
      for the providers concerned (secondary and primary care) in addition to
      revisiting action plans for improved delivery. Where issues of capacity
      have been raised (for example in relation to diabetic retinopathy) these
      have been benchmarked as part of the Operational Planning process as
      part of the consideration of additional investment.

      Ensuring sustainable progress against the 13 week referral to treatment
      target in secondary care - in aggregate and at specialty level, the
      expanded cancer waiting time targets and A&E four hour waits (with
      shadow monitoring put in place in anticipation of future 2 hour waits). For
      elective care, the PCT will have access to outpatient and inpatient
      capacity from the new NHS Treatment Centre which is planned to open
      from November 2009. As well as providing an alternative choice for local
      patients, this will provide the option of additional capacity in a number of
      specialties, including orthopaedics where there are particular challenges in
      reaching and maintaining a maximum wait of 13 weeks. The PCT is also
      ensuring clearer organisational responsibility for delivery of national
      targets where they depend on the performance of more than one
      organisation, with particular focus on ensuring single leadership for
      elective orthopaedic requirements.




                                        14
Establishing a maximum referral to treatment waiting time (to complement
the current national % achievement targets) for acute (hospital services),
diagnostic tests, and mental health treatments, based on performance
benchmarks and achieved through improved system efficiency and
service redesign.

Ensuring more equitable access to mainstream services for vulnerable
groups. This includes contesting prison health services to achieve
improvement in quality and safety, and additional support for individuals
with a learning difficulty to access mainstream health service (indicators of
our success in achieving this aim have been included in the PCT’s
selected World Class Commissioning outcomes)

Ensuring timely roll out of National Institute for Health and Clinical
Excellence (NICE) guidance, including better monitoring of roll out within
primary care and mental health services. Additional clinical leadership has
been agreed in this area to support this ambition.




                                 15
       Section 4 - Maintaining Financial Balance

Financial Position

The PCT is planning to achieve a break even position for 2008/09. It has
received an increase in resource limit allocation of £16,043k for 2009/10 (5.2%).
This increases the recurrent resources available to the PCT in 2009/10 to
£323,108k.

Following discussion with the SHA the PCT plans to deliver a break even position
for 2009/10. A further £1,215k will be held by the PCT as a notional contingency
budget with no voluntary contribution being made to the NHS South West
Strategic Investment Fund (SIF).

The position assumes a £1,034k contribution to the legacy SIF (with the balance
over four years). Discussions are underway with the SHA on additional SIF
support of £2m.

There remains significant risk to delivery of this position and this is detailed later
in the report.


Deployment of Additional Resource

These are set out in appendix 1 to this section and are as detailed in the revenue
budget proposals presented to the Board.


Risks and Mitigation

   •   The level of contract activity is above the funding available:-

          o The PCT is working closely with acute providers on an agreed
            action plan to deliver activity within the overall contract envelope.
            The agreement details the responsibilities of each party and the
            regular management and reporting arrangements necessary.

          o The PCT is working closely with the PBC consortium to determine
            the required level of referrals to be managed and also the
            supporting strategies in the delivery of non elective care - Single
            point of access, virtual wards etc.

          o Additional monitoring mechanisms are being put in place to
            capture, project and provide early warning of referrals or activity



                                         16
          moving away from planned trajectories. This will involve Practice
          Based Commissioners and the Board, providing early opportunities
          for corrective action.

       o Mitigating actions have been agreed which will be implemented on
         the first sign of over performance.

•   RUM schemes fail to deliver – the PCT has a rigorous project
    management regime to monitor impact and has the support of the PBC
    Consortium in delivering many of the schemes

•   CHC spend may be above budgeted levels – The PCT has introduced a
    robust mechanism for monitoring in year performance and as described
    above is working closely with South Gloucestershire Council on future
    contracting arrangements and market management. The PCT is also
    considering a proposal for an external review of areas of high cost spends.

•   The PCT will need to continue to regenerate significant sums in future
    years. The PCT must ensure that it is organised to deliver this and that it
    works closely with the PBC Consortium and providers to do so.

•   Unanticipated changes/pressures – As in any healthcare organisation
    there is always a risk of unanticipated changes. This is mitigated by the
    PCT held contingency and the improved reporting and control
    mechanisms that the PCT now has in place.




                                    17
Capital

The capital investments are as detailed in the capital budget submitted to the
Board as follows:-

                                                                          Memo -
                                                   2009/10   2010/11   Total Value
                                                                       of Business
                                                    £'000     £'000        case

Locally Planned Expenditure

Yate Health Centre (BHSP)                           6,126                12,340
Community Hospital Programme -Cossham               2,293    11,006      19,190
GP I,M&T                                             370      370
IT                                                   200      200
Expenditure on maintenance on capital stock          711      711
Frenchay project                                     240


Capital grants funded by Local Authority

Capital Grants to Prisons                           8,250                 8,500
Capital Grants to Local Authorities                 1,430     650
Capital Grants to Dentists                           100      100
Capital Grants to Doctors                            745


Asset Disposals

Assets disposed to non NHS bodies                   1,725



Total Capital Programme                            22,190    13,037      40,030



The plan also includes the impact of impairments on facilities as follows:-
                                              £000
Yate Health Centre                            2,000
Cossham Hospital                              3,500

At the moment these represent planning totals based on best information
available. They may therefore change in year.




