How does NEL want to develop the local market?

 

North East Lincolnshire CCG
Market Position Statement – Framework Document 2013/14 to 2015/16


 

 

Contents:

1 Introduction
1.1 Purpose
1.2 Coverage of the document
1.3 Position
1.4 Our local population
1.5 Financial context – what services do we contract for?
1.6 Framework and definitions
1.7 Ownership and revisions

2 Wellbeing and prevention services

3 Primary care

3.1 What we currently commission
3.2 Future needs and demand analysis 
3.3 Strategic direction 

4 Community assessment

4.1 What we currently commission 
4.2 Future needs and demand analysis 
4.3 Strategic direction 

5 Community services 

5.1 What we currently commission 
5.2 Future needs and demand analysis 
5.3 Strategic direction 
5.4 What we are looking for from the market 

6 Intermediate services 

6.1 What we currently commission 
6.2 Future needs and demand analysis 
6.3 Strategic direction 
6.4 What we are looking for from the market 

7 Secondary care 

7.1 What we currently commission 
7.2 Future needs and demand analysis 
7.3 Strategic direction
7.4 What we are looking for from the market 

8 Mental Health & Learning Disability specialist services 

8.1 What we currently commission 
8.2 Future needs and demand analysis 
8.3 Strategic direction 
8.4 What we are looking for from the market 

9 Long term care

10 Tertiary services 

10.1 What we currently commission 
10.2 Future needs and demand analysis 
10.3 Strategic direction
10.4 What we are looking for from the market 

 

Appendices:

Appendix 1:  The Priorities Framework
Appendix 2:  Summary needs assessment for people with mental health needs ii
Appendix 3:  Summary needs assessment for people with a learning disability iii

1 Introduction

1.1 Purpose

The purpose of this document is to set out the way in which North East Lincolnshire Clinicial Commissioning Group (CCG) wishes to see the development of the local market of care provision to meet the needs of its population.  The CCG seeks to encourage quality, consistency and innovation in the services it secures for local residents.  This ensures the right balance between value for money and the best possible outcomes for people.  Care should be close to home wherever this is safe and appropriate, and should be supported by appropriate technology.

We also want to make sure that the relationships between the CCG and the organisations that provide services that we buy is healthy.  This is a corporate responsibility, but also needs to be reflected in behaviours at all levels of the CCG and our partner organisations.  Openness about the nature of our commitment to the services we currently buy, as well as being clear about what might make us review this commitment, is the basis of a trusting relationship.  However, we expect this openness to be reciprocated through the ongoing dialogue in which all partners commit to the principles outlined above.

 

1.2 Coverage of the document

This document provides an over-arching framework for the way in which the CCG will work with providers to secure the health and adult social care services that the people of North East Lincolnshire need over the next 3 years.  There are nine areas of service covered:

  1. Wellbeing and prevention services:  where we wish to facilitate increasing capacity and collaboration between providers of primary and community health services or adult social care with the independent and voluntary sectors as well as ensuring that statutory service provision gives an appropriate emphasis to prevention.
  2. Primary care:  which will continue to provide the ‘gateway’ into health services but which will play a larger part in future in supporting and collaborating with others to enable people with long term conditions to stay healthy and therefore out of hospital or long term care wherever appropriate.
  3. Community assessment services:  where the increasingly integrated first point of contact for social care and health service responses delivered by focus independent adult social work ( http://www.focusadultsocialwork.co.uk )  will play a pivotal role in reshaping services.
  4. Community services:  that are also increasingly integrated and work in partnership with independent and voluntary sector providers to support people when there is an assessed need, either for health and/or social care.
  5. Intermediate care services:  where investment in recent years has seen a robust and effective sector of care and support that optimises people’s recovery as well as responds at time of crisis.
  6. Secondary care services:  where ensuring that quality and positive outcomes for those who need to be admitted to hospital is continually improved whilst at the same time ensuring that those who do not need to be admitted are supported elsewhere.
  7. Mental health specialist services:  supporting people whose needs cannot be met in mainstream services but who still require increasing opportunities for independent living and recovery.
  8. Long term care:  where a quality and an appropriately sized market will continue to meet the needs of the frail elderly or vulnerable adult groups in an increasingly mixed economy of extra care or supported living alternatives.
  9. Tertiary services:  where we will work with our commissioning neighbours to ensure that specialist services are of high quality and represent best possible value whilst ensuring local delivery wherever possible.


These headlines are not exhaustive but provide an overview and structure for what follows.  This ‘Framework Document’ provides an overview of all nine areas whilst separate, more detailed documents, cover specific services whenever there is a need to provide more detail at a particular time of change.

This approach is designed to give providers the information they need to plan their businesses knowing when and in what way the CCG will look to review or develop the services that the people of North East Lincolnshire need.  At the time of producing this first Framework Document three areas of service have more detailed market position statements.  Namely:

  • Wellbeing and prevention services:  the CCG sees these as critical to the long term sustainability of the local health and social care market and has specific plans to stimulate this market.
  • Secondary care:  this is where most of the money we spend goes, and yet there is evidence that we can improve people’s health and spend less if there is greater collaboration between community and secondary health care providers, particularly in the management of long term conditions.
  • Long term care:  where the CCG will continue its strategy to encourage the development of alternatives to long term care where this provides for greater independence, for example in the development of extra care housing.

