To consider a presentation on the Primary Care Trust’s Local Delivery Plan.

The Committee received a presentation on the Primary Care Trust’s Local Delivery Plan 2008/09

 

Mr Paul Edwards, the Primary Care Trust’s (PCT’s) Director of Commissioning and Strategy gave the presentation setting out the context within which the Local Delivery Plan (LDP) was being prepared and the Plan’s content. 

 

Copies of the latest version of the LDP were available at the meeting.  The Chairman proposed that these should be circulated to Members after the meeting and Members invited to provide any further comments to her for submission to the Primary Care Trust (PCT).

 

Mr Edwards noted that the PCT was normally required to produce a three year commissioning strategy/LDP.  However, this year the Department of Health required a one year LDP for 2008/09 pending the report of the review of  the National Health Service it had commissioned from Lord Darzi which was due to be published in the Summer of 2008.  This had affected the NHS allocations with only one year’s allocation therefore proposed for 2008/09 until the outcome of the review was known.

 

The presentation covered the following points:

 

·         The local vision - “ Our vision is one of developing timely, high quality Health & Care Services, which are needs led, user/patient focused and delivered as close to home as possible”.

 

·         The local priority -    “To redesign care pathways and service models to improve quality of care, value for money and to free up resources to invest in Primary Care.”

 

·         Turning the Vision into reality through assessing health need, understanding population expectation, deciding priorities, designing services, purchasing services from providers (including market development & management), managing demand and monitoring performance (including quality, finance & productivity).

 

·         Impacts on the health service included rising public expectations about health treatment, rising expectations about access to services, Increased expectation of engagement with health services about minor illnesses, increasing emergency admissions to hospital and increased numbers of elderly people – with resultant demand.

 

·         The following changes were highlighted: medical and pharmaceutical advances which are high cost, increased numbers of children with complex needs as premature birth survival rates improve, the impact of the European Working Time Directive for example on hours worked by junior doctors, changed Royal College standards so that care must increasingly be located in specialist units and a drive to develop shared care with GPs and more outreach from hospitals to the community.

 

·         The PCT’s aspirations were to improve health and address inequalities, achieve value for money, ensure choice & involvement, improve patient experience and achieve the principles of World Class Commissioning.

 

·         It was intended to do this through basing all services on sound needs analysis, easier access to services, more health services in community settings, improving preventative strategies, improving health outcomes, having an appropriate and well trained workforce, joined up commissioning capability, developing robust performance management and doing all this in partnership wherever possible & appropriate.

 

·         Key targets for 2007/08 had been achieving 18 weeks from GP referral to start of treatment, reducing rates of MRSA & other healthcare associated infections, reducing health inequalities & promoting health & well being, achieving financial health, reducing emergency & urgent care, action on current national standards in the National Standards Framework. 

 

·         A chart showing the allocation of the PCT budget for 2007/08 noting the top slicing by the Strategic Health Authority of £2.1 million, the requirement to deliver a surplus (£675,000 achieved in 2007/08) and to maintain a contingency sum (£2.1 million in 2007/08)

 

·         Investment 2008/09 - after the application of inflationary uplifts the PCT currently had a net sum of around £6.5m available for investment in 2008/9.  The targeting of resources would in part  be informed by Programme Budgeting reviews this year reviewing - Cancer, Respiratory Systems and Mental Health.

 

·         Key areas for investment in 2008/09 were Maternity and Newborn - £66K, Children’s Health - £430K, Planned Care - £1,462K, Mental Health - £554K, Staying Healthy - £252K, Long Term Conditions - £30K, Acute Care - £2,906K, End of Life - £289K, IM&T - £100K, Ambulance Services - £200K, and PCT community services - £200K

 

·         Some specific 2008/9 disinvestment examples were: Hip and knee surgery will not be available to anyone with a body mass index >40, a reduction in the number of ophthalmology follow-ups undertaken, interventions in line with revised NICE guidance, a reduction in breast reconstructions/enhancements (for cosmetic purposes) in line with revised guidance, unbundling services from acute settings, and modernising care for asthma patients and others with long term conditions to reduce 1,000 outpatient follow-ups.

 

·         The following challenges were identified: delivery of the eighteen week referral to treatment target, continued implementation of care pathway redesign work across key conditions/specialties, expansion of the range of Intermediate Care Services, redesign of the hospital discharge pathway linking to the Continuing Care agenda and associated cost pressures, high cost drugs like Lucentis for age related macular degeneration, NICE cost pressures – new technology & drugs, slippage in demand management initiatives, and the impact of the national Lord Darzi review, as yet unknown but likely to impact more in 2009/10.

 

·         In terms of consultation on the Plan, the draft document was informed by other service specific plans, clinicians, services users and carers.  Prior to completing the draft plan in December, four public consultation events had taken place across the County.  In June 2008 the PCT would hold further public/stakeholder consultation, when the final Darzi report was published.  The one year plan would be subject to review and approval by the PCT Board in April 2008.

