BARNET PRIMARY CARE TRUSTCOMMISSIONING PROSPECTUS 2007/8                           5th December 2006
BPCT Commissioning Prospectus 2007/8       BPCT COMMISSIONING PROSPECTUS 2007/8                             CONTENTS      ...
BPCT Commissioning Prospectus 2007/8                   PCT COMMISSIONING PROSPECTUS 2007/81. INTRODUCTIONIn July 2006 the ...
BPCT Commissioning Prospectus 2007/82. THE PCT’S VISION AND APPROACH2.1 The PCT’s VisionBarnet PCT will improve the health...
BPCT Commissioning Prospectus 2007/8   •   our resources should be used in the most clinically effective way;   •   our re...
BPCT Commissioning Prospectus 2007/82.3 User inputThe Introduction to this document sets out that in future years the Comm...
BPCT Commissioning Prospectus 2007/8responsible for more than 50% of this difference. But here are other healthinequalitie...
BPCT Commissioning Prospectus 2007/8Here are the amounts of funding that were spent on healthcare in Barnet in20005/6, fro...
BPCT Commissioning Prospectus 2007/8based on a systematic approach to assessing clinical and cost ineffectiveness. Areasto...
BPCT Commissioning Prospectus 2007/8Mid year analysis of expenditure demonstrates that the demand managementschemes have h...
BPCT Commissioning Prospectus 2007/84.4 Local Delivery Plan (LDP)The PCT’s Local Delivery Plan relates to the years 2005-8...
BPCT Commissioning Prospectus 2007/8       6) ENT pilot clinic in primary care       7) Emergency care practitioners preve...
BPCT Commissioning Prospectus 2007/8Where new national targets are concerned, the PCT was graded as ‘fair’.Areas for conce...
BPCT Commissioning Prospectus 2007/8Procurement and contract negotiation have been carried out by the DoH on behalf ofPCTs...
BPCT Commissioning Prospectus 2007/8 6. THE COMMISSIONING PROCESS 2007/8The PCT will adhere to the recently published Depa...
BPCT Commissioning Prospectus 2007/8                                                                            APPENDIX A...
APPENDIX B                         SERVICES FOR GP REFERRAL IN SERVICE AGREEMENTS 2007/08                                 ...
BPCT Commissioning Prospectus 2007/8Urology                             Vascular Surgery                        ...
APPENDIX C                 Commissioning Priorities 2007/20081. CANCER SERVICESBreast ScreeningThe PCT is concerned that t...
BPCT Commissioning Prospectus 2007/8Cancer DrugsCommissioners will develop a process that enables fast decision making on ...
BPCT Commissioning Prospectus 2007/8Given the lack of capacity in some areas, such as ultrasound, it may be that theadditi...
BPCT Commissioning Prospectus 2007/8The PCT scored a ‘fail’ on the Healthcare Commission assessment of the CrisisResolutio...
BPCT Commissioning Prospectus 2007/8There is no separate service agreement with BEH-MHT for the Child and AdolescentMental...
BPCT Commissioning Prospectus 2007/85    LOCAL PCT- PROVIDED SERVICESAs required by the reforms set out in ‘Commissioning ...
BPCT Commissioning Prospectus 2007/8 Alcohol Misuse Alcohol Concern completed a needs assessment on behalf of the Borough ...
BPCT Commissioning Prospectus 2007/8A review of sub-commissioning arrangements between the Barnet LD provider armand BEH-M...
BPCT Commissioning Prospectus 2007/811 PLASTIC SURGERY / BURNS SERVICESPlastic Surgery and Burns services will be relocate...
BPCT Commissioning Prospectus 2007/815 IVFBarnet PCT currently follows DoH guidance and funds one cycle of treatment perel...
BPCT Commissioning Prospectus 2007/8accessing the service at a higher level of need. The revenue savings associated with a...
BPCT Commissioning Prospectus 2007/823 SPECIALISED SERVICESThe commissioning of very specialised services (e.g. bone marro...
BPCT Commissioning Prospectus 2007/8                                                                       APPENDIX D     ...
BPCT Commissioning Prospectus 2007/8Key Financial Planning Assumptions 2007/8    1. PCT top-slice across London will be be...
BPCT Commissioning Prospectus 2007/8                                                                 APPENDIX E           ...
Barnet PCT 2007/08 Commissioning Intentions - DRAFTKey: Barnet & Chase Farm (B&CF), Royal Free (RF), University College Ho...
Commissioning Prospectus 2007 / 08
Commissioning Prospectus 2007 / 08
Commissioning Prospectus 2007 / 08
Commissioning Prospectus 2007 / 08
Commissioning Prospectus 2007 / 08
Commissioning Prospectus 2007 / 08
Commissioning Prospectus 2007 / 08
Commissioning Prospectus 2007 / 08
Commissioning Prospectus 2007 / 08
Commissioning Prospectus 2007 / 08
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Commissioning Prospectus 2007 / 08

  1. 1. BARNET PRIMARY CARE TRUSTCOMMISSIONING PROSPECTUS 2007/8 5th December 2006
  2. 2. BPCT Commissioning Prospectus 2007/8 BPCT COMMISSIONING PROSPECTUS 2007/8 CONTENTS Page1. Introduction 32. The PCT’s Vision and Approach 43. Local Health Needs and Funding 64. Strategic Context 75. Key Priorities 146. The Commissioning Process for 2007/8 15 Appendix A The Commissioning Cycle Appendix B Barnet GP Referral Matrix Appendix C Commissioning Priorities Appendix D London Planning and Commissioning Arrangements Appendix E Summary of Commissioning Intentions 2
  3. 3. BPCT Commissioning Prospectus 2007/8 PCT COMMISSIONING PROSPECTUS 2007/81. INTRODUCTIONIn July 2006 the Department of Health produced an update on health reforms thatfocussed on key changes designed to strengthen the commissioning of NHS servicesand in particular hospital services.One key component of the changes is the requirement for PCTs’ to produce aProspectus each year as an integral part of the commissioning cycle. Final guidanceon Prospectus contents in due out from the DoH at the end of 2006, with a view tothe first full Prospectus being made available by each PCT well ahead of 2008/9.The Prospectus allows commissioners to set out, in a clear way, the changes theyintend to make to local health services delivery in the following full financial year.Any changes are based on an assessment of needs, past service deliveryperformance and local health priorities within the overall funding available.In any PCT, the term ‘commissioners’ refers both to the professionals employed toinvest in the full spectrum of health services wisely for their local population and tothe GPs who take responsibility for commissioning a selection of services directly fortheir practice populations. It is essential that all commissioners work together againsta common strategic background to ensure the best possible outcomes for patientsand, in Barnet, the proposals in this document represent a joint approach by allcommissioners. The relationship between different stages of the commissioningcycle, and where the Prospectus fits in, is set out as a diagram at Appendix A.Although final guidance is still awaited, it is clear from information available alreadythat the document should be commissioning driven and should allow local residentsthe opportunity to input to the PCT’s proposals for service change in an informedway. Barnet PCT has therefore decided that it would be helpful to its residents andservice providers to produce its commissioning intentions for the coming year, aheadof full Prospectus publication, and has produced this Commissioning Prospectus inresponse to a desire to inform.This Commissioning Prospectus relates to the year 2007/8. It is available in aprécised version for wider distribution. For those who do not wish to read thenarrative text, a summary of commissioning intentions has been incorporated atAppendix E. This appendix has been designed to be read as a stand-alone version ifrequired.Although the Commissioning Prospectus is not being circulated as part of a formalconsultation process in this year, any comments on its contents and the servicechanges proposed are welcomed and should be directed to: Dominic Wright Director of Strategic Commissioning and Planning 2nd Floor, Westgate House Edgware Community Hospital Burnt Oak Broadway Edgware, Middlesex HA8 0AD 3
  4. 4. BPCT Commissioning Prospectus 2007/82. THE PCT’S VISION AND APPROACH2.1 The PCT’s VisionBarnet PCT will improve the health of the local population. The PCT will ensure thereare good quality, appropriate health services available, so the right treatment can bedelivered, at the right time, in the right place, by suitably skilled staff.Services will • foster personal responsibility for health and independence; • be based on prevention and tackle the root cause of ill health; • be directed to reduce inequalities in people’s health; • be patient centred by being built around the needs of the individual; • be accessible – provided in the most appropriate location, at the most convenient times, using the most appropriate technology; • integrate with other health and social care services across care pathways; • focus on quality – making sure people get the most appropriate, best possible care and treatment and are involved in choosing the location that might not always be geographically the closest; • be supported by a well motivated, empowered, equipped and skilled workforce who have responsibility for their actions; • be developed in line with evidence and value for money; • be innovative and creative to develop the best practice and models of care; • through the promotion of healthy lifestyles, empower and encourage individuals to retain their independence; • encourage a culture of openness, honesty and transparency throughout the organisation.To ensure that our vision becomes a reality, the PCT will support and develop staffso they can provide a high quality service to our local community.2.2 ApproachAn important component of achieving our vision and applying our values is using ourresources in the most appropriate way to enable the greatest good for the greatestnumber of people. As demand in the NHS has always outstripped supply, thisinevitably means that it is not possible for everyone to receive precisely what theymight want, or necessarily where or when they want it. When determining servicepriorities for individual people or for the whole population of Barnet we use aframework based on a number of ‘principles’. In brief, these are that: 4
