1. Panel Report East Sussex Downs and Weald PCT 05 December 2008

2. Adding life to years and years to life 2 2 Overview First, the panel thanks East Sussex, Downs and Weald PCT for participating in this round of assessments for World Class Commissioning. The panel asks the PCT to accept this report in the spirit in which it is intended: a support tool on the journey to world class commissioning as a considered perception of the organisation’s strengths and weaknesses based on the insight the PCT itself gave the panel into its commissioning approach. During our investigation of East Sussex, Downs and Weald PCT, the panel developed an overall impression of the organisation, which is that the PCT is self aware and has a mature understanding of the challenges going forward. The panel feels that the results from the competencies self-assessments largely match the panel’s perceptions during the assurance test. The panel identified 4 main recommendations that the PCT will need to consider as the PCT positions itself to drive transformation of health and healthcare in East Sussex, Downs and Weald. EAST SUSSEX DOWNS AND WEALD PCT

3. Adding life to years and years to life 3 3 Commentary The panel identifies 4 major areas for consideration by the PCT at this stage on its journey: 1. The panel acknowledges the progress the PCT has made, and encourages it to build on recent developments to ensure it is able to transform the local health system. Observation: The panel acknowledges that the PCT has made significant progress over the past 12 months in beginning the journey towards transforming the health system. Specifically the PCT has moved to a position of financial balance, has developed strong relationships with partners resulting in robust use of the JSNA and has begun to build stronger relationships with clinicians. However, the panel observed that the PCT will need to continue to build on these relationships to modernise the local health system and deliver on its strategic ambitions. Recommendation: The panel recommends that the PCT further develop its relationships with clinicians, particularly providers of primary care, to ensure it is able to effectively shift care closer to home. 2. The PCT will need to develop its capacity and capabilities to deliver its ambitious strategic plan, particularly in light of its shared executive with Hastings and Rother. Observation: The PCT acknowledges that there are additional challenges arising from the joint management arrangements between Hastings and Rother and East Sussex Downs and Weald. The panel observed that Board Governance will need to be exceptional to manage this arrangement, including ensuring that there is appropriate challenge (e.g. planning assumptions) across both PCTs. The PCT acknowledges that there is a need to implement stronger performance management of programmes and initiatives to avoid slippage Recommendation: The PCT will need to assure itself that it is building the skills and capabilities it will need to deliver World Class Commissioning. This is particularly important in light of the shared executive with Hastings and Rother, and recent changes in the executive management team. In addition, the PCT should consider how to maximise efficiencies between the two PCTs to avoid duplication.

4. Adding life to years and years to life 4 4 Commentary The panel identifies 4 major areas for consideration by the PCT at this stage on its journey: 3. The PCT will need to ensure there is sufficient focus to deliver on the overall vision and ambition for the health of the local population. Observation: The panel observed that the PCT is engaged in a wide variety of initiatives and programmes, from the older people’s strategy through to healthy living initiatives targeting young families. However, it is less clear how these initiatives are prioritised or focused to make significant impacts on the local population, or that the alignment between selected outcomes with strategic goals and initiatives is fully developed and articulated. Recommendation: The panel recommends that the PCT simplify its strategy, prioritising and rationalising its initiatives to focus on the most important issues. The forthcoming management and governance review will be a good starting point for these discussions. 4. There is a need to ensure the strategic investment plan is ambitious enough considering the local health needs. Observation: The PCT will require an ambitious strategic investment plan in order to address the significant and varying health needs of the local population. The panel observed that there is a need to translate plans which are rooted in the JSNA into action, and to ensure that levels of investment are high enough to impact health needs in the most deprived areas. Recommendation: The panel recommends that the PCT review its strategic plan to ensure it is aligned with the recognised health needs of the population (e.g. differential investments to target those in the most need). The PCT might consider strengthening its programme budgeting to enable this to be delivered. In addition the Board will need to ensure there is sufficient challenge to the planning process to ensure there is sufficient investment in priority areas to address local health challenges.

