The slides from a workshop held by the Long Term Conditions Year of Care Commissioning Programme on 14 May 2015.

1. WELCOME
LTC Year of Care Commissioning
Early Implementer Sites Workshop
14th May 2015

2. Plan for the day
NHSE visits - Early Implementer Sites Feedback and Discussion
NHS England Update – LTC YoC Commissioning and 5 year forward view
Jacquie White, NHS England
Whole population dataset analysis
Jamie Day, NHS Improving Quality
Improving data quality
Bruce Pollington, Kent EIS
Health 1000 – service model and staff profile
Colleen Atkinson, BHR EIS
15/16 LTC YoC Commissioning programme plans
Update from EIS
Discussion and group work

3. To Do list
Questions at the ready
 5 year forward view and LTC YoC commissioning @ 11.00
 Data Quality @ 12.25
15/16 LTC YoC Commissioning plans - EIS
 Summary updates on EIS plans
 Completion of template during group working session
Thinking during the day
 What can your site contribute to the LTC YoC Commissioning fast follower
community of practice

4. To register email LTC@nhsiq.nhs.uk
LTC Lunch & Learn Series ….coming soon…
Date Webinar Hosted by Bev Matthews &
27 May 2015
12.30 – 1.30pm
Primary Care Workforce for
the 21st Century
Sharon Lee
Primary Care workforce facilitator
South Kent Coast CCG
4 June 2015
12.30 – 1.30pm
Fire and rescue service –
prevention through home
health and safety checks
Peter O’Reilly, Chief Fire Officer
Geoff Harris, Asst County Fire Officer
Manchester Fire and Rescue Service
9 June 2015
12.00 – 1.00pm
(at FF workshop)
Health 1000 – A complex Care
Organisation
Rob Meaker
Barking, Havering and Redbridge

5. “What matters
most”
Jacquie White
Deputy Director for Long
Term Conditions,
NHS England
May 2015
5

6. www.england.nhs.uk
To transform the co-ordination of person centred care and quality of life for people
with Long Term Conditions through implementation of improved commissioning
mechanisms:
• Improved outcomes and wellbeing:
• Patients receive care that is planned with them, more seamless across different care
services and more needs focused.
• Clinical professionals supported to provide a more holistic service
• Reduction in acute admissions to hospital; and shorter lengths of stay when these are
required.
• Local health & Social Care economies:
• Provide care that delivers value for money and is better managed by integrated teams.
• Incentive for providers to work together to improve services for patients
• Improved joint working and shared responsibility for outcomes
6
Purpose of LTC Year of Care
Commissioning Programme – April 2012

7. www.england.nhs.uk
The LTC Year of Care journey
National
initiatives
(pre
2012)
Health &
Social
Care Act
(2012)
National
Collaboration
for integrated
care (2013)
Person
centred
co-
ordinated
care: LTC
framework
(2013)
Five year
forward
view
5YFV
(2014)
Post
election
?
Integration
pilots,
Community
Matrons, Self
management,
Technology,
PHB,
LTC Year of
Care
Commissioning
Programme
“Duty”, New
organisations,
roles and
responsibilities
– Local,
National
National
support –
Narrative,
definition,
Better
care fund,
Integration
pioneers
Permissive
framework for
local
implementation –
House of Care
Clarity of vision,
priorities, new
national
programmes:
“new models of
care”,
“integrated
personal
commissioning”
?
7
LTC Year of
Care:
Development
year and site
selection
LTC Year of Care:
1st year –
experimentation
to define scope
LTC Year of
Care:
2nd year –
technical
phase (data
and
analysis)
LTC Year of
Care:
2nd year –
technical
phase (data
and analysis
LTC Year of
Care:
3rd year –
development
of currencies
and new
delivery
models
LTC Year of
Care:
4th year –
implement
currencies
and local
prices,
testing
delivery
models

8. www.england.nhs.uk
We are facing a rising burden of avoidable illness
across England from unhealthy lifestyles:
•1 in 5 adults still smoke
•1/3 of people drink too much alcohol
•More than 6/10 men and 5/10 women are
overweight or obese
Furthermore:
•70% of the NHS budget is now spent on long term
conditions
•People’s expectations are also changing
4
5YFV:
Demand for care is rapidly growing