  5. 5. BPCT Commissioning Prospectus 2007/8 • our resources should be used in the most clinically effective way; • our resources should be used in the most cost effective way • we can only provide, contract for or commission the services that we consider are appropriate if we have enough money or other resources to do so; and our resources should be used in an equitable wayWe also seek to take an ethical approach to service prioritisation, and this includesconsidering: • respect for patient autonomy – which requires that we help people to make their own decisions (e.g. by providing important information), and respect those decisions (even when we or health professionals may believe that a patient’s or a group of people’s decision may be wrong, noting that this does not require us to provide a specific treatment just because someone wants it, but only if it satisfactorily meets the other criteria in this framework) and only requires us to provide a treatment in a particular place of their choice if that meets the requirements of the national ‘Patient Choice’ initiative or other NHS regulations; • beneficence – which emphasises the moral importance of ‘doing good’ to others, entailing doing what is ‘best’ for the patient or group of people (the question of who should be the judge of what is ‘best’ is often interpreted as focusing on what an objective assessment by a relevant health professional would determine as in the patient’s best interests, with the patient’s own views being considered through the principle of respect for patient autonomy, the two only conflicting when a competent patient chooses a course of action that might be thought of as not in their best interests); • non-maleficence – which requires that we should not harm patients, and, because most treatments carry some risk of doing some harm as well as good, the potential goods and harms and their probabilities must be weighed up to decide what, overall, is in the patient’s or group of patients’ best interests (but it must also be noted that we have a duty of non-maleficence to others – we could indirectly harm others because a decision to provide treatment to one person or group of people could prevent others from receiving other care of proven clinical and cost-effectiveness; and • distributive justice – which recognises that time and resources do not allow every patient to have the ‘best possible’ treatment and that decisions must be made about which treatments can be offered within a health care system. This principle of justice emphasises two points: − people in similar situations should normally have access to similar health care, and −when determining what level of health care should be available for one group, we must take into account the effect of such a use of resources on others (i.e. the opportunity costs). 5
  6. 6. BPCT Commissioning Prospectus 2007/82.3 User inputThe Introduction to this document sets out that in future years the CommissioningProspectus should be commissioning driven and should allow local residents theopportunity to input to the PCTs proposals in an informed way. Because this is thefirst annual prospectus, it has not been possible to gather extensive user input owingto timing constraints. It is planned to incorporate extensive input, in a co-ordinatedmanner, in successive years.However, the PCT has held one users’ event immediately prior to production of thisdocument and was able to gather useful feedback on service delivery. The mostsignificant elements of feedback, such as the need for extended practice openinghours in primary care, have been incorporated into planned review work in thecoming year. In addition, access to elective procedures such as hip replacement,where chronic and debilitating conditions may be treated effectively, was signalledby users as a priority and will be addressed as part of the speeding up of thepatients pathway to an 18-week maximum in 2008.Further user input will be gathered as the year progresses.3. LOCAL HEALTH NEEDS AND FUNDING3.1 Local Health NeedsThe population of Barnet was estimated at 329,700 for 2005. This is expected toincrease by 2016 to 366,000. Although, the population is likely to increase in2007/2008 the largest increases are not expected until after 2010. The population isvery diverse with over 27% coming from black and minority ethnic communities.Generally the population is relatively wealthy and in better health than most otherLondon boroughs.The Public Health White Paper Choosing Health (Nov 2004) lays out proposals tochange ‘a national sickness service’ into ‘a national health service’ and there is now amuch increased emphasis in the NHS on improving health and not just treatingdisease.Smoking not only increases the risk of lung disease and a number of different typesof cancer, it also increases the risk of heart disease, delayed bone healing after afracture, miscarriage, osteoporosis, hair loss, premature skin ageing and kidneydisease – among other things. Passive smoking increases the risk of many of theseconditions in non-smokers.Barnet PCT’s top health improvement activity therefore is, and will continue to be,helping smokers to quit. It’s health promotion activities around smoking werecommended in the recent Healthcare Commission report. This activity is especiallyimportant in terms of reducing ‘health inequalities’, i.e. the differences in health (andespecially death rates) between different groups in the population.In Barnet, as elsewhere in the country, someone living in one of the more deprivedparts of the borough is much more likely to die before they reach 75 years of agethan someone living in one of the more affluent areas. In men, smoking is 6
  7. 7. BPCT Commissioning Prospectus 2007/8responsible for more than 50% of this difference. But here are other healthinequalities in Barnet, some attributable to lifestyle (such as obesity) and others tofactors such as poverty or ethnic background.The PCT’s greatest inequality gaps are demonstrated in prevalence of coronary heartdisease (CHD) and uptake of breast screening. Although Barnet still has lower thanthe national average deaths due to heart disease in its population, there is a markeddifference within the borough on death rates due to CHD, depending on the ward ofresidence. Those wards with the greatest deprivation also demonstrate aproportionately high death rate due to CHD and the reverse is true of areas with lowdeprivation. The higher rate is almost 50% more than the lower rate.In the latest national comparison, Barnet demonstrated the greatest rise in teenagepregnancy in the country. Whilst of great concern, the rise was calculated on arelatively small baseline and therefore appears more significant than is really is.Breast cancer is the single most common life-threatening cancer diagnosed and theleading cause of cancer deaths among women living with cancer in Barnet. Forbreast screening to make a significant impact on reducing deaths from breast cancerit has been estimated that at least 70% of the relevant population need to bescreened. In Barnet the average across the borough is around 60% uptake, with abroad spread of results across GP practices. This inequitable uptake is the causesignificant concern.3.2 FundingEvery year a certain amount of funding is allocated to all PCTs by the Department ofHealth, based on the outcome of a formula using size and needs of the localpopulation. In the past PCTs have sometimes received an allocation that does notmatch the outcome of the formula as it is currently applied so, instead of removingfunding all at once from some PCTs and potentially destabilising local services, thegovernment has set a ‘pace of change’ policy. This means that over time PCTs arebrought to the correct level of funding.In the case of Barnet, the PCT has been relatively over-funded by about 8% (this isapproximately £32million per year). As a result the PCT will receive a lowerproportion of additional funds allocated to the NHS in 2007/8 than the nationalaverage. For the coming year this will mean approximately £5 million less income inreal terms and a similar trend will continue for Barnet over the next few years.This means that the PCT needs to be very clear about what the priorities are forfunding services for its community. During 2005/6 the annual £427.8 million fundingfor Barnet was allocated roughly as follows: General hospital care 41% Community services 12% Primary care 11% GP prescribing 11% Mental illness 8% Maternity services 6% All other 11% 7
