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Agenda Item: LW2015/44 FOI Exempt: N

Leeds West CCG Governing Body Meeting

Date of meeting: 6 May 2015

Title: NHS Leeds West CCG Strategy Review – update on progress against strategic objectives 2014-2015

Lead Governing Body Member: Susan Robins, Director of Commissioning, Strategy & Performance

Category of Paper Tick as

appropriate

()

Report Author: Becky Barwick, Head of Strategic Development

Decision and Approval

Reviewed by SMT: N/A

Information

Reviewed by: N/A

Discussion

Checked by Finance: N/A

Approved by Lead Governing Body member: Y

Strategic Objectives – that this report relates to Tick as appropriate

() 1. To tackle the biggest health challenges in West Leeds, reducing health

inequalities

2. To transform care and drive continuous improvement in quality and safety

3. To use commissioning resources effectively

4. To work with members to meet their obligations as clinical commissioners at practice level and to have the best developed workforce we possibly can

Joint Health & Wellbeing Strategy Outcomes – that this report relates to Tick as appropriate

() 1. People will live longer and have healthier lives

2. People will live full, active and independent lives

3. People will enjoy the best possible quality of life

4. People are involved in decisions made about them

5. People will live in healthy and sustainable communities

Assurance Framework - to which risks on the GBAF does this report relate?

The GBAF has been developed to manage risks to delivery of the strategic objectives. Therefore this report relates to all the risks described in the GBAF.

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EXECUTIVE SUMMARY: The Governing Body received and approved an updated three year NHS Leeds West CCG Clinical Commissioning Strategy (2013-2016) in July 2013 and received progress reports in November 2013, April 2014 and October 2014. This paper provides an update to the Governing Body around progress towards the strategic objectives and achievements in 2014-2015. There is a particular focus on the priority health goals. This update also includes a cross reference to the Governing Body Assurance Framework (GBAF) risks for each of the strategic objectives. This will allow the Governing Body to assess whether there are any gaps in the GBAF and new risks which need to be developed. This update should be read in conjunction with the Integrated Quality and Performance Report (IQPR) on progress towards strategic objectives and the latest version of the GBAF. The NHS Leeds West CCG strategy also aligns with and supports the West North West Public Health Plan. Please see the separate paper NHS Leeds West CCG Operational Plan and Strategy 2015-2016. The strategy has been revised for 2015-2016 in the light of newly identified key priorities for the organisation (Primary Care, Mental Health, Long Term Conditions), emerging commissioning priorities on Leeds and West Yorkshire footprints and the refreshed citywide Transformation Programme. PROGRESS - HEADLINES Significant progress was made in the following areas during 2014-2015:

Primary care access – significant investment agreed to enable extended primary care access in all 38 member practices. Implementation begins November 2014 with full roll out expected by April 2015. Proposal co-developed with members.

Primary care development – successful in becoming a Prime Ministers Challenge Fund Wave Two pilot, progress towards new models of care, enhancing locality working.

Primary care quality - continued progress in embedding the CCG’s statutory duty to improve the quality of general practice. 18 practices have participated in the Productive General Practice programme. We have facilitated a number of training and development programmes for practice staff aimed at improving the patient and staff experience and also held a successful training event on getting practices ready for CQC.

Primary care nursing – we have demonstrated we are a life-long learning organisation committed to developing its workforce and we have implemented advance training practice and preceptee programmes with the aim of developing and making sustainable practice nursing.

Practice Pharmacists – working in all 38 member practices full engagement has

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supported cost effective, high quality and safe prescribing. In excess of £234K has been saved on the prescribing budget in 2014/15 and we are predicted a 2.28% underspend, (£1,096,850) one of only two CCGs in Yorkshire and Humber.

Patient Empowerment Project – third sector coordination and social navigation service formally procured and contract awarded to BARCA Leeds working in partnership with Leeds Mind, Better Leeds Communities and Touchstone with phased implementation from October 2014.

Diabetes – by working with our member practices we have increased the proportion of diabetes patients receiving all nine care processes recommended by NICE from 53% to 72%.

Childhood asthma – we have secured funding to implement and ensure sustainability of gold standard care to improve the quality of life for asthmatic children and young people across Leeds West. This includes the appointment of a Clinical Lead for Paediatric Asthma who will work with member practices to implement and embed NICE Standards for Asthma Care and British Thoracic Society guidelines in practices.

Childhood obesity - we have developed a business case (together with colleagues from Leeds City Council Public Health and Education departments) which has secured funding to introduce evidence based obesity prevention programmes to five school cluster areas which will drive quantifiable and sustainable behaviour changes in eating habits and will complement and support physical activity programmes.

Advice and Guidance – 7 practices have signed up to a 6 month pilot project which is being conducted by The Elective Care Transformation Board to deliver a structured approach to Advice and Guidance via the Choose and Book system. Participating practices will consider using structured advice and guidance as an alternative way of seeking consultant/specialist opinion or treatment planning for the management of their patient, in circumstances where they would normally make a routine referral for an outpatient appointment. This will help commissioners to establish if advice and guidance can offer a convenient and effective alternative to face to face appointments with a consultant by enabling either reassurance or test first pathways. The project commenced on December 1st 2014, and is planned to cease on May 31st, after which a further month will be required for audit and evaluation.

Learning Disabilities – we developed and delivered a training package to 54 members of staff in GP practices to improve awareness of the needs of people with learning disabilities and we have developed a patient engagement exercise with the aim of improving access to primary care for people with LD to inform the forward work programme.

Staff mental health and wellbeing – In quarter four, fourteen staff took part in a preventative and early intervention workshop which demonstrated a variety of coping strategies to manage potential lifestyle issues that can impact on work capacity. The sessions have been informative and interactive. Sessions have taught staff the implications of stress and how they can effectively minimise the risks of

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stress coupled with resilience strategies. Staff apply the techniques learnt in all areas of their life at home and at work.

A happiness café network is due to start after working hours on a monthly basis shortly. Its aim to share our knowledge and experience in a peer learning environment with the occasional experiential session using trained mindfulness teachers. Cohorts of six weekly pilates sessions commenced after working hours in quarter four at the CCG for a capacity of 10 staff.

Quality Improvement Network – the aim of the network is to get people to think differently around change platforms compared with programme platforms. This links with learning and our presentations we have shared from the Jonkoping visit and approaches being shared in the Leeds Institute of Quality Healthcare. A new culture is developing and is starting to embed in the organisation. Main aims:

Embedding person centred approaches.

We want people to think in an ‘ideas lab’ type of approach where they feel comfortable to share ideas or if they are not sure where to start with a pathway or general idea supported in a safe environment with the network working together to support the individual(s). Around pathway development- we want to hear from people about what’s gone well, not so well, how the initiate has gone and what the individual(s) have learnt- creating the space for reflection with use of huddle boards.

Opportunities for external speakers.

NEXT STEPS: The Governing Body is also reviewing the NHS Leeds West CCG Operational Plan and Strategy. Progress towards strategic objectives will continue in 2015-16.

RECOMMENDATION: The Governing Body is asked to: (a) NOTE the NHS Leeds West CCG 2014-15 review of strategic objectives. (b) HIGHLIGHT whether there are GBAF risks which need to be developed.

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Section 1: Introduction 1.1 The NHS Leeds West CCG 3 year Clinical Commissioning Strategy was signed off

by the Governing Body in July 2013. The strategy described the objectives and priorities of the CCG for three years; 2013-2014 until 2015-2016, and included a detailed delivery plan for year one.

1.2 The purpose of this paper is to provide an update to the Governing Body about progress to achieving strategic objectives during 2014-15 with a focus on Priority Health Goals.

Strategic Objectives 1.3 Towards delivering the organisational vision, and in response to the key strategic

drivers, LWCCG identified four strategic objectives in order to build a highly effective organisation and tackle the health and care needs of our communities. The strategic objectives were described in detail in the strategy.

1.4 The individual strategic objectives of LWCCG are described below.

Strategic Objective 1: Priority Health Goals - To tackle the biggest health challenges in West Leeds, reducing health inequalities.

Strategic Objective 2: Quality & Safety - To transform care and drive continuous improvement in quality and safety.

Strategic Objective 3: Best use of Resources - To use commissioning resources effectively.

Strategic Objective 4 Organisational Development - To work with members to meet their obligations as clinical commissioners at practice level and to have the best developed workforce we possibly can.

