Cumbria Cluster and Cumbria CCG Integrated Strategic and Operational Plan 2012/13 TO 2014/15

1. Cumbria Cluster and Cumbria CCG Integrated Strategic and Operational Plan 2012/13 TO 2014/15 April 2012 v 5.2

2. CONTENTS 2

3. EXECUTIVE SUMMARY During 2012/13 the health economy in Cumbria must keep a grip on finance and performance and improve quality and outcomes against a backdrop of transition to a new commissioning architecture. • The 2012/13 Integrated Strategic and Operational Plan (ISOP) for Cumbria has three main objective: • To keep a grip on performance and finance during a year of significant changes required by the Health Bill; • To deliver improved quality and patient outcomes; and • To facilitate transition to the new commissioning architecture. • PERFORMANCE • Performance has improved in Cumbria over recent years alongside demand management and reductions in unplanned care. • However there are a number of performance issues still to be addressed and these include: • Stroke and RTT at NCUHT; and • A&E, Stroke and MSA at UHMBFT. • NCUHT has been clearing a backlog in Ophthalmology and Gynaecology cases since January 2012. A recovery plan has been agreed with the Trust and is being performance managed weekly by the CCG. From June 2012 the Trust will achieve all RTT indicators. NCUHT has improved in year against the stroke performance indicator and will be fully compliant by April 2012. • UHMBFT • UHMBFT has consistently failed the A&E and MSA indicators since late 2011. A series of operational changes have been implemented from 12th March 2012 and these will improve the emergency flow through the system. Early analysis shows improved performance and a trajectory will be agreed with the Trust to achieve the 95% target by early 2012/13. It is expected that EMSA will be compliant by April 2012. A fundamental overhaul of Stroke services at UHMBFT may mean that this indicator continues to be variable during 2012/13. • The CCG and NHS North have been working with UHMBFT to develop an action plan to eliminate clinically unjustified MSA. The plan has yet to identify timescales and outcome measures however these will all be agreed and embedded into the Programme Office at UHMBFT. The plan will be signed off by the end of March 2012 and weekly monitoring will be in place between UHMBFT and the CCG. • FINANCE • Commissioners have moved to a position of recurrent balance following problems in 2010/11. The CCG has also agreed realistic activity plans with acute providers which should minimise risk during the year. Contracts were agreed in March, which is a significant step forward from previous years. • However, there is a significant challenge in terms of non recurrent funding due to: • The ambitious transformational plan for primary care and long term conditions management being developed by the CCG. The GPs have agreed that their main development priority will be improving primary care, particularly increasing capacity and reorganising urgent day time care in Barrow to improve health outcomes and reduce health inequalities; • The need for funding to support acquisition of NCUHT by Northumbria Healthcare NHS Foundation Trust; • The need to fund stabilisation of UHMBFT as part of the improvement response to recent quality issues and support the development of a clinical strategy for South Cumbria; and • Investment in health improvement initiatives (linked to primary care and long term conditions strategies) to tackle the health inequalities that are prevalent in Barrow, Carlisle and parts of West Cumbria. EXECUTIVE SUMMARY 3

4. EXECUTIVE SUMMARY (cont.) Prescribing costs have been reduced through QOF Medicine Management targets, QOF QP indicators, Specials Order Products, Scriptswitch and focusing on clinical systems and processes. Localities will continue to focus on practice outliers to further reduce prescribing costs and achieve the cost avoidance targets. Use of the national contract has driven down Continuing Care costs and this will continue into 2012/12. Each locality has been developing its Community Services base with CPFT to deliver the new clinical pathways for people with long term conditions and these will now be expanded to include the new paediatric pathways. There has been a 9% reduction in unscheduled admissions since the first phase of the Closer to Home plan started in 2007. For this final phase the CCG will focus its efforts for adult admissions on the localities with most to achieve and the delivery of the targets include paediatric admissions across all localities. • QIPP & TRANSFORMATIONAL CHANGE • Commissioners have a QIPP gap of £58m, which is in line with other similar health economies. Half of this will be met through transformational change, with 6 key programmes of change identified by the CCG: • Planned care • Unplanned care • Children and Young People • Long Term Condition Management • Primary care • Secondary care transformation & reconfiguration • The first 4 of these programmes have clear milestones and outcomes and reflect the activity plans set out in the plan and 2012/13 contracts. Primary care and reconfiguration at UHMBFT are in the planning stage and will result in further transformational change. The detailed outcome measures for these programmes are currently being determined. The QIPP gap for Cumbria as a whole is £105m but in addition there is a non recurrent issue associated with the NCUHT underlying deficit which will be addressed through the acquisition process. • BUILDING ON SUCCESS • Delivery of this plan builds upon the successof recent years. Good progress has been made during 2011/12 in delivering reductions in elective referrals through the Evidence Based Referral programme. The initial focus was on 10 procedures of limited clinical value and implemented through a robust referral management system. For 2012/13 the programme has been expanded to 60 procedures. EXECUTIVE SUMMARY TRANSITION Plans are in place to ensure effective transition to the new commissioning architecture. There is a strong CCG with good clinical leadership and involvement. The CCG has been instrumental in the planning process for this ISOP. The CCG is actively managing 100% of the delegated budget and has agreed the year end financial position with providers as well as leading the negotiation of the 12/13 contracts. The CCG is also instrumental in the reconfiguration work in both North and South Cumbria. There has always been close working relationships between the PCT and local authority which has facilitated speedy development of health and wellbeing shadow board and will ensure smooth transition of the public health function to Cumbria County Council. 4

5. SECTION 1: STRATEGIC VISION - OVERVIEW xxx xxx This Integrated Strategic and Operational Plan for Cumbria PCT Cluster builds on the progress to date in transforming the NHS in Cumbria. It sets out a delivery plan for the key initiatives that will be required to meet the Quality, Innovation, Productivity and Prevention (QIPP) challenge over a four year period. It identifies how the financial, performance and activity priorities will be met in 2012/13. It identifies the key milestones for the delivery of the transformational change which will free resources in the system to address the health inequalities that exist across Cumbria. • This Integrated Strategic and Operational plan sets out a vision and delivery plan to transform the NHS in Cumbria in line with national requirements and local need. It will deliver a fully functioning Clinical Commissioning Group (CCG) prepared and ready for authorisation and accreditation. The Plan has been developed jointly between the PCT Cluster and Cumbria CCG. • The CCG will be: • Engaging locally with populations and communities; • Undertaking effective commissioning and redesign of services to meet local need as identified in the Joint Strategic Needs Assessment (JSNA); • Working effectively in partnership with the local authority partners; and • Maintaining good relationships with local providers. • This will result in: • Improved health outcomes and reduced health inequalities across Cumbria as outlined in the CCG 5 Year Strategic Plan and Clear and Credible Plan for 2012/13; • A financially resilient health economy that provides real choice to patients; and • A high performing health economy that consistently achieves the national performance requirements and reflects what is important to patients. • Patients will see a different kind of national health service that: • Builds on the principles of Closer to Home (C2H) set out in earlier Strategic and Operational Plans; • Is much more integrated between primary care, acute hospital care, community services and social care provision; and • Supports them to manage their Long Term Conditions (LTC) better. • This updated integrated plan outlines the key activities that will build on the achievements made in 2011/12 and deliver the vision through to 2014/15 and beyond. • Planning for this year has been adjusted to reflect the achievement of the strategic objectives for Cumbria Cluster in 2011/12. • Achievements in meeting the QIPP challenge during 2011/12 have focused on transactional delivery. However, ongoing delivery of a clinical strategy and associated key initiatives will create the building blocks to underpin the transformational change in 2012/13 and beyond. • The Cluster has maintained strong oversight of the key strategic initiatives throughout 2011/12 and will continue to work with the CCG and local providers during 2012/13 to deliver whole system transformation. 1. STRATEGIC VISION

6. SECTION 1: STRATEGIC VISION – TRANSFORMATION Clinically led commissioning and better integration between Primary Care, Secondary Care, Community Care, Social Care and the Third Sector has resulted in a 9% reduction in unscheduled admissions during a period when other health economies have seen significant increases in admissions. • Cumbria has been championing clinically led commissioning for some years as part of the Closer to Home (C2H) Clinical Strategy. Critical to this model of care is a joined up approach which sees greater integration between Primary Care, Secondary Care, Community Services, Social Services and the third sector. Over the last three years the health economy we has gone some way to transforming Community Services and reduced overreliance on secondary care. Clinicians across Cumbria have been involved in the development of this Clinical Strategy and reconfiguration plans to transform how services are delivered. • As a result of this over the last 3 years non elective admissions have fallen by 9% as shown opposite. • The CCG wants to deliver the remaining elements of the Clinical Strategy systematically across Cumbria through a service model whereby: • Individuals are supported to take responsibility for their own health; • Local health services are responsive to local need; • Local communities support the health needs of their local population; • Admission to acute secondary care only happens when it is in the best interest of the patient; and • Services are safe and of the quality they would wish for themselves and their families. • Delivery of this model of care will require whole system transformation to Primary Care, Community Services and Secondary Care. • Pathways are being redesigned and some of the clinical care currently delivered to patients in a hospital bed or outpatient department will be delivered in a different way in a community setting. Staff will be equipped with the appropriate skills and competencies to deliver high quality healthcare services. Our clinical services will always be driven by clinical outcomes. This approach requires systematic and consistent information and education programmes for individuals living with a long term condition as well as programmes for professionals to ensure they have the skills to deliver services that are more responsive to individual patient need. Thirty per cent of the population in Cumbria live with a LTC. Modern health services are still organised around a medical model with clinicians taking control away from the individual. Individuals living with a LTC meet with a clinician on only a few occasions within a year however they live with their condition every day of their lives. The new service model will ensure that individuals are equipped to manage their condition every day of their lives. Primary Care will be the coordinator of services for individuals in their practice populations. Each practice will risk stratify its population, coordinate integrated clinical teams based on clinical need and develop the infrastructure to support self management. 1. STRATEGIC VISION

7. SECTION 1: STRATEGIC VISION – TRANSFORMATION (cont.) • The CCG has a clear evidence base behind its decision making through the Joint Strategic Needs Assessment (JSNA) and real time patient experience and quality information. • The JSNA draws attention to the higher than average proportion of older residents resulting in more people living with a LTC such as diabetes and dementia. There are also significant inequalities for health outcomes for children alongside a higher than national average rate for suicides. The main causes of premature mortality in Cumbria are cancer and circulatory disease with significant variation in life expectancy across the county. Equally the health economy has the challenges of clinical and financial sustainability caused in part by geography but also by how primary and secondary care services are configured. Over the next three years the QIPP gap for Cumbria amounts to £105 million therefore whole system transformation is required to address these challenges. • The CCG five year strategic commissioning plan sets out key priorities to address these needs. Delivery against the priorities are supported by six initiatives. • The six initiatives are outlined in pages 11 to 17 and include: • Planned care • Unplanned care • Children and Young People • Long Term Condition Management • Primary care • Reconfiguring Secondary Care in North Cumbria and South Cumbria 1. STRATEGIC VISION • In addition to the initiatives are cross cutting themes which are key enablers to delivery of the strategy and these include: • A refreshed approach to commissioning for quality; • A new approach to improving patient engagement and experience; • Aligning the workforce; • Developing the availability and use of patient information; and • Modernising the estate.