  8. 8. BPCT Commissioning Prospectus 2007/8Here are the amounts of funding that were spent on healthcare in Barnet in20005/6, from the total budget of £427.8 million: Community services £50m GP Prescribing £47m Maternity services £23.3m Accident & Emergency £8m Other healthcare services £27.8m Primary Care £47.6m Total £427.8M General and acute care Learning difficulties £176.6m £12.3m Mental Illness £35.3mThe amount of funding the PCT has to allocate to services will be stretched evenfurther as our population size changes in future. The population in Barnet ispredicted to grow by 11% over the next 10 years. Although this will be accountedfor in the national funding formula there is a time lag between increases inpopulation and the recording of these via census data.The impact of the reduction in current ‘over-funding’ will also be felt during theseyears of growth. So the PCT has significant reasons to manage expenditure anddelivery of services in the most effective ways possible.In line with the PCT’s service strategy of providing care nearer to the patient, it isenvisaged that spending on primary and community services will need to increase to40% of the PCT’s overall budget by 2017. In addition, the PCT’s spending on mentalhealth is below the London average and we aim to increase investment from 8% to10% in the future.In order to make this shift possible, the PCT be focussing on areas where spending isrelatively high compared to local and national benchmarks.The PCT will have to make some difficult decisions and will not be in a position toinvest in service development unless funds are released from elsewhere or thedevelopment itself demonstrates service improvement allied to cost reduction.3.3 Health PrioritiesThe PCT is working with a number of neighbouring PCTs on potential areas forconsideration of disinvestment at some stage in the future. Any decisions will be 8
  9. 9. BPCT Commissioning Prospectus 2007/8based on a systematic approach to assessing clinical and cost ineffectiveness. Areasto be considered in a systematic way are: Homeopathy Varicose vein management Tonsillectomy and adenoidectomy Grommet insertion Hip and knee replacement Dental implants Wisdom teeth removal Caesarean section Management of obesity Use of some drugsThe prioritisation process will be ongoing and a list of further topics forconsideration, once these have been investigated, is being agreed.4. STRATEGIC CONTEXT4.1 Barnet Strategic Service Development Plan 2005-8The Barnet Strategic Service Development Plan (SSDP) for 2005-8 was publishedrecently and it provides a concise and cohesive planning strategy for primary,community and acute care in Barnet over the next few years. The plan is built on afoundation of several key planning processes that were already in existence andprovides continuity into the future. A review of the Strategic Plan is expected to beproduced in the spring of 2007. This will need to take account of Barnet Enfield andHaringey Clinical Strategy and the Strategy for London.The SSDP will form the strategic backdrop for all aspects of work carried out acrossthe PCT, as it does for this Commissioning Prospectus. Underpinning all the PCTsplans is the shifting of services and activity from secondary to primary and socialcare enabling patients to receive the right care, in the right place from the mostappropriate professional.Of particular significance are the commitments (both national and local) due to bedelivered by the PCT over the next three years in section 3 of the SSDP. The keyinfluencing policies underpinning the SSDP are echoed below in this section (para4.3) in the detail of the government White Paper (‘Our health, our care, our say’).4.2 The PCT’s Financial PositionDuring 2006/7 the PCT has faced a difficult financial position following the 3% topslice of its revenue allocation. A challenging savings plan has been put into place tooffset the predicted year end shortfall in funding. Incorporated into the saving plan isa series of demand management schemes that were initiated to establish pathwaysto care for the longer term that are compatible with DoH strategic guidelines andthat ensure care is provided in the most appropriate setting. 9
  10. 10. BPCT Commissioning Prospectus 2007/8Mid year analysis of expenditure demonstrates that the demand managementschemes have had a long introductory phase and have not yet delivered the benefitsthat were predicted at this stage in implementation. The savings plan as a whole hastherefore slipped and there is little potential to retrieve the situation fully in mid year.In addition, extra funding amounting to £1 million has been taken from the PCT bythe London Strategic Health Authority as part of a London wide move to top up theircontingency reserves.The PCT is now predicted a ‘likely’ forecast deficit of £7 million at year end 2006/7,with a possible reduction by 50% if the savings plan and accompanying demandmanagement schemes begin to deliver tangible benefits. This will leave the PCT withan unfunded deficit of £3.5 million at year end that will have a detrimental impact on2007/8 funding. The PCT will nevertheless still aim to achieve balance by ensuringfull implementation of savings plans. The existing demand management schemes(see Section 4.6 ) are now intended to be implemented on a permanent basis.It is likely that further schemes will have to be introduced next year and these do notfeature yet in this document as discussions are at an early stage. Service providersand the public will be informed once they have been shaped within the PCT.A top slice of 3.6% is envisaged for 2007/2008 with repayment of any 2006/2007over-spending also being deducted. Developments for the year will be minimal. Mostimprovements to services, working towards NSFs and other national targets will haveto come from service redesign.4.3 ‘Our health, our care, our say’The government White Paper ‘Our health, our care, our say’ was published at thebeginning of 2006 and sets a new direction for social care and community healthservices, with four main goals: a. Better prevention and early intervention for improved health, independence and well-being. b. More choice and a stronger voice for individuals and communities. c. Tackling inequalities and improving access to services. d. More support to people with long term needs.This guidance reaffirms the direction of travel that the PCT was already engaged in,by seeking to move out services wherever possible from an acute hospital base andmake them available nearer to the patient using settings such as health centres andthe GP’s surgery. In this way there is easier access for the patient and bettercoordination of the care provided.In a move to parallel publication of the White Paper, the DoH announced that somecapital funding would be made available to develop a new generation of communityhospitals to meet new models of care closer to the patient. At present, the PCT is inthe process of bidding for consideration of funding via this initiative in order toredevelop Finchley Memorial Hospital. 10
  11. 11. BPCT Commissioning Prospectus 2007/84.4 Local Delivery Plan (LDP)The PCT’s Local Delivery Plan relates to the years 2005-8 and sets out clear plansand milestones for delivery of the DoH’s national targets, covering a number ofdifferent service areas. The LDP is reviewed and updated annually (the latest reviewis expected by end November 2006) by PCT staff in joint working with partners(service provider and Local Authority).The most significant task facing the PCT, in terms of LDP targets, is delivery of the18-week ‘referral to procedure’ target for all GP referrals by December 2008. As thetarget time subsumes waiting for first outpatient consultation, any tests necessary toaid diagnosis and then waiting for any elective procedure required it is a difficult onefor service providers to deliver. The November 2006 reworking of the LDP may resultin milestones for commissioners to work to, with local health partners, to ensuredelivery of the December 2008 target.The aim for the PCT will be to achieve the staged reduction of waiting time withoutincurring a rise in activity levels above those predicted as part of the LDP and FTDiagnostic planning process.4.5 Barnet, Enfield and Haringey Clinical StrategyBarnet, Enfield and Haringey PCTs and local hospital trusts (Barnet and Chase FarmHospitals and North Middlesex University Hospital) are engaged in a strategicplanning process with their staff and local residents, on the pattern of services to beprovided within local hospitals in future. At the moment, four different scenarios arebeing considered in a structured process that should deliver a clear direction for anyservice changes by the beginning of 2007/8.4.6 Demand Management PlansThe PCT’s financial position in the early part of 2006/7 made the implementation of aseries of demand management measures imperative. In common with most otherPCTs, Barnet has seen consistent rises over the years in the numbers of patientsattending A/E departments, short non-elective stays associated with this service andoutpatients generally.The rise in demand would be difficult enough to accommodate and fund in itself, butit is accompanied by a gradual tightening of access targets to acute services and thewhole scenario is not sustainable. Therefore the PCT has adopted a series of demandmanagement initiatives, some have already been implemented, others are still indevelopment.The schemes are: 1) Orthopaedic referrals triage 2) Dermatology referrals triage 3) Gynaecology referrals triage 4) Management of diabetic patients in primary care 5) Diabetic retinopathy screening in the community 11