In response to strategic objective 1 above and the priorities of the Health and Wellbeing Board LWCCG will focus on the delivery of eight priority health goals for the CCG. The CCG has a responsibility to improve the health of the local population and has identified eight priority health goals for the population of West Leeds. Seven GP clinical leads are in post to lead work programmes for the priority health goals. The clinical leads’ objectives and work plans are aligned to the LWCCG strategy and priority health goals and each has a lead manager supporting them. Priority Health Goals Underpinning delivery of this strategy and aligned to the objectives above, the organisation is focused on eight priority health goals as follows:

a) Healthy Living b) Sexual Health c) Long Term Conditions

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d) Mental Health e) Cancer f) Elective Care g) Urgent Care h) End of Life

The CCG also focuses on the following priority areas in addition to the priority health Goals above:

Children and Families

Primary Care Development Section 2: Progress against strategic objective 1

Strategic Objective 1: Priority Health Goals - To tackle the biggest health challenges in West Leeds, reducing health

inequalities.

2.1 Improving quality in Primary Care What we did in 2014-15: The role of improving the quality of primary care is an evolving one and significant progress has been made in the first part of 2014/15 in working with our colleagues at NHS England in developing this agenda in Leeds West CCG. The CCG continues to work closely alongside the Area Team as the commissioners of primary medical services and we continue to engage members in our role to ensure we focus on supporting quality improvement as opposed to performance management. Patient satisfaction for general practice remains high with the recent patient survey (July 2014) for Leeds West demonstrating that 87% of patients would describe their overall experience as good. Whilst overall experience is high, problems relating to access are a common theme amongst patients when commenting on services. Leeds West CCG have comment boxes in place across all practices and access is a recurring theme for patients to comment upon. Comments relate to:

only same day emergency appointments can be booked or a week long wait to see any GP

a move to walk in services absorbs all the routine appointments and patients frequently have to wait 2-3 weeks for a pre bookable appointment

being asked to call daily to try to book an earlier appointment

problems making appointments, including

being unable to get through on the telephones

lengthy waiting times

patients feeling they are in competition to obtain the limited appointments available and being unable to choose a GP resulting in poor continuity of care

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Extending Primary Care Access Leeds West CCG has developed a business case to deliver improvements through extended access to primary care, which responds to:

National drive for 7 day working in the NHS

Current capacity of primary care and growing patient demand

Feedback from patients regarding problems accessing general practice services, evidenced by the recent national patient survey which indicated that:

o 38% of patients asked indicated that they would like to see appointments before 8am,

o 76% would like appointments after 6.30pm o 79% would like appointments on a Saturday. o 50% of patients asked were not able to access an appointment for the day

they wanted.

Local appetite from GP practices to improve services Providing extended access is voluntary for practices and therefore we are proposing a tiered approach to offering additional services so that it provides flexibility for those practices that are keen to explore extended access to those who wish to test out 7 day opening: Level 1 – Increased Capacity through Extended Hours Level 2 – Increased Capacity through Extended Access (5 days) Level 3 – Increased Capacity through Extended Access (7 days) Practices will be will be free to develop their approach, and use information from their practice profile/demographics to help inform service delivery, to meet the needs of their patients with the overall aim of:

improving patient outcomes,

enhancing patient and staff satisfaction,

reduce demand for other services, and

increase cost-effectiveness across the local health economy Developing Person Centred Care In order to support improved consultations skills we are supporting practices to implement the Year of Care (House of Care) approach to care planning with people with long term conditions. The approach is evidence based and is designed to change the relationship between patient and clinician about making routine consultations between clinicians and people with Long Term Conditions truly collaborative through care planning. Patients are supported to set their own goals and take control of their own care to support effective management of their long term condition. The sharing of clinical information prior to a care planning consultation, changes the relationship between patient and health care professional putting the patient in the driving seat giving them tools and confidence to manage their condition. We currently have 8 practices implementing Year of Care in Leeds West CCG and a further 5 practices developing implementation plans. Care Co-ordinators We have also invested locally in a scheme to support the identification of care co-ordinators at practice level to support the pro-active management of patients, through effective care and case management. These posts will be practice based but link out into the community working closely with the neighbourhood teams and primary and community

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services to ensure patients are supported in the community without the need for admission to hospital. Productive General Practice Leeds West CCG invited all practices to participate in the Productive General Practice programme, which is a whole systems approach which is evidenced based and can lead to improvement, productivity, efficiency and engagement with staff and patients. 18 practices have requested to be part of the programme with the first cohort underway and the second cohort due to commence in September. To work through the full programme can take up to two years. It requires a considerable amount of investment for practices both in time and enthusiasm but the benefits will be realised across the whole practice team and their patients. Clinical Commissioning Scheme The Clinical Commissioning Scheme for 2014/15 continues to focus on quality improvement through the identification of key actions that will help to address the key public health priorities as identified through the practice profiles based on the JSNA, with specific reference to the key areas that affect our population such as respiratory, CVD, Cancer and alcohol. The breakdown is as follows:

Topic Number of practices

Alcohol 4

Cancer 8

COPD / Respiratory 8

CVD 2

Diabetes / Pre-diabetes 8

Obesity 5

Mental Health 1

COPD / CVD / Cancer 1

Undecided 1

Through the Clinical Commissioning Scheme, the Locality GP Chair and Primary Care Manager have visited all 38 practices to review the practice profile and the primary care webtool, which has a series of indicators that have been nationally defined as being an indicator of quality. These visits have been used to develop the practice action plans for 2014/15. Practices will continue to receive their quarterly practice MOT, which helps to benchmark practices against key strategic priorities and supports quality improvement through peer review of the information. The MOT incorporates activity and prescribing information to enable an integrated quality focus. Our practices meet 10 times per year as part of our Locality Development Sessions which provide an opportunity for the membership to influence clinical commissioning decisions. Members are able to share best practice with their colleagues through these sessions. Patient representatives have attended some sessions and this will be developed further. Quality improvement is an underpinning theme to all of the sessions.

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Co-Commissioning of Primary Care In January 2015, CCGs were invited to apply to enter into co-commissioning arrangements with NHS England for the purpose of commissioning General Practice services. Co-commissioning is one of the initiatives that was highlighted in the NHS Five Year Forward View. Co-commissioning could potentially lead to a range of benefits for the public and patients, including:

Improved access to primary care and wider out-of-hospitals services, with more services available closer to home;

High quality out-of-hospitals care;

Improved health outcomes, equity of access, reduced inequalities; and

A better patient experience through more joined up services. There are 3 levels that CCGs could apply:

Greater involvement in decision making

Joint commissioning arrangements

Full delegated arrangements There is no obligation for CCGs to enter into Co-commissioning arrangements with the Area Team; however we believed that the joint commissioning of medical services is key to enabling the delivery of a truly integrated healthcare system in Leeds. Aligning commissioning responsibilities from NHSE and the CCGs will provide the greatest opportunity to undertake the change required to realise the ambition of our city wide transformation programme. The 3 Leeds CCGs submitted an application to pursue joint commissioning approach from April 2015 with a view to exploring local flexibilities for contracts and incentive schemes such as re-looking at the enhanced service for unplanned admissions. Following the submission the proposal for Leeds is to focus on Level 1 at this stage with a view to looking at delegated arrangements from April 2016. A city wide steering group has been established to develop the proposal for Leeds which is being chaired by Nigel Gray at Leeds North CCG and is represented by all three CCGs and the Area Team.

2.2 Promoting healthy living to tackle the wider determinants of health NHS Leeds West CCG matrix public health team has developed a clear public health plan aligned to the work of the public health team in Leeds City Council; The plan is led by Fiona Day, Consultant in Public Health Medicine, the team works in partnership with the Health and Well Being Board and the LCC WNW and South East Leadership Teams. The plan builds on work undertaken during 2013/14 and provided a clear workplan for the team for 14/15 with a focus on key issues:-

Implementation of the Leeds West CCG patient empowerment model

Local action on domestic abuse

Local action on Cottingley springs and gypsy and traveller populations in Leeds West/WNW

The plan is split into three parts:

Shared priorities between LWCCG and WNW public health team

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Priorities for WNW public health team

Public health priorities for LWCCG primary care development team The team also support the public health priorities around healthy lifestyles and actively promotes greater uptake of services through primary care with a focus on smoking, obesity and alcohol. Increasing the uptake of NHS Health Checks is also a priority. What we did in 2014-15: In response to high rates of emergency admissions for alcoholic liver disease in our area the CCG has commissioned and implemented alcohol training for primary care staff in practices with greatest need for support for dependent drinkers. We have also increased local capacity for specialist alcohol treatment services to address local need for services for dependent drinkers. The Public Health Clinical Lead is a member of the Joint Commissioning Group for the commissioning of drug and alcohol services for Leeds. Procurement for a new city-wide service was progressed and LCC have commissioned a new city-wide integrated Community and Alcohol Prevention, Treatment and Recovery Service starting 1st July 2015. Through the appointed clinical lead we have developed a patient empowerment service (PEP) to support patients and communities to actively self-manage their health issues through peer support. The contract to deliver PEP was awarded to BARCA-Leeds, who are working in partnership with Leeds Mind, Better Leeds Communities and Touchstone to deliver the project which started in September 2014. Following a successful early indicator report the CCG agreed a second year of funding to end of September 2016. The interim evaluation indicates that those assessed by PEP are those patients that offer the biggest challenge to the health and social care system. PEP has supported extensive links and service connections for patients to a wide range of local community and voluntary services such as healthy living services, financial inclusion, housing, domestic abuse and drugs and alcohol agencies. Working with LCC Public Health we have provided targeted support in areas where there is a higher prevalence of adult obesity and linking with healthy living services via the PEP project. The CCG has contributed to the Tobacco Management Group to support the Leeds Tobacco Action Plan 2012-15 and developed a focussed approach to provide targeted support to practices where there is a higher prevalence of smokers and increased signposting and support via PEP. Working with the Gypsy and Traveller community at Cottingley Springs, Leeds Gypsy and Traveller Exchange (GATE) and LCC we attended two family fun events at Cottingley Springs, conducting a series of health check clinics and held two focus groups with residents to better understand the health needs of the community and the best approaches to improving access to primary care services. The CCG has supported the development of health and care navigator roles within the community and we are now in a position to develop plans which will see better access to primary care to support this community.