9. www.england.nhs.uk
New technologies and treatments
•Improving our ability to predict, diagnose and treat disease
•Keeping people alive longer
•But resulting in more people living with long term
conditions
New ways to deliver care
•Dissolving traditional boundaries in how care is delivered
•Improving the coordination of care around patients
•Improving outcomes and quality
…but the financial challenge remains, with the gap in
2020/21 previously projected at £30bn by NHS England,
Monitor and independent think-tanks
5YFV:
There are new opportunities

10. www.england.nhs.uk
The 3 gaps
• Health and wellbeing
• Care and quality
• Funding
Priorities for action
• Prevention,
• Empowering patients,
• Engaging communities,
• The NHS as a social movement,
• New care models
LTC YoC Commissioning Programme laying the foundations for the
transformational action needed
10
5YFV:

11. www.england.nhs.uk
• Personal Health Budgets
• Pricing strategy
• Integrated personal commissioning programme
• Information Governance
• Improvements in data and information
• Testing new models of care
• Supporting other initiatives to progress
• Continued ministerial interest
• Increasing international interest – WHO, EU
Proving it’s possible
11
LTC YoC - Input, Impact and
Influence

12. www.england.nhs.uk
Framework: The House of Care
People*
Services –
delivery*
Services - care management*
System*
* WHO Framework for action on integrated care

13. www.england.nhs.uk
Framework
13
Organisational &
Clinical Processes
Informed and
engaged patients
and carers
Health & Care
Professionals
committed to
partnership
working
Commissioning
• Information and
technology
• Case finding & risk
stratification
• Care Planning
• Safety and
Experience
• Guidelines,
evidence and
national audits
• Self Management
• Patient activation
• Health literacy
• Information and
Technology
• Group and Peer
Support
• Care Planning
• Carer support
• 3rd sector support
• Community
mobilisation
• HSC Integration
• Multi Disciplinary
Teams
• Health coaching
• Behaviour change
(Clinical activation)
• Workforce
development
• Care Planning
• Care Co-ordination
• Needs Assessment
and Planning
• Joint Commissioning
• Joint funding (BCF,
shared risk and
reward)
• New models of care
• Metrics and
Evaluation
• Service User and
Public Involvement
• Care Planning
Key factors needed to deliver Person Centred Coordinated Care and that are
being supported nationally: Care & support planning as the golden thread

14. www.england.nhs.uk 14
Purpose of LTC Year of Care Commissioning
Programme – April 2012 May 2015
To transform the co-ordination of person centred care and
quality of life for people with Long Term Conditions through
implementation of improved commissioning mechanisms:
Improved outcomes and wellbeing:
• Patients receive care that is planned with them, more seamless across different
care services and more needs focused.
• Clinical professionals supported to provide a more holistic service
• Reduction in acute admissions to hospital; and shorter lengths of stay when
these are required.
Local health & Social Care economies:
• Provide care that delivers value for money and is better managed by integrated
teams.
• Incentive for providers to work together to improve services for patients
• Improved joint working and shared responsibility for outcomes

15. www.england.nhs.uk
• National and local co-production
• Agreed vision, case for change, definition and narrative
• Permissive framework with national guidance, enablers,
resources, case studies: local implementation irrespective
of starting point
• Local partnerships, strategy, action plan, metrics and
milestones: flexible and adaptable
• Build on learning – own and others (translate into local
system)
• Use improvement methodology to manage change
• Culture eats strategy – engagement, engagement,
engagement to gain ownership
• Keep focussed on the aim: person centred co-ordinated
care for all by understanding “what matters most”
15
Summary – creating the conditions
for change

16. www.england.nhs.uk
• @jaqwhite1
• Jacquie.white@nhs.net
• http://www.england.nhs.uk
• http://www.england.nhs.uk/house-of-care/
16
Thank you

17. www.england.nhs.uk
Health 1000 -The Wellness
Practice
An experiment
Colleen Atkinson Interim Practice Manager
and Programme Manager for Innovation BHRCCGs