                                              18
                                                            Version 11 - 2009-10
                                                                     Non-
                                                  Recurrent       recurrent         Total
                                                   £'000s           £'000s         £'000s


Opening Recurrent baseline                                                      307,065

DEPLOYMENT OF ADDITIONAL RESOURCES

Strategic Investment Contribution
AGW debt                                                                1,741              1,741
SMTC debt                                                               1,250              1,250
SHA SF 2008-09                                                            621                621
Bristol PCT A&E                                                         1,000              1,000
Bristol PCT provider services                                0              0                  0
SIF Contribution                                                       -3,000             -3,000
SHA adjustment to legacy debt                                          -3,578             -3,578
                                                             0         -1,966             -1,966

Inflation
General & acute & other inflation                        3,861                             3,861
GMS/PMS inflation                                          289                               289
Prescribing                                              1,700                             1,700
Central budgets inflation                                  284                               284
CQUIN & quality contingency                                               925                925
                                                         6,134            925              7,059

Impact of 2008-09 acute activity
North Bristol Trust                                      6,012                             6,012
UHB                                                      2,728                             2,728
RUH & other out of area activity                           600                               600
BIRU                                                       400                               400
Non contract activity                                      600                               600
Exceptional funding panel                                    0                                 0
Enteral feeds                                              200                               200
                                                        10,540              0             10,540

Secondary care investment/(disinvestment)
General PbR acute growth                                 2,410                             2,410
Non PbR investment                                         250            750              1,000
DSC investment
Ambulance services                                         200                               200
Achievement of 13 week waiting list target                                167                167
Impact of HRG4                                          -1,623                            -1,623
                                                         1,237            917              2,154

Other PCT investments/(disinvestments)
Continuing health care (incl. staffing)                  1,800                             1,800
Held in contract reserve                                   317              0                317



                                             19
BNSSG investments                                 421      9       430
Other PCT investments                             328    151       479
Specialist commissioning                           93               93
IAPT                                              230     -50      180
Mental health private placements                  200              200
NICE - other                                    1,880            1,880
Primary care premises & extended access           656     -95      561
Dental services growth funding                    991              991
Drugs & alcohol                                         1,104    1,104
Bristol PCT provider services                             525      525
                                                6,916   1,644    8,560

Contract limiters & RUM schemes
New RUM schemes                                -1,084           -1,084
Contract limiters                              -3,432           -3,432
Consultant to consultant referrals                -44              -44
Payment for bloods/S22s/ophthalmology          -1,047           -1,047
Savings to be identified                         -524             -524
QOF benefit                                      -184             -184
                                               -6,315      0    -6,315

PCT management
Brook Park                                       150              150
Management                                       250              250
                                                 400       0      400

TOTAL                                          18,912   1,520   20,432




Total resources                                18,638   1,794   20,432


Surplus/(deficit) from breakeven                 -274    274        0




                                          20
TOTAL                                          18,912   1,520




Total resources                                18,638   1,794



Surplus/(deficit) from breakeven                 -274    274




Specialist commissioning                          93
IAPT                                             230      -50
Mental health private placements                 200
NICE – other                                    1,880
Primary care premises & extended access          656      -95
Dental services growth funding                   991
Drugs & alcohol                                         1,104
Bristol PCT provider services                            525
                                                6,916   1,644


Contract limiters & RUM schemes
New RUM schemes                                -1,084
Contract limiters                              -3,432
Consultant to consultant referrals                -44
Payment for bloods/S22s/ophthalmology          -1,047
Savings to be identified                         -524
QOF benefit                                      -184
                                               -6,315      0


PCT management
Brook Park                                       150
Management                                       250
                                                 400       0




                                          21
        Section 4 - Maintaining Financial Balance

Financial Position

The PCT is planning to achieve a break even position for 2008/09. It has
received an increase in resource limit allocation of £16,043k for 2009/10 (5.2%).
This increases the recurrent resources available to the PCT in 2009/10 to
£323,108k.

Following discussion with the SHA the PCT plans to deliver a minimum surplus of
£133k for 2009/10. A further £1,215k will be held by the PCT as a notional
contingency budget with no voluntary contribution being made to the NHS South
West Strategic Investment Fund (SIF).

The position assumes a £1,153k contribution to legacy SIF (with the balance
over four years) and no contribution to the Financially Challenged Trusts.

There remains significant risk to delivery of this position and this is detailed later
in the report.

In order to match the planned investments that are outlined below, the PCT has a
challenging requirement to deliver a regeneration programme of £6.0m in
2009/10. This programme will be backed by a programme of service redesign
(see PCT Service Redesign Directory at www.sglos-pct.nhs.uk for further
details), supported by the PCT wide Practice Based Commissioning Consortium,
and a series of contract terms with providers, helping to secure delivery from our
key provider partners.

Deployment of Additional Resource

The PCT is planning to utilise the additional resources available in 2009/10,
including regeneration funding, as follows:-

                                          Recurrent          Non             Total
                                            £000           Recurrent         £000
                                                             £000
Additional Resource limit                       16,043                      16,043
allocation
Investments

Inflation                                         6,134                          6,134
Impact of 08/09 over performance                 10,100                        10,100
Acute growth (incl. Non PbR)                      2,250                          2,250
CQUIN payments                                                      925            925
BNSSG wide investments                               500            525          1,025
Impact of HRG 4.0 (inc new tariffs)              (4,709)                       (4,709)


                                         22
Achievement of sustainable 13                                  500          500
weeks
Continuing Health Care (CHC)                     1,800                    1,800
NICE                                             1,800                    1,800
Specialist Commissioning                           500                      500
Mental Health                                      500                      500
Ambulance services                                 522                      522
PCT Infrastructure                                 650                      650
Primary care access/premises                       650        (100)         550
NCG top slice                                      387                      387
Increase in SIF contribution                         -
Additional contribution/contingency                  -                        -
Financially Challenged Trusts                                    -            -
SIF contributions                                            1,153        1,153

Total investments                               21,084       3,003       24,087


Balance                                         (5,041)    (3,003)      (8,044)


Regeneration

Continuation of existing RUM*
schemes                                  500                                500
09/10 RUM Schemes                        500                                500
Contract limiters (net of investment)   5,000                             5,000
                                                 6,000
Existing surplus in base line                    2,177                    2,177

Surplus generated                           3,158         (3003)          133
* Resource Utilisation Management schemes improve the delivery of services by
providing them more efficiently (for example providing diagnostic tests and
treatment at a ‘one stop’ community appointment and therefore avoiding repeat
visits to hospital).