8. SECTION 1: STRATEGIC VISION – TRANSFORMATION (cont) There will also be greater support through decision aid tools to enable patients to take informed decisions on secondary care procedures, such as orthopaedic operations. Patients will have access to their care records and summary information will be available to all clinicians to provide better care. There will be integrated working with the local authority public health team to help improve lifestyles and stay healthier for longer and actively mobilising the many community assets. There will be greater consistency in the quality of Primary Care with an expansion of capacity in Barrow to address the health inequalities. There will be better management of long term conditions and frail older people to improve quality of life, keep people healthier for longer and reduce unnecessary admissions. Delivery of the strategy will result in shifting activity and the diagram below sets out how services will be configured. • In line with the strategic vision and the JSNA priorities the health and social care system in Cumbria in five years time will have the following characteristics: • Improved outcomes and performance; • Improved safety and quality; • Greater integration of care across pathways breaking down traditional barriers between primary, community, secondary and social care; • Clinical leadership at all levels; • Financial stability for all organisations; • Individuals supported to take responsibility for their own health care; • Meaningful engagement of patients and communities in decision making and active use of patient experience to improve care; • Greater innovation and use of technology to drive improved outcomes and transformation; • Earlier intervention through better identification of patients at risk and targeted support; and • Innovative forms of contracting which incentivise integration and joint delivery of better outcomes and quality. • In five years time there will be a higher level of engaged patients and engaged communities, with more patients taking responsibility for their own health and wellbeing. There will be better education for patients to help them co produce their care plan and manage their long term conditions. 1. STRATEGIC VISION

9. SECTION 1: STRATEGIC VISION - TRANSFORMATION (cont) A significant shift will take place across the health and social care system based on clinical pathways. Primary Care and Community Services will focus on case finding, care planning, education programmes, minor surgery and end of life care. Cumbria Partnership Foundation Trust will be a key player will be a key player in delivering community services to support LTC management and providing more community alternatives to acute secondary care. They will also provide an improved interface with North Cumbria University Hospitals Trust and University Hospital of Morecambe Bay Foundation Trust to speed up and ensure appropriate admissions and discharge. These will be co ordinated through a Single Point of Access and supported by integrated health and social care teams. There will be enhanced integration between Community Services, Mental Health Services and Social Care particularly for dementia. There will be an increased move to more community mental health services rather than inpatient care and more effective drug and alcohol services. Over the next five years there will be continued move to higher quality acute units with mortality rates in line with national averages. Provision will be from larger, more sustainable Foundation Trusts with financial stability and provision within tariff. Acute hospital services will deliver care which cannot be delivered in Primary Care or community settings and there will be more effective networking across the north of England to improve skills in Cumbria and provide specialist skills where they cannot be sustained within Cumbria. There will be full integration between Primary and Secondary Care to deliver the Emergency Floor Model and for consultant support for better long term condition management and care for frail older people in community settings. Non elective admission rates per 1,000 population will be maintained despite demographic change although there will be a particular focus on reducing the high levels of unnecessary emergency admissions in Barrow. Paediatric emergency admissions will be reduced through the implementation of a Short Stay Paediatric Assessment Unit linked to the Emergency Floor. Reductions in elective procedures of limited clinical value will create capacity in acute hospitals to repatriate routine procedures that are currently carried out outside Cumbria alongside the development of new services such as PCI which will be available during 2012/13. Integration with Social Care will focus on priority areas such as dementia and frail older people)and children and young people. There will be more integrated nursing and social care to support discharge from hospital and reduce delayed transfers of care. There will be more joint commissioning to ensure value for money and more joint deployment of technology such as telehealth. 1. STRATEGIC VISION

10. SECTION 2:TRANSFORMATION PROGRAMME Outcomes/outputs QIPP Programmes & deliverables Priorities Cross Cutting Initiatives Context • 83% of people with a long term condition to feel independent and in control of their own condition • Reduction in unplanned hospitalisation for adults with chronic ambulatory care sensitive conditions* • 15% reduction in patients using anti-psychotics (on primary care dementia registers) • 10% reduction in unscheduled admissions from  residential care homes to acute trusts • Net 2.3% reduction in adult non elective admissions • Net 5% reduction in number of elective admissions Improve care to respond to the challenges of an ageing population Quality Commission for quality and improve quality management information Long term conditions management • Deliver C2H Pathways for diabetes, respiratory, heart failure and service models for older people in care homes and end of life care • Develop a holistic strategy for long term conditions and integrated primary and community delivery models Engagement Improve patient and community engagement arrangements and arrangements for assessing patient experience Information Technology Increase capability and capacity to produce information and integrated systems to support better patient care Excess cancer & CVD deaths Children and young people • Implement short stay paediatric assessment services integrated with Emergency Floor model • Improve outcomes across 6 key pathways • Improve access to and quality of CAMHS • Improve quality of maternity and paediatrics (see Morecambe Bay programme) • 35% reduction in the overall number of paediatric non elective admissions across three years • Reduction in unplanned hospitalisation for under 19s for asthma, diabetes, and epilepsy* Improve the health of children and young people and the quality and integration of care services Health inequalities Unplanned care • Implement integrated emergency floor • Implement single point of access for urgent care • Implement new care pathways Improve mental wellbeing and reduce alcohol misuse • 13.5% of people with depression receiving psychological therapy • 48.5% of people who complete psychological therapy moving to recovery • 95% of people under adult mental illness specialties on CPA followed up within 7 days of discharge from psychiatric inpatient care • Reduction in number of alcohol related hospital admissions** Planned care • Implement referral protocols and guidelines for clinically agreed EBR procedures and increase repatriation of out of county activity • Transfer ophthalmology & MSK into community setting • Repatriate out of county activity Premature mortality 2. TRANSFORMATION PROGRAMME Reduce health inequalities and premature mortality from cancer and cardiovascular disease • Reduction under 75 mortality rate from cancer** • Reduction under 75 mortality rate from CVD** • Reduction in mortality within 30 days of hospital admission for stroke** • 85% of patients receive first treatment for cancer within 62 days of an urgent GP referral • 98% of patients receive subsequent treatment for cancer within 31 days for surgery, anti-cancer drug regime or radiotherapy treatment course (94%) • 3,807 four week smoking quitters • 20% of people aged 40-74 have been offered an NHS health check Primary Care • Reduce unacceptable variation • Implement long term conditions strategy • Deliver more focused health improvement work such as health checks and smoking cessation • Increase primary care capacity in Barrow, and reconfigure urgent day time primary care • Provide more straight forward planned care • Develop a strategy for managing the changing age and skill profile of the general practice workforce Ageing population Limited resources • 95% of patients seen in A&E in 4 hours or less • 90% of patients referred for treatment admitted within 18 weeks • 95% ambulances respond to category A calls within 19 minutes • Reduce hospital acquired infections etc. Reconfigure and modernising health services to provide more sustainable and higher quality care Secondary care transformation & reconfiguration • Deliver the North Cumbria Clinical Strategy in line with the recent NCAT review and support the acquisition of NCUHT by Northumbria Healthcare • Develop and deliver a clinical strategy for the Morecambe Bay area and ensure rapid improvement in the quality of services for: maternity; paediatrics; A&E; stroke; and outpatients 10 *New indicator – awaiting guidance on target setting ** Targets for these indicators are currently being developed with Public Health as part of transition planning to ensure future clarity on responsibilities for delivery.

11. SECTION 2: TRANSFORMATION PROGRAMME – PLANNED CARE OBJECTIVE To improve planned care quality, efficiency and access and repatriate care back to Cumbria. WHY IS CHANGE NEEDED? Levels of planned care have not reduced in Cumbria in the same way unplanned admissions have. NHS Cumbria has agreed a strategy with NCUHT to reconfigure acute services internally and address its underlying deficit in year. This requires a reduction in the cost of service delivery, achieving efficiency in service utilisation and creating opportunities to refocus activity towards repatriation of out of area activity. DESCRIPTION • Reduce activity in areas of service with limited clinical value (evidence based referrals-EBR) by implementing referral protocols and guidelines for clinically agreed EBR procedures, supported by ICT tools for procedures to be online on GP desk tops; • Increase internal efficiency to repatriate activity (Orthopaedics and PCI) currently undertaken out of Cumbria; implement theatre efficiency programme in NCUHT to increase capacity to repatriate out of area activity; and improve access to services using the Choose and Book system; • Reduce out patient activity in line with clinical models and agreed good practice targets; • Reduce length of stay and improve early discharge in Orthopaedics; • Transfer services as appropriate into community settings – Ophthalmology in North Cumbria and MSK in South Cumbria. 2. TRANSFORMATION PROGRAMME WORKFORCE IMPLICATIONS None expected. RESOURCE IMPLICATIONS 11

12. SECTION 2:TRANSFORMATION PROGRAMME – UNPLANNED CARE OBJECTIVE To redesign integrated urgent care services to reduce hospital attendances & manage care more effectively in community settings WHY IS CHANGE NEEDED? National and regional trends for urgent care admissions are rising; in Cumbria admissions were down by 8% in the last two years but concerns remain over continued high levels of urgent care admissions, particularly in Barrow. Acute trusts In Cumbria have substantial resource and demand management challenges resulting in a need for alternative solutions to hospital based care. DESCRIPTION • Implement the new integrated model for unplanned care (as agreed in North Cumbria at the Systems Board), with the following key components: • Implement the integrated emergency floor, with an improved medical assessment & observation model in urgent care services and co-location of urgent care services (A&E and PCAS) on acute sites; • Implement single point of access into urgent care; • Implement new pathways of care – see long term condition management and paediatric programs; • Provide specialist clinical out-reach support into communities; • Maximise ‘step up & down’ care in community hospital beds and ensure effective discharge/admission liaison arrangements with acute beds; and • Increase care in community settings, particularly capacity for community based short term intervention services. 2. TRANSFORMATION PROGRAMME WORKFORCE IMPLICATIONS Detailed workforce plans for Integrated emergency floor in production- expected April 2012 RESOURCE IMPLICATIONS 12

13. SECTION 2:TRANSFORMATION PROGRAMME - CHILDREN AND YOUNG PEOPLE OBJECTIVE To improve the health of and care services for children and young people. WHY IS CHANGE NEEDED? Cumbria’s acute hospitals have a high rate of admission for paediatric care and there is a focus towards ‘admission to assess’ which results in a longer length of stay and unnecessary admission for the child. An expert review undertaken in 2010 recommended services become more integrated, with more care delivered in the community and the overall delivery model for children integrated across organisational boundaries. There are concerns around maternity and paediatrics in the South of the County. There is also concern around access to CAMHS. DESCRIPTION • Improved pathways for Children, young people and families and promote greater range and use of community based and self managed care: key pathways include: Constipation; Fever; Acute respiratory; Emotional Wellbeing; Attention Deficit Hyperactivity Disorder (ADHD); Autistic Spectrum Disorder (ASD) • Deliver an integrated response to urgent care needs including development of short stay assessment services and integration of care within an Emergency Floor model and maximise range of clinical skills • Review of CAMHS service • Design a new model for working collaboratively across organisations and to deliver seamless services through the Health Builders partnership. • Improve quality of maternity and paediatrics (see Appendix 6 Morecambe Bay programme) 2. TRANSFORMATION PROGRAMME WORKFORCE IMPLICATIONS • Workforce modelling underway as part of redesign of urgent care services • Integration and co-location of staff expected in a phased approach • Staff skills training will be required and as yet unknown • Recruitment expected for some specialist clinical skills • Resource implication to be identified RESOURCE IMPLICATIONS 13