18. www.england.nhs.uk
May
2013
• Early Implementer
site for YOC
• Advanced data
sets from primary
care, acute
community and
social care
• PMCF Bid to
include testing of
capitated budget
being developed
to one provider in
early 2014
• PMCF Bid to include
testing of capitated
budget being
developed to one
provider in early
2014
• PMCF bid approved
may 2014
May
2014
• Started work
on project
May
2014
June-September
2014
• academic development of
the service model and
staffing requirements
with UCLP
• Set up of the legal entity
to operate the service
• Source premises
• Source clinical leadership
October 2014-
January 2015
• Commence recruitment of
staff
• Training
• Premises set up
• Legal entity formed
• APMS discussions started
• Engagement with practices
• January 16th APMS contract
signed
• January 19th first patient
registered

19. www.england.nhs.uk
Key features of the proposed model
• GP lead model of chronic disease management with
proactive case management of medical and social care
• Tele-monitoring
• Patient and carer education and enhanced self-
management
• Promotion of independence and personal responsibility
• Shared care record with agreed care plan
• Quality improvement embedded in culture
• Key worker skills and competencies developed

20. www.england.nhs.uk
Diabetes
DementiaStroke
COPD
HypertensionCVD
Heart Failure Depression
Patient cohort for the service 5 or more long term conditions.
2000 patients eligible across BHRCCGs and aim to recruit 1000

21. www.england.nhs.uk

22. www.england.nhs.uk
0
200
400
600
800
1000
1200
1-Jan-15 1-Feb-15 1-Mar-15 1-Apr-15 1-May-15 1-Jun-15 1-Jul-15 1-Aug-15 1-Sep-15 1-Oct-15 1-Nov-15 1-Dec-15
Numberofregisteredpatients
1-Jan-15 1-Feb-15
1-Mar-
15
1-Apr-15
1-May-
15
1-Jun-15 1-Jul-15 1-Aug-15 1-Sep-15 1-Oct-15 1-Nov-15 1-Dec-15
Actual cumulative 2 14 61 74 87
Planned 4 35 55 115 205 325 445 565 685 805 925 1045
Patients recruitment planned and actual

23. www.england.nhs.uk

24. www.england.nhs.uk
ROLE WT Cover provided
MD and Geriatrician (50:50
role)
1.0 20 hours direct patient care plus 17.5 hours management
plus on call support as required
HCS Key workers 5.0 73.5 hours per week 8am to 18.30pm Monday to Sunday.
This is a dual function role covering reception and health
care support and requires two members of staff to be on duty
during 08.00 to 18.30pm Monday to Friday
GPs 3.0 52 hours per week 08am to 18.30pm Monday to Friday plus
On call for 5 hours per week Monday to Friday 6.30 to 8pm
and 24 hours on Saturday and Sunday from 8am to 8pm
A total of 81 hours per week
Practice Manager 1.0 37.5 hours per week as required to cover 7 days per week
on rota
Nurse 1.0 37.5 hours per week during 8am to 6.30pm
OT 0.5 18.5 hours per week during 8am to 6.30pm
Physiotherapist 0.5 18.5 hours per week during 8am to 6.30pm
Pharmacist 0.5 18 hours per week Monday to Friday as required
Workforce Plan

25. www.england.nhs.uk
Challenges in setting up the service provision
• Establishing the financial arrangements for the service as set up and
then BAU and capitated budget moving forward
• CQC registration
• Insurances wider provision of services
• Accountancy for new provider and challenge of complicated pass
through costs in addition to the back office function provided by CCG
• GPs and the Provider list and having a non GP as the clinical lead
• CCG membership
• Receiving records from practices- system challenges
• Legal requirements for the Limited Company, APMS contract

26. www.england.nhs.uk
will
• Recruiting clinical teams for a time limited project and people leaving
• GPs and the Provider list and having a non GP as the clinical lead
• Setting up the new practice on Vision, registration links, CQRS,
prescribing, training all staff, setting up templates to ensure
consistencies in data collection
• Remote working on clinical system
• Set up clinical rooms, equipment, IT, estates, cleaning waste,
consumables, telephony, courier drops
• Training new staff from start with no leaders
• Receiving records from practices- system challenges
• Summarising records by GP

27. www.england.nhs.uk
Changes to clinical management
• Visiting patients in hospital to speed discharge
• Visiting consultant appointments with patient
• Rationalising hospital appointments
• Providing responsive social care interventions and
support
• Providing joint assessments with therapists and
managing clinical risk

28. www.england.nhs.uk

29. www.england.nhs.uk
Cultivating a team with different dynamics and
culture
Clear shared vision, goals and ethos
Flat structure
Learning and development philosophy
Everyone counts, has a voice and is listened to
Quality improvement methodology
Regular team meetings
Comprehensive induction programme
Time to think and test
Joint assessments and care planning
Shared goal orientated care plans
Holistic patient focus

30. www.england.nhs.uk
Integrated Personal Care project
Joint venture with Age UK to provide care
navigators in practices

31. www.england.nhs.uk
Evaluation of pilot by Nuffield Trust using
Outcomes per £
Spent
PROMS

32. www.england.nhs.uk
Thank you
Any questions?