All of the investments listed above are currently being reviewed and challenged,
particularly:-

   •   The recurrent impact of the 08/09 over performance in NBT and UHB
   •   The level of growth necessary in 09/10 and the non recurrent impact of
       reaching a sustainable waiting list by 31/03/10.
   •   The benefit of HRG 4.0 where the Trusts currently have a lower
       expectation of reduced income.
   •   Investment in ambulance services where we believe our costs benchmark
       as high against comparator PCTs




                                         23
   •   Contractual management of Patient Transport Services (PTS) – currently
       being negotiated on the basis of blocking back funding to the Trusts in
       2009/10

The investments above meet the South West Strategic Health Authority (SHA)
expectations of:-

   •   An investment in Health Improvement – the PCT is currently ensuring that
       health improvement investments are reported consistently with other local
       PCTs, acknowledging the SHA requirement of an investment equivalent to
       0.8% of baseline in 2009/10

   •   0.3% set aside for improving access – The PCT already meets the GP
       access targets (including exceeding the target for extended hours) and is
       making good progress on reducing waits for mental health assessment.
       The PCT has made a non recurrent allowance of £500k to reach
       sustainable 13 week waiting lists, at specialty level, for hospital treatments
       by the end of March 2010.

   •   0.3% set aside for Quality over and above CQUINS.

   •   A net inflation for commissioned providers of up to 1.7% (4.7% inflation
       minus a cash releasing efficiency savings ‘CRES’ requirement of 3%). For
       some providers / activity, inflation will be less than 1.7%. In line with
       national recommendations, 5% (8% less 3% CRES) has been allowed for
       primary care prescribing.

Approach to Cash Releasing Efficiency Savings (CRES)

For all providers, inflation will be applied net of CRES, as outlined above. As
lead commissioner, the PCT is working closely with the Avon and Wiltshire
Partnership NHS Trust (AWP) and with the PCT provider service to deliver
2009/10 CRES requirements by October 2009 and to plan in advance for the
additional 0.5% CRES requirement in 2010/11.

For the PCT provider arm, the majority of CRES requirements will be met by
implementing the review of bank services and anticipated reduction in use of
agency staff. The delivery of the recurrent CRES requirement within AWP is
dependent on a broad programme of service redesign; again the PCT will work
alongside the Trust to monitor progress and to support the involvement of
associate NHS and Local Authority commissioners.

Approach to Productivity




                                         24
In addition to the 3% CRES requirement across all commissioned providers, the
PCT has carried out a review of the productivity opportunities available and is
developing a series of contract limiters to ensure delivery of productivity
improvements within year. The benchmarking analysis performed by the SHA in
relation to acute (general hospital) care suggests productivity gains of up to
£19.4m can be made by matching the efficiency of the top 25% of NHS Trusts
nationally.

The analysis highlighted the following areas:-


                                                                 Potential Savings
                                                                       £000

Non elective admissions                                                9,165
Elective (planned) admissions                                          5,592
Outpatients                                                            1,587
First to follow up outpatient ratios                                   3,079

Total                                                                 19,423

This analysis is currently being updated by Tribal Consulting using the latest
available data.

The PCT’s own analysis of Standardised Admission Ratios (SARs) confirms that
there is excess activity in elective activity; non elective activity is currently below
national indicators for the PCT.

The latest SARS data indicate the following (against a national benchmark of
100):-

    •   Elective admissions -106.8
    •   First outpatients – 102.7
    •   Follow ups – 110.9
        For the above we are working with the PBC consortium and Trusts on
        plans to bring activity in line with the national standard.
    •   Non elective - 90.2 – the aim would be to restrict activity to this level but
        target a reduced spend in length of stay and rehabilitation where the PCT
        is an outlier.

National programme budgeting information has highlighted that the PCT may
spend more than expected in the following areas:

    •   Primary care (not prescribing) – see below
    •   Cardiovascular (predominantly stroke care) – see below
    •   Learning difficulties – we have reduced spend in this area by £1m since
        the benchmarking data was released.


                                          25
   •    Renal – this relates mainly to specialist commissioning and we have
        challenged the South West team to bring South Gloucestershire
        expenditure more into line with comparable PCTs.

This information has been used to inform the PCT’s decisions about additional
investments in these areas, for example: planned investments in stroke and
cardiac care are being incorporated into the 2009/10 CQUIN programme rather
than being subject to an additional recurring investment. Differential inflation is
also being considered in primary care. The programme budgeting data is
currently being analysed nationally and will be reviewed when available.

A review of the NHS productivity data indicates that at provider Trust level there
is significant opportunity for productivity gain as follows:-

                                             North Bristol NHS   University Hospitals
                                                   Trust             Bristol NHS
                                                                  Foundation Trust
                                                  £000                  £000
Length of stay                                   14,800                10,600
Pre op bed days                                  11,800                 8,900
Did not attends (DNAs)                            1,200                 1,500
Follow ups                                        2,400                 2,200
Day surgery                                      minimal               minimal

Total                                             30,200               23,200

Taking all this together, the data indicates a high level of productivity gain that
needs to be delivered across the health system. To ensure delivery of this
productivity, and linked to SARs, the PCT is proposing negotiating contract
limiters aimed at defining levels of activity that the PCT should reasonably be
expected to commission for a population of its size and make up. This approach
is supported by other local PCTs and the following have been actively discussed
with provider organisations:-

   •    Elective intervention rates

   •    First to follow up ratios

   •    Consultant to consultant protocols

   •    Readmission rates

   •    Non elective intervention rates

   •    Length of stay




                                          26
Based on collective discussions with Practice Based Commissioners as part of
the Operational Planning process, an indicative referral rate per 1,000 population
is being finalised with the Practice Based Commissioning Consortium, based on
national comparative figures and affordability in line with the PCT’s resource
allocation. This will be supported by SAR based maximum rates agreed with
Trusts for both elective and non-elective admissions, together with contract
limiters for other points of entry / demand into secondary care (including new to
follow up outpatient ratios, consultant to consultant referrals (including from
A&E), admissions from medical assessment units etc). To support these limiters
the PCT has been working with its Practice Based Commissioning Consortium to
develop a significant programme of service change. This will include:-

   •   A single point of access (SPA) for non elective admissions

   •   The roll out of the successful virtual ward programme where GPs and
       local health care professions maintain patients in their own homes.

   •   A continuation of the current process of in practice ‘peer’ reviews of out
       patient referrals.