5. Adding life to years and years to life 5 5 Potential for improvement The panel acknowledges that the PCT has made significant improvements over the past 12 months, including achieving financial balance and making inroads into improved relationships with primary care. The panel acknowledges that the PCT has potential for improvement. The panel would expect the PCT to build the foundations for World Class Commissioning over the coming year. Strategy Finance Board A A A GOVERNANCECOMPETENCIES Local leader of NHS Collaborates with partners Patient and public engagement Clinical leadership Assess needs Prioritisation Stimulates provision Innovation Procurement and contracting Performance management Level 4 Level 1 EAST SUSSEX DOWNS AND WEALD PCT

6. Adding life to years and years to life 6 6 Outcomes Outcomes chosen 1. Life Expectancy 2. Health Inequalities 3. Under 18 conception rate 4. Proportion of children who complete their MMR immunisation by their 5 th birthday 6. Cervical screening: Coverage of women Aged 25-64 7. Patient and user reported measure of respect and dignity 8. Rate of hospital admission per 100,000 for alcohol related harm 5. Smoking Quitters 9. CHD controlled Cholesterol 10. Percentage of people screened for diabetic retinopathy EAST SUSSEX DOWNS AND WEALD PCT Panel observations on outcomes: Board developed outcomes based JSNA and prioritised through a set of criteria (e.g. local need, ability to achieve, patient and public input). Board and PEC provided challenge to proposed outcomes to ensure that they were aligned with JSNA. PCT considers that there are no national indicators which would directly measure their ambition in older people’s services. PCT took advice from PEC on selection of LTC outcome measures, which led to choice of CHD controlled cholesterol rather than CHD controlled blood pressure. PCT has not selected stroke measures because of data challenges with the trust. Recommendations: The panel recommends that the PCT revisit its outcome measures to ensure these are aligned with the most pressing health needs of the population over the next five years. For example, the panel recommends that the PCT include a stroke measure. In addition, the panel recommends that the PCT consider including local indicators to measure the impact of their older people’s and mental health strategies.

7. Adding life to years and years to life 7 7 Overview - Competencies Uncalibrated Panel Assessment PCT's Self Assessment PCT Self-Assessment Competency 1. Locally lead the NHS 2. Work with community partners 3. Engage with public and patients 4. Collaborate with clinicians 5. Manage knowledge and assess needs 6. Prioritise investment 7. Stimulate market 8. Promote improvement and innovation 9. Secure procurement skills Level 1 Level 2 Level 3 Level 4 10. Manage the local health system EAST SUSSEX DOWNS AND WEALD PCT Topline introduction The panel agreed with 22 of the PCT’s 30 self-assessment ratings. However, the panel found it necessary to adjust the remaining ratings. The panel acknowledges that in some areas where it has adjusted self- assessment ratings, the PCT has made inroads into achieving the sub-indicators.

8. Adding life to years and years to life 8 8 Competency 1: Self assessment Are recognised as the local leader of the NHS Reputation as the ‘local leader of the NHS’ Reputation as a change leader for local organisations Position as the local healthcare employer of choice CompetencyMeasure Level 3Level 4Level 2Level 1 Source: East Sussex Downs and Weald PCT self assessment submitted on 29/10/2008 EAST SUSSEX DOWNS AND WEALD PCT Rationale for scoring: The PCT acknowledges that stakeholders hold a wide range of perceptions of the PCT. The PCT is embarking on a number of actions to address this (public campaign on priorities, internal governance review, rebranding). The PCT is able to articulate which of their stakeholders hold positive and which less positive perceptions, and are putting plans in place to address these. The PCT is currently developing plans to ensure they are able to attract and retain commissioning staff (e.g. training, development, recognition schemes). Recommendations going forward: The panel recommends that the PCT continue to build on its relationships with local stakeholders and partners, and ensures that recent actions to address reputational risk are followed up in the coming months. Uncalibrated Panel Assessment PCT's Self Assessment