Of the remaining six service areas, each of these has either been the subject of recent redesign and market development, in which case the CCG's approach is to monitor implementation, quality and service outcomes, or they will be the subject of more detailed review at a specified point in the future.  These are summarised in this document with a timetable for review so that providers know when and in what way reviews will take place.

 

1.3 Position

The position in North East Lincolnshire is unique in providing an opportunity for health and adult social care expenditure to be commissioned by the same organisation.  This arrangement has already brought benefits, for example in aligning fee rates and quality requirements for people in long term care, irrespective of whether health or social care pays for this.  It has also enabled some services to become increasingly integrated, for example when people first contact us at a time of crisis or when there is a need for support when leaving hospital. 


Service providers should take note of this opportunity to provide integrated services across these two sectors and should work to maximise this opportunity.

The Clinical Commissioning Group in North East Lincolnshire has taken over the commissioning responsibilities of the former Care Trust Plus.  The relationship between the commissioning of social care and that for health care in illustrated in Figure 1 and shows:

  • A partnership between health, social care and the wider Council, including the public health function (through the working of the Health and Wellbeing Board) to further develop prevention and ‘staying healthy’ approaches at a neighbourhood level;
  • A single strategic commissioning responsibility for health and social care led by the CCG incorporating the full range of commissioning and contracting activities (where appropriate with the support of the Commissioning Support Group (CSG) which will operate across the Humber region) as well as market shaping and development;
  • The local delegation of micro-commissioning responsibilities to focus for people with social care needs including access, safeguarding and complex case management for the most needy within the local population.

This is entirely in line with the direction of travel already set, but will enable even greater integration and enhanced clinical leadership across the health and social care system. 

Figure 1          The commissioning partnership in North East Lincolnshire

 

1.4 Our local population

There is no doubt that pressure from an increasing number of older people is already a factor in strategic commissioning plans.  North East Lincolnshire is distinctive in this respect as it has a higher than average over 75 population as illustrated in Figure 2.

Figure 3 reflects this growing demographic pressure by showing that there will be an increase in the number of people over the age of 75 between 2011 and 2018 of c.15%, with a slightly higher increase in the number of people with dementia, which is another indicator of potential need.  However, it is also well attested that a large proportion of health and social care costs are incurred during the last months or year of life.  The index of expected deaths across North East Lincolnshire is also therefore reflected in Figure 2 and shows a lower increase of only about 5% over the same period. 

Whilst approximately two thirds of spend on adult social care services is for older people there are additional challenges in supporting people with a physical or learning disability or with mental health needs.  Socio-demographic factors as well as advances in medical treatment for the very young will play their part in future funding challenges.  The precise level and growth in overall need for adult social care within the population is therefore unclear, but is likely to be somewhere between the two figures quoted above of 5 to 15% between 2011 and 2018. 

 

Figure 2          Proportion of the population >75 years of age

 

 

Figure 3          Three alternative indices of need for older people in North East Lincolnshire

 

 

1.5 Financial context – what services do we contract for?

The North East Lincolnshire Clinical Commissioning Group has responsibility for securing all health services for people in North East Lincolnshire and adult social care spend for people over the age of 18.  Together this amounts to planned expenditure in 2013/14 of £281 million pounds.  A split of the estimated spend based on details of contracts in place in 2012/13 is shown in Figure 1 .  

Figure 4          NE Lincolnshire PCT & CTP summary of contractual arrangements in £'000's (2012/13)

 

Nearly £58M, or just over 20% of this money will now be purchased on behalf of the CCG by the NHS Commissioning Board.  This spend is primarily for Primary Care and for specialist or tertiary services.  In addition £5M, or approximately 1.7% of the spend indicated above is the responsibility of the Public Health function within the Local Authority. 

1.6 Framework and definitions

We have structured this document in such a way as to provide a ‘directory’ of the services we buy.  In doing this, and to ensure that current spend can be identified, we have necessarily structured the document in line with current budgetary and contractual commitments.  This should not, however, be taken to mean that this breakdown of services is the best for the future.  New ways of describing, organising and therefore funding services that cuts across traditional boundaries may be appropriate in a number of service areas.


Because of the reliance that people place on the services we commission we have described them in a number of different ways:

  1. Some services are ‘restricted’, i.e. we will always need to buy these services from a particular organisation.  This does not, however, mean that the most stringent quality, consistency and innovation will not be expected and that the amount of these services might not change.
  2. Some services are ‘protected’, i.e. only a certain number or type of organisations might ever be suitable to provide these services.  This might mean limited ‘competition’ for services.
  3. Some services are ‘open’, i.e. where a wide range of providers might be invited to tender.