  12. 12. BPCT Commissioning Prospectus 2007/8 6) ENT pilot clinic in primary care 7) Emergency care practitioners preventing admissions 8) Consultant to consultant referral management guide 9) Direct GP access to MRI scanning 10) Reduction in long lengths of stay 11) Increased primary care to support A/E 12) Community matrons 13) Telecare 14) Disinvesting in uneconomic services 15) Investing only in service changes that deliver demonstrable service improvements and are cost neutral or cost saving 16) Unbundling current service tariffs to achieve service improvementsWhere schemes will have an impact that does not come into effect until 2007/8, theyhave been embedded in the contents of Appendices C and E.The development of care pathways across many specialties and individual conditionsis underway within the PCT and is an important accompanying strategy to most ofthe demand management initiatives above.4.7 Annual Performance RatingsIn October 2006 the Healthcare Commission published its findings on the PCT’sperformance during 2005/6. The Trust was rated ‘fair’ for use of resources(managing finances and demonstrating value for money in the services it offers topatients). It was graded as ‘weak’ for quality of services, with failure to meet someexisting national targets the cause for concern. As the PCT is responsible forcommissioning services from other bodies, they also share responsibility for the otherbodies’ performance against targets (e.g. LAS).Those existing targets that were failed or under achieved in 2005/6 were: • Crisis resolution services for mental health needs • Thrombolysis for heart attack patients • LAS response times to Category B calls • Sustained success of smoking quitters • Total time in A/E (target – four hours or less) • Appointments booked via Patients ChoiceRectifying action has been taken where possible in 2006/7 but a more strategicapproach via commissioning is being incorporated into individual service areas forthe coming year (2007/8) to ensure sustained improvement into the longer term. Itis interesting to note that, using a different set of criteria to assess tobacco control,the PCT achieved an ‘excellent’ score in a different section of the report. 12
  13. 13. BPCT Commissioning Prospectus 2007/8Where new national targets are concerned, the PCT was graded as ‘fair’.Areas for concern were: • Teenage conception rates • Access to GUM clinics within 24 hours • Number of high intensity users • Delivery of community equipment • Number of community matrons • Ongoing diabetic monitoring4.8 Practice Based Commissioning ClustersBarnet has four practice based commissioning (PbC) clusters. The strategic backdropfor commissioning of services by these clusters is provided by PCT wide strategicdirection. In turn, some of the PCT wide priorities are derived from the focal pointsof the clusters. All GP practices in Barnet are part of a PbC cluster. In 2006/7 theclusters had the following service developments as common priorities: 1. Moving the provision of dermatology services into the community wherever possible. 2. The use of the Referrals Assessment Service to direct musculo-skeletal referrals to the most appropriate setting for diagnosis and treatment. 3. Prescribing statins in line with NICE guidance.There is in addition a locality element to their priorities, based on local health need.These are: North Locality - A/E access and preparatory work on diabetes, COPD and ENT South Locality - Access to diagnostics West Locality (Edgware/Mill Hill) - Diabetes management and data collection Wes Locality (Burnt Oak/ Hendon) - Gynaecology care pathway and data collectionIn 2007/8 the clusters will consolidate progress made the previous year and willimplement schemes in preparation at present. Data collection falls into this categoryas it will be used to make informed strategic decisions about the future of services.4.9 Diagnostic ServicesFrom April 2007 the PCT will be able to access increased diagnostic capacity via thenational DoH initiative to introduce new independent sector provision to workalongside the NHS. This will offer shorter waiting times in some diagnostic areas andhelp commissioners to deliver the 18-week referral to procedure target by December2007. 13
  14. 14. BPCT Commissioning Prospectus 2007/8Procurement and contract negotiation have been carried out by the DoH on behalf ofPCTs and Amicus in Health will be the provider for this region. It is anticipated thatthe service will be provided from the Garden Hospital, Edgware Hospital and BarnetMRI but under the terms of the agreement patients can access Amicus’ serviceswherever they are provided in London if they prefer.It is anticipated that the following services will be provided and pathwayarrangements from referral to reporting are being finalised at present: MRI, ultrasound, radiography (may be reporting only), sigmoidoscopy, echocardiogram, electrocardiogram, phlebotomy.Given the lack of capacity in some areas, such as ultrasound, it may be that theadditional capacity provided by the IS is necessary to meet the 18 week accesstarget without reducing any current activity levels.The PCT will also be working with its practice based commissioners on thedevelopment of one-stop assessment services for a range of different conditions.For further detail, see section 2 in Appendix C.5. KEY PRIORITIESThe PCT has identified a small number of key priorities for 2007/2008 that willinform and direct its operational planning. These reflect national and local policydrivers. These are: • Returning to financial balance • Successfully Implementing demand management plans to reduce acute sector activity • Achieve the required reductions in waiting times from referral to treatment • Meet smoking cessation and access to genitor urinary medicine targets • Ensure health services are safe minimising the risks of acquired infections • Deliver the systems and support to the public and patients to enable them to make informed choices concerning their care • Develop community and primary care services in line with the direction of travel outlined in ‘Our health, Our Care, Our Say’. • Take forward the outcome of the Barnet, Enfield and Haringey clinical strategy.Proposed commissioned services for 2007/8, by provider, are set out atAppendix B.Specific changes proposed for individual services are identified at Appendix C.A summary of proposed commissioning changes, with indicative targets whereapplicable, is set out at Appendix E. 14
  15. 15. BPCT Commissioning Prospectus 2007/8 6. THE COMMISSIONING PROCESS 2007/8The PCT will adhere to the recently published Department of Health guidance on theapplication of Payment by Results for 2007/8 and on any successive guidance whichfollows. Commissioners will discuss the implications of roadtesting an unbundledtariff with acute and community providers, where appropriate, particularly wherediagnostic or rehab services are concerned.The PCT will also adhere to the London-wide financial and commissioning terms, asset in the document entitled ‘London Wide Commissioning - Primary Care Trustbusiness intentions/terms of business for 2007/8’. A summary of these terms is setout at Appendix D.The PCT wishes to move away from block contracts for non-PbR services whereverpossible and will put in place shadow cost and volume contracts during 2007/8 forBarnet PCT provider services and diagnostic services provided by BCFH and RFH,with a view to establishing full cost and volume contracts in 2008/9 at locallynegotiated prices. (BCFH, RFH and Barnet PCT provider services please note) 15
  16. 16. BPCT Commissioning Prospectus 2007/8 APPENDIX A THE COMMISSIONING CYCLEThe commissioning cycle describes activities carried out by healthcare commissionersthroughout the year to ensure the best possible health outcomes are achieved forfunding available for investment.As most NHS service agreements are renewed annually, the commissioning cycletends to be managed annually although activities are not necessarily delivered instrict rotation and for many are an ongoing and coordinated process. The Commissioning Cycle for Health Services (simplified) National Reviewing targets Deciding service priorities provision COMMISSIONING PROSPECTUS Assessing Designing/ needs services Patients/ the public Managing Shaping performance supply Managing demand 16
  17. 17. APPENDIX B SERVICES FOR GP REFERRAL IN SERVICE AGREEMENTS 2007/08 COLLEGE HOSP LONDON NORTH MIDDLESEX UNIVERSITY UNIVERSITY Univ. UNIV. MOORFIELDS EYE HOSPITAL ST BARTS & THE LONDON BARNET & CHASE FARM GUYS & ST THOMAS GT ORMOND STREET KINGS HEALTHCARE ROYAL BROMPTON HOSP ROYAL NATIONAL ROYAL FREE HOS ROYAL MARSDEN SPECIALTY OTHER ORTHOPAEDIC HAMMERSMITH WHITTINGTON NW LONDON NW LONDON ST MARYS St MARKSAllergy    Audiological Medicine    Breast Surgery      Cardiology      Cardiothoracic Surgery       Clinical Immunology Clinical/Medical Oncology       Colorectal Surgery      Dental Medicine    Dermatology      PCTDiabetic Medicine     Endocrinology     ENT     Gastroenterology     General Medicine     General Surgery     Geriatric Medicine    Gynaecology     Gynaecology Oncology    Haematology (Clinical)     Haemophilia Hepatobiliary Surgery    Hepatology      Infectious Diseases    Maxillo-Facial Surgery    Nephrology    Neurology     Neurosurgery     St GeorgesObstetrics     Ophthalmology    Oral Surgery    Orthodontics    Paediatric Cardiology    HomertonPaediatric Neurology    St GeorgesPaediatric Surgery   Paediatrics      Pain Management RAPID ASSESSMENT SERVICEPlastic Surgery    Restorative Dentistry    St GeorgesRheumatology      Thoracic Medicine     Thoracic Surgery   Trauma & Orthopaedics RAPID ASSESSMENT SERVICEUpper GI Surgery    
  18. 18. BPCT Commissioning Prospectus 2007/8Urology     Vascular Surgery      18