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We linked residents to targeted health improvement work such as screening and cancer awareness projects and have submitted a bid to Yorkshire Cancer Research to support increased awareness and uptake of the breast and bowel cancer screening programmes and open access to chest x-ray in Gypsy and Traveller and Roma communities in West Yorkshire. Promoting and supporting the Leeds Domestic Violence Strategy and Action Plan 2013-15 at a local level – we have developed relevant links to a 24 hour helpline and key information via the Map of Medicine. Working with LCC Public Health and Dr Yen Anderson, strategic CCG lead for Domestic Violence we have agreed workforce development as a key area of action for the CCG, with a planned TARGET event and work to support practices who are working towards Level 1 Domestic Violence Quality Mark. We are increasing the uptake of NHS Health checks with member practices taking up opportunities to improve performance: 14 member practices identified where increasing NHS Health checks as an action in the clinical commissioning scheme. Performance of the NHS Health Check is monitored via the Primary Care Quality Surveillance Group. LWCCG is a member of the city wide integrated Sexual Health Project Board. During 14/15 work was undertaken to procure a new city wide integrated Sexual Health Service starting on 1st July 2015. The new service will be delivered by a consortia including LTHT GUM, LCH CaSH service including citywise (service for young people), MESMAC and other third sector organisations. 2.3 Proactive management for people with long term conditions. What we did in 2014-15: Approximately 2000 patients at high risk of hospital admission have been reviewed by member practices through the risk stratification tool and many have also been discussed at multi-disciplinary team meetings supported by local social and community workers alongside GPs to agree care plans for individuals. As part of the £2.64 support for practices to deliver the national enhanced service to reduce emergency admissions, there are now practice care co-ordinators within practices to support integrated neighbourhood teams. We have increased the proportion of diabetes patients receiving all nine care processes recommended by NICE from 53% to 72%. As part of the diabetes work going forward, this will be taken forward as part of reducing clinical variation in diabetes care.

i) Supported self-management.

Year of Care training has now been rolled out to 18 practices trained. Sixteen practices can implement as part of extended hours. Four practices are implementing the Year of care with some practice keen to commence diabetes care. Integrated care records are also developing as a result of this work. Evaluation-This is in the process of being evaluated with a focus on patient experience and outcomes in relation to improved control and self-management, clinicians experience

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and skills, delivery issues for practices – and how this relates to the rest of the health and care system. Also clinical outcomes/ changes. Diabetes - Leeds West CCG has led the development of diabetes as part of the city wide pathway development work stream for the Adult Integrated Prevention Transformation Board Programme. Key themes which have emerged following a recent workshop were: focus on person centred care for quality improvement. Such themes raised were to have education programmes in place for health care professionals to enable effective supported self-management. Opportunities were identified for preferred pathways and better communication. The aim is to enable an integrated diabetes system. Leeds West CCG continue to contribute to these meetings aligning with the methodologies of the Leeds Institute for Quality Healthcare (LIQH). In addition, Diabetes colleagues at the CCG will be part of the professional leadership programme, Summer 2015. To complement the diabetes work in the short term:

A business case has been discussed at the community PMG for resources to support increased demand on the Community Diabetes Service and reduce the current waiting list. This will be funded for one year and provided by Leeds Community Healthcare which has commenced.

Following consultation with patients locally, it was recommended that the current X-PERT patient education programme needs to be more flexible around people’s lifestyle and needs. A bespoke programme could offer something more flexible which would increase accessibility while maintaining outcomes and satisfaction. This is linked to current thinking around the diabetes pathway in Leeds and would help support the increased demand for patient education in this area.

A business case from Leeds Community Health has also been discussed at the community PMG recently in order to replace the commissioned X-PERT programme. This will be taken forward as part of the Transformation Board work.

Part of the work which will be ongoing locally is around patient empowerment and peer support groups and innovation around information technology.

A generic structured education framework for generic and disease specific long terms conditions (diabetes, COPD, CVD) has been procured in April 2015. The provider is Self-Management UK. This will be a pilot scheme running for nine months.

ii) Integrated Health and Social Care-

As part of improving integrated care, a city wide framework has been established for primary care as part of the Integrated System Change network.

All practices now have access to a named clinical lead within the neighbourhood teams in order to support proactive case management (Better For you) and reduction in non-elective activity. Social workers are in the process of moving into the teams with named contacts for each practice.

Electronic systems are developing across the city. In addition, all practice agreements are in place as part of Leeds Community Health’s CQUIN to engage with practices around the work of the integrated neighbourhood teams.

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There are opportunities for integrating mental health services within the neighbourhood model. Cardiovascular disease This is a new piece of work, commenced December 2014. An action plan will outline areas over a three year period. This year the focus will be on:

Improving the uptake of NHS health checks and also smoking cessation services.

Increased anticoagulant therapy in atrial fibrillation

Improved blood sugar control in diabetes and reducing clinical variation in practices in which the Year of Care approach will compliment this.

2.4 Improving the mental health of the population What we did in 2014-15: We have commissioned a two year Employment Support project facilitated by Leeds Mind which provides two Job Retention Specialists to work with patients who are in employment but are currently off work and/or at risk of losing their jobs through mental health problems to return to their jobs. This project has been based in Thornton Medical Centre and Windsor House Surgery. It has now been extended to Highfield Medical Centre for 2015/16. The Leeds Suicide Audit (2012) highlighted that suicide trends do not appear to be changing over time and that the highest number of recorded deaths was in the LS12 postcode. In response to this, we are working on a number of initiatives in the LS12 and 13 areas:

- Working with Community Links, we have developed and delivered a bespoke half day training session (based on the Applied Suicide Intervention Skills training (ASIST)) for GPs to teach suicide first aid skills in order to raise confidence in effective suicide intervention.

- Community Links have also delivered four suicide awareness training sessions - safeTALK - to front line staff.

- We are supporting the delivery of five courses by Oblong Leeds which is targeted at patients with low self-esteem.

- We are working with BARCA Leeds to deliver four ‘positive communication’ groups across community groups which aim to improve quality of life, health and wellbeing and reduce risk of harm in vulnerable, isolated and socially excluded people. The success of these groups has enabled a further year of funding to be granted with a view to evaluating this work to inform future commissioning in this area.

To support our work around the early identification of dementia we have been involved in the CANTABmobile pilot which aimed to support the identification of dementia through the use of an assessment tool (via an iPad). We have promoted the use of the Dementia Quality toolkit across our practices and supported them to improve early identification of patients with dementia. These initiatives have enabled us to reach our target of 67% diagnosis rate for 2014/15.

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We are involved in the redesign of the citywide Leeds dementia pathway which we will be implementing across our Practices during 2015. This includes three of our practices hosting memory clinics as part of the redesign. We will also be providing training for front line staff to raise awareness of dementia as part of the ‘Dementia friendly’ initiative’.

We are actively supporting the development of the citywide Mental Health Framework for 2014-2016. We have developed our work plan for 2015/16 which responds to the priorities set out in the Framework and also our areas of need in Leeds West. We will also be ensuring that there is a process for feedback both from city wide initiatives to our members and from our members in to citywide initiatives. We are involved in the citywide IAPT service redesign programme which aims to improve access and provide improved self-management support pre-IAPT. We have secured funding to develop a Student Mental Health service that will be integrated within the University of Leeds and Leeds Student Medical Practice to deliver care to students that is appropriate, timely and accessible. 2.4.1 Improving the health of patients with Learning Disabilities What we did in 2014-15: During 2014/15 we have been developing our work plan in relation to this area of work. The citywide Learning Disability Strategy and Health Improvement Framework are due to be launched (April 2015) and we will develop our response to these once received.