   •   Supporting the delivery of existing and new RUM schemes

The Consortium has accepted a significant role in managing these system
changes and has confirmed that this will form a key part of the 2009/10
commissioning plan to be agreed with the PCT. Taken together the PCT
believes that it is realistic to expect £6m to be delivered through contract limiters
and RUM. This is after an anticipated investment of £2m to support the change.

To ensure that collective responsibility is maintained for the achievement of
activity within planned levels, the PCT is working jointly with the Trusts to
develop action plans which will clearly define the respective actions to be taken
in respect of controlling activity within the levels specified by the contract limiters.
Actions to be taken by relative bodies are:-

              PCT Actions                                 Trust Actions

Strengthened peer review of referrals Strengthened             monitoring    and
within general practice                    implementation      of   the   agreed
                                           consultant to consultant referrals
                                           protocol
Agreement with PBC commissioners Implement changes to bring pre-
on working within target referral rates    operative bed days within the top
                                           quartile nationally
Focusing PBC commissioning plans on Agreement on phased reductions in
elective   and      non-elective     care, bed base as part of planned progress
supporting activity within planned levels towards 2013/14 levels as set out in


                                          27
(with associated incentives)                the Bristol Health Services Plan,
                                            supported by length of stay reduction
                                            programme
Working with Trust and other                Working with PCTs to identify service
commissioners to identify service           redesign opportunities to deliver
redesign opportunities to deliver           reduced SARs towards national
reduced SARs towards national               comparators
comparators
Implement       integrated    discharge     Enact agreed policies for elective
management teams within PCT                 procedures of limited clinical value
provider       arm       and      South
Gloucestershire Council to support
reductions in delayed discharges
Implement a Single Point of Access     Review clinical practice to ensure Trust
(SPA) to reduce and             supportworks within national new to follow up
unplanned care pathways                outpatient benchmarks
                                       Advocating and monitoring the use of
Roll out successful virtual ward pilot in
priority areas                         community alternatives, as appropriate,
                                       for example within A&E and MAU
Monitoring and supporting the delivery Monitoring and supporting the delivery
of the contract terms                  of the contract terms

Work on delivering productivity continues with an aim to increasing the savings
and bringing the PCT, as a minimum, in line with national averages. The PCT is
currently reviewing the following areas with a view to releasing additional
savings:-

   •   The inflation uplift on PMS contracts

   •   The use of LES/DES payments to general practice – with a view to using
       existing resource to better support service change effectively requiring
       additional productivity within existing levels of funding to achieve key
       priorities (e.g. increased smoking cessation, increased uptake of
       Chlamydia screening).

   •   Identifying and delivering productivity opportunities with other
       commissioned providers, including within the PCT’s own provider arm.
       Benchmarking work is currently close to completion within mental health
       services. NHS South Gloucestershire will lead the delivery of this work in
       its lead commissioning role with the Avon and Wiltshire Partnership NHS
       Trust

   •   Working closely with South Gloucestershire Council to better procure and
       market manage Continuing Health Care (CHC) spend, given indicators
       that local costs are higher than the average in the South West.


                                        28
   •   Working with NHS Bristol and North Somerset, and PCTs elsewhere, to
       review potential additional RUM schemes.

   •   Renegotiation of current non-PbR spend including reducing the current
       block funding commitment in areas of underperformance

   •   Using external support to review, and where appropriate challenge, high
       cost CHC cases

   •   Using the FESC arrangements, where proven to be effective elsewhere, to
       gain external support for reviewing the overall PCT spend profile and
       indentify and deliver more savings.

The PCT is conducting a review of its exiting RUM schemes and those that are
successfully delivering reductions in acute activity will be continued. Additional
schemes for 09/10 are being identified. Taken together and based on feedback
from Trusts these are expected to contribute £1m.


Risks and Mitigation

   •   The level of proposed contract limiters is significant and contentious and
       will meet resistance from provider organisations. To support its
       acceptance the PCT will need to work closely with providers to identify the
       service changes required – both by the providers and by the PCT /
       commissioning GPs. The PCT has planned for a significant investment
       (for example in community based services) to support the required
       changes.

   •   Additional monitoring mechanisms are being in place to capture, project
       and provide early warning of referrals or activity moving away from
       planned trajectories. This will involve Practice Based Commissioners and
       the Board, providing early opportunities for corrective action.

   •   HRG 4.0 – There is a significant difference between the PCT calculation of
       the impact of HRG 4.0 and that currently reported by provider
       organisations. The BNSSG PCTs have a higher expectation of the benefit.
       To date the provider work is at Trust level and therefore it is not possible
       to form a view at PCT level. Work is underway to reconcile and
       understand the difference with a target for completion by 30/01/09.

   •   There is a risk that it will not be possible to agree provider contracts at a
       level that is affordable to the PCT. Significant work is taking place with the
       Trusts to resolve any issues before the national deadline of 28/02/09.


                                         29
   •   Acute activity may be above the contracted level – the contract limiters will
       negate the impact of this in year such that no performance outside these
       limiters will be paid. In addition, in line with South West SHA guidance,
       elective over-performance will not be paid unless 13 week targets are met
       at specialty level.

   •   RUM schemes fail to deliver – the PCT has a rigorous project
       management regime to monitor impact and has the support of the PBC
       Consortium in delivering many of the schemes. No RUM scheme will be
       accepted in the plan unless it is backed up by a supporting contract term
       or evidence that it clearly offers better VFM and it can be delivered within
       the agreed timescales. Contract terms are being put in place to support
       delivery, reflecting the more rigorous approach adopted in the current
       financial year. The PCT also has a broader regeneration programme in
       place for 2009/10 and is therefore placing less reliance on such schemes
       in 09/10.

   •   CHC spend may be above budgeted levels – The PCT has introduced a
       robust mechanism for monitoring in year performance and as described
       above is working closely with South Gloucestershire Council on future
       contracting arrangements and market management. The PCT is also
       considering a proposal for an external review of areas of high cost spend.

   •   The PCT will need to continue to regenerate significant sums in future
       years. The PCT must ensure that it is organized to deliver this and that it
       works closely with the PBC Consortium and providers to do so.