 

In the ensuing discussion the following principal points were made:

 

·         It was asked whether the proposed investment in a walk in medical centre in the County in 2009 was in response to an assessment that there was a need for such a facility in Herefordshire or to a Department of Health Initiative.  Mr Edwards said that the proposal was in response to a national initiative.  This was driven by the position in the larger cities where the quality of primary care provision was markedly inferior to that which Herefordshire enjoyed.  However, national surveys, which also separated out local findings, did show that patients wanted to be able to see the GP of their choice at a time convenient to them.  The challenge was to develop a facility that met Herefordshire’s needs.  In response to concern that the facility might be underused and the investment better directed elsewhere he said that the likelihood was that the facility would be in Hereford City.  A number of GP practices in the City had outgrown their present facilities and there was the opportunity to discuss the development of a new purpose built facility that would accommodate them, providing a new service rather than potentially introducing a new provider.  There was scope to integrate any such new development with the negotiation of a new contract for out of hours services consequent upon the expiry of the current contract in April 2009.  Members welcomed the intention to develop a local solution.

 

·         The difficulties caused by the plethora of contact points faced by patients seeking treatment and their carers were raised.  Mr Edwards reassured the Committee that work was continuing, with the Council’s Social Care Services amongst others, to reduce the number of contact points.  Asked further about the need for improvements to joined up working arrangements, including communication he said that in the majority of cases patients should have a named worker to co-ordinate care.  Health and Social Care were working to deliver services that were best for the patient.   He believed there was awareness of where gaps remained and improvements were being made.  He reiterated that the PCT welcomed any problems being brought to its attention so that lessons could be learned and improvements made.

 

·         It was stated that some patients were still being discharged from hospital without adequate facilities being in place in their homes and without appropriate intermediate care being available.  It was suggested that improved joined up working with homecare services was needed and that there should be careful monitoring of patients to ensure that they were coping with living at home.  Mr Edwards said that readmissions to hospital were routinely monitored and the trend was for a reduction in readmissions.  The PCT was mindful of the importance of intermediate care support being in place and joined up working.  It also had processes in place to investigate any cases where difficulties were experienced to find the causes, learn from the mistakes and seek to prevent similar incidents occurring again. 

 

      Mr Martin Woodford, Chief Executive of Hereford Hospitals NHS Trust, explained that a weekly schedule was produced listing those who no longer needed acute care and were awaiting discharge from hospital and he described the monitoring arrangements in place.  Mr Edwards added that there were a range of reasons why discharges may be delayed but reminded the Committee of the financial incentive to the PCT to ensure patients left hospital as soon as possible, the desire of the Hospital to discharge patients and the wishes of patients to be discharged.

 

      Following further discussion of the investment in intermediate care it was proposed that a detailed report on this aspect should be made to the next scheduled meeting. 

 

·         The proposed investment in end of life care to allow people to die at home if they wished was discussed.  It was noted that this would involve a range of services and data would not necessarily have historically been collected to inform an assessment of need.  Mr Edwards acknowledged that whilst some data had been produced by the Department of Health, the baseline data was still being determined and it was difficult to be precise.  The PCT had formed a strategy group to work on this subject and he commented briefly on the breadth of its membership.  However, the overriding point was the need to meet the wish of the majority of patients to be able to die with dignity at home.  Members supported the objective whilst recognising the challenges involved.

 

·         A question was asked about the level of additional investment proposed in Information Management and Technology in the LDP and the extent to which work in this area was being linked to that of partners, in particular the Council.  Mr Edwards outlined the PCT’s approach and confirmed that opportunities for joint working between the PCT and the Council were being explored by the joint Chief Executive, looking also at links with the Hospitals Trust.  The intention was to develop a shared information base and an information sharing protocol had been developed. 

 

·         The Director of Adult and Community Services added that Cabinet had now approved the acquisition of a new software package to replace outdated client systems.  Linkages with health partners would be considered as part of this process.

 

·         In response to a question about information security Mr Martin Woodford, Chief Executive of the Hospitals Trust said that he considered appropriate action in line with national guidelines had been taken to minimise risk.

 

·         A question was asked about the PCT’s plans for the future of Community Hospitals.  Mr Edwards said that they were an integral part of provision and it would be self-defeating not to make use of this resource.  The PCT was increasing investment in them and supporting the provision of clinical services locally. 

 

·         Mr Woodford noted that there were 230 beds in Hereford Hospital and 128 beds in the Community Hospitals.  The beds in the Community Hospitals were therefore clearly needed to provide care.  Recognising patients liked to access services locally rather than in Hereford, clinics were being provided at the Community Hospitals where this could be done effectively.

 

RESOLVED:

 

That  (a)    the key areas for investment proposed in the Local Delivery Plan 2008/09 be supported, welcoming especially the increase in patient focus from assessment to treatment;

 

(b)         the development of the end of life strategy be supported;

 

         (c)     any further comments from Members on the Local Delivery Plan 2008/09 be referred to the Chairman within a fortnight for submission to the PCT Board;

 

         (d)    a report be made to the Committee on Intermediate Care Services; and

 

         (e)    a report be made to the Committee on proposals for rolling forward the Local Delivery Plan beyond 2008/09 as prepared for consultation following the publication of the Darzi review.