We have developed six weekly meetings with the Learning Disability (LD) Commissioning Manager and Clinical Lead to ensure we share learnings, develop our action plan alongside citywide objectives and support citywide initiatives.

We have been supported by Change to deliver nine training sessions to 52 members of staff (including GPs, Practice Managers, Receptionists/Admin, Pharmacists, Practice Nurses, Health Care Assistants and Locality Support Managers. The aims of these sessions were to raise awareness of the needs of people with a learning disability and improve uptake of the full range of screening and prevention programmes. In addition we have supported city wide training initiates in relation to the LD CQUIN. We plan to work with the LD Commissioning Manager to improve our LD register to ensure we have accurate information as to who and where our patients are which will allow us to target initiatives e.g. increase uptake of annual health checks. The LD nurses are working in practices to review the LD practice register and to increase the uptake of the annual health checks. These nurses are already making improvements and so far have been working in New Croft, Ireland Wood, Leigh View and West Lodge.

We have completed our engagement exercise with our patients (supported by Change and Leeds Involving People). The findings from this exercise are being collated and these will be reviewed with a view to developing our actions in response to this, which will include working with our citywide commissioning colleagues to ensure that every practice in Leeds West has relevant LD friendly health information available.

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2.5 Improving outcomes for those diagnosed with cancer What we did 2014-15: The Leeds Transformation Board has set its programme of work, which incorporates 6 main transformation programmes and a series of enabling groups. Under the Elective Care Transformation Programme, Cancer has been identified as a priority area for transformation and is one of the work streams. The “Leeds Cancer Locality Network” group had been reconfigured and renamed as the “Leeds Integrated Cancer Services (LICS) Steering Group”. This is now the steering group responsible for leading the implementation of the vision for integrated cancer services across Leeds, This group meets every 6 weeks and is co-chaired by a GP Clinical Lead Commissioner and the Lead Cancer Clinician for Leeds Teaching Hospitals NHS Trust. Within a relatively short amount of time we have created an operational and governance framework for LICS across Leeds. Representatives from key organisations working across all aspects of cancer care in Leeds, including commissioners, clinicians, Leeds City Council public health and a range of medical colleagues have worked together to identify and scope immediate priorities for Leeds cancer services. Four priorities identified are:

Review and potential re-design of the Breast Diagnostic Pathway.

“Follow-up” across multiple cancer pathways

Enhanced assessment and management of co-morbidity in patients receiving cancer treatment (potentially starting with cancer and diabetes)

Screening variation – initial focus on bowel cancer The first phase includes the Breast Diagnostic pathway and “Follow up” across multiple cancer pathways. These are now being taken forward by project groups with representation from commissioners/ providers and public health. A company called ‘Brainbox is leading the Patient and Public Engagement, this is key to the success of developing and delivering cancer services that ultimately improve patient outcomes and experience. Breast Diagnostic Pathway The proposal for this project is to design a diagnostic service which will benefit patients and clinicians greatly. This will ensure that highly specialist clinical resources become focused on patients diagnosed with cancer, whilst ensuring that those with no evidence of cancer continue to receive effective advice and support. We believe this will improve the service for both patients diagnosed with breast cancer, and also those referred on a two-week wait pathway where no cancer is diagnosed, with a view to exploring alternative models of care. Follow-ups across multiple cancer pathways The LICS group recognised that health and social care services across the UK were not set up to deal with the needs of large numbers of people, who have survived cancer, but who often continue to require considerable support. Services need to radically transform how they deal with patients’ aftercare, which may well mean a move away from routine hospital follow ups; for example using technology or delivery of follow-up care by a

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different range of healthcare professionals in alternative locations. Alternative models are being explored including (i) the Calderdale model of discharge in low risk breast cancer patients with a programme of education (ii) the stratified pathway to determine frequency of investigation in colorectal cancer developed in Bradford (iii) the use of remote technology to facilitate patient-led follow-up based on models developed in the Yorkshire Testicular Cancer Service. Evaluation All of the projects will include the development of an evaluation strategy using the Outcomes Based Accountability methodology; this will provide a number of change measures where the potential impact of the change delivered through the projects will be able to be monitored. This approach is also aligned to the Health and Well Being Strategy for Leeds and is being embedded across all transformational activity across the health and care sector in Leeds 2.6 Improving access to elective care services What we did in 2014-15: Data shows that 80% of practices viewed Map of Medicine pathways between April and October 2014, the average across the city being 69% (most up to date figures available). Choose and Book utilisation is currently 73% for LWCCG, i.e. 73% of referrals to first outpatient appointments are being made electronically. 7 practices have signed up to a 6 month pilot project which is being conducted by The Elective Care Transformation Board to deliver a structured approach to Advice and Guidance via the Choose and Book system. Participating practices will consider using structured advice and guidance as an alternative way of seeking consultant/specialist opinion or treatment planning for the management of their patient, in circumstances where they would normally make a routine referral for an outpatient appointment. This will help commissioners to establish if advice and guidance can offer a convenient and effective alternative to face to face appointments with a consultant by enabling either reassurance or test first pathways. The project commenced on December 1st 2014, and is planned to cease on May 31st, after which a further month will be required for audit and evaluation. Member practices have received 4 MOT datasets that include secondary care activity for peer review. Following extensive formal engagement with patients, we procured new community services in, ENT, audiology and hearing aids and ophthalmology We also undertook reviews of services, for the management of anticoagulation and chronic pain, both of which also involved full formal engagement with patients across the city, and include the introduction of new technologies which will help support patients in better managing their conditions. We also worked closely with our providers of hospital and community services to introduce more streamlined patient journeys in dermatology, gastroenterology, and urology.

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In addition to this we have begun introducing long term clinical networks in chronic pain, ophthalmology and dermatology; to foster and share best practice, look at potential new service developments; and aim to continuously improve. 2.7 Commissioning an effective response to urgent care needs What we did in 2014-15: Below is a summary of the progress in 2014/15 within urgent care to support the continued delivery of high quality services to our patients.

Implementation of new System Resilience plan and prioritise funding

New guidance was published in June 2014 to assist CCGs and Provider organisations in their planning which recognised that there is pressure on services all year. In response the Leeds System Resilience plan was developed which highlighted priority areas for investments and ensured a system wide approach to identifying and resolving problems to support the robust delivery of services across health and social care.

Urgent Care Engagement

In total we have gathered the views of approximately 4000 people across 3 different engagement projects, which has provided us with valuable insight into the behaviours and experiences of those using urgent care in Leeds. To our knowledge this is one of the largest pieces of Urgent Care engagement work undertaken anywhere in the country, and has already proved extremely useful in informing the priorities for allocating our system resilience funding and targeting the work of the Urgent Care team to best effect.

Tour de France 2014

The Urgent Care team, worked with their partners to coordinate a city-wide health and social care plan as the world’s biggest bike race came to the city. The detailed planning ensured the success of the event and showcased Leeds as a city major for large scale events in the future.

The CCG has reviewed and updated its business continuity plan. 2.8 Increase choice and control at the End of Life What we did in 2014-15:

Collaboration of our clinical lead and other citywide representatives have allowed the implementation and roll out of the electronic palliative care system and associated care pathways.

Leeds End of Life Care Strategy finalised May 2015. The City-wide Strategy has informed the local workplan aiming to improve access to end of life care services, improve choice and reduce inequalities, and increase the percentage of patients who are cared for and die in their preferred place of care. Work is underway to develop a single point of access for patients and carers 24/7, and seeking feedback from bereaved carers.

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Our Clinical Lead is progressing work to improve understanding of the experience of end of life care for patients, family and carers from protected groups. We contributed to a city wide end of life care review led by Leeds SE CCG and future developments exploring the development of a managed clinical network for end of life care. 2.9 Priority Group – Children and Families What we did in quarters 1 and 2 2014-15: We have identified children and families as a priority group and in response to this we are working closely with our commissioning partners to deliver a number of work streams. We have developed a direct GP referral route for the Support and Guidance process (i.e.TaMHS) in Leeds West. This is currently being piloted in three school cluster areas (Aireborough, Pudsey and Bramley). Initial findings have indicated that rejection rates to CAMHS from those practices who have engaged in this pilot have reduced. We are currently reviewing referral outcomes from the pilot practices to establish any capacity concerns resulting from increased referrals to the clusters from GPs. We have contributed to a city wide review of the CAMHS service and will be involved in the emerging work streams. We have secured funding to implement and ensure sustainability of gold standard care to improve the quality of life for asthmatic children and young people across Leeds West. This includes the appointment of a Clinical Lead for Paediatric Asthma who is working with member practices to implement and embed NICE Standards for Asthma Care and British Thoracic Society guidelines in practices. Our Clinical Lead is working with primary and secondary care, pharmacies, schools, public health and commissioners to improve care for our children with asthma. The work of our Clinical Lead will be supported by three days per week of Practice Nurse support (starting June 2015) and supported through the use of the Asthma UK self-management materials. We have developed a business case (together with colleagues from Leeds City Council Public Health and Education departments) which has secured funding to introduce evidence based obesity prevention programmes to five school cluster areas which will drive quantifiable and sustainable behaviour changes in eating habits and will complement and support physical activity programmes. These programmes will result in not only sustained change in the child’s eating activity but also sustained change in the schools, caterers, retailers and parents attitudes and behaviour. We have completed a full procurement exercise which has resulted in Food Dudes Health Ltd being appointed as the preferred provider of these programmes which will commence in schools from April 2015.