There are also sometimes differences in how we expect to buy services, and whether it is intended that this should change in the future.  For example, will we pay for outcomes rather than inputs, and we are expecting to move away from ‘block’ contracts and pay for activity in future.  There will also be some areas where what we have commissioned in the past on behalf of groups of people will become the subject of individual budgets, where the market will be made up of a number of individual purchasers.


Finally, even when there is no intention to change what we buy in future there is a requirement to ensure we continue to get the best possible quality of care and support.  Where this quality falls below acceptable standards the CCG reserves the right to undertake a review and re-commission such services as necessary.


For each service we will set out the underlying needs assessment that tells us how much of something, both now and in the future, we might need to buy.  We will also identify the current spend and with whom this is spent, how long we are committed to this spend and the circumstances under which we might review this position. . There will be a clear commitment, in line with the restricted/protected/open categories identified above, as to when we expect to review what and from whom we buy services.


This clearly presents a complex set of arrangements, but one that we feel is nonetheless justified in the light of the wide range of services that we buy.  Each service provider will need to identify their current position, or future opportunity, in the context of this framework.

 

1.7 Ownership and revisions

The CCG will provide a detailed table of information covering all areas of contracted activity. In part, this will satisfy the requirements of Monitor but will also provide potential providers with a succinct briefing on when procurement exercises are likely to take place.

Below is an example of the table you will find under each "service area" button. For a complete list you can also click here

 

Name of Current Service                                                                                
Current provider  
Value of contract in 2013/14  
Contract currency  
Quantity (i.e. episodes/people etc.)  
Key quality or performance criteria  
Contract last reviewed  
Expected review date  
Nature and extent of expected review  
Interdependence with other services we buy  

 

 

 

 

 

 

 

 






2 Wellbeing and prevention services

Wellbeing and prevention services play a vital role in the overall strategy and market development approach.  Approximately £6.6M is already spent in this areas including a wide range of services contracted with the independent and voluntary sector. These include Carelink, St Andrews Hospice, Alzheimer’s Society, The Stroke Association, Red Cross and over 23 other contracts with voluntary groups previously supported by the PCT plus Universal Services amounting to just over £2.3M purchased by the CCG.  A more detailed Market Position Statement outlines the approach envisaged to these services.


The CCG will work to stimulate this market in line with the more detailed Market Position Statement to provide an increasingly effective first line of support at a local community and neighbourhood level.  The primary partners in this will be the independent and voluntary sector who will be supported to develop their capacity and capability.  This will be achieved through:

  1. Grant funding from the Local Authority to set up Priority 3 services with suitable guarantees of targeted spend.
  2. For these targeted prevention services the ability to charge a maximum of £10pw.
  3. The opportunity to raise funds through charitable and other fund raising activities and to manage costs through the use of volunteers where appropriate.

Alongside these wellbeing and prevention services the Local Authority contracts for c.£4.8M of services including Drugs & Alcohol services, Substance Misuse and Sexual Health services.  The CCG informs the commissioning of these services through its participation in the Health and Wellbeing Board.

 

3 Primary care

3.1 What we currently commission

The Local Area Team of the NHS Commissioning Board is responsible for spend on GP medical services and prescribing.  In 2012/13 this expenditure amounted to £27,517k and £26,708 respectively.  In addition, during 2012/13, the PCT funded 52 SIP contracts with a total value of £1,550k.

3.2 Future needs and demand analysis

The population of North East Lincolnshire is c.170,000, and is not expected to increase significantly in the next 3-5 years.  However, it has already been noted that the >75 population accounts for a larger proportion of the whole than in similar areas or the average for the whole of England.  With the number of people >75 also expected to rise significantly the demand on primary care services will continue to rise despite the overall static population size.

The ratio of GP headcount to population is used nationally as a comparator.  For the whole of England the figure is 1:1,692, i.e. there are 1,692 people per GP.  In the East Midlands as a whole the figure is 1:1,821 and in North East Lincolnshire (with 102 GPs) it is 1:1,686.  There are therefore more people per GP in North East Lincolnshire despite the higher levels of need.  In addition, table 1 identifies the age profile of GPs in North East Lincolnshire compared to the whole of the East Midlands.  It shows a significantly higher number of GPs who are over 55, which means that the proportion retiring in the near future will be greater than in East Midlands as a whole.

  <40 41-54 >55
North East Lincolnshire 25.0% 45.9% 29.1%
East Midlands 28.4% 53.2% 18.4%

Table 1:                     Age profile of GPs in NEL compared to East Midlands 

                                        

3.3 Strategic direction

3.3.1 Future services models

Our vision, mission, and values are reflected in our strategic plan on a page which provides an overview of our stated intentions, how we will achieve them and how we will manage our work to enable us to reach our goals.

The vision for North East Lincolnshire is for a health and social care economy that enables its citizens to care for themselves, delivers care at home or close to home, offers services which are accessible seven days a week, of the best quality available and are financially sustainable into the future.