9. Adding life to years and years to life 9 9 Competency 2: Self assessment Work collaboratively with community partners to commission services that optimise health gains and reduce health inequalities Creation of Local Area Agreement based on joint needs Ability to conduct constructive partnerships Reputation as an active and effective partner CompetencyMeasure Level 3Level 4Level 2Level 1 Source: East Sussex Downs and Weald PCT self assessment submitted on 29/10/2008 EAST SUSSEX DOWNS AND WEALD PCT Rationale for scoring: The PCT can describe joint working with the local authorities, and can provide some examples of joint working to deliver against the LAA. The PCT can provide some examples of working with partners to achieve common goals (e.g. agreement of local priorities, teenage pregnancy). The PCT has a number of shared posts and pooled budgets with the local authority (public health, learning disabilities, IM&T). Recommendations going forward: The panel recognises the strong relationships between the PCT and other local agencies. Going forward, the PCT should continue to build on these to ensure performance management processes are aligned to deliver coherently against LAA targets and plans. Uncalibrated Panel Assessment PCT's Self Assessment

10. Adding life to years and years to life 10 10 Competency 3: Self assessment Proactively build continuous and meaningful engagement with the public and patients to shape services and improve health Influence on local health opinions and aspirations Public and patient engagement Delivery of patient satisfaction CompetencyMeasure Level 3Level 4Level 2Level 1 Source: East Sussex Downs and Weald PCT self assessment submitted on 29/10/2008 EAST SUSSEX DOWNS AND WEALD PCT Rationale for scoring: Although the PCT shares a communications strategy with Hastings and Rother, there are specific plans in place for each PCT which are localised down to ward or GP practice level as appropriate. The PCT can provide examples of drawing on public or patient views to inform the shape of service (e.g. wheelchair service, tissue viability service). The PCT has an integrated feedback group which looks at complaints, PALS, feedback. In addition, the patient experience tracker has been implemented in community hospitals. The panel commends the PCT for inclusion of LINKs representative on the WCC panel, and recognises the value this added in demonstrating patient engagement. Recommendations going forward: The panel recommends that the PCT continue to build on its existing programmes and plans to ensure that engagement with the public and patients both encourages the public to take control of their own health opinions and lifestyles and to get involved with the development of healthcare services. Uncalibrated Panel Assessment PCT's Self Assessment

11. Adding life to years and years to life 11 11 Competency 4: Self assessment Lead continuous and meaningful engagement of all clinicians to inform strategy and drive quality, service design and resource utilisation Clinical engagement Dissemination of information to support clinical decision making Reputation as an active and effective partner CompetencyMeasure Level 3Level 4Level 2Level 1 Source: East Sussex Downs and Weald PCT self assessment submitted on 29/10/2008 EAST SUSSEX DOWNS AND WEALD PCT Rationale for scoring: The PCT has established a new PEC, and is developing initiatives to address historic challenges with engaging GPs (e.g. GP Forum, PBC incentive schemes). The PCT has been taking a direct approach to working with clusters from the bottom up. The PCT acknowledges that it is on a journey with primary care. Although the PCT has made significant progress, there is a need to ensure that momentum is not lost. PBCs have signed up to differential investment outlined in Investing in Life programme. The PCT can provide examples of services where clinicians have led improvement programmes (glaucoma, community xray facilities, cardiology in the community). The PCT acknowledges that further development is required in terms of ensuring GPs are satisfied with the quality, format and frequency of information. The panel acknowledges that the PCT consulted with GPs when self-assessing on this competency. Recommendations going forward: The panel recommends that given the importance of moving care closer to the community, the PCT continue to build on recent progress in its work with clinicians, particularly primary care providers. Uncalibrated Panel Assessment PCT's Self Assessment

