Support for Chronic Disease Management Service design & implementation.

1. Thames Valley support Programme to Deliver Outcomes Above Developing Thames Valley’s Ways of Working “Rule Book” Service Redesign & Reconfiguration @ Local or Cluster Level Managing Contract Placement & Performance @ Thames Valley Level Building Clusters of Service Commissioning Plans @ 3 Levels • Develop new ways of working and plurality of service provision where local care pathway developments and problems drive the approach and level of aggregation; • Redesign service where @ risk factors exist e.g. SCBU/PICU/Obstetric services in light of Children’s NSF and Bill; • Redesign service where excess demand oversupply/critical mass factors exist e.g. ENT, Ophthalmics, Vascular, Emergencies. • Contract negotiations and administration service to support Payment by Results; • Contract currency development and agreed Thames Valley menu of services for “choice”; • Contract monitoring and operational gearing performance management including financial risk analysis and pooling, and relationships with the Monitor (Regulator). • Specialist/tertiary level service plans @ Thames Valley Level; • Local clusters of commissioning partnerships for some local services e.g. where economies of scale can be applied and Local Authorities partnerships are in place; • GP/practice-based commissioning where appropriate and driven by local circumstances. Development Outcome FINANCIAL CONTROL FRAMEWORK Development Outcome SERVICE DESIGN & COMMISSIONING PLANS Development Outcome SERVICE REMODELLING PRIORITIES AGENDA • Support for Chronic Disease Management Service design & implementation. • Workforce development & planning requirements e.g. to deliver “Community Matrons” by 2008. • Support for patient communications & engagement in service redesign & reconfiguration. • Financial risk assessments & modelling esp. low volume/high cost services & referral gateways & arbitration framework. • Quality standards development as part of NSF delivery Performance Management System. • Agenda for Change full financial impact assessment inc. new role development, training implications, double run costs, & appeal risks. • Decision support system & information flows. • Lead PCT role & structure of delegated authority & accountability. • PCTs’ role development as a future service commissioner/as part of a commissioning agency. Summary prepared by Dr. Patricia Oakley, Director, Practices made Perfect Ltd., who facilitated the discussions held on 1st October 2004.

2. Primary Care Led NHS Elderly Trauma Centre • Parkinsons • ALC • Dementia Specialist Medical • Dermatology • Oncology • Diabetes M.I.U. Pain Clinic Carer Support • Acupuncture • Osteopathy • Chiropractice GPs Specialist Mental Health Day Surgery • CPN • Psychology • Psychotherapy • Counselling X-ray & Imaging

3. Care Planning & Management Involving Patients & Carers Complex Case Management Programmewith a Case Manager who coordinates care from several groups of experts joining up care for patients and carers. c. 20% of chronic Care Management (but c.80% of resources). Level 3:Highly complex patients who need case management. Disease Care Management Programmeand Proactive support from Multi-disciplinary Teams using Care Protocols & shared information. Level 2: High risk patients who need disease management support e.g. diabetes. 70-80% of Chronic Care Management. “Expert Patient” Programmesand Carer Support involving Voluntary Groups eg. BDA, Age Concern etc. Level 1: right support, many people can look after themselves, living with and managing their condition(s). Health Promotion Health Promotion Programmeseg. Diet, exercise, and education.

4. NHS Direct on-line triage service Ambulance/Paramedic Primary and Level 1 assisted triage at roadside Community Care Trusts receiving hospital GP Practices and • helipad Level 2 community nurses • 24hr full A&E receiving hospital organised under Primary Level 3 Care Trusts • consultant cover and • helipad receiving hospital led service • 24hr full A&E • 24hr A&E service • full backup in consultant cover and led • Minor Injuries Units - neuro/head service • some specialist • Drop-In Centres - trauma/ortho clinical backup but • some specialist clinical • Healthy Living - cardio/CLU not full portfolio of backup but not full Centres services • full backup in: portfolio of services • High St Pharmacy - imaging • some specialist Services (upgraded) • full backup in: - pathology backup in • Approved helplines - imaging - theatres diagnostics and and on-line services - pathology support but not • @ Home Services - theatres 24hrs • Night Sitting and REHABILITATION SERVICES • Respite Care Specialist Hub Networked Services • PT • SALTs Community-based • OT • Psych Teams for long-term maintenance care Integrated Health and Social Care Provision Trauma System/DGHs/Primary and Community Care Services