Building on our proud track record of innovation and pioneering and our unique position as an integrated commissioner, we will utilise all of these opportunities and skills to deliver services which meet local needs and ensure a strong and thriving health and social care sector in North East Lincolnshire for generations to come.
There are some principles common to all CCGs in Yorkshire and Humberside, including North East Lincolnshire, which underpin the way services will be commissioned over the next 5 years:

  • Quality and safety must be the highest priority
  • There will be an increasing requirement for focus on prevention and self-care / independent living rather than reliance on hospital based care
  • A small number of hospital services, particularly specialised services, will be commissioned from centralised locations if necessary to improve outcomes
  • To deliver the right care, in the right place at the right time; for example reducing inappropriate admissions to inpatient beds in hospitals and care homes through better management of care in the community
  • Organisational barriers need to be broken down where needs are complex and patient care crosses numerous boundaries to improve co-ordination and reduce fragmentation of care
  • Providers will be expected to work within the financial constraints of each health community

Local services will go through a process of transformation over the next five years with the whole health and social care economy needing to deliver savings against increased growth.

Our local transformation programme, Healthy Lives, Healthy Futures, is aimed at developing and delivering clinical models and care pathways that will shift the emphasis to self-care and independence, with care in the home and community rather than hospitals or other care facilities.  In order to achieve this change, 24 hour, 7 day services will be required across the range of primary, secondary and social care services; and urgent/unplanned care services will be transformed to ensure that services are responsive to unplanned care needs, across a range of environments, so that patients are supported outside of traditional hospital settings.

Planned / elective care services will be streamlined to deliver service improvements and efficiencies whilst providing clinically safe and secure services. This will improve the quality of services, and as a result, patient experience. Efficiencies released as a result of streamlining can be used to further invest in redesign and improvement including through the Better Care Fund.

Healthy Lives, Healthy Futures

The strategic plan and delivery of the vision for North East Lincolnshire and North Lincolnshire units of planning revolves closely around our joint programme for transformational change, Healthy Lives, Healthy Futures.

The vision we have set out for the next five years in North East Lincolnshire, working with commissioning partners, local providers, stakeholders and local people is ambitious in its scope and enables local health and social care services to meet the needs of people in the area within the resources available.

A key element of this vision is to enable local people to manage their own health and wellbeing more effectively and to engage with their communities to deliver solutions based on self care and self responsibility.

Our vision can be described in the diagrams below which is drawn from our system wide transformation programme, Healthy Lives, Healthy Futures.

Our vision and direction of travel has been shared and developed with the local Health and Wellbeing Board as well as all the commissioner and provider stakeholders who comprise the Programme Board.

The Shared Vision – A Shift to the Left…


 

4 Community assessment and micro-commissioning


Within the Partnership Agreement between the Local Authority and the CCG c.£3.3M (2012/13 figure) is spent on the social work functions related to assessment and case management of adults who need care or support.  These functions also include the adult social care contribution to ‘A3’ (the integrated health and social care response to urgent need), complex care management, adult safeguarding services and continuing health care hub. 


These functions are carried out by focus independent adult social work, which become a free standing social enterprise on 1st September 2013 (focus).   The Council and the CCG have entered an agreement under Section 75 of the National Health Service Act 2006 (Section 75 Agreement).  This agreement requires focus to account to the CCG for its performance and overall budgetary control. 

Whilst the resource required to deliver social work functions amounts to c.£3.3M the resources at focus' disposal in securing the best value for money across a range of integrated health and social care services responses makes its work critical to the longer term sustainability of the local health and care system.

5 Community services

5.1 What we currently commission

Community services (c.£38.9M):  Care Plus is contracted to provide a range of integrated community health services.  A key component of this spend is accounted for with the provision of an integrated intermediate tier of services.  The value of the Care Plus contracts accounts for nearly three quarters of the community spend with the remainder being made up of domiciliary and day care, direct payments and supported living.

Covering:

  1. District Nursing
  2. Health Visiting
  3. School nursing
  4. Specialist nursing
  5. Palliative care nursing
  6. Continence nursing
  7. Community Learning Disability Services
  8. Community Physical Disability Services
  9. Community older people’s services
  10. Services for people with mild to moderate mental health needs
  11. Home care
  12. Social care transport services
  13. Community meals
  14. Housing with support
  15. Telecare and telehealth
  16. Carers support
  17. Involvement and engagement
     

6 Intermediate Tier services

The purpose of this document is to outline the status and future direction of NEL Intermediate Tier Services

Intermediate Tier services are concerned with reablement - most often as a “half-way home” service on hospital discharge, recovery as a step down from hospital and urgent community response with hospital avoidance potential by means of swift interventions at home or using a short term step-up bed.

Services are currently arranged as follows:-

  • Intermediate Care ( Reablement/ rehabilitation )
  •       IC@Home
  •       The Beacon
  •       Diana Princess of Wales Hospital based ICF beds
  • Recovery & recuperation bed based service
  • Step-up bed based service ( Part of Rapid response pathway )
  • Rapid Response including nurse triage ( linked to NEL Single Point of Access ) 
  • HOME Team ( Hospital based liaison )


Financial Context

The CCG Commissions Intermediate Tier services through the contract with Care Plus group, our main Community Services provider.