  19. 19. APPENDIX C Commissioning Priorities 2007/20081. CANCER SERVICESBreast ScreeningThe PCT is concerned that the uptake of routine breast screening has been assessedas relatively poor and efforts will be directed towards those women who, for whateverreason, do not accept the offer of routine screening. This may be due to personalchoice, administrative error or cultural reasons. The PCT will work with primary carestaff to encourage all relevant women to attend screening sessions. As the service isblock funded, there will be no financial implications to commissioners. (North London Breast Screening Service please note)Specialist Palliative CareThe PCT is working with the North London Cancer network to produce a model of careand service specification for specialist palliative care (including hospice provision) witha view to full implementation from April 2008, although the model of care should beapplicable from April 2007. The implementation of the new commissioningarrangements will depend upon the development of a specialist palliative care tariffand consideration of moving to full 100% NHS funding of services at some stage inthe future. (North London Hospice, Marie Curie Hampstead and St John’s Hospice please note)General Palliative CareThe issue of reducing length of stay in the acute sector, with increasing reliance oncommunity services, has grown over the past year or two. This is often laudable andin line with the Department of Health direction of travel for modernised services.However, the savings benefit to the acute sector has not been used to meet increaseddemands for funding in community based services. A particular area of creeping LOS reduction concerns patients needing palliative care.Barnet PCTstill has comparably high proportions of patients receiving palliative careand then dying in hospital. Service redesign is expected to increase the communityend of life care to allow more patients to be treated and cared for at home. This willsee reductions in length of stay across many HRGs, a factor that will need to bereflected in reductions in tariff payment by the sum being used to support thecommunity service. There is a national tariff being developed for palliative care thatmay help although this is not expected to be in place for 2007/8. The PCT will bediscussing a partnership approach to this issue with its providers (Local acute providers please note)
  20. 20. BPCT Commissioning Prospectus 2007/8Cancer DrugsCommissioners will develop a process that enables fast decision making on the use ofdrugs / devices associated with the delivery of cancer services, to work in tandem withthe NICE and pre-NICE processes.Mount VernonThe PCT will continue to support Mount Vernon cancer services. However, it isexpected that more clinical networks will be developed between Barnet and the RoyalFree Hospital. This will lead to increasing numbers of patients being referred forradiotherapy and other cancer treatment to the Royal Free Hospital rather than MountVernon. (Mount Vernon and RFH please note)Urology / Gastro-intestinal ServicesBoth Urology and Gastro-intestinal Cancer Surgery Services are planned to move fromthe Royal Free Hospital to UCLH during 2007/8. The commissioners take the view thatthis move should be revenue neutral to them. One of the drivers behind the move isthe need to maintain compliance with quality standards and this is part of a sectorwide strategic direction overseen by the North London Cancer Network in conjunctionwith local commissioning PCTs. ( RFH, UCLH and Mount Vernon please note)2 DIAGNOSTIC SERVICESFrom April 2007 the PCT will be able to access increased diagnostic capacity via thenational DoH initiative to introduce new independent sector provision to workalongside the NHS. This will offer shorter waiting times in some diagnostic areas andhelp commissioners to deliver the 18-week referral to procedure target by December2007.Procurement and contract negotiation have been carried out by the DoH on behalf ofPCTs and Amicus in Health will be the provider for this region. It is anticipated that theservice will be provided from the Garden Hospital, Edgware Hospital and Barnet MRIbut under the terms of the agreement patients can access Amicus’ services whereverthey are provided in London if they prefer.It is anticipated that the following services will be provided and pathway arrangementsfrom referral to reporting are being finalised at present: MRI, ultrasound, radiography (may be reporting only), sigmoidoscopy, echocardiogram, electrocardiogram, phlebotomy.Where the PCT has block arrangements for funding direct access diagnostic services atpresent, they will be reviewing the level of funding for next year in order toaccommodate potential reductions in activity in the acute sector in future as a result ofthe independent sector (IS) capacity. This may take the form of a shadow cost andvolume contract being held with local providers for diagnostic services during 2007/8with a view to formalising this arrangement in future years. 20
  21. 21. BPCT Commissioning Prospectus 2007/8Given the lack of capacity in some areas, such as ultrasound, it may be that theadditional capacity provided by the IS is necessary to meet the 18 week access targetwithout reducing any current activity levels.PBC is also a driver for the introduction of cost and volume contracts in direct accessdiagnostics, with the disaggregation of funding to practice level being the aim by2008/9.The issue of commissioners funding outpatient and elective activity through PbR(which includes diagnostic costs associated with that specialty) and also having tomeet the additional costs of independent sector provision for the diagnostic capacityhas yet to be resolved - guidance is awaited on the potential to manage this doublefunding. (BCFH, RFH, NW London, Whittington please note)During 2007/8 the direct GP access to diagnostics MRI at Edgware CommunityHospital will be extended to cover patients with chronic headache.The PCT will also be working with its practice based commissioners on thedevelopment of one-stop assessment services for a range of different conditions. (Local acute providers please note)3 MENTAL HEALTH SERVICESThe PCT has been working in partnership with local statutory and voluntary sectorproviders to review and modernise mental health services in Barnet. In line withgovernment White Papers, the new mental health strategy aims to shift emphasis frommental illness to mental wellbeing. As such, more services are being provided out tothe community wherever possible, to make them more accessible to patients and tolink in to primary care services for greater continuity of care and to offer greaterchoice.Primary Care Mental Health Teams (PCMHTs) have been established within the Barnetsite of Barnet, Enfield and Haringey Mental HealthTrust (BEH MHT) that are linked tothe Psychological Therapies Service and provide a more accessible and timely therapypathway for patients. It is anticipated that at least 2 Star (Support, Time & RecoveryWorkers) and 3 Community Development Workers will be added to the teams in2007/8.The PCT and BEH Mental Health Trust is failing to meet the target levels of clientcoverage, as set out in the 2005-8 LDP. An action plan to address the shortfall is inplace in 2006/7, including a specific performance improvement bonus of £50,000. Thiswill be continued in 2007/8 with the funds deducted from the SLA and payable onsuccessful completion of the target level. In continuing to apply a Performance Bondwith BEH-MHT in 2007/8, the PCT wishes the trust to note that provision of provideractivity data for commissioners is still a significant issue.Following the creation of the PCMHTs Complex Community Mental Health Teams(CMHTs) will refocus and absorb more complex cases. In 2006/07, the CMHTs willabsorb the caseloads previously managed by the Assertive Outreach Team and theMentally Disordered Offenders Team which are now disbanded. 21
  22. 22. BPCT Commissioning Prospectus 2007/8The PCT scored a ‘fail’ on the Healthcare Commission assessment of the CrisisResolution service it commissions for Barnet residents. This was on the basis that thetwo teams across the borough were not reaching activity targets. The PCT expectsthat the teams will reach their target from now on and will consider including this inthe performance bond for next year if they fail again.The PCT will be extending the EIP service from the one pilot area operating in highBarnet to the whole of the borough. The areas of roll out will be determined by theexpected health gain by population and the support of primary care and the primarymental health team functionality.During 2007-8 the PCT in partnership with the King’s Fund will be reviewing servicesfor older people with functional mental health needs. There may be some servicechanges that occur as a result during the year although most are anticipated to impactin 2008/9.During 2007/08, The Holly Oak Unit which is on the Colindale site will be relocated onthe newly refurbished site at Dennis Scott Unit to provide 12 beds for older peoplewith chronic functional mental health problems in a modern setting.During 2008/09, the fully refurbished East of Barnet Psychiatric Unit (BPU) isexpected to be completed following a £12m capital refurbishment approved by theSHA in 2005. This will provide good quality accommodation in a comprehensivelyrefurbished and upgraded BPU provide for 30 Adult inpatient and 12 older peopleensuite beds with associated day and community services. (BEH-MHT please note)4 CHILDREN’S