QIPP Projects Update Newbury and District CCG April 2016

Transformation Team In 2015/16 the Transformation and Planning was brought back in house from the CSCU. Your Transformation Leads are: Joe Smart – Transformation Lead (Planned Care) 07799070840 joe.smart@nhs.net Ruth Horner – Transformation Lead (Long Term Conditions) 07799070840 ruth.horner3@nhs.net

Planned Care Projects 15/16 IPASS Arthritis Care

Long Term Conditions Projects 15/16 Care Homes Renal

QIPPs for 16/17 £17m QIPP requirement £0 implementation plans The QIPP identified in business cases: £8.2m

Roles and responsibilities All projects rely on Clinical Leads All projects require implementation plans Project Managers are there to support you

QIPP Projects Overview Description Role of Primary Care Investment £'000 NET Savings £'000 Gynaecology Review To reduce clinical variation through DXS, Rollout telephone follow ups and reduce F2F Follow Ups To support the full use of DXS for gynaecology referrals 71 Dermatology Pathway Increase the use of tele-Derm; Use DXS for dermatology referrals; Development of See and Treat clinics The expansion in the use of Tele-Derm, full utilisation of the new clinical referral guidelines through DXS 63 IPASS continuation To provide an integrated pain and spinal service; Assess and treat patients in the community with a range of strategies; Reduce the number of referrals to secondary care Continue to utilise the IPASS service which was set up in 2015 for patients normally referred directly to the pain and spinal service unless clinically contraindicated 515 111 Arthritis Care expansion* To provide an intervention for all hip and knee patients who would normally be referred direct to secondary care. Secondary care to reject hip and knee referrals which have not been to Arthritis Care. So patients have access to shared decision making, lifestyle redesign and dietary & exercise advice. To refer all hip and knee patients to the Arthritis Care Service prior to referral to Secondary Care. To clearly indicate on referrals the patients have been to Arthritis Care. 80 717 General MSK Reduce clinical variation in MSK treatment and Monitor the treatment of MSK in secondary care Further work with Arthritis Care To support the reduction in clinical variation in MSK treatment Use of the proformas in DXS TBD TBA

QIPP Projects Overview Description Role of Primary Care Investment £'000 Savings £'000 Gastro The project has 3 work streams which includes: Service Review; Reduce clinical variation through clinical proforma. The introduction of Telephone Follow ups; Review Meds Management for patients; To support the reduction in clinical variation in referrals to gastro through the use of the clinical proforma. Support the patients with self-management and meds education 58 Ophthalmology To reduce Minor Eye Conditions being treated in secondary care. To manage Ocular refinement within the Community Service to reduce false positives being referred to secondary Care Increase the use of Community Service to support the reduction in minor eye conditions being managed in secondary care. - 300 Telephone follow ups in elective clinics To work in conjunction with the providers to reduce the number of F2F follow ups and introduce telephone follow ups where possible for elective clinics To be aware of the change in the management of elective care follow ups TBD 230 Reducing Variation in Primary Care To reduce variation in referral activity to secondary care. Ensure referral data is regularly reviewed at practice level data on referrals and activity rates, review of the data at practice visits and the CCG Council of member practices 500 Diagnostics To reduce the high levels of variation in the requesting frequency and method for direct access radiology in West Berks CCG’s Utilisation of ICE better and any good practice 30 75

QIPP Projects Overview Description Role of Primary Care Investment £'000 Savings £'000 Safer, Faster, Better implementation To transform urgent and emergency care Details to follow once the work programmes have been defined 95 SCAS Falls & Frailty Service Working with the South Central Ambulance Service to deliver a Falls and Frailty Service, full mobilisation following the 1 year pilot   12.5 120 Resilience investments Admission avoidance, effective discharge, improved patient flow to support system resilience Investment was made in 2015/16 continued support in admissions avoidance and supporting effective discharge investment made in 2015/16 70 Respiratory Promote the early identification of COPD and asthma, self-management and intervention to improve the wellbeing of patients with respiratory disease. Reduce medical and prescribing costs, reduction in non-elective admissions and out-patient appointments To support the early detection and self management of patients with COPD and Asthma. To support the upskilling of primary and community care services to maximise the potential support is given to the patient population. 130 long term plan with savings not realised till 17/18 End of Life To support patients choices once the have been diagnosed as End of Life. Avoid unecessary admissions to hospitals if patients can be cared for in their homes and/or hospice. Support the patient choices for their End of Life care and support care in the patients homes or hospice if required 438 261

QIPP Projects Overview Description Role of Primary Care Investment £'000 Savings £'000 Care Homes To avoid unnecessary admissions for patients in care homes, reduce delayed discharge of patient to their care home and reduce length of stay for residents during acute illness and hospitalisation   1460 782 Neuro Implementation of headache care pathways and management guidelines; Support and better aid diagnosis and treatment using clinical decision tools; invest in supporting primary clinicians to manage chronic headache in the community Identify, define and improve pathways for patients with Epilepsy. To utilise the care pathways and the decision aids to support the management of patients with headaches. TBC Diabetes Increase patient education programmes to meet the level of need. Review the success of the HCP training programme and commission a new service for complex community patient to reduce non-elective repeat admissions 70 31 Obesity To provide a weight management service for the management of obesity To refer patients to the for weight management to follow a structured programme prior to referral to secondary care for bariatric services 464 162

QIPP Projects Overview Description Role of Primary Care Investment £'000 Savings £'000 Renal/CKD Project To review the care quality and referral pathways To utilise DXS for renal referrals TBC Fracture Liaison (Falls) Work with RBFT to provide a liaison for patients >75yrs with fragility fractures, to provide bone density scans for patients <75yrs with fragility hips. Reduce NEL admissions for fractures utilisation of NICE recommendations for the management of bone fragility Details to follow once the work programmes have been defined  TBC TBC  Leg Ulcer/tissue viability Pathway Pathway redesign to include all BW CCGs following the pilot in Newbury and District in 15/16, upskilling practice and district nurses TBD 95