   •   Unanticipated changes/pressures – As in any healthcare organisation
       there is always a risk of unanticipated changes. This is mitigated by the
       PCT held contingency and the improved reporting and control
       mechanisms that the PCT now has in place.

Capital

The PCT has a significant capital programme for 2009/10 which consists of the
following:-

                                                                  £000
Yate health centre                                                6,126
Cossham hospital                                                  2,293
IM&T                                                               570
Backlog maintenance                                                711
Other                                                              990
Total                                                             10,690


                                        30
The plan also includes the impact of impairments on facilities as follows:-
                                              £000
Yate Health Centre                            2,000
Cossham Hospital                              3,500

At the moment these represent planning totals based on best information
available. They may therefore change in year.




                                        31
      Section 5 – Ensuring Appropriate Levels of Separation
                 with the PCT’s Provider Services

The PCT is committed to ensuring fair and transparent separation between its
commissioning and provider responsibilities, such that the PCT’s current provider
services are ultimately commissioned equitably to those provided by other
commissioned providers.

To this end, the PCT has already implemented a number of actions to progress
separation, which include:

      Establishment of a separate Provider Board, acting as a sub committee to
      the PCT Board
      Separate reporting of performance to the Board
      Development of a separate Provider Strategy, together with supporting
      business planning arrangements
      Services commissioned under a formal NHS contract between the PCT’s
      commissioning and provider ‘arms’
      Separation of commissioner and provider budgets
      ‘Chinese Wall’ arrangements implemented to ensure no conflict of interest
      or advantage where the provider arm responds to commissioner tenders
      Clarification of individual Board member roles, to ensure clear oversight
      and sponsorship of provider priorities

Working within the PCT’s broader Strategic Plan, the following additional steps
are planned in 2009/10:

      Adoption of the national Community Services contract from April 2009
      (including contract penalties and CQUIN payments where applicable e.g.
      in support of the roll out of RIO)
      Conclusion of discussions with South Gloucestershire Council on the
      possibility of shared strategic leadership for PCT services under the wider
      PCT and Council Integration Programme (March 2009)
      Completion of the separation of PCT support functions, including clinical
      governance and HR (May 2009)
      Completion of a joint Primary and Community Services Strategy with
      South Gloucestershire Council (September 2009)
      Completion of a community services needs assessment, building on
      existing locality profiles and the draft Joint Strategic Needs Assessment
      (September 2009)
      Reporting by service line as part of Practice Based Commissioning
      contract monitoring (September 2009)
      A review of priority community services in collaboration with Practice
      Based Commissioners, building on analysis already undertaken in support
      of the PCT’s RUM programme and the recent review of children’s services
      (in which health visiting has been re-specified). Consideration of re-


                                       32
procurement will be considered in line with the PCT’s Contestability
Framework (for example if services are found to be of poor quality or value
for money, or are to be subject to significant re-specification) – September
2009
Confirmation of staff interest in the right to request consideration of either
Social Enterprise or Community Foundation Trust models (October 2009)
Completion on proposals for the future organisational form of provider
services (October 2009)
Review the PCT Contestability Framework and Procurement Strategy as
required (October 2009)
Finalisation of plans and arrangements for the use of community NHS
estate (March 2010)




                                  33
                  Section 6 – Supporting Priorities
Contestability

The PCT has an established Contestability Framework and Procurement
Framework. Current plans for 2009/10 include:

       Implementation of tender decisions made in 2008/9 in relation to dental
       provision in Bradley Stoke, a new 8-8 health centre and Black Horse
       Medical Centre
       Contesting primary care, nursing and pharmaceutical services in Leyhill
       and Eastwood Park prisons
       Tendering new primary care mental health services as part of the national
       Improving Access to Psychological Therapies initiative
       Contesting general practice branch surgery provision in Filton (Elm Lodge
       Surgery)
       Contesting oral surgery services
       Contesting new NHS dental provision in deprived communities (subject to
       confirmation of additional funding awarded)
       Contesting minor injury services (Yate Health Centre)
       Progressing contestability plans following market analysis work completed
       across the South West, to include dementia services, childhood obesity
       and brain injury rehabilitation
       Working with Practice Based Commissioners, identifying priority
       community services for potential competition as part of the wider
       Transforming Community Services agenda
       Finalising a decision in relation to the potential tender of MRI scans and
       reporting, following the planned cessation of the national MRI contract with
       Allied Medical in July 2009
       Finalising a decision in relation to the potential tender of Patient Transport
       Services across the BNSSG health community in 2009/10
       Finalising with the Board a decision on whether to contest out of hours
       services in 2009/10

Information Management & Technology (IM&T)

Priorities for IM&T in 2009/10 directly link to the PCT’s Operational Plan priorities
and National Programme for IT (NpfIT) deliverables:-

   •   Receiving weekly data from NBT and UHB in support of key contract
       performance indicators
   •   Improving data and financial reporting to Practice Based Commissioners
       (including community service performance)
   •   Supporting the implementation of the National Care Record System
       (NCRS) in provider Trusts
           o BT Cerner with North Bristol NHS Trust


                                         34
           o BT RiO in Avon and Wiltshire Partnership Trust
           o BT RiO within the PCT’s own provider arm
   •   Delivering Electronic Prescribing Service (EPS) within practices and
       pharmacies
   •   Prisons – Deployment of nation-wide clinical system solution to Eastwood
       Park and Leyhill prisons
   •   Ensuring the new NHS Treatment Centre in Emerson’s Green has
       appropriate IM&T systems including network interfaces to allow key data
       sharing with NHS partners
   •   Ensuring good governance on data security including the completion of
       encryption roll out.
   •   Implementing any appropriate changes on GP System of Choice

The PCT will continue to work with the Avon IM&T Consortium (AIMTC) on
delivering these priorities and ensuring an equitable approach is taken to
supporting priority development across providers.