33. Data Quality
LTC Year of Care Commissioning Programme Early
Implementer Sites Workshop
14th May 2015
Dr Bruce Pollington

34. What is Data Quality?
Data is of high quality if, "they are fit for their
intended uses in operations, decision making,
and planning.” (J.M.Juran)

35. ISO 9000 - Quality Guidelines
•data quality can be defined as the degree to which
a set of characteristics of data fulfils requirement to
describe a situation. Characteristics are,
•completeness,
•validity,
•accuracy, - typos, missing spelling
•consistency, use of standards
•availability and timeliness.

36. Quality data requires planning
•the proliferation of data sources and exponential
growth in data volumes can make it difficult to
maintain high-quality data.
•To fully realize the benefits of big data,
organizations need to lay a strong foundation for
managing data quality.

37. Data Quality tools /processes
• Data profiling – understand the quality issues
• Data standardization – conform to quality rules
• Matching or Linking - use "fuzzy logic" to find duplicates
recognising that 'Bob' and 'Robert' may be the same
individual.
• Monitoring - keeping track of data quality. Software can
also auto-correct the variations based on pre-defined
business rules.
• Batch and Real time - Once the data is initially cleansed
(batch), put in place processes to keep it clean.

38. What is a Quality Management System?
•A quality management system (QMS) is a set of
policies, processes and procedures required for
planning and execution (production/ development/
service) of the core business.
•ISO 9001:2008 is an example of a Quality
Management System.

39. Uk Bodies Responsible for Quality Standards for
NHS and Social Care
• The Information Standards Board for Health and Social
Care (ISB) closed on 31 March 2014.
• Responsibility for information standards has transferred to
the Standardisation Committee for Care Information (SCCI).
• SCCI is responsible to NIB for the identification,
commissioning and successful implementation of
information standards, collections and extractions.
• New standards - Information Quality Assurance Programme
(Data Quality) replaced by Standards Consulting Group
(SCD) - consultancy service within Data Standards and
Products, part of the Technology Office.

40. Some YoC pertinent standards
• IQAP - Merging Trust Master Patient Indexes in Shared Instances - LSP
Requirements - Nov 2005.
• The UK edition of SNOMED CT, ISB 0034,
• READ v2 & v3 withdrawn by April 2020
• ISB 0021 International Classification of Diseases
• ISB 0090 Organisation Data Service
• ISB 0084 OPCS Classification of Interventions and Procedures
• ISB 0149 NHS Number
• ISB 1554 Data Transfer Service - secure application-to-application messaging
• ISB 1523 Anonymisation Standard for Publishing Health and Social Care Data
• ISB 0092 Commissioning Data Sets (CDS)
• ISB 1500-8 Common User Interface - Address Input and Display - Time
Display
• ISB 0070 Healthcare Resource Groups (HRG)

41. Costing Guidance
•HFMA - Acute Health Clinical Costing Standards
2015/16
•HFMA - Materiality and quality score (MAQS) template
- Acute (February 2015)
•Monitor - Approved costing guidance Updated
February 2015
•Currently intra–org focused cover Acutes and Mental
health only, but intention is for linkage across orgs in
future.

