Our plans are about joining up patient care – not just in health care but also with social care.
Commissioning long term conditions services
During 2014/15 we have focussed on improving joint working with the local authority for the benefit of patients. For example, we have put in place 80 personal health budgets for CHC patients across the county. We have also worked with the local authority to further develop our integrated approach to improving quality in care homes. In September, we agreed a joint dementia strategy for Northumberland and are now working on implementation with all partners, focusing on 10 priorities ranging from improved access to diagnosis and post-diagnostic support; supporting people to remain independent and prevent unnecessary hospital or care home admissions; to end of life care. We are now developing a social prescribing programme with the local authority.
We have continued to develop the community hospitals model of care across Northumberland and have worked with NHS England and Altogether Better to pilot practice health champions with a view to promoting patient involvement and self-care.
Clinical guidelines are crucial for good medical care and we have developed new guidelines for managing COPD and have commissioned a pulmonary rehabilitation service; we have developed guidelines on abnormal valve findings on echo and have contributed to development of FATS 7 guidance.
In 2015/16 our priorities are:
- Continuing to build on our partnership with the local authority for continuing healthcare services, to further develop our integrated commissioning and achieve excellent quality care and patient experience. Our existing partnership is now delivering improved patient outcomes, increased transparency in the commissioning of services and financial stability. This provides a good foundation to build on.
- Reducing admissions for people living in care and residential homes as part of a coordinated programme to increase medical, nursing and community support into these settings.
- Delivering the outcomes of the new specification for all six community hospitals in Northumberland. This develops seven day working across health and social care, an increased focus on rehabilitation and re-ablement and a particular focus on working out from hospitals into people’s homes and the community – ‘care without walls’. This work is closely linked to the Better Care Fund work and we are already piloting the new model in Blyth community hospital.
- Improving the quality of long term conditions management in the community through our clinically led, condition specific groups. We will secure improved care across patient pathways with reduced variation and better outcome. This work is supported by the long term conditions data set and underpinned by the house of care model. Our initial focus will be on dementia, respiratory conditions, alcohol, cardio vascular disease and diabetes.
Financial recovery already achieved
Our three year financial recovery programme included ambitious targets for savings in long term conditions and have been achieved in full.
Community hospitals were a priority for development during 2013/14. The rural nature of Northumberland means we have a network of community hospitals delivering care close to people’s homes, which is a great asset for the county. We introduced the community hospitals specification in April 2014, which built upon work the previous year, to deliver the concept of ‘care without walls’. This specification formed the basis of our overall approach to delivering services across the county and is a foundation of the ‘primary care at scale’ programme. In 2014/15, we reduced the block contract for community hospitals by £1m, in agreement with the provider to reflect the efficiencies to be realised in the new specification as services work more flexibly between hospital and community settings.
Continuing Healthcare spend in Northumberland was traditionally very high and expenditure year-on-year increased by £7m in both 2011/12 and 2012/13. In 2012/13 national benchmarking shows that the Care Trust was amongst the highest in the country for spend per head and unit cost
National benchmarking analysis October 2012
Given the inherited financial CHC position, it was clear that a change in approach was required. The history of integration in Northumberland and expertise of the local authority in commissioning home care and care home packages presented an opportunity for the CCG to exploit and seek to address the inherited financial pressure.
The CCG and Local Authority (LA) agreed a partnership agreement in April 2013 to enable the LA to undertake assessment and review function, (including case management and management of appeals) and the commissioning of care packages, including homecare services and care home placements (with or without nursing care). The core aims of entering this arrangement were to improve integration and quality of care for patients whilst also ensuring value for money from the CHC budget. The partnership agreement includes incentives to promote financial control on the part of the Local Authority and encompasses a gain share schedule which in effect means any under spend on the agreed budget will be shared if delivered.
Progress in the first two years include:
- Delegation of CHC budgets to team managers
- Systematic review of rates charged by providers
- Use of the risk and independence team to ensure high cost packages are appropriate and risk and independence is being balanced
- Establishment of CHC activity group where staff from across the council and CCG meet provide further focus on efficient commissioning
Each of the above actions has contributed to the initial halt in increasing year on year spend in CHC and subsequent reduction in spend during 2014/15. Figure 1 illustrates the impact on expenditure using the forecast out-turn position across quarters since the partnership agreement was implemented. Despite some turbulence due to system pressures felt across the NHS, forecast out-turn is now close to the CCG’s budgeted spend and with continued focus on efficient commissioning it is forecasted that spend will be in line with budget by the end of 2014/15.
It is important to recognise that the integrated arrangements have also realised improved patient experience, delivered more personalised care through personal health budgets (PHB) and allowed a greater focus on quality.