Workforce

The PCT’s strategic priorities have a number of implications for workforce,
including:

   •   A significant and increasing shift of care so that many more staff will work
       in community settings, including an expansion of services directly provided
       in primary care (e.g. primary care mental health services) and in
       individual’s homes
   •   Greater integration, and where appropriate, joint leadership and / or
       management of health and social care teams – with progress towards
       providing a more seamless service across health and social care with
       some new roles spanning health and social care responsibilities
   •   A wider range of organisational settings; linked to an expansion in the
       range and type of organisations commissioned to provide services as part
       of the NHS (e.g. independent and third sector organisations)
   •   A new model and focus of care towards an individual’s needs and
       preferences, with patients and professionals increasingly jointly agreeing
       the pathway or plan of care and supporting patients to navigate into and
       out of health and allied services, considering a choice of provider,
       treatment and care setting
   •   Greater (sub) specialisation and service centralisation in some very
       specialised services where there is evidence that this provides improved
       outcomes for patients
   •   An increasing separation of the PCT’s commissioning and provider
       functions. For some staff undertaking ‘shared’ or support roles, this may
       mean some changes to their future job role




                                        35
During 2008 and as part of the World Class Commissioning assessment process,
the PCT took the opportunity to review progress made, and identify future actions
in respect of developing its own workforce so that it is fit for the future and
promotes the PCT’s vision – to maximise the health and well being of people in
South Gloucestershire.

Recognising that its staff are its most valuable resource, the PCT is committed to
ensuring that all commissioned providers (including its own provider arm):

   •   Actively support staff to promote honesty, probity, accountability and the
       responsible and effective use of healthcare resources.
   •   Support staff in organisational, professional and personal development
       planning.
   •   Support staff from black and minority ethnic backgrounds to ensure equal
       access to employment and development opportunities.
   •   Proactively promote equality schemes around race, disability and gender.
   •   Recruit staff working within current employment legislation, making
       sufficient pre and post employment checks to ensure the clinical and
       personal safety of patients and other staff.
   •   Ensure that staff adhere to relevant professional codes of practice and
       that there are systems in place to identify and manage poor performance.
   •   Ensure that staff have the information, skills and support to adopt and
       develop best working practice.

More specifically the PCT as an employer will:

   •   Review the organisational structure and its effectiveness, ensuring that the
       right people are in the right roles. This includes progressing the work
       undertaken already in separating the Provider Services. In reviewing the
       structure, consideration will be given to providing a career structure
       particularly where there are skills shortages and developing existing staff
       as part of succession planning.
   •   As part of the above, the PCT will ensure that all staff have the right skills
       and knowledge to do their roles. The PCT aims to improve on the
       numbers of staff having Performance Development Reviews (PDRs) and
       who have PDPs, which will be measured through the Staff Attitude
       Survey. This includes a focussed piece of work regarding implementation
       of the Knowledge and Skills Framework and e-ksf.
   •   Continue working to further develop and enhance leadership capability in
       the organisation.
   •   Roll out a programme of commissioning skills development and training,
       and enhanced induction, in support of World Class Commissioning
       competencies and linked to the PCT’s strategic priorities
   •   Implement the Communications Strategy which has a focus on internal
       staff communications and engagement. The PCT aims to promote
       interest and understanding of its core business and ensure that staff


                                         36
       receive the right information, using different media in order to do their jobs.
       The PCT is also keen to receive feedback from staff and work will be done
       to build on what has already been achieved in order to encourage this.
   •   Retain existing staff and attract new recruits through being an employer of
       choice. The PCT will progress work already started in creating a healthy
       workplace by improving the environment, managing absence and
       proactively addressing stress and security issues in the workplace.

As a commissioner, the PCT will:

   •   Take on responsibility for agreeing priorities for the Service Improvement
       Fund for the Avon and Wiltshire Partnership NHS Trust from April 2009.
       This will be managed with clinical involvement from both organisations
       and ensuring fit with the service priorities of associate commissioners,
       overseen through regular quality meetings.

   •   Work alongside the Department of Health and UK Specialist Hospitals to
       plan workforce and training provision in the new Avon, Gloucestershire
       and Wiltshire NHS Treatment Centre scheme

   •   Progress the initial pilot of a new workers who undertake combined NHS
       and Local Authority roles to provide a seamless service to local people,
       with South Gloucestershire Council, as part of the development of a wider
       joint workforce strategy

   •   Plan workforce requirements (in terms of numbers, skill mix and new
       roles) in support of larger scale service developments, for example the
       Yate Health Centre and Cossham Hospital Developments.

   •   Work to integrate the NHS and Local Authority employed teams to provide
       an integrated hospital discharge team

   •   Ensure workforce changes do not adversely affect commissioned
       performance; for example by monitoring the impact of vacancy control on
       contracted performance

   •   Support the professional development of clinical staff through a new
       Associate Director (Clinical Development) post within the PCT, which is
       providing additional support to clinicians engaging in commissioning,
       service redesign and innovation

Emergency Planning

NHS South Gloucestershire has worked closely with partners in the Local
Resilience Forum during 2008/09 to further develop and refine arrangements to



                                         37
manage the response to an influenza pandemic in accordance with the
objectives set in the National Operating Framework 2008/09 (Department of
Health, 2008c). The recent DoH Pandemic Influenza Preparedness Self
Assessment showed high compliance, but ensure that the plans are robust,
continued work is focusing on:

   •   Developing systems and processes for distribution of anti-viral medication,
       in particular to fit with the implementation for the National Flu line service
       by April 2009
   •   Testing of multi-agency arrangements through a programme of exercises
       commencing April 2009
   •   Appointment of a specific post to work with primary care contractors to
       ensure business continuity plans are of sufficient quality to provide an
       acceptable level of resilience - to have revised and updated business
       plans by December 2009

Wider emergency planning will focus on ensuring appropriate training of staff at
different levels, linked where appropriate to exercising and testing plans. The
following plans will be reviewed and either revised or further developed

   •   The pan-Avon strategic major incident plan during February 2009 to be
       ready for consultation in March 2009.
   •   CBRN (Chemical, Biological Radiological and Nuclear) preparedness
       developing capabilities in line with the requirements of the Home Office
       Model Response document
   •   Developing flood resilience, lessons learnt from the LRF Multi-Agency
       Flood Plan test “Exercise Nemo” incorporated into the multi-agency flood
       plan and where necessary into the plans of individual NHS organisations
       by October 2009

World Class Commissioning

The PCT has been assessed against the new national World Class
Commissioning (WCC) competencies for the first time in 2008. Based on initial
feedback and the final assessment report the PCT has developed an action plan
for 2009/10 to support the PCT’s onward development.