42. Personal Social Services Research Unit (PSSRU)
•Unit Costs of Health and Social Care
•Nationally-applicable unit costs for more than 100
health and social care services
•Can be used where other cost information is not
available - is the source of primary care costs

43. Principles of NHS costing Monitor
• Principle 1: Stakeholder engagement
• Effective costing requires input from a wide range of stakeholders, including
frontline clinical staff and departments providing clinical support services
such as pathology
• Principle 2: Consistency
• A consistent approach to costing is required across or within organisations
• Principle 3: Data accuracy
• Accurate costing relies on the quality and coverage of the underlying data
input
• Principle 4: Materiality
• Costing effort should be focused on material costs and activities
• Principle 5: Causality and objectivity
• Costing should be based on how resources are used during the patient
journey, to minimise its subjectivity

44. So what does this all mean for YoC EI
•What are our data quality issues?
•Common themes
•Data completeness
•Variation to interpretation of terminology
•Intra-organisational data consistency
•Inter-organisational data consistency
•Kent for example has 107 orgs data flowing will end up
with over 200
•Variation in costing methodologies
•No standard or guidance fully covers a whole place
capitated funding model

45. What can we achieve during life cycle of YoC EI
•What processes do we already have in place for DQ?
•What can be learn from each other
•Plan Do Study Act cycles
•Data Profiling – target areas for high impact
•Peer review/ critical friend for cross pollination of
good practice
•Is there a need to develop a ‘whole place capitated
funding quality standard & guidance’ informally for
YoC & parallel stream with SCCI / Monitor

46. The Kent Data Quality Programme
The initial work will include the following
• Frequency count and proportion of total records with missing
NHS number
• Bias assessment of to check for systematic/random bias,
Completeness/data stability:
• Frequency and proportion of variables by field including null
values
• Agreed data dictionary for each data set
• Assessment of critical variables TBA defined
• Periodic assessments of variance in frequency (especially for
critical variables) to check for data completeness and stability
over time
• Built in fatal/non-fatal error thresholds - TBA
• Assessment of the scale and scope multiple GP practice
registrations

61. 15/16 planning
Summary from EIS

62. Kent LTC Year of Care Programme:
Using whole population linked
datasets to develop higher value
models of care
Dr Abraham George KCC Public Health

63. EK- 38 GP practices pop – 352307(of 88 practices pop 752374)
Band B = 3549, Band C = 4993 Band D = 562
Band E = 22 – total 9129 (cumulative – 1 double count)
WK – 13 GP practices pop 141,504 (of 64 practices pop 533585)
Band B = 1097, Band C = 1702 Band D = 256
Band E = 10 – total 3065 (2 duplicates)
NK – DGS 33 practices pop 250999 (of 34 practices pop 253646)
Band B = 2304, Band C = 3401 Band D = 425
Band E = 20 – total 6150
Currently Kent totals are 18568 of 744,810
Key achievements
• Currency developed using RS and LTCs
• Linked Data for 18k people
• Linked and costed for 18k people

64. Will link at individual level from
April

65. QoF LTC 75+ incl Hypertension -1

66. QoF LTC s 75+ excl Hypertension -1

67. Multi-morbidity excl Hypertension

68. Top 20 x 3 LTCs – all age ex Hypertension

69. COPD –Top 20 other conditions

70. Variation between YoC and Non YoC Anon
April – Dec 2014
YOC Currency Total Cost Total YoC Patients at end Sep
Average Cost per patient
by Band
Average Cost of
Activity
No Activities per
patient
Not YoC £49,792,527.82 114679 £434.19 £178.87 2.43
B £2,035,833.58 1031 £1,974.62 £156.74 12.60
C £4,988,804.06 2193 £2,274.88 £172.66 13.18
D £2,151,609.96 795 £2,706.43 £164.41 16.46
E £399,402.89 112 £3,566.10 £134.07 26.60
Total YoC 9575650.49 4131 £2,318.00 £165.25 14.03
Overall Total 59368178.31 118810 £499.69 £176.53 2.83
Not YoC £89,888,222.62 187197 £480.18 £193.30 2.48
B £5,276,325.30 2291 £2,303.07 £179.57 12.83
C £8,583,289.03 3303 £2,598.63 £188.22 13.81
D £1,747,937.81 522 £3,348.54 £173.13 19.34
E £219,997.45 44 £4,999.94 £228.69 21.86
Total YoC 15827549.59 6160 £2,569.41 £183.95 13.97
Overall Total 105715772.20 193357 £546.74 £191.84 2.85

71. Av cost by provider & Av cost per record

72. Next steps – EK
• Develop detailed implementation plans in SKC to support ICO
• Develop detailed plan to support dashboard use with
Vanguard site – Estuary View Whitstable.
• Increase the number of GP practices flowing data to KMHIS
– need SKC and Thanet for ICO work
• GPs to give permission for their practice data to be reported –
– the list of consultations. This gives basic details on when the consultation was,
where it took place, who did it and the cost.
• Develop a Data Quality Improvement Plan across the system
starting with EK
• Agree evaluation framework for each initiative and build
dashboard.