14. SECTION 2: TRANSFORMATION PROGRAMME – LONG TERM CONDITIONS MANAGEMENT common menu of services from which to create packages of care for patients; a common approach to care planning and clinical teams with the right skills. These are all underpinned by a common set of outcome measures. In order to deliver appropriate care to people with complex physical and mental health care needs and also for people who have reached the end of their lives, it is necessary to deliver care through integrated practice, community and social care, across a population base of 15,000 - 40,000, in a natural community wherever possible – i.e. bigger than most general practices. These groupings would be known as Accountable Care Partnerships (ACPs). OBJECTIVE To build on previous long term condition pathways and the work of Cumbria diabetes to develop a holistic Long Term Conditions Strategy which encompasses a preventative, anticipatory and whole person approach to managing care, based on self-management by confident patients. WHY IS CHANGE NEEDED? The number of people, in Cumbria, with one or more Long Term Condition (LTC) is set to increase significantly over the next 20 years in line with a rapidly ageing population. Premature mortality and morbidity from LTCs and Cancer are the main drivers of health inequalities across Cumbria and LTCs currently account for 70% of overall health and social care spend with a projected increase. The current system for managing LTCs will not meet this challenge and does not equip individuals to make informed decisions about their own health needs or to be confident about managing their own health (only one third of diabetes patients currently feel very confident about managing their own health). Whilst we have developed individual LTC pathways (eg for diabetes, COPD and heart failure) there is currently no overall strategy for managing LTCs and reconfiguring the relevant services in Cumbria. 2. TRANSFORMATION PROGRAMME DESCRIPTION PERFORMANCE INDICATORS PHASE 2 This programme is in two phases: Phase 1: this is based on continued delivery of existing Closer to Home Pathways for diabetes, COPD/respiratory, heart failure and the service models for care for older people in care homes and end of life care. We have already provided resources for additional community capacity during 2011/12 which will ensure delivery of non elective admissions avoidance targets. Phase 2: We are developing a holistic strategy for long term conditions which will continue in 2012/13 to ensure CCG member practices and other partners are involved in design and delivery. The service model starts by identifying what common resources are required across Cumbria to support practices in delivering care to their registered population. This will be care directed both at those at risk of developing a long term condition as well as those with established problems. The core principles underpinning the model are: Know your population; Know your team; Know your community’s resources; Know how to help people become confident self-managers; Know how you are doing. There will also be a ‘common platform’ approach (drawn from the modern production line found in car manufacturing) to ensure consistency of service delivery across Cumbria, based on a common infrastructure with: integrated electronic records; • The outcomes for the Phase 2 Strategy will be determined in detail as part of the of the strategy development, but the broad outcomes are to: • Reduce premature mortality and health inequalities; • Reduce the rate of increase in the number of people developing a long term condition (we know rates will increase given the aging population; but we want this rate of increase to be significantly reduced compared to ‘doing nothing’); • Improve the number of patients feeling in control of their own self management; • Further reduce the number of unnecessary acute admissions through more effective care planning; and • Increase value for money by better integration of health and social care and more patients being confident self managers. RESOURCE IMPLICATIONS Resources for phase 1 were put in place in 2011/12. Resource implications for phase 2 will be determined as part of the Strategy development process. 14

15. SECTION 2: TRANSFORMATION PROGRAMME – PRIMARY CARE OBJECTIVE Develop and deliver a strategy for transforming primary care to move from a group of individual practices and community services, into community-aligned federations within an integrated system necessary to deliver sustainable health care WHY IS CHANGE NEEDED? The quality of primary care in Cumbria is generally good but this masks variation, with unacceptably low standards of care in some practices (often caused by capacity, poor infrastructure or a need for improved skills) leading to unacceptable variation. There is a need to support other strategic change areas such as long term condition management and unplanned care and the age profile and increasing demand on practices means we need a new strategy to attract, retain and skill-up new entrants within the approach outlined above; and consider the skill mix of primary care . We are developing a strategy to address these issues and this work will continue in 2012/13 to ensure CCG member practices are involved in design and delivery. Hence this plan is indicative of the issues and outcomes the Strategy is likely to address. PERFORMANCE INDICATORS • Performance indicators will be developed in detail as part of the Strategy development, but will focus on improving the following outcomes and outputs, many of which link to other programmes: • Reductions in premature mortality and health inequality rates • Reduction in unnecessary non elective admissions, especially in Barrow • Increased levels of smoking cessation and health checks • Improvements in the quality of prescribing, with further reductions in outliers for prescribing per 1,000 population and BCBV PIs (both high and low) • Maintenance of high levels of patients satisfaction with primary care • Increase in the percentage of LTC patients feeling confidently managing condition 2. TRANSFORMATION PROGRAMME DESCRIPTION • The emerging Primary Care Strategy is likely to focus on: • Reducing unacceptable variation (e.g. in referrals, prescribing, the level of exceptions etc.) caused by capacity, poor infrastructure or a need for improved skills; • Implementation of the Long Term Conditions Strategy (appendix B4) in primary care, with greater integration with community and secondary services; • More focused health improvement work such as increasing delivery of CVD health checks, smoking cessation and brief interventions on alcohol and exercise: there will be increased targeting in deprived areas such as Barrow, Carlisle and the West Coast to help reduce health inequalities; • Increasing primary care capacity in Barrow, and the reconfiguration of urgent day time primary care to reduce unnecessary admissions, provide a greater focus on the management of long term conditions targeted to improve health outcomes and reduce health inequalities; • Providing local service alternatives in straight forward planned care; and • Producing a strategy for managing the changing age and skill profile of the general practice workforce. RESOURCE IMPLICATIONS 15

16. SECTION 2: TRANSFORMATION PROGRAMME – SECONDARY CARE TRANSFORMATION & RECONFIGURATION DELIVERY OF THE CLINCIAL STRATEGY AND TRUST ACQUISITION IN NORTH CUMBRIA OBJECTIVE Milestones and perfromance indicators are included in the Unplanned and Childrens’ Transformational Workstreams. A System Board has been established in North Cumbria to support delivery of these key building blocks. The diagram below outlines the relationships between the System Board and stakeholders in North Cumbria. • To develop and deliver a clinical strategy for North Cumbria alongside an acquisition process which: • Improves health outcomes and reduces health inequalities; and • Ensures the provision of safe, high quality and clinically and financially sustainable services. DESCRIPTION The Strategic Vision for North Cumbria was first set out in the Closer to Home (C2H) Public Consultation in early 2008. C2H was embraced within all six localities in Cumbria and underpinned their commissioning intentions year on year. A series of care streams developed clinical pathways for Planned Care, Unplanned Care, Long Term Conditions, Children’s Services and Mental Health. The membership of each care stream included clinicians from both secondary and primary care and Social Services. A Locality Board exists in each locality and has representation from each GP practice and other local stakeholders. Each Locality Board is responsible for ensuring their commissioning intentions reflect the needs of their local populations. Rapid response nursing and social care teams have been created to help people get the care and support they need in their own homes and GPs are working with hospital consultants in emergency departments. A refreshed Clinical Strategy for North Cumbria was agreed by the PCT and NCUHT in 2011, building on C2H Strategy. As part of the implementation of the Clinical Strategy, a number of key building blocks have been identified, including delivery of an Emergency Floor, Short Stay Paediatric Assessment Unit and Single Point of Access in addition to community based specialist teams. 3. PROGRAMME DELIVERY The other important element of secondary care improvement in North Cumbria is the acquisition of NCUHT by Northumbria Healthcare FT. This will facilitate and accelerate secondary care reconfiguration and ensure greater clinical and financial sustainability of services in the north of the County and better patient outcomes and experience (e.g. through more service delivery within the area). The milestone plan for the acquisition process is set out in Section 10 on Transition and Reform. 16

17. SECTION 2: TRANSFORMATION PROGRAMME – SECONDARY CARE TRANSFORMATION & RECONFIGURATION DEVELOPMENT OF A CLINICAL STRATEGY FOR THE MORECAMBE BAY AREA • Work to develop the Strategy will continue in 2012/13. The key next steps are to: • Bring partners together to recognise the issues, challenges and opportunities and create a consistent and owned impetus for change; • Develop an integrated Clinical Strategy for the Morecambe Bay area (which links to other transformational programmes such as Primary Care and Long Term Conditions) bringing in experts and good practice to address stroke care, paediatrics, maternity etc.; • Engage communities, patients and stakeholders in the process to understand and champion the need for change and consult if appropriate, on new models of care; and • Develop effective programme management and operational arrangements to ensure effective and timely delivery of the strategy across the health and social care system. • Performance indicators will be developed as part of the Strategy formulation and will focus on the following : • Reductions in premature mortality and health inequality rates; • Reduction in unnecessary non elective admissions, especially in Barrow; • Improvements in the quality of care and achievement of core standards in services such as stroke, paediatrics and maternity; and • Improvements in the level of confidence of the local communities and stakeholders in health services and improvements in patient experience. • Effective programme management and arrangements for operational delivery will be put in place across the health and social care system. Whole system governance arrangements will be put in place with similar arrangements to the System Board in North Cumbria. OBJECTIVE • To develop and deliver a clinical strategy for the Morecambe Bay area which: • Improves health outcomes and reduces health inequalities; and • Ensures the provision of safe, high quality and clinically and financially sustainable services. DESCRIPTION • There have been a number of quality issues at UHMBFT over the last 6 months, some of which have been highlighted through major reports from regulators, covering maternity, paediatric, outpatients, A&E and stroke care. These quality issues link directly to poor performance on the Operating Framework indicators in Section 7. • At the same time there is an emerging strategy for improving primary care that will increase capacity in Barrow and improve the quality of care for people living with a Long Term Condition. • The Cumbria CCG, supported by the Cluster and NHS North of England, are beginning the process to develop a strategy to address these issues in partnership with the Lancashire Cluster, UHMBFT and CPFT. Emerging principles include: • Having a clear approach to health improvement, tackling inequalities and using a needs assessment, data driven plan; and • Being driven by quality including Clinical Effectiveness, Patient Safety and Patient experience. • Patients and communities will be reassured that much of this isn’t new; however, there are some “big issues” to tackle and articulate a better vision for services such as maternity services at Barrow. 3. PROGRAMME DELIVERY 17