The Integrated Intermediate Tier service is joint funded through contributions from both Health and Adult Social Care, totalling £8m in 13/14. The funding includes contributions via the Re-enablement and Better Care Fund along with core funding.

Underpinning Principles

National Guidance and best practice for Intermediate Care is a relatively modern concept with policy guidance and funding arrangements emerging and developing in the last 10 to 15 years. The implementation of Intermediate Care services nationally is inconsistent and varied as demonstrated by the recently established (voluntary) national audit regime ( NAIC ) though there is clearly a significant drive to provide the services and outcomes as described by the guidance.

Under the CCGs predecessor, NEL CTP, with the unique arrangements on integration and funding between Health and Social Care, Intermediate Tier (including intermediate care) services have been a  fundamental strategic feature of the design of the local health and care system.
 

CCG Responsibiities

The CCG is responsible for commissioning high quality, cost effective  services for the population of NEL and will continue to develop intermediate tier services to minimize the dependency on long term care and hospital services through a variety of intermediate service mechanisms

Current supply

The Care Plus Group are the lead provider commissioned to deliver Intermediate Care Service in NEL.  The lead provider has entered into an integrated partnership arrangement with NLaG for the delivery of therapy services that includes AHP services for Intermediate Care. There are currently a variety of arrangements for the supply of Intermediate Tier bed facilities with Care Plus Group's own facilities, their own contracted supply from community nursing homes and the CCG's direct arrangements with community facilities and NLaG. CPG also work with focus on integrated call handling arrangements through the NEL Single Point of Access (SPA).

Future demands and needs

Demand for intermediate tier services is predicted to increase both through demographic factors and in that step-up, rapid response and hospital avoidance services have a clear role in the transformation of care services and any shift from hospital to community based care. Further, the opportunity to expand the scope and improve outcomes for re-enablement and rehabilitation should be constantly examined.


Strategic direction

Develop further the seamless, integrated nature of Intermediate Tier service delivery as part of the wider NEL integration approach.

Ensure that capacity meets projected demand.

Ensure performance is optimized in terms of individual outcomes and to minimize DToCs associated with access to intermediate care services.

Develop step-up/hospital avoidance, further shifting to care at/nearer home where hospital specialist care is not appropriate.

To focus on rehab/reablement outcomes to reduce long term care and potentially increase rehab/reablement capacity based revised models.
 

Commissioning principles and aims, including timings for any significant developments in commissioning

The commissioning principles with respect to intermediate care are to ensure that services are delivered in the most appropriate setting, are outcome focused, are high quality, cost effective and patient centered.
In line with the strategic direction and in conjunction with the developing provider network 2014 will need to include the establishment of enhanced hospital avoidance step/up services.

Provider implications – how the CCG expects the market to respond

In the context of the NEL approach to integration, the Healthy Lives, Healthy Futures program and the 7 day working pilot, providers are expected to work together and with the CCG to contribute to the development on improved,  integrated, value for money Intermediate Tier services.

Quality and performance monitoring

Contract KPI and provider performance data reporting covers a significant dataset on activity and outcomes across the range of services.

7 Secondary care

 Acute service (c.£124m): a separate Market Position Statement is being developed for acute services in line with the North Lincolnshire ‘Sustainable Services’ Programme.  The major part of the acute spend is with NLaG but significant sums are also spend on ambulance services, other local acute services and further afield on specialist services.  A relatively small but important part of this spend, particularly on tertiary or specialist services, is the responsibility of the NHS Commissioning Board.

The ‘Sustainable Services’ strategy is a joint strategy across Northern Lincolnshire covering three hospital sites (Princess Diana of Wales, Scunthorpe and Goole).  It is also engaging with GPs community services, social enterprises and social care providers to achieve high quality care in centres of excellence, to reduce mortality rates and to achieve a rebalancing of care across the local area and between hospital and community services. 

 

8 Mental Health & Learning Disability specialist services

8.1 What we currently commission

Mental Health and Learning Disability services (c.22.5M):  Whilst significant contributions are provided to supporting people with mental health needs or learning disability by the independent and voluntary sector this element of spend for specialist support is predominantly contracted from Navigo.  Both the former PCT and CTP contracted with Navigo, which helps to ensure an integrated service solution.

North East Lincolnshire (CCG) wishes to develop a diverse market for care and wellbeing offering real choice for people with mental health. difficulties To achieve this vision North East Lincolnshire CCG recognise that we need to know how best we can influence, help and support the local market to achieve better outcomes and value for people. This Market Position Statement is an  important part of that process, initiating a new dialogue and relationship with our providers in our area, in which we will

  • meet the Government’s requirements as set out in the Care Act 2014 and the financial challenge facing the health and social care system.
  • The CCG is committed to providing choice and control to people and to working with providers to ensure we are transparent about the way we intend to strategically commission and influence services in the future in order to meet the personalisation agenda for both health and social care.
  • Financial context : currently our actual spend on mental health services within North East Lincolnshire 