73. Next steps WK
• Create letter template for GPs and brief
presentation to go to clinical cabinet.
• Links to CPMS work – Malti and Andrew
• Agree Evaluation and funds to support beyond
2015-16.

75. Year of Care – Southend on Sea
Working together for a healthy Southend
Steve Downing

76. Success so far;• Single Point of Referral (SPOR)
• Integrated Community Teams
• Successful section 251 application
• Shadow tariff developed Provider sign up
• Integrated Commissioning Team – NHS Southend CCG and Southend
Borough Council have formed a new Integrated Care Commissioning
Team, this joint venture sees the commissioning function of both
organisations coming together to be directly responsible for
commissioning across health and social care in Southend, supported by
clinical and social care leads and will be accountable to both the CCG
and Council.

77. Next Steps
• Care co-ordination is a key theme running through future
plans, specifically to improve services and patients experience
for those with LTC’s.
• Work with the providers and data teams to implement
processes to run shadow tariff.
• Task and finish groups established to progress review, redesign
and enable commissioning of truly integrated services
• Develop LTC pathway with emerging personalised health
budget project with care co-ordinators

78. How will we be doing this;
Link to pioneer & Better Care Fund (BCF)work streams;
• Community Recovery & Independence – Merge SPOR and social care
assess team.
• Review community MDTs’ reablement, step up/down beds.
• Facilitate prevention, escalation a& maintenance ( particularly for LTCs)
through care co-ordinators.
• Primary Care Hubs – Co-ordination of care, geographical areas, all ages
with a focus on LTCs.
• End of life – Early identification and increased access to appropriate
support and co-ordination. Enabling people to achieve their preferred
place of death.
• Develop risk sharing arrangements with both providers and social services

79. Leeds EIS update
Tricia Cable
Year of Care Lead

80. •Data analysis of ~320,000 people across Leeds
who have one or more LTC
•Business case development for agreed Leeds
West CCG pilot
•National EIS visit from Martin McShane and
Jacquie White
Progress to date

81. YearofCareEIS
projectteam
YearofCare
citywideproject
NHS Leeds North
CCG pilot
NHS Leeds South
and East CCG pilot
NHS Leeds West
CCG pilot
Whole
population
~320,000
patients
Shadow
monitoring
15/16
Identified
patient
cohorts
Leeds CCG
populations
Testing:
• Form of capitated budget
• Provider to provider relationships
• Evaluation of pilots
Track patients over 15/16 to:
• Understand what
happens to patients
• Service utilisation
• How much services cost
• Cross reference the
cohort costs with
contract costs
• Understand variation
from baseline data
• Refine currency
categories

82. Shadow monitoring (from 1April 2015 data):
• Whole population (320,000 patients)
• Each individual CCG
• Specific patient cohorts
Each CCG in Leeds will identify a different cohort and
develop their own pilot model
Shadow monitoring plans 15/16

83. Informatics/analysis
• Investigate links between multimorbidity/comorbidity
with age, frailty and cost
• Analysis by GP practice and Neighbourhood Team (NT)
Finance/capitated budget
• Define basis for calculating budget; whole population,
CCG population and CCG pilot population
• Understand inclusions/exclusions, activity and spend
• Agree estimated currency categories by number of LTC
15/16 headline plan

84. Pilot models
• Engagement with each CCG around their pilot model
• Agreement of each CCG pilot model
• Define and agree service delivery model for each pilot
model
Evaluation
• Social value - University of Leeds
• Economic
• NHS outcomes measures
• Patient agreed outcomes/benefits
15/16 headline plan

85. Any questions?

86. West Hampshire CCG – 2015/16
Year of Care: A key enabler
In progress;
Governance and leadership
Messages
Refresh data and shadowing
Data Quality Improvement
Supporting Integrated working;
Profiling and modelling – simul8
Cross referencing – ACG and 2%
Integrated care teams, MCPs etc
Outcomes framework and peer review
Proactive modelling – transformation fund
Care homes
Mental Health
Embedding frailty
Improving commissioning;
Commissioning models
Impact, levers and mechanisms for change
Outcomes