SERVICESAt present services for children are commissioned separately by health and social carestaff, although they work together wherever possible on a common approach. TheChildren’s Plan for Barnet, produced as a result of partnership working at thebeginning of 2006/7, provides a framework for delivery of the NSF for Children andYoung People and includes workstreams around integration across health and socialcare of commissioning and of front-line services, whilst separating commissioning andservice delivery functions. Although there should be little practical impact on the waythat services are delivered during 2007-8, work on delivering the various workstreamin the plan will continue and will probably impact from 2008-9 on.We will be working with the Royal Free Hospital on the delivery of a consultantdelivered paediatric service as outlined in the Healthy Starts Healthy Futuresconsultation. (RFH please note)In parallel with moves around adult services to refocus care from hospitals to acommunity setting wherever possible, the PCT is working with acute providers torelocate outpatient care for children from a hospital setting, particularly for follow-upcare. Consideration is also being given to managing appropriate paediatric A/Eattenders in a different way. Draft proposals for remodelled outpatient and A/Eservices for children are being developed and directed at Barnet and Chase FarmHospitals initially. It is not clear at this stage whether there will be an impact on2007/8. (Acute providers please note) 22
  23. 23. BPCT Commissioning Prospectus 2007/8There is no separate service agreement with BEH-MHT for the Child and AdolescentMental Health Service (CAMHS) at present, it is provided within an overall blockcontract for provision of a range of mental health services. As a first step towardscreating a designated service agreement, the activity baseline needs to be establishedusing historic activity information. The PCT will be working with the trust to establishthis. (BEH-MHT please note)Access to CAMHS Tier 4 provision is being reviewed at present across London and anychanges arising may impact on services next year. Existing providers will be informedat an early stage of any potential changes. (CAMHS Tier 4 providers)A new referral pathway for accessing the Tavistock and Portman Clinic is beingconsidered at present and, once agreed, it is anticipated that it will be implementedfrom April 2007. The new pathway will include a single point of access to services. (Tavistock and Portman Clinic please note)Issues around transition within Children’s and Adult’s care in Mental Health andLearning Difficulties services are apparent, and it is intended to review these during2007/8. (London Borough of Barnet and BEH-MHT please note)The PCT will be providing and additional £100k worth of annual CAMHS grant fundingnext year. This is in recognition of the Local Authority providing a similar level of extramoney in 2006/2007. (All CAMHS providers please note)Service agreements with New Beginnings are being renegotiated for next year, to beimplemented from April 2007. (New Beginnings please note)Where Northgate is concerned, a service redesign process is planned for the comingmonths and may be implemented, in part or wholly, in 2007-8. (Northgate please note)For children with sexualised behaviour, the PCT is working with LBB on a model ofcare based on Cognitive Behaviour Therapy which has proved very effectiveelsewhere. (LBB and BEH-MHT please note)A borough based Children’s Community Nursing Team will be established, as part of aborough based agreement across North Central London Sector. It is likely that fundingwill transfer from the Royal Free Hospital to Barnet and Chase Farm Hospital toprovide this service at some stage in the future. (RFH and BCFH please note) 23
  24. 24. BPCT Commissioning Prospectus 2007/85 LOCAL PCT- PROVIDED SERVICESAs required by the reforms set out in ‘Commissioning a patient led NHS’ and the WhitePaper ‘Our health, our care, our say’ the PCT’s commissioning arm is establishing amore formal and separate relationship with services provided within the PCT in acommunity setting. An essential step towards achieving this more formalisedrelationship will be the introduction of a service specification ahead of 2007/8 and thecreation of shadow unit pricing of services wherever possible during 2007/8, in orderto inform a possible cost and volume contract in 2008/9.In this way any changes in the profile of services delivered may be funded moreappropriately in future, services can be better performance managed via serviceagreements and they can be benchmarked when operating in a more competitiveenvironment. We will be working with the PCT’s provider services to implement thenew national targets from the Healthcare Commission and this will be part of theservice specification process.As the development will depend on robust data collection and analysis, there will be atime delay on shadow cost and volume arrangements until the RIO community datacollection system is fully operational (should be by end 2006/7). (Barnet PCT Provider Services please note)6 SUBSTANCE MISUSEDrug misuse Barnet has seen a steady increase in the number of people accessingstructured tier 3 and tier 4 treatment which includes specialist prescribing, counselling,Psychology, inpatient detoxification, rehabilitation and shared care. The numbers intreatment rose to 725 in 05/06. This years estimated target is 834 and the Borough isalready showing signs that this will be achieved. However, Home Office prevalencedata estimates that Barnet has around 1290 level opiate or crack cocaine problemdrug users in total and the aim is to keep increasing the numbers in treatment infuture.Beyond 2008 it is not yet known whether the Pooled Treatment Funding will exist in itscurrent format and whether there will be continued investment in the sector, so weplan to consolidate existing services in 2007/8. The following are the priorities for thenext 2-3 years. - Set up a North London Drug and Alcohol Detox Centre with Islington, Haringey, Enfield and Herts if a current bid to the DoH for capital funding is successful. - Develop Hepatitis B/C testing and ensure robust services are in place to for Hep B vaccinations and Hep C treatment pathways for IV drug users. - Implement a Borough wide Harm Reduction Strategy and reduce drug related deaths - Increase delivery of prescribing services in the Community through shared care with GP’s - Develop an aftercare service for those exiting treatment, maintain their stability and enable them to renter their community as fully contributing members return as fully functioning as full members of their community. - Continue to support and develop user and carer services 24
  25. 25. BPCT Commissioning Prospectus 2007/8 Alcohol Misuse Alcohol Concern completed a needs assessment on behalf of the Borough in Feb 2005 estimating that 47,000 adults in Barnet are drinking at levels that risk harm to their health and of which 14% are at high risk of alcohol related health problems. There has been little investment in alcohol services for some years. The report makes several recommendations and the following could be considered in terms of needing some urgent attention from the PCT: - Increase the investment in specialist community based alcohol services - Develop primary care response to identify early, treat and support patients who are risking their health through drinking and reduce longer term harm - Ensure all health and social care staff routinely receive training on recognising an managing alcohol issues - Implementation of the model of care for alcohol misusers (MoCAM) best practice guidance for health organisations in delivering planned and integrated local treatment system for adult alcohol users. (Providers of drug and alcohol misuse services please note) - Identify those presenting at A&E and for inpatient admission with symptoms and conditions associated with alcohol abuse. The PCT will work with local providers on the use of clinical coding to identify those at risk and the development of clear pathways for referral to follow up care. (All local providers please note)7 LEARNING DISABILITIESBarnet Learning Disability Partnership Board recently produced a joint health andsocial care plan for services for clients with learning disabilities (‘A Small Plan to Makea Big Difference’). This plans sets the strategic context for changes in service provisionover the next three years.The PCT jointly commissions services for patients with learning disabilities with LBB. In2007/8 it is proposed that the 8 Specialist Residential Services (SRS) beds atHarperbury Hospital, that are used by Barnet will be decommissioned and patients willbe provided with alternative services.Forensic and assessment and treatment beds will remain at Harperbury but those inthe specialist residential services will move locally to community accommodation thatmeets their assessed individual needs. It is recognised that more robust assessmentand treatment services must be developed locally to support his move. (Hertfordshire Partnership NHS Trust please note)Recommendations for a commissioning strategy for Learning Disabilities services arebeing drawn up as part of a review being carried out by LBB. The outcome of thestrategy will be published in January 2007 and may impact on the commissioning ofhealth services in future.The strategic direction of Learning Disabilities services is being considered as part ofthe longer-term commissioning strategy and will address the issues of increasingnumbers of children with complex health needs and severe learning disabilities, anincrease aging population of people with learning disabilities who all have a higherprevalence of developing dementia and an increase of children with diagnosed autisticspectrum disorders. 25