18. SECTION 3: PROGRAMME DELIVERY – MANAGING RISK The approach to programme delivery is based on a cycle of planning and implementation followed by benefits realisation. During 2011/12 each of the six localities in Cumbria has implemented a series of community based initiatives that will deliver the planned reductions for 2012/13. Appendix B contains the detail by locality however a summary is contained on the next page. Alongside this planning has been underway to deliver an Emergency Floor Model and SSPAU both of which will be fully implemented by late 2012. The key aim of the Emergency Floor and SSPAU is to direct patients to the appropriate service through a Single Point of Access and to provide senior clinical assessment to prevent admission. There will be some in-year benefit from the models during 2012/13 however the full year benefits will be realised during 2013/14. Also during 2012/13 the CCG will focus on developing a Primary Care Strategy to deliver the infrastructure to support risk stratification, integrated clinical teams and self management using a Year of Care approach. This programme is less well developed however during 2012/13 the CCG will be working though a programme of engagement with Primary Care, Secondary Care and Community Services to identify outcome measures and implementation timelines for 2013/14 and beyond. In addition the PCT Cluster and CCG will be working with secondary care clinicians to implement the Clinical Strategy in North Cumbria and develop a Clinical Strategy in South Cumbria. For 2012/13 the PCT Cluster is assured that there is a sound and realistic plan through conservative activity reductions and increased community based activity. The emerging plan for 2013/14 will focus on the localities in Cumbria with the furthest to travel in achieving top quartile admission rates. • Cumbria has had some serious financial and quality issues although through Closer to Home the Cluster and CCG collectively are in financial balance. CPFT which provides Mental Health and Community Services is also in financial balance. • NCUHT has yet to achieve financial balance and this will only be achieved through the impending acquisition by Northumbria Healthcare NHS Trust and subsequent reconfiguration of clinical services. This will be a two or three year programme of work and will require significant resources to support the acquisition. • UHMBFT has until recently had recurrent financial balance however significant quality issues means that the CIP programmes may not be achieved. In addition significant stabilisation resources will be needed to reconfigure service models and improve quality. • The PCT Cluster and CCG can therefore expect non recurring resource pressures from four key areas: • The need to pump prime transformation in Primary Care; • The need to invest in Public Health initiatives that will address the health inequalities challenge; • The need for resources to support the acquisition of NCUHT; and • The need to support service reconfiguration at UHMBFT. • The resource impacts in each of these four areas are currently being determined but in total are likely to be in excess of the resources available from the 2% top slice. This issue is currently being considered with NHS North of England and a resolution to the funding issue is expected early in 2012/13. 3. PROGRAMME DELIVERY 18

19. SECTION 3: PROGRAMME DELIVERY – MANAGING RISK (cont) Service Initiatives in Place to deliver the 2012/13 Commissioned Activity Reductions 3. PROGRAMME DELIVERY 19

20. SECTION 4: RESOURCES: NHS CUMBRIA FINANCIAL PLAN xxx xxx The NHS Cumbria financial plan is consistent with the NHS North financial planning guidance. A planned surplus is delivered in each year of the plan. Contracts have been agreed and signed for 2012/13. A limited amount of additional resources are being provided to build capacity in primary and community care settings to support the delivery of the CCG commissioning intentions. The funding requirements and funding sources to support transformation change in NCUHT and UHMBFT are still being considered with NHS North of England. KEY RESOURCE ISSUES AND ASSUMPTIONS The NHS Cumbria plan is based upon maintaining the 2011/12 planned surplus of £4.1 million as identified in NHS North financial planning guidance. In addition, the plan reflects the requirement to utilise 2% of the recurring revenue resource limit non-recurrently each year. The secondary care activity plans reflect NHS Cumbria CCG’s commissioning intentions to secure further reductions in secondary care activity. These plans are phased realistically across the plan period, reflecting the need to implement new service models at a time when major reform is taking place in the local acute sector. Similarly transformation is required in primary and community care (notably in the Furness locality) to ensure appropriate capacity and capability is in place to deliver the expansion in local, community based services. At this stage no specific assumptions are included in respect of the costs relating to the planned acquisition of NCUHT or any long-term transitional requirements of the on-going major incident at UHMBFT. Discussions on resource requirements in these two Trusts during the plan period are being held with NHS North of England. The next discussions on funding requirements and the availablility of resources within NHS Cumbria is set for mid April. The Operating Framework investments planned reflect the need to address key target areas such as dementia, health visiting, health checks and implementation of the summary care record, along with specific investment in re-ablement. Local investment priorities include the expansion of breast screening, the further expansion of PCI in Cumbria along with the re-instatement of deferred investments from 2011/12 (e.g. EMIS web). The financial plans include, for each year, a contingency for demographic growth to cover secondary care activity, non-PBR drug costs and continuing care. Details of the planned cost improvements across the three years of the plan are shown in Section 4. The PCT currently has a significant number of equal value claims outstanding for which it is not possible to make a reliable estimate of the costs, although should this change then provision would have to be made. A key assumption is that the transfer of resources relating to changes in organisational responsibilities for managing resources (i.e. public health & specialist commissioning) will be revenue neutral. 4. RESOURCES 20

21. SECTION 4: RESOURCES: NHS CUMBRIA FINANCIAL PLAN (cont.) The resource plan includes resources for the assessed impacts of demographic change, the requirements of the Operating Framework and new service investments. These investments are essential for securing the delivery of agreed clinical strategies and for tackling health inequality. The allocation of the £17 million non recurring resource in each year is being reviewed. xxx xxx SUMMARY 3 YEAR KEY RESOURCE CHANGES FOR NHS CUMBRIA USE OF 2% TOP SLICE • The use of the 2% top slice non recurrent allocation across the plan period is currently being considered. The key demands for funding from this source are: • Pump priming service transformation in Primary Care across Cumbria particularly in Barrow; • Investing in Public Health initiatives that will help to address health inequalities; • Underpinning transitional resources for the NCUHT acquisition; and • Service reconfiguration at UHMBFT. 4. RESOURCES 21

22. SECTION 4: RESOURCES: NHS CUMBRIA FINANCIAL PLAN (cont.) RESOURCE MOVEMENTS BETWEEN 2012/13 AND 2014/15 £14.3m £50.5m £17.4m £30.2m SURPLUS 2014/15 £4.1M SURPLUS 2011/12 £4.1M £25.6m £16.1m 4. RESOURCES £11.5m £11.6m CQUIN £13.5m INFLATION £17.9m DEMOGRAPHIC CHANGE £19.1m NEW GROWTH FUNDING COST IMPROVEMENT £12.7m B/FWD UNALLOCATED FUNDS 2012/13 NON RECURRENT SPENDING (ANNUALISED) OPERATING FRAMEWORK INVESTMENTS OTHER INVESTMENTS COMMISSIONER REDUCTIONS TARIFF REDUCTION SOCIAL CARE FUNDING 22

23. SECTION 4: RESOURCES: NHS TRUST FINANCIAL PLANS All three provider Trusts are expected to have a minimum 4% cost improvement programme in place in each of the plan years. CPFT is expected to retain its annual surplus position. NCUHT is taking action to remove its underlying deficit position and will require further external financial support during the plan period as identified within the Trust acquisition process. UHMBFT is now the subject of a transformation project to deliver improved service quality and stability and it is anticipated that it will similarly require external financial support during the three year plan period. xxx xxx CUMBRIA PARTNERSHIP FOUNDATION TRUST NORTH CUMBRIA UNIVERSITY HOSPITALS TRUST In 2011/12 Cumbria Partnership FT successfully took over the management of the PCT’s provider arm under TCS without any adverse impact on the Monitor Financial risk rating of 5. The expectation is that CPFT will continue to deliver the nationally mandated efficiency targets over the planning period. The contract for 2012/13 has been agreed and signed with the Trust. In 2011/12 NCUHT received strategic support funding of £28 million to address an identified underlying deficit, slippage in its in-year cost improvement programme and the excess costs of its PFI Hospital. NCUHT has developed a Long Term Financial Model to demonstrate how the historic recurring deficit and future mandated efficiency targets can be addressed. This information has been provided to bidders as part of the acquisition process. In conjunction with this NCUHT has produced hospital based trading accounts (which again demonstrate how the Trust anticipates getting back into financial balance) and these have been used to support the decision to progress with the redevelopment of the West Cumberland Hospital in Whitehaven. The Trust, and its preferred bidder, have both identified that further underpinning transitional financial support will be required and this is being considered with NHS North as part of the Trust acquisition process. 4. RESOURCES UNIVERSITY HOSPITALS OF MORECAMBE BAY FOUNDATION TRUST UHMBFT currently has a financial risk rating of 3 and in 2011/12 received agreed financial support from both NHS Cumbria and NHS North Lancashire to ensure the short-term financial consequences of the major incident while maintaining the current financial risk rating. The expectation is that UHMBFT will continue to deliver the nationally mandated efficiency targets over the planning period but it will require external financial support during the three year plan period. The extent of this support is currently being determined. The contract for 2012/13 has been agreed and signed with the Trust. 23

24. SECTION 4: RESOURCES: NHS CUMBRIA CAPITAL PLAN xxx xxx A £40 million Capital Programme has been identified across the 3 year planning period, which includes the Cockermouth and Cleator Moor projects. KEY PROJECTS NHS Cumbria cluster is working with the Cumbria Partnership FT to identify the priorities for estate renewal. The programme below includes funding of a rolling programme to maintain existing infrastructure and the two projects for which the Cluster has now received Stage2 Business Case approval – the Cockermouth Hospital and GP practices project and the Cleator Moor Health Centre. The programme also includes provisional funding to address the infrastructure requirements for the modernisation of primary care premises in Barrow. • An annual commitment of £3 million is assumed to maintain the existing estate in line with current underlying expenditure patterns; • The ‘on balance sheet’ treatment of the Cockermouth & Cleator Moor projects is shown when the buildings become operational in 2013/14 based on the Stage 2 business case approval and financial close during March 2012. These schemes are developed by ELIFT Cumbria (eLC), NHS Cumbria’s LIFT partner; • Negotiations are currently in place with UHMBFT to refurbish redundant premises on the Furness General Hospital site in Barrow to provide GP premises, with an outline cost estimate of £1 million; • A provisional sum of £17.5 million has been included as the necessary capital investment to address the infrastructure requirements for the modernisation and optimisation of primary care premises in Barrow. Currently feasibility work is being undertaken in conjunction with eLC and it is anticipated that the final scheme will be ‘on balance sheet’; • The capital expenditure profile has been shown based on the current asset base of NHS Cumbria, and therefore for planning purposes potential asset transfers have been excluded; • In addition to the above projects the financial plans include the recurring revenue costs of new Primary Care premises developments in Kendal (Captain French), Grange and Carlisle (Stanwix). 3 YEAR CAPITAL PLAN FOR NHS CUMBRIA The Capital Resource Limit for NHS Cumbria is set out below. 4. RESOURCES The associated Capital Programme across the plan period is as follows: 24