12. Adding life to years and years to life 12 12 Competency 5: Self assessment Manage knowledge and undertake robust and regular needs assessments that establish a full under-standing of current and future local health needs and requirements Analytical skills and insights Understanding of health needs trends Use of health needs benchmarks CompetencyMeasure Level 3Level 4Level 2Level 1 Source: East Sussex Downs and Weald PCT self assessment submitted on 29/10/2008 EAST SUSSEX DOWNS AND WEALD PCT Rationale for scoring: The PCT has developed a complete JSNA broken down by ward which informs strategies and services, and can clearly demonstrate that it understands the links between the health needs of the population and the development of service strategies and pathways (e.g. older people’s health needs). The PCT can describe insights generated by the JSNA (e.g. extent of alcohol problem, difference in life expectancy between most and least deprived wards). The PCT is committed to moving to fair share budgets. The JSNA is the basis for opening a dialogue on this. PCT uses ONS twin and cluster data as well as SEC to benchmark health needs. The PCT shares benchmarking data with stakeholders (e.g. GPs), but is still developing plans to improve these. Recommendations going forward: The panel recommends that the PCT works with its peers to develop a wider range of benchmarked health needs, including developing plans to improve performance against them. Uncalibrated Panel Assessment PCT's Self Assessment

13. Adding life to years and years to life 13 13 Competency 6: Self assessment Prioritise investment according to local needs, service requirements and the values of the NHS Predictive modelling skills and insights Prioritisation of investment to improve population’s health Incorporation of priorities into strategic investment plan CompetencyMeasure Level 3Level 4Level 2Level 1 Source: East Sussex Downs and Weald PCT self assessment submitted on 29/10/2008 EAST SUSSEX DOWNS AND WEALD PCT Uncalibrated Panel Assessment PCT's Self Assessment Rationale for scoring: PCT recognise that predictive modelling skills and insights need to be developed and these are addressed in the OD plan. The panel acknowledges the input the PCT has solicited from the public and patients as it develops and refines its prioritisation criteria. The PCT can demonstrate some level of prioritisation of investment, but the rigour and processes used will need further development (e.g. PCT will need to be able to consistently and clearly articulate the criteria by which it prioritises investment). The PCT acknowledges that it is still developing its capacity to evaluate projects and initiatives against prioritisation. Recommendations going forward: The PCT will need to develop its process and methodology for prioritisation, including the alignment of initiatives and outcomes. In addition, the panel recommends that the PCT ensure there is sufficient challenge to planning assumptions, and that the strategic investment plans are robust enough to deliver against the high level of ambition.

14. Adding life to years and years to life 14 14 Competency 7: Self assessment Effectively stimulate the market to meet demand and secure required clinical and health and wellbeing outcomes Knowledge of current and future provider capacity Alignment of provider capacity with health needs projections Creation of effective choices for patients CompetencyMeasure Level 3Level 4Level 2Level 1 Source: East Sussex Downs and Weald PCT self assessment submitted on 29/10/2008 EAST SUSSEX DOWNS AND WEALD PCT Uncalibrated Panel Assessment PCT's Self Assessment Rationale for scoring: The panel acknowledges that the PCT has made a realistic self-assessment on this competency. The panel recognises that the PCT has a clear opportunity to create choice in both setting of care and hospital given the diversity in the provider landscape. Recommendations going forward: PCT will need to further develop its market analysis potential (building on KPMG work) to fully understand its ability to offer patient choice. Panel recommends that as part of this the PCT focus on non-acute services (e.g. primary and community care, mental health services).

15. Adding life to years and years to life 15 15 Competency 8: Self assessment Promote and specify continuous improvements in quality and outcomes through clinical and provider innovation and configuration Identification of improvement opportunities’ Implementation of improvement initiatives Collection of real time quality and outcome information CompetencyMeasure Level 3Level 4Level 2Level 1 Source: Hastings and Rother PCT self assessment submitted on 29/10/2008 Rationale for scoring: PCT can provide examples of benchmarking service performance in acute (e.g. productivity indicators, admissions). However, the PCT acknowledges that they are still developing their ability to identify improvement opportunities in non-acute settings (i.e. beyond prescribing). PCT uses a patient experience tracker to redesign services to improve patient experience through action from feedback (e.g. on a community hospital ward). Recommendations going forward: The panel recommends that the PCT build on the patient tracker and expand its toolkit of improvement techniques to ensure it includes pathway redesign tools (e.g. lean). The panel recommends that the PCT ensure it is developing real time quality and outcome information. Uncalibrated Panel Assessment PCT's Self Assessment EAST SUSSEX DOWNS AND WEALD PCT