  26. 26. BPCT Commissioning Prospectus 2007/8A review of sub-commissioning arrangements between the Barnet LD provider armand BEH-MHT for provision of psychology and psychiatry support will take place aheadof 2007/8. (BEH-MHT please note)8 OLDER PEOPLE’S SERVICES / STROKE SERVICESThe PCT is strengthening the commissioning of continuing care by increasingmanpower and the use of technology. There will be a focus on value for money innegotiating placements and greater joint commissioning with London Borough ofBarnet in order to manage the care market where appropriate. In addition, the PCT isconsidering linking to the procurement and contracting hub for continuing care,currently being established in North-West London.The PCT is reviewing stroke accommodation across acute and community providersbecause current capacity does not meet need appropriately. There will be an emphasison establishing the number of acute or rehab designated beds required – at presentpatients are managed wherever there are spare beds in times of high demand. It maybe that the Strategic Outline Case for redevelopment of the Finchley Memorial siteoffers a longer term solution to the issues of dedicated stroke servicesaccommodation. Until then it may be necessary to rebalance existing accommodation.Of particular concern is the lack of local rehab accommodation for younger strokevictims, who have to be managed out of borough at present. (BCFH and Barnet PCT Provider please note)The Intermediate Care Team will be expected to improve their response rate to thedischarge of patients from acute trusts and to develop expertise in areas such asstroke to facilitate earlier discharge. (Barnet PCT provider please note)9 LONG TERM CONDITIONSThe PCT has already set in place a new model of care to meet the needs of patientswith long term conditions and the caseloads managed by specialist staff are rising.This trend will continue in 2007/8 with the focus on preventing hospital admissionwhere possible by closer clinical management in the community. This has already beenan effective approach to managing patients with respiratory disease in Barnet. Many ofthe schemes outlined in the rest of this section also benefit those with long termconditions.10 SEXUAL HEALTHThe PCT is looking at the provision of GUM services from all of its providers. Thecurrently hosted GUM service by Barnet and Chase Farm will be reviewed to assesswhere services can be provided within a primary care setting. The patient pathway willbe developed according to this model including assessment of primary carecontribution from GP practices, family planning and the appropriate use of secondarycare. Key to this work is the careful planning of how the national target of 48 houraccess is met, including the understanding of demand and capacity for GUM provision. (BCFH please note) 26
  27. 27. BPCT Commissioning Prospectus 2007/811 PLASTIC SURGERY / BURNS SERVICESPlastic Surgery and Burns services will be relocated from West Herts Hospital to RFHfrom April 2007 as part of a planned strategic development to strengthen theseservices. There will be no financial implications for commissioners. (West Herts Hosp and RFH please note)12 REFERRAL ASSESSMENT CENTREThe Barnet Referral Assessment Centre (RAS) currently assesses referrals from GPs formusculo-skeletal opinion and sends them on to the most appropriate service formanagement, which may be an acute hospital outpatient service, a community basedservice or increasingly an alternative in primary care.During 2007/8 the RAS will expand its function to cover referrals for paediatrics, painmanagement and direct access to MRI scanning. It is anticipated that the range ofspecialties covered by this service may expand further in 2008/9.From December 2007 the PCT will be commissioning one provider to run the triageservice with an expectation that this will be operationally independent of any acuteorganisations to avoid possible conflicts of interest.For more detail on individual specialties please see points 4-6 in the table atAppendix E. (All acute providers please note)13 DERMATOLOGYPathway development for dermatology referrals has been supported by the creation ofadditional GP Specialists in Barnet, so that patients only need to access secondary carewhen higher level intervention is required. Although this service has been indevelopmental phase during 2006/7 it will impact fully on secondary providers for thewhole of 2007/8.For more detail please see the entry at point 7 in the table at Appendix E. (Secondary providers of Dermatology services please note)14 GYNAECOLOGYDuring 2006/7 a GP with Special Interest in Gynaecology has been involved in a pilotgynaecology triage service in primary care, for referrals requiring specialist opinion, forone of the PBC commissioning clusters. The PCT will be looking to introduce a fullerprimary care based triage service, via a tendering process. It is anticipated thatcurrent providers of secondary care services will be excluded from tendering, toensure no conflicts of interest. (Secondary providers of Gynaecology services please note) 27
  28. 28. BPCT Commissioning Prospectus 2007/815 IVFBarnet PCT currently follows DoH guidance and funds one cycle of treatment pereligible couple. One important aspect of eligibility is the age of the woman and NICEguidance is followed (this excludes women aged over 39 being treated oneffectiveness grounds). The average waiting time for treatment is currently around 2years and there are issues with patients who are approaching the upper threshold foreligibility when they are put onto the waiting list exceeding it before they are treated.In addition, service monitoring demonstrates that there may be alternative providersin London with better outcomes.IVF provision is being reviewed at the moment with a view to potentially switching thepreferred provider arrangement at King’s College Hospital to another hospital withbetter outcomes. However, the PCT needs to be assured that equitable access toservices will not be diminished if alternative arrangements are made. Althoughconsideration will be given to increasing the amount invested in IVF, in order toreduce waiting times, this will have to be considered along with competing priorities. (Kings College Hospital please note)16 URGENT CAREThe PCT has been running a pilot scheme providing primary care expertise in the localA/E department which has proven to be successful in providing patients with moreappropriate clinical care. It has been estimated nationally that between 30-50% of allattenders at A/E departments are for primary care management. It has been decidedthat the pilot will be fully implemented in 2007/8 and should be self-funding fromApril. Work on a longer-term model for primary care in A/E will continue. (BCFH and RFH please note)17 NEUROLOGYThe direct GP access to diagnostic MRI at ECH will be extended fully to cover patientswith chronic headache. This will be included in a specific service specification andpatient pathway for the management of this condition.Further appropriate neurological conditions will be added in year including thedevelopment of improved services for people with or at risk of epilepsy. (Local acute providers please note)18 HOMEOPATHYThe PCT will cease commissioning all homeopathic treatments from April 2007, unlesspatient referrals has been approved by the Individual Treatment Panel (ITP). Allexisting patients under treatment will be reviewed. The ITP will consider referralwhere there is proven and substantiated evidence of clinical and cost effectiveness. (UCLH – Royal Homeopathic Hospital please note)19 REDUCING LENGTH OF ACUTE STAYThere has been a measurable reduction in length of inpatient stay in local acuteproviders over the past year or two. This is highly laudable and compatible with thedirection of travel required by the Department of Health. However, the trend has putan increasing pressure and cost on community service provision, as patients are 28