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We continue to be involved in the citywide maternity services review. We are working with the citywide team to ensure on going improvement around issues relating to safeguarding, child protection and looked after children. 2.11 Medicines Optimisation There are a number of schemes being delivered by the Medicines Optimisation team in 2014-2015 and there is a focus on supporting Transformation Programme workstreams. Care homes and Medicines Optimisation Implementation Service is a project to optimise the use of medicines for care home residents, provide a specialist pharmacist clinical medication review service and ensure the safety and quality of medication for frail elderly patients.

A team of specialist elderly care clinical pharmacists provide an annual clinical medication review to care home residents of all our 38 GP practices.

The project has been shortlisted for a HSJ award and has been presented as a poster to a national pharmacy seminar. This work has generated much interest nationally.

We are now working closely with the Clinical Lead in planning an integrated model. Practice Pharmacists working in all 38 member practices has supported cost effective, high quality and safe prescribing. In excess of £234K has been saved on the prescribing budget in 2014/15 and we are predicted a 2.28% underspend, (£1,096,850) one of only two CCGs in Yorkshire and Humber. The maintenance and update of the traffic light list is a powerful tool in helping to ensure consistent prescribing across primary and secondary care. Recommendations for medicines which are not cost effective are classified Black Light, and those only recommended for certain conditions classified Grey. Through an incentive scheme in 2014/15 prescribing of these medicines has significantly reduced. Patient care is transformed as medicines are re-categorised and those previously hospital only are prescribable in primary care. This work supports safe prescribing, with the aim to reduce attendance at OPD clinics, and reduce acute admissions due to incorrect management of a patient’s medication, and the resulting complications. Quality and safety reporting has significantly improved through the number of DATIX reports submitted, safety snippets are shared to raise awareness of key themes. Additionally updated clinical pathways bring prescribers to the fore where they can use their unique skills and knowledge in direct patient care. These service redesign approaches have improved the quality of care but have also resulted in significant cost savings. The team have recently started a discharge project for the frail elderly post discharge whereby these patients have a clinical medication review by a specialist pharmacist within 30 days. A support service for patients and member practices to review patients with Atrial Fibrillation who are at risk of stroke and not currently receiving appropriate treatment is currently being planned.

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2.12 GBAF risks associated with strategic objective 1 There are currently no GBAF risks associated with strategic objective 1. Section 3: Progress against strategic objective 2

Strategic Objective 2 Quality & Safety - To transform care and drive continuous improvement in quality and safety.

Programmes underway to deliver the priority health goals are described above. All these projects have an underlying principle related to strategic objective 2. 3.1 Communications and Engagement Patient and public involvement We are committed to listening, learning and responding to our patients and the public and our Governing Body ratified our approach as outlined in our communications and engagement strategy. We have actively sought the views of our local population when considering proposals for change as well as involving them in helping to develop our plans. We have established strong working relationships with key community and voluntary groups as well as Healthwatch Leeds, the statutory body that acts as the consumer champion for health. We have also used networks set up by our partners such as Leeds City Council’s Citizen’s Panel. In 2014-2015 we held monthly meetings for our patient assurance group (PAG). The PAG has been established as a sub-group of our Governing Body in line with our standing orders and schemes of delegation. Members of the PAG help assure that our engagement plans are effective, take into consideration the needs of our diverse communities and ensure we provide sufficient opportunities for people to get invovled. We have established a patient leader programme giving our patient volunteers a chance to be closely involved with all elements of the commissioning cycle from planning, implementation and evaluation of services. The programme ensures that a patient voice is present at all key decision making meetings and builds on the success of patient involvement in setting up the Patient Empowerment Project (PEP). This was the first time we involved a patient throughout the procurement process for the PEP programme. Our community involvement network continues to attract new members, both individuals and organisations. We have also invested in a new database that will allow us to effectively manage our network and target members with details of activity in topics that are of interest to them. We have established a new quarterly magazine called Engage which helps network members, as well as patients and the wider public, be aware of the work we do as well as being kept up to date on wider health and community news and information. Some examples of our patient and public involvement activities in 2014-2015 are listed below.

We held a deliberative event at Yeadon Town Hall asking local people about their views on our proposed model for primary care. Our proposals reflect the multi-specialty care providers outlined in the NHS Five Year Forward View. We asked

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local people what services could be provided at GP practices in the future in a move away from traditional models of primary care.

We launched an animation called ‘Kevin makes friends in hospital’ based on the experiences of local children and young people who have been treated at Leeds Children’s Hospital.

We’ve been working with three primary schools to talk to school children with asthma, their friends, parents and school staff to find out what it is like living with asthma. This is to support our work to improve the care of children with asthma so that we can meet the gold standard set out by NICE.

Support was provided to the Leeds Integrated Cancer Services as we undertook insight work into the current provision of cancer services including initial diagnostic tests as well as treatment and follow up care for those patients that needed it. The insight will help inform future proposed changes to services that closely meet the needs of patients as well as addressing anticipated challenges in the future.

We attended Leeds City Council’s lesbian, gay, bi and transsexual event. This event gave us an opportunity to understand the views of this community. It was also an opportunity to seek views on current engagements and recruit to the patient network.

Gypsy and traveller event at Cottingley Springs. This health promotion event is part of our ongoing work to improve access to primary care for the gypsy and traveller community.

We supported the citywide practice nurse conference a yearly event celebrating the work of practice nurses in the city. We supported the event by interviewing patients on stage where they talked about their experience of using practice nurses.

We were asked by Healthwatch Leeds to help facilitate an event for deaf and hard of hearing people. We worked with our primary care team to host a table about deaf people accessing GP practices.

When developing services or proposing changes to existing services it is a legal requirement for us to involve and seek the views of patients before we implement any changes. In the past year we have asked for feedback from patients, carers, health and care professionals and the wider public on the following:

Extended access to primary care services;

Chronic pain services;

Community ear, nose and throat (ENT), ophthalmology, audiology and hearing aid services;

End of life care – single point of access;

Access to primary care GP services for people with learning disabilities;

Provision of community beds for people who can be discharged from hospital but are unable to return home due to care needs; and

Support for citywide engagement on urgent and emergency care, maternity services in Leeds and the best start project for children with complex health needs.

We now produce a quarterly update on our communications, engagement and equality and diversity activities which can be found on our website. Supporting our partners We are committed to working with partners in the city to get a broader understanding of the diverse communities we serve. We also acknowledge the community based assets our partners have and look to support them with their work with a particular focus on those

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projects that can help us get a better insight into current patient experiences. Over the last six months we have:

Attended an event organised by Healthwatch Leeds looking at services available to those who are hard of hearing

Actively involved in the People’s Voices group led by Healthwatch Leeds

Attended an event looking at how public sector organisations can support people from the LGBT community

Took part in an event for the Gyspy and Traveller community working with other partners in an effort to engage more closely with this traditionally hard to reach group

Supported Leeds Teaching Hospitals NHS Trust to gather patient insight for a project designed to encourage patients to bring their medicines to hospital if they have been referred for treatment

Attended and participated in the Campaign to End Loneliness Summit

Continued promoting the Friends and Family Test Other We attempted a CCG, and possibly NHS, first by reporting live from the majority of our GP practices covering approximately 30 practices in one day. The live reporting event involved patient and staff engagement featuring a mix of text comments, photos and film. We worked on producing our first patient engagement magazine featuring a mix of health news, lifestyle issues and links to community activities that could be of interest to a broader group of patients and the wider public. We continued to use Twitter to report live from all our Governing Body meetings as well as from our first AGM held in September.