25. SECTION 5: QIPP: OVERALL APPROACH NHS Cumbria has a confirmed plan to achieve change and increased efficiency across all clinical services. However there are four key demands on non recurring resources and these are likely to outstrip the level of non-recurring resources available within the community during the next three years. PROGRAMME CONTENT RESOURCE PRESSURES • We have had serious financial and quality issues in Cumbria. However, through implementing the Closer to Home programme, which was consulted on in 2007, commissioners have achieved recurrent financial balance and have begun to change the way patients are managed across Cumbria. • The Cumbria-wide community and mental health provider, the Cumbria Partnership FT, is in recurrent financial balance and has a significant agenda for service change across community and mental health services. • NCUHT has a significant deficit which requires a large and sustained cost reduction programme and will need significant underpinning resources to support the acquisition of the Trust. • UHMBFT has until recently had recurrent balance but significant quality problems means there is a risk that CIP programmes will not be achieved and that significant stabilisation resources will be needed to help deliver new service models to secure quality improvement and reconfiguration across sites to deliver long term clinical sustainability. • Commissioners can therefore expect to have a significant call on non recurrent resources from four key areas: • The need for non recurrent investment to pump prime change in the transformation of primary care; • The need to find resources to address the significant challenges of health inequalities across Cumbria; • The need for resources to support the acquisition and transformation of NCUHT by Northumbria Healthcare FT; and • The need for transformation and stabilisation funding for service change to improve service quality in UHMBFT. • The source of funding which is available to deal with these four key areas is the 2% top slice which is to be applied for non-recurring purposes. The short term QIPP Plan centres on the completion of the Closer to Home initiatives, including providing a single point of access to emergency services, implementing integrated emergency floors and providing improved short stay paediatric assessment services. These key initiatives will improve clinical quality and sustainability, integrate care for better patient experience and help to secure reductions in admission rates. The three year strategy is to maintain non elective admission rates in most localities, despite the increases in demand which we are expecting from an ageing population, but look for significant improvement in Furness. The CCG will seek to reduce paediatric non elective admission rates across all of Cumbria by providing more accessible and child friendly, community based services. There will also be a reduction in elective referral rates which will be achieved through addressing procedures of limited clinical value and making available to GPs more effective decision tools and providing referral management support. Delivery of Phase 1 of the long term condition strategy, which delivers pathway improvements in diabetes, respiratory and cardiac care, will also allow the CCG to achieve improved admission rates. It is highly likely, given the substantial change agenda experienced by the two main providers, that the service changes outlined will only be implemented and embedded during the course of 2012/13. For this reason the CCG has planned to achieve its key activity changes across the full three years of the plan period. An overall 4% efficiency target has also been built into contracts with all providers. Approximately 58% of the QIPP programme across the three years can be classified as transformational. In addition to these plans there are transactional QIPP initiatives, such as continuing changes in GP prescribing practices which will deliver cost savings and management cost reductions. 5. QIPP 25

26. SECTION 5: QIPP: THE COMBINED GAP ACROSS CUMBRIA xxx xxx The combined commissioner and provider gap amounts to £105 million for the three year period 2012/13 to 2014/15. Of this, £9.5 million relates to service providers outside of Cumbria. In addition there is a £28 million underlying deficit at NCUHT which will be managed through the Trust acquisition process. OVERALL QIPP GAP The overall QIPP gap for NHS Cumbria is identified at £105 million. In addition there is a £28 million underlying deficit at NCUHT which Is being managed as part of the Trust acquisition process. This is set out in the table below. PROVIDER QIPP GAPS The QIPP gaps which have been estimated for the three Cumbria provider Trusts, based on the 4% efficiency requirement, are as follows: 5. QIPP The expectation is that the QIPP gaps identified for UHMBFT and CPFT will be delivered through the internal CIP programmes in those Foundation Trusts. As a result of the acquisition process, NCUHT is expected to deliver a significant CIP programme as a contribution to the gap identified. However, closure of the gap will require external support during the plan period. • The provider efficiency targets exclude the value of the tariff deflator • which is included in the figures for the Commissioning QIPP gap.

27. SECTION 5: QIPP GAP: COMMISSIONER GAP xxx xxx A commissioner QIPP gap of £58 million (including the targets for cost avoidance) has been identified across the three year plan. NHS Cumbria Cluster and CCG has identified a robust plan to close this gap so that the required revenue surplus can be delivered in each year. IDENTIFICATION OF THE QIPP COMMISSIONING GAP • The key issues which have been taken into account in this • reassessment are: • Amended PCT funding levels; • The CCG decision to rephase the commissioner plan following discussions with NHS North, where 2012/13 becomes a year for consolidation and a lower level of commissioner savings; • Reconsideration of service investment requirements; and • Reassessment of committed funding requirements. NHS Cumbria has a QIPP gap of £58 million across the three years of the plan. This is constructed as follows: PLAN TO DELIVER THE NHS CUMBRIA QIPP RESOURCES TARGET The savings plan which has been identified is set out in summary below. Delivery of this programme will ensure the closure of the identified £44 million QIPP resources gap. 5. QIPP The QIPP resources gap (which excludes the cost avoidance targets) can be compared to the four year QIPP gap which was identified in May 2011, as shown in the table below. The PCT has completed the triangulation analysis utilising the SHA template. • Per QIPP plan dated May 2011 as submitted to NWSHA • and which forms the baseline for monitoring in 2011/12 27

28. SECTION 5: QIPP (cont.) TRANSFORMATIONAL CHANGE • In addition, the following can also be cited as further contractual mechanisms to mitigate risk: • It is expected that funding for transition/stabilisation with NCUHT and UHMB will be conditional on this being used as the first call on any additional activity; • A risk sharing arrangement for controlling the cost of high cost mental health patients and incentivising repatriating patients to lower cost local alternatives has been established with CPFT; • The NWAS contract provides marginal relief for over activity; and • NHS Cumbria supports the proposal of collective risk sharing for specialised commissioning. • In addition: • The net impact of growth/tariff deflator identified in 2012/13 is quantified at approximately £33 million (circa 3.5% of total RRL); considerably more prudent assumptions have been used for 2013/14 (2.5%) and 2014/15 (1.55%); and • In addition to the prudent assumptions on growth further planning contingencies have been established of circa £15 million for both 2013/14 and 2014/15. Approximately 58% of the QIPP target will be delivered through transformational change (see table opposite). NCUHT has a dual challenge of delivering the 4% efficiency target, amounting to £19.4 million across the three years of the plan and eradicating the £28 million underlying recurring deficit. This will require transformational change to provide sustainable clinical services. This will be achieved through delivery of the clinical strategy for north Cumbria and the acquisition process with Northumbria Healthcare FT. The North Cumbria System Board will oversee delivery of the transformational change. The QIPP efficiency gap will be delivered through a combination of transactional and transformational change. The Cumbria three year QIPP efficiency target for UHMBFT is £13.8 million. In view of the deep rooted clinical quality issues there is a need to consider reconfiguration of services across the three hospital sites into primary, secondary and tertiary services. This transformation will be achieved through the emerging system wide Clinical strategy. The three year QIPP efficiency target for CPFT is £18.9 million. In line with the clinical strategies for both North and South Cumbria, CPFT is planning to deliver more activity for less income. This will result in better integration and more effective services. There are two key priorities. The first is the further integration of community and mental health services following the TCS transfer in April 2011 alongside the integration. The second is securing integration between primary and secondary care in the delivery of a transformed emergency flow pathway including Single Point of Access, Integrated Emergency Floor and Short Stay Paediatric Assessment Service. 5. QIPP HEADROOM IN THE NHS CUMBRIA QIPP PLAN Significant headroom exists in the 2012/13 plan with over £9 million allocated for demographic growth (i.e. activity over and above 2011/12 levels). In some instance this has been encapsulated in contracts with specific providers, and in other areas retained as a generic contingency to manage costs. The prescribing budget also contains a CCG contingency of £900,000 (1%) over and above planned growth.

29. SECTION 5: QIPP SAVINGS ANALYSED BY PROGRAMME AREA ANALYSIS OF SAVINGS BY PROGRAMME AREA The £105 million savings plan across Cumbria has been analysed by service area and this is shown in the table below. This analysis is consistent with the content of the FIMS QIPP return for 2012/13. 5. QIPP

30. SECTION 5: QIPP: PLANS TO CLOSE THE QIPP GAP NHS Cumbria has well developed plans to deliver the cost reduction measures necessary to close the £58 million QIPP gap. These are a combination of transformational and transactional changes. Four of the six localities are at or below the national average rate for elective admissions, although there is scope for improvement to upper quartile rates. The Audit Commission benchmark tool for procedures of limited clinical value confirms that there is scope for significant improvement. The detail for each of these three programmes for reducing hospital admissions and referrals is set out later in this section. The CCG will seek to ensure provider commitment to achieving the target activity shifts in the interest of our patients as a condition of stabilisation support. • The £28.1 million commissioning QIPP gap for 2011/12 and the reductions to contracts for provider efficiency targets have been delivered, reducing the NHS Cumbria cost base by £50.1 million. • The majority of the gap for the next three years will be managed by Cumbria CCG. The CCG has cost reduction and cost avoidance plans which are fully developed for delivery in 2012/13. • Plans to close the gap in the following two years are currently being reviewed. These plans are a combination of: • Reductions in hospital based activity in line with the CCG’s clinical and commissioning strategies; • The impact in each year of the PbR tariff deflator; • Continuous improvements in efficiency which lead to cost reduction, for example in primary care prescribing; • Securing the benefits from the national contract for continuing care; and • Standard housekeeping projects. • The activity reduction plans were set out in a Commissioning Framework which was produced in November 2011. These cover unscheduled and elective activity for both adult and children’s services. • Overall, Cumbria has the lowest rate of unscheduled admissions in either the North West or North East and therefore the opportunities to secure further reductions need to take this into account. However, the position varies across the six localities and the strategy therefore is to deliver the agreed patient pathways and to set target admission rates for each locality which reflect the opportunities available to secure reductions in hospital admissions. • Paediatric admission rates are high for all localities and action will be taken • to reduce these through the Children and Young People work programmes. ASSURANCE PROCESSES FOR DELIVERY • The cash releasing QIPP savings have been embedded into the PCT budget that is approved by the Board with formal delegation to the CCG through an accountability agreement. The financial reporting systems of the PCT have been developed to provide information at PCT, CCG and, where appropriate locality level. Financial performance is monitored through the following formal mechanisms: • The PCT Board, through the Resources Committee, monitors in-year financial performance of the whole NHS Cumbria resources; this process includes scrutiny of year-to-date position (and hence progress on targets), forecast position and the impact of any recovery measures required and implemented to manage variances from plan; • The CCG is in addition monitored on financial performance through monthly performance meeting on delivering its financial targets; and • The CCG has implemented a formal system of “peer review” to review financial performance and corrective action at a locality level. • In addition, this approach is supplemented by weekly reporting of key “informal” activity indicators to highlight trends in localities and with individual providers to identify potential risks (e.g. out-patient referrals, admission rates, OOH activity) in advance of receiving formal contractual information. This information, coupled with use of benchmarking tools, is also used to provide assurance of “costs avoided” in addition to planned cash releasing savings. 5. QIPP 30

