Market Positon Statement Secondary Care 2013-2014
North East Lincolnshire CCG
Market Position Statement - Secondary Care
DRAFT v1, 7th May 2013
1.1 Purpose of the document
This document provides details about the way in which the Clinical Commissioning Group (the CCG) will work with providers to secure the secondary care services that the people of North East Lincolnshire need over the next 3 years and beyond. It is written at a critical time with significant pressures being experienced alongside challenges to secure the best possible value for limited resources that will not grow in the foreseeable future.
1.2 Underpinning principles
This Market Position Statement focuses on Secondary Care. However, these services are not provided in isolation meaning that market development themes identified here are also reflected in an overarching Framework Market Position Statement that covers all the health and social care services that the CCG commissions.
The CCG seeks to encourage quality, consistency and innovation in all 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 generally 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, and 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.
2.1 Current commissioning: What do we spend on secondary care?
Secondary care services are those that respond to the needs of people when the generalist skills of the primary and community care sector are not sufficient to ensure effective assessment and treatment. The majority of these services are provided by acute sector, hospital based services – in the case of North East Lincolnshire it is North Lincolnshire and Goole NHS (NLAG) Trust that provides the bulk of these services these services from the Princess of Wales Hospital, as well as from various community locations.
North East Lincolnshire spent £102M with NLAG in 2012/13. Whilst the vast majority of the secondary care spend is incurred at the main hospital site there are significant elements of service that are community oriented or delivered, including:
• £2.1M on outreach services such as those for children’s services, cancer services, breast care, contraception and sexual health services and community diagnostics;
• £2.4M on community therapy services;
• £3.5M on community midwives; and
• £1.0M on wheelchair services, orthotics and equipment.
In addition to this the PCT contracted with St Hughs’s private hospital for £3.4M worth of activity and the Local Area Team of the National Commissioning Board secured £251k worth of Independent Sector Treatment Centre activity. Finally the PCT contracted for £9.4M of services in adjacent hospital Trusts (particularly Hull). To support these local services a further £6.2M was spent with East Midlands Ambulance Service (EMAS), of which £1.1M was on ‘blue light’ services.
The Local Area Team of the National Commissioning Board also has responsibility for £2.7M of tertiary other specialist services further afield. These services are not part of this current Market Position Statement for secondary care.
Whilst the money available for health care at today’s prices is set to remain constant in otherwise challenging financial circumstances there are significant cost pressures from inflation and rising demand that will not be met in the near future. This has meant that the CCG has set a challenging target for secondary care services to realise 4% cost savings each year between 2012 and 2015 with the need for similar savings anticipated through to 2020.
2.2 Strategic context and timescales for action
In March 2013 the two predecessors to the North East Lincolnshire and North Lincolnshire CCGs issued a consultation document entitled ‘Northern Lincolnshire Sustainable Services – Quality for all’. It was a joint document because of the two CCGs dependence on a single main secondary care provider, i.e. NLAG. The vision set out in this document is for greater support in the community and reduced demand for specialist care in hospital. However, where the specialist skills of secondary care are needed then this care should be of the highest quality, delivered in an integrated way with other providers and at an affordable price.
‘Sustainable services – quality for all’ provides the basis for a programme of change that will engage with NLAG as well as a range of other local providers including GPs, community-based providers, social enterprises and social care provides. Fundamental to this programme will be the setting of minimum standards based on national guidelines and good practice.
Key themes within this strategic consultation document include:
• Reviews of all secondary care services across North Lincolnshire to consider if they are better provided at one ‘Centre of Excellence’ in either Grimsby or Scunthorpe rather than two;
• Reviewing and addressing higher than average mortality rates;
• Integration across the primary, community and secondary care services.
2.3 Future needs and demand: demand for services
Two major underlying factors affect the demand for secondary care services, the changing local demographic and people’s lifestyles. Compared to the England average the percentage of people who are over the age of 75 in North East Lincolnshire is higher (approximately 9% compared to 8.2% in 2013) and the percentage of the total population who smoke regularly is higher (25.6% compared to 20.4%). Other lifestyle factors are also impacting on the number of people with long term conditions, for example those associated with obesity such as diabetes, which is expected to increase by 13% in North East Lincolnshire by 2030.