This includes:

   •   Updating the PCT’s 5 Year Strategic Plan to better articulate the PCT’s
       vision and priorities
   •   Priority actions to be taken in support of the PCT’s WCC Development
       Programme, including details of areas in which progress might usefully be
       made in partnership with other PCTs




                                         38
   •   Plans to make further progress against the national WCC competencies
       and how this will support the PCT in achieving its strategic priorities and
       milestones
   •   An overview of the PCT’s Transforming Community Services plans,
       including the steps that will be taken to achieve further separation
       between the PCT’s commissioning and provider functions
   •   Key actions to be taken as part of the PCT’s agreed Organisational
       Development Plan
   •   A review of the PCT’s 2009/10 WCC outcomes and trajectories /
       assurance programme

Practice Based Commissioning

A new PCT wide Practice Based Commissioning Consortium will go live from
April 2009 and is already active in shadow form. The Consortium is becoming
increasingly key in supporting service change and transformation initiatives on a
PCT wide basis.

Actions in 2009/10 include:

   •   Early consideration and agreement of the Consortium’s 2009/10
       Commissioning Plan (in line with the Operational Plan and Strategic Plan
       and focusing on elective and non-elective activity in line with the PCT’s
       priorities)
   •   Realignment of the PCT’s management structure to provide direct support
       to the Consortium (commissioning, finance and information)
   •   Improvement the provision of monthly finance and activity information,
       including detailed community services reporting by September 2009
   •   Building engagement with the Consortium on care pathway design and
       operational planning
   •   Support for the PCT’s Transforming Community Services programme

Reputation Management

The PCT has well established partnership arrangements with local key
stakeholders, and is recognised as a leader of the NHS locally (as evidenced by
recent World Class Commissioning stakeholder survey results).

The PCT acknowledges that a positive reputation rests on the delivery of key
national and local commitments, and has consequently prioritised key milestones
for 2009/10, within the broader framework of the PCT’s strategic priorities and 5
year plan. Clear lines of leadership have been agreed in respect of each target
and progress will be reported at Board level; effectively acting as corporate
objectives. A review has been undertaken of the PCT’s structure and capacity to
better align resources to these milestones, agreed with the Board.



                                       39
The PCT has developed a comprehensive Communications Strategy and
Organisational Development plan, with the associated action plans being
implemented. The emphasis of the Communications Strategy is to build on
existing external relationships, to strengthen engagement with people living in
South Gloucestershire and to maximise the effectiveness and impact of
improving health messages. Joint work with partners, including the Local Area
Agreement, Planning for Real and the Joint Strategic Needs Assessment,
together on work our key community developments (Yate, Thornbury, Frenchay
and Cossham) have acted as cornerstones for an increasing dialogue with, and
accessibility for, local residents.




                                      40
                                                                       Appendix 1
                          PCT Vision and Values
The PCT works within the principles of the NHS Constitution which has now been
published nationally. The PCT has developed, and consulted on, its local vision
and values, which are set out below, and act as the framework within which the
Operational Plan has been developed.

The PCT’s vision is:

“To maximise the         health   and    well   being    of   people    in   South
Gloucestershire”

The core values that we have developed with staff and Board members are:



    •   We listen to local people in deciding how local services are developed
        and improved

    •   We buy a range of services that are safe, of high quality, are provided as
        close as possible to people’s homes, and are responsive to the needs
        and choices of individuals and their carers / families

    •   We pay particular attention to promoting good physical and mental
        health, and supporting individuals and communities who have
        traditionally experienced poorer health

    •   We are accountable to our stakeholders in all we do, ensuring that our
        decisions are transparent and open to scrutiny

    •   We recognise that we need to work collaboratively and pro-actively with
        others to achieve our vision and to ensure easily accessible and ‘joined
        up’ services

    •   We establish and maintain effective partnerships with other organisations
        and with the public

    •   Where necessary, we challenge or contest the way in which services are
        currently provided where we feel this will improve service quality or value
        for money

    •   We use the resources available to us responsibly, commissioning
        clinically and cost-effective services, ensuring value for money for tax-
        payers and considering the impact of our decisions on the environment




                                        41
•   We value the role of clinicians and other staff, both in directly providing
    care and in managing resources, driving innovation, leading service
    improvement and improving patient experience

•   We support individuals and local communities to take appropriate levels
    of responsibility for their own health and well being, providing easy to
    access information and clearly sign-posting sources of help and advice

•   We promote and support a healthy work / life balance amongst our own
    staff

•   We value our staff and the skills and experience that they bring, and will
    continue to build commissioning capacity and effectiveness to world class
    standards, supporting staff to fulfill their responsibilities and potential




                                    42
                                                                                                                                 Appendix 2
                                           Operational Plan 2009/10 - Key Local Milestones

STRATEGIC PRIORITY                 KEY MILESTONES FOR DELIVERY IN 2009/10                 WCC OUTCOME                        RELATED LAA TARGET
(1) Improve the health of people   1. Reduce levels of obesity in reception children to   Tackling childhood obesity.        Obesity among primary school
 living in South Gloucestershire   10% and in year 6 to 14%                               Increasing life expectancy.        age children in reception year
  by effective partnerships with                                                          Reducing inequalities.
   other organisations and with
            local people
                                   2.To contribute to achieving a national target of an   Reducing over 16 smoking           16+ current smoking prevalence
                                   adult smoking rate of 21% or less by helping 1,332     prevalence. Increasing life        rate
                                   local people to stop smoking. To reduce the local      expectancy. Reducing
                                   percentage of women who smoke during                   inequalities. Reducing
                                   pregnancy to below 10%                                 cardiovascular disease (CVD)
                                                                                          mortality
                                   3. To ensure a co-ordinated multi-disciplinary team    Reducing length of stay in acute   The number of emergency bed
                                   approach for long term conditions to be in place by    settings. Increasing life          days per head of weighted
                                   31 March 2010 in each locality, with a single point    expectancy.                        population
                                   of access
                                   4. To achieve and maintain a maximum 6 week                                               Return to employment / reduction
                                   wait for primary care mental health counselling                                           in reliance on benefits
                                   service from December 2009.