31. SECTION 5: QIPP: CLEAR & CREDIBLE ACTIVITY PLANS – ADULT EMERGENCY ADMISSIONS xxx xxx Cumbria has a good track record of reducing hospital based activity over the last three years, particularly in non elective patient care. However, the track record on delivering against plan has not always been consistent and a more rigorous approach is being taken to the activity plans for 2012/13 which reflects the relative position of each of the Cumbria localities. Overall, Cumbria has the lowest rate of admissions in either the North West or North East. Three out of the six localities are at or below upper quartile levels; two are at or below national average. Only one, Furness, has high levels of admissions. The strategy, therefore, is to maintain rates in South Lakes, Eden and Allerdale; work to improve rates in Carlisle and Copeland (accepting the relatively high levels of deprivation there); and to significantly improve rates in Furness. Considerable investment in Furness will be necessary to achieve admissions reduction. There is a particular need to address primary care capacity which impacts on the ability to manage urgent day time patient care effectively. This is in line with the CCG primary care strategy. 5. QIPP *NB Overall emergency reductions are the net position excluding paediatric reductions (shown on the next page) to avoid double count. 31

32. SECTION 5: QIPP: CLEAR & CREDIBLE ACTIVITY PLANS – PAEDIATRIC EMERGENCY ADMISSIONS Paediatric admission rates remain high across Cumbria and the strategy is to reduce the level of admissions in each locality by providing more accessible community based assessment facilities. Paediatric admission rates are high for all localities and action will be taken to reduce these through the Children and Young People work programmes, particularly implementation of the paediatric assessment unit in each of our main hospitals linked to the emergency floor and single point of access; alongside implementation of new children’s pathways (e.g. for the acutely ill child). During the plan period, three of the six localities will move to the current national average position, Allerdale will move to the mid point between the average and top quartile position and the Eden and South Lakes localities have an opportunity to deliver top quartile performance. 5. QIPP 32

33. SECTION 5: QIPP: CLEAR & CREDIBLE ACTIVITY PLANS – ALL ELECTIVE ACTIVITY There is scope to improve referral practices in each locality and during the next three years the focus will be on reducing referrals for procedures of limited clinical value. Four out of the six localities (South Lakes, Eden, Allerdale and Carlisle) are at or below the national average rate for elective admissions, although there is scope for improvement to upper quartile rates. Copeland and Furness are above average (3rd quartile). Comparisons through the Audit Commission benchmark tool for procedures of limited clinical value indicate there is scope for significant improvement. The strategy for elective admissions is to move four of the six localities to the current top quartile position and to target performance improvement in Copeland and Furness localities to the level currently achieved in the Allerdale locality. 5. QIPP 33

34. SECTION 5: QIPP: SUMMARY OF COMMISSIONING PLANS SUMMARY OF THE COMMISSIONING PLANS The commissioning plans are brought together in the next two pages to demonstrate the impact of the commissioning policies on overall hospital activity and PbR payments. These tables also show the anticipated impact on hospital activity of demographic change over the three years of the plan. The CCG has reviewed the way in which it assesses the impact which its ageing population will have on clinical services. This will ensure there is a more accurate assessment of the likely impact of demographic change on elective and non elective admissions. The summary table below shows the net activity changes that are anticipated over the next three years in the level of hospital based activity. 5. QIPP 34

35. SECTION 5: QIPP: CHANGES IN PATIENT ACTIVITY LEVELS 5. QIPP The figures shown for outturn 2011/12 and 2012/13 are consistent with contracts for 2012/13 35

36. SECTION 5: QIPP: CHANGES IN PATIENT ACTIVITY LEVELS – RESOURCE IMPLICATIONS 5. QIPP The figures shown for outturn 2011/12 and 2012/13 are consistent with contracts for 2012/13 36

37. SECTION 5: QIPP: ESTATES NHS Cumbria and its associated provider services are working on a number of estates projects which will assist in closing the QIPP efficiency gap. The eight key projects are listed below. DRIVING EFFICIENCY FROM ESTATES RATIONALISATION NHS Cumbria is working with UHMBFT to investigate the feasibility of relocating staff from the Tenterfield site in Kendal to the Westmorland General Hospital site. The 111 proposals are likely to consolidate the infrastructure in Cumbria, improving utilisation of space & technology. NHS Cumbria is working jointly with NCUHT and CPFT to review the scope for vacating peripheral buildings on hospital sites to improve the space utilisation of the main buildings and release costs. NHS Cumbria is working with its associated provider organisations to secure efficiencies from new capital projects or through the rationalisation of the existing Cumbria estate. The eight key initiatives are listed below. NHS Cumbria has signalled its support for the new West Cumberland Hospital. This will deliver an operating surplus of £3 million per annum through more efficient buildings infrastructure and space layout, improved clinical adjacencies and new ways of working facilitated by the new hospital. The DoH has identified the Cumberland Infirmary, Carlisle as one of a small number of first stage PFI hospitals where excess operating costs can be identified as a result of the contractual conditions which exist. A national funding stream has been identified from which these excess costs will be met. NCUHT anticipates that this will make a significant contribution to its underlying deficit position. The new estate projects in Cockermouth and Cleator Moor will deliver annual savings of £528,000 per annum (of which £226,000 has been identified from estates services).  Both these projects consolidate four existing buildings into one location in each town. NHS Cumbria is considering the refurbishment of a building on the Furness General hospital site (owned by UHMBFT) to provide new GMS accommodation.  This will be a cost effective solution when compared to a new building on an acquired site. The new GMS development in Stanwix is being built on land owned by Cumbria County Council at less than open market value. This avoids potential costs estimated at around £25,000 per annum. 5. QIPP 37

38. SECTION 6: ENGAGEMENT : Patients and Communities xxx xxx The CCG has always set great store on the engagement of patients in decision making and service re-design and will introduce a ‘Listening to Cumbria’ campaign and other initiatives as an early priority. Clinicians in Cumbria have always set great store on the engagement of patients in decision making and service re-design. For example, engagement of patients is at the heart of the diabetes pathway re-design, with a focus on patient education and co-production of the care plan. In line with the ‘promise to patients and communities’ the CCG is keen to make a quantum leap in the development of its engagement arrangements, and like quality, embed them at the heart of all the commissioning arrangements. Members of CCG will work with the emerging Healthwatch organisation to ensure efforts are joined up and there is no duplication. An early priority for the CCG will be to carry out an extensive ‘Listening to Cumbria’ campaign throughout the spring of 2012. This will involve health roadshows, ‘meet your GP’ surgeries and other public facing events in every locality in the county. It will be led by the elected GPs from each locality and seek the views, aspirations and needs of patients. It will also be an introduction to the new world of GP commissioning. There will also be programmed meetings with key stakeholders such as the Overview and Scrutiny Committee, emergent Health and Wellbeing Board, MPs, League of Friends, LMC and social care and local authority representatives. We will also actively seek patient views about how they can be more closely involved with decision-making on both individual and collective levels. • The outcome of the listening campaign will be an evaluation which will lead to a new and dynamic ‘multi-channel’ methodology for capturing and acting upon patient experience on an ‘industrial scale’. • This ‘multi-channel’ methodology will focus include: •  Near time, post treatment, out-bound telephone follow-up interviews; • On-line opportunities to comment on-line with moderated feedback and publication; • Structured attitudinal surveys; • Patient experience sampling across service lines and provider geography; • Proactive mobilisation of community and voluntary groups to monitor; • Primary care satisfaction surveys; • Comments and notes boxes in every GP surgery; • Requirements of providers to carry out satisfaction surveys in situ; • Deliberative patient groups in every locality; and • Feedback loops to patients to demonstrate how their experience has been taken into organisational and contractual learning to make service changes. • It is expected that the CCG will commission these services from an external agency to provide a regular and systematic monitoring of patient experience. This data will be reviewed by clinicians at monthly locality and CCG Executive Boards as a core metric in the quality dashboard and for contract monitoring and service development. 6. ENGAGEMENT

39. SECTION 6: ENGAGEMENT : Public Sector Equality Duty xxx xxx The PCT Cluster has met the first part of the PSED and is engaging across the whole system to develop equality objectives. The Cluster and CCG are working together to develop an implementation plan. The PCT Cluster met the 1st part of the PSED by publishing information of the effects of policies on people protected by the Act on 31st Jan 2012. In addition the Cluster is reviewing EDS evidence with self assessment due mid March 2012 alongside providing training to enable grading of self assessment by wider Stakeholders 6th March. A Joint accreditation event where wider stakeholders will verify self assessments leading to a Cumbria wide assessment proving a baseline for EDS will be held on 26 March 2012. From the event Equality Objectives will be drafted for verification by the Board and publication by 6th April. The Cluster and CCG will work together to develop performance measures to show how Equality Objectives will be met over the next 4 years. 6. ENGAGEMENT 39

40. RAG - YTD RAG - Forecast Cumbria Cumbria UHMBT NCUHT NCUHT UHMBFT Referral to Treatment A&E 4 hour wait Cancer - 62 day Stroke Mixed Sex Accommodation HCAI Ambulance Cat A SECTION 7: PERFORMANCE AND QUALITY – KEY PERFORMANCE INDICATORS Good progress has been made in achieving the 2010/11 Operating Framework performance however there are still some key issues that need to be resolved. Good progress has been made in achieving the 2011/12 Operating Framework performance however there are still some key issues that need to be resolved. The table below sets out the most recent position alongside the year end forecast. In summary NCUHT will achieve 5 of the 6 key performance indicators from April 2012 and all 6 indicators from June 2012. However NCUHT remains an outlier in relation to Delayed Transfers of Care (DToC). A series of operational changes have recently been implemented and a whole system event is to take place early May. This will result in a whole system action plan and trajectory and will be performance managed through the current System Board arrangements. UHMBFT UHMBFT has consistently been failing the A&E and Mixed Sex Accommodation (MSA) indicators since late 2011. A series of operational changes have been implemented from 12th March 2012 and these will improve the emergency flow through the system. Early analysis shows improved performance and a trajectory will be agreed with the Trust to achieve the 95% target early in 2012/13. A weekly review meeting takes place between UHMBFT, the Cluster, the CCG and the Cluster and CCG in Lancashire. The CCG and NHS North have been working with the Trust to develop an action plan to eliminate clinically unjustified MSA. The plan has yet to identify timescales and outcome measures however it is expected that MSA will be eliminated from April 2012. The plan will be signed off by the end of March 2012 and weekly monitoring will be in place between UHMBFT and the CCG. A fundamental overhaul of Stroke Services at UHMBFT may mean that this indicator continues to be variable during 2012/13. In summary, UHMBFT will achieve 4 of the 6 indicators by end March 2012 and will have agreed plans in place to achieve all 6 indicators early in 2012/13. 7. PERFORMANCE & QUALITY NCUHT NCUHT has been clearing a backlog of Ophthalmology and Gynaecology cases since January 2012. The anticipated additional capacity was not fully realised in early 2012 therefore the backlog will not be cleared until May 2012. A recovery plan has been agreed with the Trust and is being performance managed weekly. From June 2012 the Trust will achieve all RTT indicators. NCUHT has improved in year against the stroke performance indicator and will be fully compliant by April 2012. 40