  29. 29. BPCT Commissioning Prospectus 2007/8accessing the service at a higher level of need. The revenue savings associated with areducing length of stay (LoS) have been retained by acute providers to date, but thissituation cannot continue.The structure of the national tariff currently rewards acute Trusts for reducing LoS butgives no compensatory reward to community based services to cover increasingdemands. Early indications from the DoH are that local negotiations around splittingnational tariffs are to be allowed for 2007/8. In the meantime the PCT expects all localacute providers to indicate where further LoS reductions are planned, together withthe support required from community services to achieve them. A proportion ofsavings achieved can then be properly attributed to community and/or social care.Where schemes begin without this consultation and agreement there will be a highchance of failure because of insufficient capacity in place outside of hospitals. (Local acute providers please note)20 PERFORMANCE BONDThe PCT will be applying a Performance Bond to local acute providers of services,which will contain financial penalties if benchmarked consultant-to-consultant referralrates and first to follow-up outpatient attendance ratios are not met. (BCFH and RFH please note)21 PRIMARY CAREConsideration is being given to the role that wider (i.e. non-GP) primary care can playin supporting the strategic direction of the PCT to move the focus of care away fromacute and into a community setting. The role of pharmacists, dentists andoptometrists is being explored to assess potential to expand their role in this respect.An initial Users’ Forum for service planning in the future has indicated that poor accessto primary care in the evenings and at weekends is a significant concern. The PCT willbe carrying out a study of demand for services and the best way that requirementscan be met so that a more specific target can be established around access for ourlocal services. The PCT will work with practice based commissioners on urgent accessout of hours, alternatives to primary care and issues such as benchmarking thenumber of planned appointments per patient. It is anticipated that specific targets forprimary care access will be developed during 2007/8.22 CHOOSE AND BOOKThe PCT has an LDP target of 90% of all GP referrals to be booked electronically byend February 2007. At present, only 15% of these referrals are booked this way. Asignificant block to progress has been the lack of capacity at RFH to handle patientbookings in this way at present, either on their site or at outreach clinics on theEdgware Hospital site, although the staffing and technology solutions should be inplace by end December. Certain BCFH sub-specialties are not available electronicallyyet.Both providers must ensure that their services are fully bookable via the electronicroute before 2007/8. (RFH and BCFH please note) 29
  30. 30. BPCT Commissioning Prospectus 2007/823 SPECIALISED SERVICESThe commissioning of very specialised services (e.g. bone marrow transplants) iscarried out on behalf of the PCT by a team of commissioners who work across the fivePCTs in North Central London. This team is responsible to the PCTs for the strategicdirection of the specialised services.Proposals for 2007/8 include: • Activity plans for 2007/8 will be the baseline plan for 2006/7. The exception will be where commissioning consortia apply a 3-year rolling average, which will continue to be applied. • Commissioning consortia will undertake a price audit and benchmarking exercise to ensure value for money. No service developments will be considered for funding unless they are implemented on a cost neutral or cost saving basis. • Services being considered for inclusion in the specialised commissioning portfolio, rather than that of PCTs, include burns and neurorehabilitation. • A referral pathway, including gate keeping procedure, has been agreed for patients accessing the Personality Disorder Treatment Service at the Henderson Hospital. Patients will be funded on a cost and volume basis, and only when compliance with the referral pathway has been demonstrated. • Development of plans for a low secure mental health unit in the sector, so that patients do not have to be placed at risk on routine wards or at a great distance from home.The first formal specialised commissioning plan for the sector is expected to be issuedin mid-December and service providers should consider it a companion document tothis one. (All providers of specialised services please note) 30
  31. 31. BPCT Commissioning Prospectus 2007/8 APPENDIX D LONDON PLANNING and COMMISSIONING ARRANGEMENTS 2007/8NHS London has recently published the 2007/8 Planning Framework for London,ahead of the London Commissioning Regime which will be published in December2006. The Planning Framework acknowledges that national targets and the currentfinancial challenges faced by PCTs will drive service reforms via the commissioningprocess.The new commissioning regime will require PCT’s to produce the following: 1. A Strategic Plan (produced every 3 years with a 5-10 year outlook) to establish direction and set priorities. This plan will drive and inform the Operating and Organisational capability Development Plans. The Strategic Plan will overlap with the PCT’s Prospectus and will be aggregatable to sector and London-wide level. 2. An annual Operating Plan, with a 3 year horizon. In the first year this will contain detailed targets and financial plans. It incorporates elements of the existing LDP and Local Area Agreements. The Operating Plan will set targets by month and form the basis for financial and risk rating. 3. An Organisational Capability Development Plan produced in line with the Strategic Plan which establishes the capability needs and gaps in delivering on strategy and operations, and sets out to address these. Will be based initially on the PCT’s FfP development plans.The next tranche of guidance will also address PCT risk-rating and incentives systems.There will also be details of the arbitration process for 2007/8 contracts, with financialpenalties incorporated.Timetable for 2007/8 November 2006 – PCTs finalise FfP Development Plan Commence development of LDP and Operating Plans December 2006 – DoH publishes National Operating Framework 2007/8 London Commissioning Regime issued Arbitration process announced 2nd January 2007 – PCTs submit LDP, Operating Plan, FfP Plan Turnaround Plans submitted where required February 2007 - Contracts to be signed by 28th Feb March 2007 1st – 9th Arbitration for unsigned contracts 16th All Plans finalised for NHS London Board approval 28th PCT Plans signed off by NHS London 31
  32. 32. BPCT Commissioning Prospectus 2007/8Key Financial Planning Assumptions 2007/8 1. PCT top-slice across London will be between 2.6% and 3.6%. Planning should be on the basis of 3.6% at present. 2. £70m risk reserve and 2006/7 PCT surpluses to be repaid in full in 2007/8. 3. Repayment of the initial 2006/7 3% top-slice to be deferred beyond 2007/8 (to be repaid in full by 2010). 4. All unplanned deficits to be repaid in 2007/8 5. Tariff inflation at 2.5% (5% inflation net of 2.5% cost improvement programme) 6. PPA on the same basis as 20006/7, albeit reduced by 25%. 7. Prescribing uplift of 8%, GMS uplift of 2.5%. 8. Unbundling of the PbR tariff may be road tested locally and set at locally negotiated levels.Key Service Planning Assumptions 2007/8The top priorities will be:  Delivering the 18-week wait milestones  Maintaining the 98% A/E 4 hour maximum wait  Maintaining the cancer wait targets  Healthcare associated infections (i.e. MRSA and C-diff)High priorities will be:  Smoking cessation  Obesity  GUM waits  Patient choice  Choose and bookPoints to notePCTs in financial balance should deliver the other LDP targets for 2007/8 as well aslocal targets.Providers’ service plans should reflect PCTs commissioning intentions, which should beincorporated in contracts between PCTs and Trusts. 32
  33. 33. BPCT Commissioning Prospectus 2007/8 APPENDIX E COMMISSIONING INTENTIONS SUMMARYThe table on the following 8 pages represents a summation of the PCT’scommissioning intentions for 2007/8 and may be read as a stand-alonecompendium, without reference to the rest of this document.In some instances, entries contain specific targets for service delivery againstwhich commissioning performance may be monitored as the year progresses. 33
  34. 34. Barnet PCT 2007/08 Commissioning Intentions - DRAFTKey: Barnet & Chase Farm (B&CF), Royal Free (RF), University College Hospital (UCLH), PCT Provider Arm (PCTPA), BarnetEnfield and Haringey Mental Health Trust (BEHMHT), Tavistock and Portman (T&P).• All of the PCTs providers should note that the PCT will be conforming and adopting the London wide business rules as agreed with the new London Strategic Health Authority. This will include the application of a new and updated standard contract. For Foundation Trusts the PCT will act in accordance with the new contract that is being negotiated to begin from 1st April 2007.No. Type of Action Outline of Proposal/Purpose Expected Outcomes Trusts/Providers Affected • General Acute • General Acute To achieve the staged reduction in waiting times • Trusts will be expected to achieve the reduction in waiting times All acute with whom 1 • Waiting Times making progress towards the December 2008 target through more efficient working including: Barnet PCT has an of having no patient waiting longer than 18 weeks o Maximising capacity through reviewing outpatient SLA. between referral and treatment. The aim for the PCT new to follow up rates. 95% of specialties will be will be to achieve the staged reduction without expected to be at least compliant with the national seeing a rise in activity levels above the LDP/FT average with 25% of specialties in the top 25% diagnostic predicted activity levels. band of England performance. Baseline will be 2005/2006 national data. o Unbundling elective tariffs to segregate the diagnostic test elements. o Complying with Barnet PCTs and applicable London wide Commissioners policy governing consultant to consultant referrals. Where this is not complied with the PCT will not reimburse the trust for activity generated. General Acute To cease commissioning all Homeopathic treatments • Overall PCT spend at the National Homeopathic Hospital will be UCLH/National 2 • Homeopathy unless the patients referral has been agreed by the reduced by £300,000 in a full year. Homeopathic Hospital PCTs ITP. This will also include a review of all patients currently being treated. The ITP will consider referral where there is proven and substantiated evidence of clinical and cost effectiveness.

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