                                   5. To ensure timely implementation of NICE             Increasing life expectancy.        All age, all cause mortality rate
                                   guidance (within 4 weeks of implementation for
                                   Technical Appraisal Guidance) and equitable roll
                                   out across all healthcare sectors
                                   6. To implement an agreed integration programme           Reducing average hospital            The number of emergency bed
                                   with South Gloucestershire Council to include:            length of stay. Supporting           days per head of weighted
                                   establishment of Single Point of Access to                individuals who choose to die at     population
                                   emergency support, service integration across             home.
                                   provider services, and closer integration between
                                   health and social care teams supporting discharge
                                   from hospital by October 2009

                                   7. To commission comprehensive primary care               Reducing average hospital            All age, all cause mortality rate
                                   based brief intervention support to help at risk          length of stay. Increasing life
                                   individuals to reduce their alcohol consumption, in       expectancy.
                                   at least half of local practices by March 2010


(2) Reduce differences in health   8. To target smoking cessation services at                Increase life expectancy at birth.   All age, all cause mortality rate
 between people and places in      communities with the highest prevalence, ensuring         Reducing over 16 smoking
     South Gloucestershire         50% more successful quitters / 1000 population            prevalence. Reductions in
                                   from the most deprived quintile compared with the         cardiovascular disease (CVD)
                                   least                                                     mortality.
                                   9. To reduce the level of teenage pregnancies from                                             Under 18 conception rate
                                   30.8 (2006 levels) to 21.6 per thousand females
                                   aged 15 – 17 by March 2010
                                   10. To improve blood pressure monitoring rates in         Increasing life expectancy.          All age, all cause mortality rate
                                   individuals with a learning difficulty towards the rate   Reducing cardiovascular
                                   of the general population in South Gloucestershire        disease (CVD) mortality

                                   11. To reduce levels of self harm within the 3 local      Prison health - reducing self
                                   prisons to national average benchmarks, with a            harm & suicide
                                   particular focus in Eastwood Park Prison
                                   12. To contest prison primary care service (Leyhill),     Prison health - reducing self
                                   prison nursing services (Eastwood Park and                harm & suicide
                                   Leyhill) and pharmacy services (Eastwood Park
                                   and Leyhill) to achieve improvements in
                                   accessibility, quality, integration and safety.




                                                                         44
(3) Bring more health services   13. To achieve timely assessment and review of          Reducing average hospital          The number of emergency bed
   closer to local people by     patients for Continuing Health Care funding with the    length of stay                     days per head of weighted
 delivering more primary and     current backlog of cases cleared by December                                               population
  community-based services       2009 and regular reviews in line with national
                                 recommendations
                                 14. Responding to individual preferences, reduce        Increase the percentage of all     The number of emergency bed
                                 by 10% year-on-year the number of adult deaths in       deaths that occur at home          days per head of weighted
                                 acute hospitals supporting individuals who wish to                                         population
                                 Be supported to die at home
                                 15. To agree the model of rehabilitation services                                          The number of emergency bed
                                 and complete the outline brief for the services to be                                      days per head of weighted
                                                                                         Reducing average hospital
                                 commissioned from the Frenchay site from                                                   population
                                                                                         length of stay
                                 2013/14, including consideration of further public
                                 engagement or consultation, as appropriate
                                 16. To approve the Cossham service developments         Reducing average hospital
                                 and capital Full Business Case by May 2009.             length of stay




                                 17. To progress the review of community facilities      Reducing length of stay in acute   The number of emergency bed
                                 in Thornbury – with the Strategic Outline Case          settings.                          days per head of weighted
                                 produced by May 09, and Outline Business Case                                              population
                                 achieved by Nov 09

                                 18. To open the new community health centre in          Reducing length of stay in acute
                                 Yate in November 2009                                   settings
                                 19. To achieve more efficient use of healthcare         Reducing length of stay in acute   The number of emergency bed
                                 resources                                               settings                           days per head of weighted
                                 - reduce unnecessary pre-operative stays in                                                population
                                 hospital
                                 - reduce unnecessary follow ups in secondary care
                                 - reducing lengths of stay avoiding unnecessary
                                 delays
                                 - avoid unnecessary admissions to hospital




                                                                     45
                                   20. To commission new primary care based               Reducing average hospital          The number of emergency bed
                                   services, including:                                   length of stay. Supporting         days per head of weighted
                                   - expansion of GP with Special Interest services       individuals who choose to die at   population
                                   - community respiratory services                       home.
                                   - palliative care support infrastructure
                                   21. To improve access, including:
                                    - 13 weeks referral to treatment times delivered at
                                   specialty level for hospital services
                                    - maximum six weeks waits from referral to
                                   assessment in community mental health services
                                    - extend opening hours in general practice
                                   available to all patients by March 2010
                                    - Year-on-year improvements in numbers of people
                                   accessing NHS dental services


 (4) Improve the experience of     22. To deliver local Commissioning for Quality and     Reducing average hospital          The number of emergency bed
  local patients when they use     Innovation (CQUIN) targets for improvements in         length of stay                     days per head of weighted
   health by making sure that      quality of services across commissioned services                                          population
  health services are provided
promptly, safely and effectively
                                   23. To achieve all NHS targets within the national     Improving life expectancy.         All-age, all cause mortality rate
                                   requirements                                           Increasing access to diabetic
                                                                                          retinopathy. Reducing over 16
                                                                                          smoking prevalence.

                                   24. To implementation new pathways for acute           Improving life expectancy.         All-age, all cause mortality rate
                                   myocardial infarction and acute stroke during 2009     Reducing cardiovascular
                                                                                          disease (CVD) mortality



                                   25. To implementation of the Primary Care Trust's      Reducing length of stay in acute
                                   "Maternity Matters" action plan within agreed          settings.
                                   timescales




                                                                       46
26. To implement the new AGW NHS Treatment        Reducing average hospital
Centre implemented on time (November 2009), and   length of stay
planned capacity utilised




                                47

								
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