3.2 CQuINs The Commissioning for Quality and Innovation (CQUIN) payment framework enables commissioners to reward excellence, by linking a proportion of healthcare providers' income to the achievement of local quality improvement goals. We achieved all our quality and safety CQUIN goals in 2013-2014. Local CQUIN goals for 2014-15 included: Leeds Teaching Hospitals NHS Trust

Continued progress and implementation in Making Every Contact Count

Timeliness and format of outpatient clinic letters

Joint review of patient’s discharge experience (LTHT and LCH)

Central venous catheter related blood stream infection surveillance

Implementation of respiratory care best practice bundles - asthma in A&E

Reduction in hospital associated Venous Thrombo-Embolism

Joint development and delivery of a whole pathway service development plan for children with complex needs (LTH and LCH)

Leeds Partnership Foundation Trust

Improved recording of key health indicators smoking and nutrition and increase level of intervention

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Liaison with Primary Care to improve the quality and up take of annual health checks for people with learning disabilities

Development and implementation of cluster care pathways

Improvement of communication of dementia diagnosis with GPs, service users and family/friends

Cardio metabolic assessment for patients with schizophrenia

Improved communication with GPs of care plan, medication and physical health condition

Leeds Community Healthcare

Joint review of patient’s discharge experience (LTHT and LCH)

Joint development and delivery of a whole pathway service development plan for children with complex needs (LTH and LCH)

Multi-disciplinary working with primary care to deliver proactive case management for patients with complex health and care needs

All of the goals have been achieved, with the exception of one element of the best practice bundle in at Leeds Teaching Hospitals for Q3. 3.3 Clinical Governance and Quality Serious incidents The CCG Governance Team receives notification of serious incidents from all providers of healthcare in Leeds. The team is responsible for risk assessing any immediate impact on the organisation and informing directors of what has happened. The provider organisation is then monitored in reporting, investigating and learning from the incident. In the reporting period of 1st April 2014 to 31 March 2015 a total of 238 serious incidents have been reported to the CCG. Out of the 238 serious incidents 125 were serious incidents relating to Pressure Ulcers. 24 serious incidents have been managed by the CCG on behalf of other CCGs. The CCG serious incident review panel is tasked with reviewing submitted reports and action plans from the providers. This is to assure the CCG that the provider concerned has undertaken a robust investigation, identified the reasons for the incident occurring and put in place actions to prevent something similar from happening again. Never Events Certain types of serious incident are termed ‘Never Events’. These are incident types that, if the necessary safety systems are in place and operating effectively, are expected not to occur. Never Events are nationally defined and most apply primarily to acute hospital care. These types of incident are subject to further detailed scrutiny from the CCG and in some instances providers are penalised when they occur. There have been 6 Never Events reported from 1st April 2014 to 31 March 2015.

Provider Never Event Type

Leeds Teaching Hospitals NHS Trust Wrong Site Surgery

Leeds Teaching Hospitals NHS Trust Wrong Site Surgery

Leeds Teaching Hospitals NHS Trust Wrong Site Surgery

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Leeds Teaching Hospitals NHS Trust Wrong Site Surgery

Leeds Teaching Hospitals NHS Trust Retained swab

Leeds Teaching Hospital NHS Trust Retained swab

Two of the above Never Events occurred within Leeds healthcare providers but affected residents of other CCGs outside of Leeds: Provider CCG Never Event Type

Leeds Teaching Hospitals NHS

Trust

Bradford Districts

CCG

Wrong Site Surgery

Leeds Teaching Hospitals NHS

Trust

Hambleton,

Richmond and

Whitby

Retained swab

The CCG has worked with the provider relating to systems and processes in operating theatres across the Trust to ensure learning from the incident investigations is introduced and embedded in practice. In addition a significant project on a national level has been commissioned by NHS England in response to the number of retained surgical instrument incidents that have occurred nationally. This is the most commonly reported Never Event in the NHS. Responding to concerns and complaints Complaints are taken seriously by the organisation because they are a genuine means of helping the improvement of services. They also help us to manage our performance and highlight any areas where closer monitoring may be needed. In the reporting period of 1st April 2014 to 30th March 2015 the Leeds West CCG received 54 concerns and complaints in relation to health services in Leeds.

Type No.

Formal complaints about NHS providers 26

Formal complaints regarding the CCG’s business 10

Other comments or concerns in relation to NHS services 18

3.4 GBAF risks associated with strategic objective 2

1A

Sub-Optimal Quality - Provider

Risk - There is a risk to Leeds West CCG that the requirement to demonstrate continuous improvement in standards of care in provider organisations may not be met.

Cause -This could be due to competing priorities, financial pressures and workforce capacity within and across providers.

Effect - This could result in sub-optimal care, poor health outcomes, compromised access and service quality for our patients and a failure to achieve financial sustainability

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1B

Sub-Optimal Quality Primary Care

Risk - There is a risk to Leeds West CCG that the requirement to demonstrate continuous improvement in the quality of care in member organisations may not be met

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Section 4: Progress against strategic objective 3

Strategic Objective 3: Best use of Resources - To use commissioning resources effectively.

4.1 Finance and best value update We are on track to achieving financial balance in 2014-15, in our second year of operation and in spite of further baseline allocation changes during the year. The planning guidance for 2015/16 sets out the financial framework for the next year providing funding certainty as to the resources that will be available up to March 2016 only. The financial resources available to the CCG are likely to continue present us with significant and compounding challenges over the coming years, and within the context of major organisational deficits and cost pressures in NHS and Social Care Organisations across the city of Leeds. We have continued to take a best value approach in the formulation of our commissioning plans and intentions and towards the implementation of our one year operational plan. During 2014/15, the Leeds City Wide Transformation Programme has seen increasing support from the Finance community across the Leeds Health and Social system with senior finance leads being assigned to the Project Management Office, and to all main workstreams from both the Provider and Commissioner organisations. This development is expected to add a more structured approach to the reporting and evaluation of the financial impact of the schemes in train, from 2015/16, and to provide the Transformation Board with the level of financial assurance and scrutiny they have been seeking for some time and which has been unavailable until now. We continue to develop our understanding and governance of the Better Care Fund initiative, where a proportion of our current budget is being pooled with Leeds City Council as part of a nationally mandated process to better Integrate Health and Social Care services. The Better Care Fund seeks, through integration of budgets, to drive a greater focus on the integration of health and social care services and improve the services provided to patients whilst reducing waste through removing duplication in pathways of care provided by a previously fragmented system. The Health and Well Being Board has been overseeing bids for initiatives and service developments which best address the

Cause

This could be due to competing priorities, financial pressures and workforce capacity within and across member practices.

Effect

This could result in sub-optimal care, poor health outcomes, compromised access and service quality for our patients and a failure to achieve financial sustainability

6 Emergency Planning

Risk - There is a related risk that business continuity plans are not fully developed and tested for the CCG

Cause - This could potentially compromise the organisation's ability to lead the local healthcare system

Effect - This could result in an inability to commission services for patients effectively.

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requirements of Integrated Care in Leeds and support the longer term resilience of the system, overall. In parallel, we have invested substantively in primary care as part of our drive to develop new models of care to patients in the most appropriate environment and to improve access to primary care services. Our expectation is that the extended services will reduce the number of inappropriate admissions to expensive secondary care settings and our stage 1 evaluation of the scheme will be undertaken in the summer of 2015. The CCG has a Procurement Policy (available on its website) which sets out the processes for commissioning services in the most (cost) effective and transparent way possible. The CCG will be producing its longer term financial strategy in the early part of the 2015/16 financial year. This document is designed to support the CCG’s overall strategy as a Commissioner and to provide assurances on, and identify risks to, the CCG’s longer term financial resilience

4.2 GBAF risks associated with strategic objective 3

3 Y&HCSU

Risk - There is a risk that the WSYBCSU is not able to meet the requirements of the CCG specification for commissioning support.

Cause - This would be due to a failure to mobilise new systems and processes on time and within budget, or through gaps in skills and capacity. This could also be due to the organisation not qualifying to provide services under the national Lead Provider Framework model

Effect - This could both result in LWCCG being unable to commission effectively and significant duplication of activity across CCG and CSU organisations.

4

4 Partnership & Collaboration Risk - There is a risk that the governance arrangements for collaboration, partnership working, risk sharing and commissioning across the Leeds CCG network, Local Authority, NHSE and other partner agencies are not robust

Cause - This would be due to more complex governance arrangements, increased time commitments and reduced workforce capacity in the system.

Effect - This could result in a failure to coordinate action around shared priorities, planning, duplicated activity and weak commissioning engagement with partners and providers. This will weaken NHS Leeds West CCG's ability to commission effectively

4

7 Finance Risk - There is a risk of failure to achieve financial stability and sustainability.

Cause - This is due to LTHT cost improvement pressures, demands for specialist services rising costs, expectation of greater access to healthcare and continuing care legacy debts transferred to the CCGs

Effect - This could result in resources available to the Leeds Health and Social Care economy being outstripped by demands and pressures on services

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Section 5: Progress against strategic objective 4

Strategic Objective 4 Organisational Development - To work with members to meet their obligations as clinical commissioners at practice level and to have the best developed workforce we possibly can.