Current Supply

One in four people in the UK will suffer a mental health problem in the course of a year. The cost of mental health problems to the economy in England have recently been estimated at £105 billion, and treatment costs are expected to double in the next 20 years. Mental health is high on the government's agenda, with a strategy, 'No Health without Mental Health', published by the Department of Health in 2011. The strategy takes a cross-government approach, with a focus on outcomes for people with a mental illness

Future

There is a wide range of social, economic and environmental factors that influence the health and wellbeing of individuals and populations, and these factors can be used to provide an indication of the potential for mental illness and related conditions.
In North East Lincolnshire we expect demand for mental health services to be influenced by:
• An ageing population
• Social deprivation
• Unemployment

NEPHO publish comprehensive mental health profiles NEL 2013 profile.  Highlighted the Percentage of adults with depression, 2011/12 = significantly better than England average
• Directly standardized rate for hospital admissions for mental health, 2009/10 to 2011/12 = significantly worse than England average L
• Directly standardised rate for hospital admissions for unipolar depressive disorders, 2009/10 to 2011/12 = significantly worse than England average L
• Directly standardised rate for hospital admissions for Alzheimer’s and other related dementia, 2009/10 to 2011/12 = significantly worse than England average L
• Directly standardised rate for hospital admissions for schizophrenia. Schizotypal and delusional disorders, 2009/10 to 2011/12 = significantly worse than England average L
• People with mental illness or disability in settled accommodation, 2011/12 = significantly better than England average J
• Directly standardised rate for emergency hospital admissions for self-harm, 2011/12 = significantly worse than England average L
• Indirectly standardised mortality rate for suicide and undetermined injury, 2010/11 = No significant difference compared with England average

Strategic direction

Understanding how the market in mental health works is critical - both for the development of future government policy, and for the implementation of existing policy relating to competition and choice. Ensuring we as a CCGs have a clear understanding of the way in which the market currently operates in the mental health sector will be central to developing effective commissioning arrangements and examining how a more level playing field for providers might be achieved.
Our view of the current state of supply
Overall, the evidence suggests that the mental health market in North East Lincolnshire is dominated by statutory NHS provision now developed by a social enterprise.   Most focus and resource is on acute needs; those elements of the market concerned with the early identification of emerging problems and community-based support for those with ongoing problems are less well developed. 
Services can be categorised as follows;
• Services for people with common mental health problems 
• In-patient, crisis and home support 
• Community and acute mental health and memory service: services for people with dementia  
• Support in the community 
• Employment & training
There needs to be more choices given to people that require long term care, especially to focus on support and enablement as opposed to residential care.
Personalisation needs to be more actively promoted to people with mental health issues in order that they can have control over their recovery.

Commissioning principles and aims, including timings for any significant developments in commissioning

As part of the national direction all mental health,services are required to implement payment by results (PBR) for all mental health services from 2015.  This year will be a shadow year in which we will be monitoring all the activity with NAViGO and aligning pathways for people across the clusters.  The set-up entails assessing service users into one of 21 clusters; for example ‘(6) non-psychotic disorders of overvalued ideas’ or ‘(19) cognitive impairment or dementia (low need)’.
Within these a 1-4 scale indicates the seriousness of the condition, and clusters are pegged to various maximum review periods ranging from four weeks to annual. Each cluster is linked to a care package – under PBR this is what commissioner’s pay for, as opposed to the traditional ‘block contracts’ that are commonly used to fund care. The theory is that resources follow the patient. We are working with Navigo to ensure the pathways remain integrated by providing patients an enhancement of care which will keep integration at the heart of our mental health service.
Part of the CCG’s strategy as set out in Healthy Lives, Healthy Futures and the Adult Social Care Strategy is to better manage demand to ensure the right professional responds to situations at the right time. To help deliver this vision we are currently working with NAViGO to find ways of better integrating NAViGO into our single point of access arrangements. We believe there are huge benefits from having mental health workers (say) alongside community nurses, social workers and other care professionals. This is a commissioning intention for 2014/2015. This will support the development of one single access point for all in North East Lincolnshire, regardless of the need.

Provider implications – how the CCG expects the market to respond
 

Over the last 2 years we have being working with the providers whom we appointed on the framework to support them to develop services that are fit for purpose.  This has involved reviewing and remodeling residential care and undertaking a review of all people under the age of 65 currently in residential care and looking at moving people on to more supported living services.
The care market is now in a much better place to meet the demands of people requiring long term support with much more focus on enablement and independence.

We will be focusing on preventive and implementing the government’s policy on “no health without mental health“

Providers need to be in a position to offer people choice and control and look at ways of supporting personalisation in order for people to have a market in which they can purchase person-centred care.

Quality and performance monitoring

Current performance against other mental health providers
The two measures within the CCGs performance framework that NAViGO either solely deliver or influence are set out below along with current performance and how we benchmark against other CCGs. There are no current issues relating to patients being followed up within 7 days of discharge from inpatient care. The concern is around the number of people receiving psychological therapies. The performance shown here only includes activity undertaken by the IAPT service provided by NAViGO. Some practices have in-house provision which isn’t included however the activity undertaken by these practices would see the CCG achieve its target. The CCG is currently reviewing the contract for the primary care provision to ensure that any in-house service meets the full IAPT requirements and therefore activity can be included. The alternative is that the practices currently not referring or referring low numbers in to the NAViGO service change the pathway for their patients and refer those that need IAPT support to NAViGO.
 