Frail older people are known to be vulnerable to episodes that can lead to a hospital admission. Recent research has identified the likely level of frailty within a local population based on a simple prevalence, as shown in Figure 1 below. This represents a 15% increase in the number of frail older people over 6 years at a time when the overall population is relatively stable.
We also know that the rate of admission to hospital for unscheduled emergency care increases with age. So, for example, in 2009 the rate of hospital admissions per 1,000 population was 115 for 65-74 years olds, 239 for 75 to 84 year olds and 378 for people over the age of 85. Translated into likely increases in acute admissions, were no other action taken to avert this increase, there would be rise of 12% in unscheduled hospital admissions amongst this older population. The cost of non-elective emergency admissions in General Medical specialities and Elderly Medicine, where the majority of patients are over the age of 65, already costs £14.6M or 59% of total emergency admissions.
Figure 1. Estimate for the frail older population in North East Lincolnshire
At the other end of the age spectrum the number of births and the proportion of the population who are young is falling. For example, the local birth rate is expected to fall by 7% between 2013 and 2021. This makes providing a safe and effective service in what will become smaller units across North Lincolnshire less likely to be sustainable.
3 Strategic direction
The overall vision for hospital based care in North East Lincolnshire reflects the strategic shift towards self-care and home and community based services as part of the shared vision with North Lincolnshire CCG linked to Healthy Lives, Healthy Futures
The commissioning vision for these services is that people will be admitted to hospital when necessary, and only when necessary. We know that now there are often inappropriate admissions to hospital which occur when community based services are not correctly configured to deal with people as they should.
We will seek to commission services in line with the vision outlined below
3.1 Future service model
The service model being developed for North East Lincolnshire is based on encouraging healthier lifestyles and greater capacity for self care supported by an accessible and equitable range of primary and community services. When hospital care is needed then this will be made available, following best practice guidelines, including treatment by appropriately qualified and experienced specialist followed by support to get people back to managing their own health as quickly and safely as possible.
3.2 Primary care
Getting the right level of secondary care services means starting in primary care. Specific objectives based on local intelligence include:
• Prevention: Improved and consistent levels of preventive care, for example primary care screening or flu vaccination rates both have the potential to reduce demand on secondary care services through timely intervention;
• Access to Primary Care: The coverage and accessibility of primary care also has an impact on the use of secondary care services. North East Lincolnshire has fewer GPs per head of population than the national average and below average weekend cover.
• The nature of Primary Care: North East Lincolnshire also has a higher proportion of small GP practices when it is know that people registered in practices with only one or two GPs have mortality rates 13% above those in larger practices.
3.3 The intermediate tier
The intermediate tier of services provides a safe and effective interface between primary and community services and the acute sector. The Care Trust Plus has already invested heavily in this service over recent years but needs to ensure that such services keep pace with demand and are fully integrated and supported by the wide range of community and voluntary sector provision.
3.4 Dementia and end of life care
People with dementia or at the end of life both have a significantly higher likelihood of admission to hospital than the general population. For dementia it is well attested that admission to hospital is up to twice as likely for any specific condition where the person also has dementia. At the end of life studies have shown an average cost of over £8,000 for inpatient care during someone’s last year of life . This equates to approximately three hospital admissions. In North East Lincolnshire there are approximately 2,100 people with dementia (which will rise to over 2,600 in 2020) and approximately 1,500 people who will be in their last year of life (which is not expected to increase in the near future).
Providing an integrated response for people with dementia or at the end of life that includes a strong primary and community element are therefore critical to ensuring a sustainable secondary care sector.
3.5 Mortality rates
Where the current configuration of secondary care services might contribute to higher than average mortality rates there will be a strong case for change. Factors include the availability of specialist medical and other professional support and the ability to provide equally high levels of service out of hours or at busy times. Concerns about higher than average mortality rates covers a wide range of services, including neonatal services.