5.1 Membership development and engagement Members continue to be engaged in CCG business through the Locality Development Sessions. We have changed the format and frequency of Locality Development Sessions, ensuring that each session has dedicated time for a CCG Clinical Lead to feedback to members of their individual work programme and allows members the opportunity to influence that work programme where necessary. The Locality Development Sessions have adapted to ensure a business section is included to ensure appropriate feedback from internal meetings along with ensuring a summary of each session is shared by to the Clinical Commissioning Committee to promote a two-way sharing of information. We are constantly looking at ways of evolving the sessions and allowing members to become closer to the decision making of the organisation. The Primary Care Locality team has established itself and has taken the opportunity of developing the locality focus with individual members of the team assigned to Localities to support continuous engagement. A success of this approach has been the focus (of the Clinical Commissioning Scheme) for the Morley practices on Obesity; ensuring a locality focus is likely to ensure demonstrable improvements for the CCG overall. The 360 survey was used at the start of the year to influence our approach to engaging with members; one of the recommendations was to ensure that CCG Executives were represented for part of the Locality Development Sessions again to promote the two way communication. Significant improvements have been made to this action but we probably need to progress this further, in part this will be done through the Member practice review meeting in November 2014.

5.2 Clinical leadership The CCG constitution identifies four Locality Lead GPs to represent and lead engagement with the GP membership. The four GPs are also non-executive directors on the CCG’s Governing Body. During the second half of 2014/15 we have replaced two of our lead GPs following the retirement of one and resignation of another.

The CCG has taken the opportunity of reviewing the post and an appointment was undertaken. Two new locality leads were appointed; Dr Simon Hulme and Dr Mark Liu this ensures all four of our identified localities remain represented.

Ten clinical leads (GPs) are in-post with objectives aligned to the priority health goals in the LWCCG Strategy. There is currently one vacancy for Mental Health.

The clinical lead roles have been identified for the following health areas: - Primary Care Transformation (Dr Chris Mills) - Cancer (Dr Adrian Rees) - Long Term Conditions / Frail Elderly (Dr Keith Miller) - End of Life (Dr Pablo Martin) - Mental Health (vacancy)

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- Public Health / Healthy Living (Dr Mark Fuller) - Children and Families (Dr Hilary Devitt) - Technology (Dr Pablo Martin) - CVD (Dr Bryan Power) - Diabetes (Dr Ian McDermott) - Medicines Optimisation (Dr Gaye Sheerman-Chase) - Elective care pathways (Dr Jamie O’Shea)

The CCG has also appointed four programme leads aligned to one or more of the clinical leads with shared objectives. These programme leads will provide managerial support to the clinically led work programmes. In order to develop new clinical leadership the CCG invested in four clinical fellow roles in 2014-15. The fellows were recently qualified GPs and undertook project work and a post-graduate certificate in co-production to develop their leadership skills. Two of the 2014-15 cohort are planning to continue their CCG work and there are plans for recruit a new cohort for 2015-16.

A lead practice nurse has also been appointed to lead and support the involvement and development of practice nurses and to ensure that nursing is a key part of clinical commissioning.

5.3 Primary care workforce development

Benchmarking data shows that the number of GPs per 100,000 population in Leeds is well above the figures for the north of England and England overall. However, we know that more and more GPs are choosing to work part-time and that there are a significant number of GPs approaching retirement. In 2014/15, insufficient GP trainees were recruited to Yorkshire & Humber due to lack of interest from newly-qualified doctors. In addition, there are pressures in practice nursing arising from an ageing workforce profile and difficulties with recruitment, and a need to consider the workforce requirements for new “at scale” / integrated care models. Against this background, NHS England and the CCGs have put in place a number of initiatives to understand and improve the workforce position in general practice:

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Commissioning Approach for 2014-16

Work with Health Education England to complete GP Workforce survey for 2014.

Clinical fellowship posts to work alongside clinical leaders

TARGET programme of clinical training in practice

Development of city-wide Practice Nurse Conference and local practice nurse forums.

Practice manager development programme - Managing people with Confidence – is a five day programme accredited by the ILM – the Institute of Leadership and Management. Successful completion of the award will lead to a nationally recognised qualification titled ILM Level 3 Award in Leadership & Management

Sessions were well attended, and well received. There was much positivity in the training rooms, with a great willingness to participate and learn. Feedback received … “Just to let you know that X thought that the practice manager training yesterday was brilliant and that the trainer was the best she's ever experienced. She is very enthusiastic about it, although a little nervous about the assessments because it's so long since she's done anything like that. Thanks for arranging the sessions.”

Undergraduate and post-graduate nursing scheme started in 2014

Leadership course for nurse members – a bespoke leadership opportunity led by a performance coach.

Development of HCA apprenticeships.

Skills audit undertaken to inform future training provision.

5.4 Practice nursing

ATP Scheme Since May 2014 Leeds West CCG has hosted the Advanced Training Scheme hub within one of its member practices. The practice underwent a city-wide transparent and competitive scrutiny process by Health Education Yorkshire and the Humber to assure it meets all quality standards and can support undergraduate training for student nurses attending both Leeds Universities. Nine spoke practices have been recruited across the city to date with ambitions to expand the process so twenty practices are recruited by May 2015.

Student nurses are now actively supported through a thirty day general practice experience, gaining insight into practice nursing in Leeds so they are inspired and consequently may aspire to a practice nurse role as a first destination career at graduation. Interprofessional learning is embedded within the program so students gain a quality, holistic experience.

Preceptee Practice Nurse Programme Leeds West CCG has further demonstrated it is a life-long learning organisation committed to developing its workforce so patients are cared for by staff with the right skills, knowledge, attitudes and behaviours by funding ten new to general practice nurses through a one year educational and experiential opportunity; the preceptees started in post in September 2014. Royal College of General Practitioner aligned competencies will be developed by attendance on a structured educational pathway in recognised further and higher education establishments and through experiential learning in two differing general practice placements so preceptees are able to work operationally; occupationally

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competent colleagues will assess and confirm competence before the preceptees are able to work independently. A further dimension is added enabling the preceptees to think strategically, considering how practice nursing may evolve beyond its traditional confines because of focused work with CCG colleagues and additional placements in secondary care, community and third sector organisations so patients can access care seamlessly by nurses able to meet their wider needs safely, appropriately and responsively. Workforce demographics have been carefully considered so Leeds West CCG can develop a sustainable staffing infrastructure in anticipation of our pending retirement crisis within five years, taking into consideration mentorship requirements. This latter concept strengthens success of the ATP scheme through a close partnership working arrangement

5.5 Workforce and staff development

The Workforce Strategy was approved in March 2014 and the previous update was provided to SMT in September 2014.

The update will also take account of any new workforce developments or requirements that may not be identified in the original workforce strategy.

The Workforce Strategy provides a framework of workforce delivery across the key strategic objectives of the CCG.

The four key areas identified as key strategic workforce objectives are:

• Being a Well Governed and Effective Organisation • Being a Collaborative Organisation • Supporting a Healthy, Happy, Motivated and Highly Performing Workforce • Being an Employer of Choice

These elements require a competent and capable workforce with the right skills, attitude, behaviours and approach to ensure a modern and supportive commissioning provision in Leeds. The CCG has a well-established Human Resources and Learning and Development working group which has recently been reviewed to incorporate Organisational Development and Equality and Diversity. The group is chaired by the Director of Nursing and Quality and has been renamed the Workforce and Diversity Management Group to reflect the wider remit of the group. The group monitors progress against the workforce strategy action plan on a monthly basis. Progress Update The action plan was refreshed in October 2014 after the last update to redefine priorities and outcomes where required. The details of all actions aligned to the strategy are listed in detail at Appendix 1 Workforce Strategy Action Plan. Some of the major areas of work which have been completed over the past 6 months from 1st October 2014 to 31st March 2015 are outlined within this report, it should be noted that there are some pieces of work which address more than one workforce objective, however these have been aligned where possible below:

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Being a Well Governed and Effective Organisation The organisation must provide assurance that there is a grip and commitment to deliver the statutory requirements, balanced against the values and the ethos of the organisation: quality and patient safety, performance, financial probity and balance.

Employee Relations Training To support the application of HR Policies and ensure managers are compliant with employment legislation, Recruitment and Selection and Line Manager training has been provided. The Equality Act 2010 was covered as part of the training to ensure managers act in accordance with the legislation to protect the CCG and themselves at work to avoid discrimination claims particularly in recruitment. Due to low numbers Sickness Absence Training was cancelled, however this will be re-promoted and offered to managers in 2015. The HR team work closely with managers on a day to day basis in order to support the application of CCG policies and procedures.