Tendering

Wherever possible tender procedures have and will continue to include services users and community members to guide the process and choice of provider to win the tender. The CCG will ensure that the Any Qualified Provider procurement model will aim to reduce barriers to entry for potential providers, and so improve patient choice and access, and deliver value for money.

9 Long term care


Long term care and continuing NHS healthcare (c.24.9M):  These two elements of spend have previously been commissioned by the PCT and CTP separately, although they should be seen as supporting overlapping needs and will in future be increasingly integrated.  The individual circumstances for each person with long term or continuing needs means that this commissioning activity involves working with a wide range of providers both locally and further afield.  A more detailed Market Position Statement outlines the approach envisaged to these services.

10 Tertiary services 

Northern Lincolnshire and Goole NHS Foundation Trust

Northern Lincolnshire and Goole NHS Foundation Trust (NLaG) provides acute secondary health care services to residents of North and North East Lincolnshire, East Riding of Yorkshire and East and West Lindsey, Lincolnshire and community services in North Lincolnshire. Networked services are provided in collaboration with HEY as the Trust’s main adult tertiary service provider, and the trust hosts pathology services for Northern and Greater Lincolnshire (there is currently a review of Pathology Services across the Midlands).  NLaG employs approximately 6000 staff, with an annual turnover of £310m.
 

Additional tertiary or specialist services to North East Lincolnshire

Sheffield Children’s NHS Foundation Trust provides specialist children’s services.   Outpatient clinics are undertaken by Sheffield Consultants in DIANA, PRINCESS OF WALES HOSPITAL and Scunthorpe General Hospital for paediatric surgical and medical specialties.  All specialist children’s surgery, surgery for children under the age of 2 and children’s cancer services are provided by Sheffield Children’s NHS Foundation Trust.  Neonatal care for babies lof ess than 27 weeks gestation is also provided by Sheffield with plans in place to increase the gestational age for transfer to 28 weeks.   Transfers are undertaken by EMBRACE (a specialist paediatric transport service).
Leeds Cancer Centre delivers a comprehensive range of treatments, for Leeds, Yorkshire and the North of England.

 

Appendix 1:  The Priorities Framework

 

Needs

The ‘market’

Social care

Health care

Social care

Health care


People needing care support as a result of presenting a high degree of risk and vulnerability, facilitated through ongoing case management provided by professional social workers.

People needing diagnosis and/or treatment as a result of presenting health needs that, in addition, require ongoing review by clinicians as part of an MDT approach.

Services provided by a range of providers in line with personalisation and choice, likely to be of an intensive nature requiring input from trained professionals working in partnership with complex case managers and primary/secondary healthcare staff. 

Provision of high quality, specialist healthcare intervention in secondary or tertiary care to address acute, long term or life-limiting illness.  


People with the capacity to re-gain, maintain or improve their level of independence through a programme of time limited re-enablement or intermediate care who are not, or are no longer, requiring hospital care.  [Note that no social care charging applies to services in this category and there are no plans for individual budgets to apply so current block purchase arrangements by the CCG will continue.]

Delivered by qualified health and social care practitioners working in people’s own homes or in a residential setting dependant on the situation.

Intermediate care services will include GP provision in primary care, with an increased focus on dealing with appropriate urgent care and providing community based diagnostic services.  Community based services such as district nursing; health visiting and community midwifery will also contribute.


People who, without some time limited or ongoing support would be placed at a heightened risk of progressing to higher levels of need in the medium term, or who experience repeated episodes of crisis.

People with a recognised or diagnosed long term condition but without the need for ongoing MDT case management except in crisis for whom the risk of progressing to higher levels of need is recognised.

Services for this group of people would typically be delivered by the voluntary and community sector within the local community.

A range of services targeted specifically at health conditions with known trajectories or risks can be developed to minimise the risk of an escalation of need.  Voluntary and community sector providers with access to the right professional skills are well placed to provide this support.


People who would benefit from advice and changes in lifestyle to reduce the longer term risk of them progressing to require higher levels of support. 

People whose current lifestyle choices place them at higher risk of long term health problems such as smoking.

Services would be delivered through a wide range of community, voluntary and public health services within their local community.

Public health service provision such as smoking cessation, healthy eating or sexual health services alongside other voluntary and community sector services aimed at improving healthy lifestyles such as exercise classes.


Those not included in the priority groups above do nonetheless benefit from ‘Universal’ services that make health and wellbeing more attainable and sustained over greater lengths of time.  In addition, people who are otherwise fit and healthy require access to mainstream health services in the event of physical injury or similar short term non-condition specific events.

The wider Council, with other partners, has the responsibility to ensure a safe environment for people to thrive individually and in their communities.