41. SECTION 7: PERFORMANCE AND QUALITY: CLUSTER APPROACH Every effort is made to ensure quality and safety is firmly embedded in all commissioned services. This function has remained the responsibility of the Cluster for 2011/12 however the CCG constructed and performance managed the CQIN contracts. During 2012/13 CCG will have full accountability for the quality agenda. CLUSTER APPROACH Whole system innovation Performance Management Service Delivery We aspire to deliver high quality safe services whilst improving efficiency, performance and productivity. This vision will be supported by clear leadership for quality in the new NHS arrangement with patients at the heart of what we do and robust methods for delivering innovative solutions. Patient and public experience is a key driver and will help shape commissioning and service provision. New techniques will be used to understand and act of patient wishes. A whole system approach will be taken to make quality everyone’s business and there will be a “Quality Alliance” for Cumbria. Clear expectations will be outlines for al providers of healthcare. Integrated governance arrangements will be in place and will underpin good quality outcomes. “Scaling up” and “spread” techniques will be promoted and facilitated where necessary. Workforce changes will be made explicit to ensure that individual clinicians have the right skills and competencies to deliver care outside hospital as well as supporting individuals to manage their LTC. Systems will be in place to prevent harm, learn lessons and ensure clear board reporting. The Cluster is developing an assurance framework taking a 360 view. This allows safety programmes to be viewed alongside increasing efficiency by “scaling up” areas of innovation. Pathways redesign Clinical Strategies Energising for Excellence High Impact Actions Safety Express and Safety Thermometer Primary Care/CHOC CPFT NCUHT UHMB NHS Funded Care External regulation PC performance CQIN/Contracting Management of SUIs Gold Command Safeguarding • 5 Outcome measures • Helping people recover from episodes of ill health and injury; • Preventing people dying prematurely; • Enhancing the quality of life for people with Long Term Conditions; • Treating and caring for people in a safe environment and protecting from avoidable harm; • Ensuring people have a positive experience. 7. PERFORMANCE & QUALITY A proposal is currently being developed to support Cumbria Health Watch to become a strong body for surveillance of our health and care facilities.  This work is complemented by ‘deep dives’ in to specific areas such as the care of older people. The Quality Framework will focus on the five NHS outcomes and the CCG will embed this approach into their commissioning arrangements. Organisations will be held to account through robust contracts and performance measures for quality, safety and outcomes and financial incentives or penalties will be applied through CQIN. 41

42. SECTION 7: PERFORMANCE AND QUALITY: THE APPROACH OF THE CLINICAL COMMISSIONING GROUP The Clinical Commissioning Group is developing its approach to delivering quality with a key focus on clinical leadership, embedding quality in the commissioning and contracting processand the integration of care between providersacross the primary, community and secondarycare sectors. • The CCG recognises the importance of ensuring quality and is developing its approach to quality, with a focus on clinical leadership and embedding quality in the commissioning and contracting process. • The CCG has committed to ensuring that its approach to contracting and quality concentrates on the following major areas: • Patient experience: both more effectively acting upon what patients tell them and strengthening their voice in service improvement and in targeting specific aspects of patients experience, such as personal dignity and communication; • Safety of clinical services: targeting areas of concern raised by external or local intelligence including proactive assurance of performance against national standards and ensuring that action from lessons learnt is taken effectively; • Good clinical practice: Ensuring that clinicians and services are systematically working to accepted good practice guidelines, and that there are good systems of clinical communication that are timely, accurate, relevant and systematic; • Agreed pathways of care: ensuring the effective adoption by primary, community and secondary care services of agreed care pathways in Cumbria, with care indicators that measure the quality of a whole pathway of care; • Commissioning intentions and implementing new models of service delivery. • In each area there will be a strong emphasis on integration of care between providers, primary, community and secondary, with the CCG recognising its responsibility as a partner to ensure that primary care works effectively as part of the health system. The CCG understands integration to mean the effective management of care for a patient between providers, requiring collaboration and communication. • From the patients perspective the CCG will ensure that the service they receive is coherent and of high quality across the health system. That requires individual NHS providers to provide good quality care, but it also requires collaboration between organisations and clinicians to make sure that the patient is the focus of how care is provided. Promoting and supporting that collaboration will be a key feature of the contracts with providers. • The approach will centre on: • Incorporating common indicators across individual Trusts, to support integrated working and improved communication; • Being actively led by clinicians; • Motivating staff and focusing on direct patient care, at team or ward level; • Including specific quality measures for children’s services in all contracts. • During the next few years the CCG will develop alternative approaches to contracting that better support integrated working between primary, community and secondary care and place quality at the heart of the contracting process. In agreeing contracts for 2012/13 the CCG will to anticipate those developments by laying foundations for this changed approach. It will maximise the potential in existing contracting arrangements towards supporting its aims for quality. • The CCG regards contracting as a major lever, for both commissioners and providers, in driving attention to and improved performance in the quality of health and health care in Cumbria. It will use contracting as an integrated part of its commissioning processes to support the focus on quality. • CQIN will be agreed in 2012/13 and beyond as an incentive to improve performance. This may be performance beyond that nationally mandated or in areas of specific local concern. CQIN will not be used to incentivise practice or performance which would normally be expected to be delivered as part of the national NHS contract. In line with national guidance, targets previously incorporated within local CQIN schemes will be incorporated within the main contract, with CQIN focusing on new areas of improvement or higher levels of performance in areas that remain a priority. 7. PERFORMANCE & QUALITY 42

43. SECTION 7: PERFORMANCE AND QUALITY: THE APPROACH OF THE CLINICAL COMMISSIONING GROUP (cont.) • The CCG will work supportively with its NHS provider partners to ensure that they have a small number of high priority areas that remain at the top of their agenda, and drive the overall approach to quality care. These will be common to all contracts. Service Reviews: • Each Trust will be required to undertake two service reviews per year. These reviews will be in areas highlighted through shared understanding of Hospital Mortality data (SHMI) and the NHS Atlas of Variation. The reviews will be against NICE or best practice guidelines with the review scope jointly agreed with Commissioners. Improvement plans, where required, will be jointly agreed between commissioners and providers and progress monitored through the Quality Contract Meetings. • Each Trust will be required to report regularly on the outcome of lessons learnt from complaints, serious incidents and external service reviews, providing evidence of the effective implementation of lessons learnt or agreed action plans. • Each Trust will participate, with primary care, in two shared clinical audits per annum. These will be across jointly agreed patient pathways and have jointly agreed development plans monitored through implementation. • Each Trust will demonstrate effective collaboration across provider Trusts for the implementation of agreed models of care for Children’s Services. • In addition the contract is being used to incentivise the CCG’s commissioning intentions, as set out in the following section on developing services, by ensuring that performance measures and incentives are used effectively in each contract. • The CCG will ensure that the care that it pays for through its contracts is of good quality. Therefore the CCG will: • Not pay a Trust for care carried out that is agreed locally or nationally as a ‘never’ event; • Reduce the total contract payment to a Trust should the Trust be in receipt of an improvement notice from the CQC. • Clear expectations for performance and quality are embedded in the CCG’s relationship with its providers, with all quality and performance standards mapped against the NHS Outcome Framework, developed in collaboration wit the Cluster. • The CCG is developing its governance arrangements and its intelligence systems with clinical leadership, through forums such as Clinical Advisory Groups where clinical leaders from all Trusts address outcome, service quality and development issues in open discussion and work projects across Trusts. • The CCG’s six localities ensure clinician and patient feedback are as close to the patient as possible, with delegated authority to address local issues. This local intelligence, is brought together with information from a broad range of data sources ( lessons learnt, public health mortality and trend data, etc) to proactively identify quality issues for action at local, or countywide level. • Quality contracting meetings will be appropriately supported at Director level with clear communication between and within organisations. • Each quality component of the contract, individual targets and major areas of focus, will have a named clinical lead from the CCG and from the NHS Provider Trust. It is expected that this lead will be a Consultant, GP or Senior Clinical Professional at an equivalent level 7. PERFORMANCE & QUALITY 43

44. SECTION 7: PERFORMANCE AND QUALITY – CQIN TARGETS CONTRACTING FOR QUALITY IMPROVEMENT IN 2012/13 There are a significant number of improvement areas in the CQIN and other contract schedules which will drive quality improvements in our providers. Examples linked to other elements of the Plan are shown in the tables below. These cover delivery of transformational initiatives, targets for improving quality in under performing areas and delivery of operating framework priorities. 7. PERFORMANCE & QUALITY 44

45. SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES CANCER SERVICES LONG TERM CONDITIONS • Cancer is the second greatest cause of death in Cumbria and although overall incidence rates are lower than the national average, mortality rates are higher. The five-year survival rate is 46.9%, which is considerably lower than the regional and national average. • The Cumbria Cancer strategy, produced in 2010 aims to reduce the number of deaths from cancer, the number of premature deaths and the variation in death rates across the county. • In 2011, an external review of cancer services was undertaken, which built on the strategy and enabled the identification of key priority areas for Cumbria: • Improve early presentation with cancer symptoms, by educating the public, public health campaigns, exploration of incentives in primary care and engaging GPs in the early diagnosis agenda; • Improve early diagnosis by improved GP response and consistent access across the county to diagnostics to exclude possibility of cancer e.g. ultrasound, CT, MRI; • Improved screening, increased ownership in primary care of the take up of breast & bowel screening, follow up of patients who do not attend and use of incentives e.g. through a LES; • Primary care education e.g. by practices undertaking the RCGP audit, develop education programme with secondary care colleagues; • Information and data at practice level e.g. on screening targets, use of 2 week waits, routes to cancer diagnosis; • Appoint clinical leads in each locality; • Develop world class oncology for Furness; and • Follow up support with community/practice nurse for cancer survivors and palliative care patients. • The Cluster can confirm that there is sufficient capacity available to manage the anticipated increased demand resulting from the national Bowel Screening Programme. • The CCG is refreshing the strategy for 2012/13 to ensure it is focused on the right areas and to invigorate these services for patients. The number of people, in Cumbria, with one or more Long Term Conditions (LTC) is set to increase rapidly over the next 20 years in line with a rapidly ageing population. The current system for managing LTCs does not equip individuals to make informed decisions about their own health needs and be in control of their lives. The vision for LTCs in Cumbria is of a whole system approach that improves the lives of people with one or more long term condition. The patient will be the key decision maker and will be equipped to take control of their own healthcare. The vision addresses the health care needs of the population alongside the individual needs of all patients living with or at risk of a LTC. Service delivery will be centred on GP led care that is wrapped around the needs of individual patients and population. The emerging model describes multi-disciplinary teams that will be organised to reflect local needs and local characteristics. The multi-disciplinary teams will be organised to deliver care based on the needs of those patients who can walk in to receive their care and those who can’t. Care will be supported by specialist teams mapped to areas of need. Use of telehealth and telecare will be considered to enhance the model. NHS Cumbria recognises that whilst Primary Care and Community Services have a key role to play in the delivery of an effective system all providers, including Social Care and the 3rd sector, will need to work in a different way. We are therefore working with partners to develop a framework and model that makes things better for both patients and staff who deliver care to everyone with a LTC.When agreed, the implementation of the model and performance monitoring will be overseen by the existing North and imminent South Cumbria Integrated Systems Boards. 7. PERFORMANCE & QUALITY

46. SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.) MENTAL WELLBEING SERVICES • Within this context, priorities for 2012-13 for NHS Cumbria are: • Continued focus on improving access to psychological therapies, particularly for people with long term conditions; • Continued improvements in physical healthcare of people with mental health problems, supported through CQUIN targets; • Development of mental health PbR in a shadow year, for implementation in 2013/14, linked to domains and improved pathways of care; this will also allow the development of more and better community service alternatives alongside preventative models of care; • Whole system reviews of: • Rehabilitation and recovery pathway; • The effective use of the Psychiatric Intensive Care Unit to ensure all PICU activity is managed within county; • Child and Adolescent Mental Health Services, to include review of targeted support for children and young people at particular risk of developing mental health problems, such as looked after children; • Continued repatriation of out of county placements for treatment in Cumbria; • Improved substance and alcohol misuse services through a market testing exercise undertaken in collaboration with the Cumbria DAAT; and • Support to deliver the Cumbria suicide prevention strategy. • In line with England’s Mental Health Strategy, No Health without Mental Health, Cumbria launched in October 2011 its own Strategic Framework, Working Together for Wellbeing and Mental health 2011-14. Informed by the national strategy and a mental health joint strategic needs assessment (JSNA), and co-produced through a programme of engagement, it sets out both to improve mental health and wellbeing of people in Cumbria and to improve outcomes for people with mental health problems through high quality, community oriented, services that are equally accessible for all. • It identifies the following key outcomes to ensure more people recover sooner from mental health problems: • More mental health problems are identified and treated early in the community; • People with mental health problems have better physical health and live longer; • High quality, recovery focused specialist services are available to all when needed; and • Citizens, service users and carers are fully engaged and empowered and more people have a positive experience of care and support. • The JSNA has highlighted concerns about the high levels of alcohol related hospital admissions and suicides in Cumbria, and about the quality and capacity of the CAMHS service. • A multi agency Cumbria Mental Health Partnership Board, co chaired by adult social care and a person who has personal experience of mental illness, has been set up to assure delivery of the Strategic Framework. This Board reports to the Mental Health Commissioning Steering Group and the Cumbria Joint Commissioning Group, then through these into the Health and Wellbeing Board. 7. PERFORMANCE & QUALITY

47. SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.) EMERGENCY CARE ELECTIVE CARE • The CCG is commissioning a new model of emergency care in north Cumbria which is outcomes focused and performs against a set of measurable service aims. All providers of health care are integrating emergency and urgent care services to improve the experience for patients whilst achieving greater efficiency and use of resources. • Adopting a whole systems approach to managing urgent care demand has become a priority as the trend for urgent care is rising at national level and within Cumbria there are pockets of patients who are more likely to experience an admission to hospital than others. • The new ‘Integrated Emergency Floor’ based on each acute hospital site will: • Be clinically led and collaborative; • Deliver a single point of access into urgent care services, including ‘out of hours’ services; • Clinically triage patients into a primary care & community minor illness/injury pathway and a more serious acute pathway of care; • Case manage patients through emergency care and improve discharge; and • Divert inappropriate admissions from secondary care. • Whilst the model for emergency and urgent care changes, ambulatory pathways of care are being implemented for a range of conditions with the intention to manage patients with chronic conditions or acute exacerbation in a more efficient and effective way. • A systematic high quality Integrated Emergency care service will be in place by April 2013 with the aim of reducing admission to hospital for some conditions, focussing resources on the most effective treatment for patients and removing organisational boundaries that cause patients to experience a higher rate of admission than may be acceptable. NHS Cumbria has delivered significant change in recent years in the commissioning of planned care and is now in the top quartile of performance in the North. However the CCG believes that there are further opportunities both to deliver care in non secondary care settings and to ensure the appropriateness of referrals. Service Transfers Following a procurement process, optometrist-led ophthalmic follow ups will be available, together with Low Vision triage services. Both of these will contribute to easing the significant capacity issues in this specialty in the north of the County. Evidence Based Referrals Although NHS Cumbria already has an EBR policy in place, this is being extended and strengthened for 2012/13 with IT led decision support through GP clinical systems to aid effective referral management. In addition compliance with EBR protocols is being negotiated into acute contracts. Repatriation of Services Commissioners will be working with providers to ensure that patient choice is available locally for all secondary care services which can be safely and appropriately provided in local hospitals and that these are correctly applied through Choose and Book and associated service directories. Earlier Discharge Commissioners and providers are developing business cases to determine the viability of earlier discharge into the community for selected procedures (e.g. Joints). Any Qualified Provider NHS Cumbria is committed to offering three services to AQP from the national directory. These will be community continence, community diagnostics and primary care psychological therapies. 7. PERFORMANCE & QUALITY

48. SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.) NHS 111 HEALTHCARE ASSOCIATED INFECTIONS • Cumbria is below trajectory for both MRSA Bacteraemias and • Clostridium difficile infections. There is a Cumbria wide approach to dealing with these infections with close cooperation between primary care, secondary care and commissioners. We have worked with providers and the Health Protection Agency to comply with the mandatory reporting for meticillin sensitive staphylococcus aureus (MSSA) and E.coIi bloodstream infections. • Preventive activity will continue to focus on high impact interventions of known efficacy, such as hygiene and appropriate use and care of lines and catheters. We will be assured of sustained, reduced rates of Clostridium Difficile associated diarrhoea and MRSA bacteraemias across the health economy via the Provider Assurance Framework. • Specific initiatives that we plan to progress in the Cluster this year • include: • Ribotype initiative; • Clostridium difficile testing flowchart; and • Root cause analysis review • The above initiatives will be progressed through the Cumbria Infection Prevention Steering Group. There are already effective County wide networks which will be used to implement the protection and prevention initiatives outlined above. MRSA targets will be included in contracts and the framework outline above will deal with underperformance. • We will continue to use the HCAI assurance frameworks as evidence that all relevant actions are being taken and that compliance with the Health and Social Care Act and national guidance is delivering significant improvements for patients. • The CCG has played an active part in the development of the 111 project in the North West and is committed to the regional procurement process. • The CCG has elected to seek a ‘sub-regional’ footprint for provision of 111 telephony as it believes local knowledge and content are vital to the success of the project. A full and functioning directory of services has been compiled for the county. • The CCG has made clear that 111 is an integral part of improving primary care and community services. The CCG’s expressed wish is to create a single point of access (SPoA) for Cumbria with 111 as the front end public number for a range of non urgent clinical services. • A specification is being drawn up to supplement the regional procurement process.  This specification will require providers to demonstrate that they will deliver not only non urgent call handling but also develop services such as: • Out of Hours services; • Long term condition advice; • Specialist nurse services; • Social services advice and contact; and • Booking services for patient transport, dentistry etc. • This list is not exclusive and the CCG will be seeking partners who can add the greatest value to enriching primary care and community services. • This service will be fully functional by the start of the 2013/14 financial year.  7. PERFORMANCE & QUALITY

49. SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.) STROKE SERVICES • Recommendations from the review: • Thrombolysis: The Coronary Care Unit does not have the facets required for hyper acute stroke care. A process mapping exercise needs to be undertaken once again. In the interim the organisation needs to decide on where to locate circa 6 beds where it will be possible to deliver appropriate hyper-acute stroke care on a 24/7 basis. For thrombolysed patients there will be a requirement for monitoring; other patients with more severe strokes will be sicker and need to be properly and safely managed and this would help to reduce current mortality rates. • Early Supported Discharge: pursue plans to develop this. • Commit to engage positively with the Cardiac & Stroke Network. • The above recommendations will be built into the 2012/13 contract with the Trust, along with a requirement for a recovery plan that addresses the Peer Review concerns. • It is apparent that there is a need for a fundamental overhaul of stroke services, which may mean that achievement of performance targets continues to be variable in the south of Cumbria in the coming year. • The Cluster has highlighted difficulties associated with the delivery of stroke • targets in 2011/12 predominantly as a result of the issues faced by UHMBFT. • Whilst performance at NCUHT is close to achieving the 80% on a • consistent basis, the variable performance at UHMBFT means that the Cluster will struggle to attain the target across Cumbria by 31st March 2012. This is despite recent improvement in Q3 where the 80% target was achieved by UHMBFT in two months out of the three. • Overall, there is still concern about the ability of UHMBFT to achieve longer • term sustainable performance. This is a view shared by North Lancashire • Cluster. • To address the current issues, the Royal College of Physicians was invited by the Lancashire Stroke and Cardiac Network to undertake a peer review. • The informal outcome of the peer review highlights significant concerns: • Lack of ownership across the whole pathway; • Lack of responsibility across the organisation at all levels; • Key relationships are not working; • Pathways are haphazard and fragmented; • Lack of co-ordinated approach; • No proper setting of targets or effective action planning; and • Multiple disconnections in the layers of the organisation. • The review concluded that current stroke unit cannot provide safe and effective care for neurological emergencies and is probably 15-20 years behind current best practice for Stroke care.There needs to be: • Rigorous, robust ownership and accountability at all levels; • Review of Clinical leadership with support for development of key roles; • A full review of what can be delivered on the RLI site; • Revision of the whole pathway - thinking about the whole service differently; and • A Stroke champion at Board level. 7. PERFORMANCE & QUALITY

50. SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.) HEALTH CHECKS SMOKING QUITTERS • The Stop Smoking Service (SSS) was transferred to the Cumbria • Partnership NHS Foundation Trust in April 2011. Important developments • have resulted in improved patient experience: • The introduction of a central telephone booking system has enable patients to be offered immediate appointments; • Patients can access immediate support via a telephone consultation called ‘Direct Quit’; and • The development of an online database via EMIS web, which allows for immediate access to patient notes and also paperless working. • Some difficulties have been experienced in producing documentation for • the Department of Health return, which is being addressed. • Advocacy work and campaigns have been delivered addressing the accessibility and visibility of tobacco products by children: • The removal of vending machines and point of sale displays; • Smoke free environments for children – in homes and cars; and • Raising awareness of illicit tobacco. • There is growing support amongst Authorities in Cumbria to introduce a voluntary ban on smoking in children’s play areas. • Women who smoke during pregnancy are being rewarded for not smoking as part of a North West program to reduce the Smoking at Time of Delivery (SATOD) target. Evaluation by Stirling Universityshows that the program results in fewer women smoking throughout their pregnancy. • A program to identify those at risk of undiagnosed COPD targets customers at two pharmacies and the local Stop Smoking Services. Customers are offered the chance to be tested, with results being forwarded to their GP. Between 2010 and 2012 NHS Cumbria piloted a primary care based Health Check programme within one locality in Cumbria. This targeted hard to reach individuals. Clinical audit within one participating practice suggested that the programme has been successful in identifying and engaging patients with previously undiagnosed vascular conditions. A specification for a primary care Local Enhanced Serviced (LES) has been developed which will roll out within all localities during 2012/13. The specification meets the full requirements of the NHS Health Check programme and will use the national dataset to record findings. Practices will be encouraged to prioritise hard to reach and high risk individuals and will be supported by the Department of Public Health and primary care information systems to enable them to do this. Once the primary care programme is established, the Department of Public Health will also commission social marketing activity to promote further uptake in more deprived communities. This will build upon the lessons learned from the recent successful ‘cough, cough’ Lung Cancer campaign which utilised a mix of professional engagement, media and community partnership approaches to increase patient ‘push’ factors as well as service ‘pull’ factors. The department of Public Health is also currently developing a Health at Work programme with major employers in the county and will be exploring the potential for implementing NHS Health Checks in workplace settings. 7. PERFORMANCE & QUALITY