Review of Appraisal and Pay Progression An internal audit of the appraisal and pay progression system was undertaken in January 2015 by Baker Tilly. The report gave substantial assurance that the controls in place to manage risks were suitably designed, consistently applied and effective. The Workforce and Diversity Management Group have nonetheless considered the recommendations and conducted a review of the process. It was acknowledged that during the first year of implementation the stages may be out of sync with increment dates for some staff where they did not have the opportunity of a 12 month review period. This is now rectified as the system is embedded and adjustments have been made to the recording and monitoring process. As part of the review 360 degree feedback has been removed from the mid-year review and will be offered to staff via the Leadership Academy Healthcare Leadership Model on an individual need basis.

Statutory and Mandatory Training The Learning and Development Team have assisted the CCG by being available on site on a regular basis to answer technical queries about e-learning and contacting individuals directly to assist. The compliance rates fluctuate but most subjects have achieved the targeted 100% in one or more months over the last 6 months. Access to modules has improved with the implementation of a new Learning Management System in February 2015. The Learning and Development Team have also continued to support the CCG in following up staff to obtain completed induction checklists. This has enabled the target of 100% compliance to be achieved during the last 6 month period.

Governing Body Effectiveness Review In January 2015, Baker Tilly conducted an internal audit which reviewed the effectiveness of the Governing Body (GB) and its committees. The report, which has been circulated to all GB members, concluded that the GB has developed significantly since authorisation; has strong and effective leadership; a strategic focus and works well together, basing its decisions on robust and challenging discussions of the issues. There is a clear action plan with recommendations for further development. Work is already underway to address these, both through SMT and in the form of a bespoke workshop (April 15) for the GB to address what good assurance is; the relationship between the GB and Assurance Committee: the

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role and future development of GB members and delegated authority across organisation boundaries.

Being a Collaborative Organisation The organisation strives at all times to ensure it works collaboratively in everything it does, and in recognising it has important partners across the city of Leeds and a wide delivery workforce it ensures everyone has the opportunity to contribute towards the CCG success. The CCG embraces its ability to collaborate successfully.

HR Policy Sub Group The HR team continue to take responsibility for the review of HR policies in line with review dates and horizon scan local, regional and national changes in law, NHS initiatives and best practice updates. In order to improve the mechanism to review policies in partnership with trade unions before they are ratified at the Leeds Social Partnership Forum, a West Yorkshire wide Policy Sub Group has been implemented. This ensures when policies are due for review a partnership approach is taken to consult and develop policies which are compliant with employment legislation and best practice. The group provides a forum for discussion and exchange strengthening the process and ensuring the quarterly Social Partnership Forums are managed more effectively.

Workforce reflective of the local population It is an aim of the CCG to work towards employing a workforce that is more reflective of the local population. It is recognised as a small organisation this is more challenging to achieve. In order to reach wider groups we have integrated social media with the recruitment process to promote vacancies with the aim of targeting new groups who may not traditionally view NHS Jobs. An employability guide has also been developed for line managers outlining the various ways they may want to engage people with the CCG such as work placements and apprenticeships. In the longer term it is envisaged this will support fostering an inclusive and diverse workforce.

Staff Survey The second local staff survey has been conducted in December 2014. A report has been presented to SMT summarising the key themes, achieving and development areas. This has provided the CCG with a rich data set to understand staff’s experience of development, job satisfaction, engagement, management and health and wellbeing. A comparison has also been conducted against last year’s results to look for improvements and areas of decline. It has also been analysed against national staff survey averages for CCG’s. Overall the results are extremely positive. The Workforce and Diversity Management Group will focus on developing an action plan to make improvements over the next year.

Supporting a Healthy, Happy, Motivated and Highly Performing Workforce In order for the CCG to be successful the workforce must be able to perform at an optimum level, evidence supports that a workforce that is highly performing is happy, healthy and motivated.

Staff Awards The first CCG staff awards event the “Star Awards” led by the Communications Team was held in March 2015 alongside the whole organisational time out. The

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awards contributed to the CCG’s approach in recognising and valuing staff in the contribution they make. There were six award categories in total which aligned to the values of the CCG. The nominations showcased some excellent achievements and the format of the awards had a really positive impact on team building and the culture in the CCG. Independent judges were engaged from Healthwatch Leeds, Leeds City Council and Leeds Teaching Hospitals NHS Trust who commented on the quality of staff. The whole organisation time out was held on the same day as the staff awards. During the morning, senior leaders across the organisation gave an overview of the CCG’s many achievements over the life of the CCG and thanked staff for their part in this. They also set the out the future strategic context and challenges for the organisation and in relation to the CCG’s strategy and the NHS 5 Year Forward View. This was well received.

Health and Wellbeing Initiatives The Health and Wellbeing Group has progressed a number of health and wellbeing initiatives. A six week Lifestyle Management and Resilience Course has been delivered by Leeds Beckett University to fourteen members of staff. The course is currently being formally evaluated however feedback from attendees has been extremely positive indicating staff are utilising new techniques at home and work. The course focused on building resilience/managing stress and lifestyle management in order to improve mental health and wellbeing and learn skills to prevent issues arising in the future. A six week Pilates course has also been coordinated for a group of ten staff to attend after work. The intervention aimed to improve staff’s physical wellbeing and promote healthy lifestyles. The Health and Wellbeing Group is considering the continuation of successful initiatives and the introduction of new initiatives to support staff in adopting healthy behaviours.

Being an Employer of Choice This is an important objective for the CCG to achieve and will increase the CCGs recognition both locally and regionally as an organisation which is a good place to work. Staff working for the CCG will feel developed and supported, and others will want to work for the CCG as they see the CCG as a good employer.

Personalised Annual Leave Scheme The personalised annual leave scheme was introduced in January 2015, giving staff the option to buy or sell annual leave subject to a minimum and maximum ceiling. The purpose of the scheme is to improve the working lives of staff by offering more flexible benefits options. The scheme contributes to the CCG’s total reward package and supports the CCG being a flexible employer and hence a good place to work.

New Learning Management System E-TREVOR,the new learning management system, was implemented in early 2015 and has improved access to statutory and mandatory training and reduced access issues. A range of additional e-learning modules are also available on e-TREVOR including time management, personal resilience, meeting skills and a full range of IT e-learning modules. This is supplemented by an electronic brochure of learning and

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development solutions and training courses delivered outside of e-TREVOR. This was communicated to staff by the L&D team towards the end of 2014.

Workforce Conclusion The CCG has continued to make good progress to deliver the 2013-2016 Workforce Strategy over the last six months. Where areas have not progressed there has been a formal discussion in the Workforce and Diversity Management Group to look at what has impacted on this. The relevance of some actions have been scrutinised by the group and as such it is recommended some of the required outputs are revised to better fit with the CCG context and needs for instance the need for a People Development Plan/Workforce Planning Tool. The majority of key success criteria’s outlined in the strategy have now been achieved or contributed to by the work which has been undertaken in the first two years of the CCG. The Workforce and Diversity Management Group have identified the duplication and overlap of workforce objectives and actions in both the Organisational Strategy and Organisational Development Strategy. It is recommended the Workforce Strategy and Organisational Development Strategy are embedded into the CCG’s Organisational Strategy to ensure workplans are aligned and integrated with the CCG’s priorities and objectives. This will provide a refocus for the Human Resource, Learning and Development and Organisational Development and Equality and Diversity functions to re-scope priorities and workplans for 2015/16. 5.6 GBAF risks associated with strategic objective 4

6. STATUTORY/LEGAL/REGULATORY/CONTRACTUAL ISSUES

N/A

5A Member Practice Engagement as Commissioners

Risk -There is a risk that Leeds West CCG member practices do not engage adequately as clinical commissioners

Cause - This could be due to

a) time constraints

b) capacity and capability c) a lack of buy-in e) system constraints

Effect - This could result in the organisation being unable to fulfil its purpose of working for members to improve the health of the local population, to deliver the strategy at a local level.

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5B . Member Practice Engagement as Providers of primary medical services

Risk -There is a risk that Leeds West CCG member practices do not engage adequately as providers of primary medical services.

Cause - This could be due to

a) time constraints

b) capacity and capability c) a lack of buy-in e) system constraints

Effect - This could result in the organisation being unable to fulfil its purpose of working for members to improve the health of the local population, to deliver the strategy at a local level or its statutory duty to improve the quality of primary care through transformation

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7. FINANCIAL IMPLICATIONS AND RISK

Please refer to the finance section of the document at section 4.

8. COMMUNICATIONS AND INVOLVEMENT

Please refer to the communications and engagement section of the document at section 3.

9. WORKFORCE

N/A

10. EQUALITY IMPACT ASSESSMENT

N/A

11. ENVIRONMENTAL

N/A

12. RECOMMENDATION:

The Governing Body is asked to:

(a) APPROVE the NHS Leeds West CCG 2015/16 Operational Plan and Strategy. (b) NOTE that further development will take place following the general election.