Community hubs supported by Primary care provides the natural point of contact for people into services to meet these needs as well as widely available health and care information and advice alongside other health campaigns.

 

Appendix 2:  Summary needs assessment for people with mental health needs

It is estimated that there are just over 3,000 people who are likely to be affected by severe mental disorders requiring high levels of support from secondary mental health services.  A further 500 are affected predominantly be substance misuse and may require high levels of support from substance abuse services and in some cases mental health services.  Approximately 8,930 people may benefit from GP prescribing and/or psychological therapies for mental health problems , although a proportion of this group may need additional intervention. Some 11,600 may benefit from lower level preventive initiatives.


Common Mental Health Disorders include generalised anxiety disorder, mixed anxiety and depressive disorder, depressive episode, phobias, obsessive compulsive disorder and panic disorder.  An estimated 17,100 adults aged 16-64 living in private households in NEL in 2009 had a common mental disorder. This represents 16.8% of adults in this age group, slightly below the 17.6% in the region and 17.4% nationally.  The proportion of people with common mental disorders is projected to increase only slightly in NEL to 2029, compared with a large 11% increase across the region, and 7% across England.   Based on the 2007 Psychiatric Morbidity Study, some groups are at significantly higher risk of CMD, including women, women aged 45-54 (with 25% meeting the criteria for at least one CMD), men aged 25-54, divorced people, and those with low incomes (after adjusting for age, men in the lowest household income group were three times more likely to have a CMD than those in the highest income households).


The main types of psychotic disorders are schizophrenia and affective psychosis such as bipolar disorders and manic depression. In 2009, 460 adults aged 16-64 living in private households in NEL are estimated to have a psychotic disorder. This represents 0.5% of adults in this age group, the same as seen across the region and nationally.  The proportion of people with psychosis is projected to increase slightly (by 0.9%) in NEL between 2009 and 2029, compared with 7% across England. The biggest increases are expected in the older 55-64 age groups.


Dementia can occur amongst people from ‘middle age’ although prevalence is very low, being below 1% until the age of 65 (although for people with a Learning Disability onset can be earlier).  This makes dementia a condition associated with old age and therefore often developing alongside other long term conditions or increasing frailty.  Overall dementia prevalence in NEL is c.2,000, growing to just over 2,500 by 2020.  Only about 39% of people with dementia had a diagnosis recorded by their GP in 2010, although this is now rising.  This level of diagnosis was below the regional average of 43% but identical to the England average.

Appendix 3:  Summary needs assessment for people with a learning disability


In NEL in 2009 there were an estimated 3,200 people with a learning disability (LD) of which there were an estimated 48 with profound and multiple PM(LD) and 407 with severe (S)LD.  In 2011, 759 people with a learning disability were registered with a GP practice and 530 were recorded by NEL Council suggesting that between 25 and 30% of the overall prevalence is identified as having a learning disability in health and social care systems – the majority of these being people with a profound and multiple or severe learning disability (it is assumed that there is significant overlap between those registered with a GP and those known to social services).


Overall, numbers are projected to rise by around 2.6% by 2019; this is well below projected increases across England (9%) and the region (13%).  The largest increase is estimated to be in the (PM)LD group, with a projected growth of 36% to 2029, due to expected future improvements in infant mortality and life expectancy for those with PM(LD) and also in the population of older people with a learning disability (people with a learning disability known to services and over the age of 65 in 2009 was 40 but this is expected to rise to over 60 by 2019).  The general population aged 14 – 17 years is expected to reduce, translating to reduced numbers in this transitions group.


More than 80% of learning disability respondents, to a local survey in 2009 of people with disability known to services, reported that their health was excellent, very good or good. 59% indicated they had feelings of depression always, often or sometimes and 72% said they were anxious always, often or sometimes.


The health needs and service response for people with a learning disability has been identified (the Learning Disability Annual Self Assessment Framework 2011 reported the following in respect to access to healthcare as at January 2011) as:

  • 62.4% of people with LD registered with a NEL general practice had been offered a comprehensive health check in the last 2 years and 60.2% had received a check;
  • 28 people with Down’s Syndrome were seen in the multidisciplinary LD health assessment clinic during the past year, of whom 12 were found to have a previously undiagnosed health problemsand referred to their GP.
  • There were 40 admissions for people with LD into hospital during 2010 and Health and Wellbeing Coordinators visited the hospital 81 times to support the individual, carers and hospital staff.
  • 11 women with LD have received breast screening in the last two years and 48 have received cervical screening. 9 adults have received bowel screening in the last 2 years.
  • 124 people with learning disability known to services and with a BMI >30 (i.e. obese) had been offered dietary advice;
  • Of the 15 people with LD and with heart disease, 14 had received a review in the past 15 months;
  • Of the 45 with diabetes, 41 have had a review within the last 15 months;
  • There were 63 people with LD with asthma known to services;
  • Of the 99 with dysphasia, all had been screened and had care plans in place, 124 people with LD had epilepsy;
  • 21 young people with LD had been screened for Chlamydia.