16. Adding life to years and years to life 16 16 Competency 9: Self assessment Secure procurement skills that ensure robust and viable contracts Understanding of providers economics Negotiation of contracts around defined variables Creation of robust contracts based on outcomes CompetencyMeasure Level 3Level 4Level 2Level 1 Source: East Sussex Downs and Weald PCT self assessment submitted on 29/10/2008 EAST SUSSEX DOWNS AND WEALD PCT Uncalibrated Panel Assessment PCT's Self Assessment Rationale for scoring: The panel acknowledges that the PCT is participating in the Purchased Healthcare pilot, which will provide a good starting point to build non-acute procurement skills. However, there is still room to develop a robust negotiation strategy to ensure the PCT is best placed to engage with acute and non-acute providers in contractual negotiations. The PCT has engaged in a demand management pilot to understand the drivers of increased referral activity. Recommendations going forward: The panel recommends that the PCT build on the output of the market analysis currently being procured through KPMG to design a robust procurement strategy. The PCT will need to review its procurement capabilities in partnership with local authority partners in the context of this work. The panel recommends that the PCT further develop its approach to negotiations

17. Adding life to years and years to life 17 17 Competency 10: Self assessment Effectively manage systems and work in partnership with providers to ensure contract compliance and continuous improvement in quality and outcomes and value for money Use of real time performance information Implementation of regular provider performance discussions Resolution of ongoing contractual issues CompetencyMeasure Level 3Level 4Level 2Level 1 Source: East Sussex Downs and Weald PCT self assessment submitted on 29/10/2008 EAST SUSSEX DOWNS AND WEALD PCT Uncalibrated Panel Assessment PCT's Self Assessment Rationale for scoring: The PCT acknowledges that it is still developing its ability to collect real time performance data (less than one month old for monthly data) from non-acute providers. The PCT acknowledges that there is a need to develop more regular performance discussions with primary care and community services. Recommendations going forward: The panel recommends that the PCT revisit its performance management processes with primary and community providers, ensuring regular performance discussions are in place and contracts are monitored robustly.

18. Adding life to years and years to life 18 18 Governance: Panel assessment on Strategy A Overall recommendation: The panel acknowledges that the PCT has recently emerged from a position of historic deficit to create financial balance. Going forward, the PCT has the opportunity to build on this position, for example by taking a more ambitious approach to strategic investment and disinvestment plans based on the health needs of the population. In addition, and particularly given the shared executive with Hastings and Rother, the PCT will need to ensure the Board and staff have the capacity and capabilities to build on recent progress with clinical engagement to develop transformational relationships with acute and non-acute providers. Strategy: The PCT can clearly describe the links between the health needs of the population, the chosen outcomes measures and the strategic goals and initiatives outlined in the strategic plan. However, there are some areas of strategy (e.g. older people) which are not currently reflected explicitly in the chosen outcome set. The panel observed that the strategic plan does not fully link the initiatives with impact on the health of the local population, and that there is a need to further prioritise these. The PCT has used the JSNA to prioritise potential initiatives in the SCP. In addition, the PCT has invested in ensuring that the public and patients have been involved in the development of the strategic goals. The Board can demonstrate examples of providing challenge to the strategic plan (e.g. selection of outcome measures, stroke initiatives). EAST SUSSEX DOWNS AND WEALD PCT

19. Adding life to years and years to life 19 19 Governance: Panel assessment on Finance and Strategy AA Finance: The PCT plans to capture future savings by moving care from acute to community settings. This will depend on successful engagement with PBCs going forward. The panel observes that the PCTs acute trusts are over-performing on contracts. The PCT will need to assure itself that it is able to deliver on demand management plans and proposed shifts to settings of care. The PCT will need to consider how it will achieve further contingencies to ensure recent progress in financial stability is maintained and accelerate the pace of delivery against the strategic goals. Board: The panel acknowledges the unique challenges faced by the joint management board. The relationship with Hastings and Rother also provides opportunities and potential benefits which should be further developed (e.g. through the pending management and governance review) to improve the effectiveness of the PCT. The PCT will need to continue to strengthen the Board’s ability to provide appropriate leadership and challenge as the organisation develops. For example, the PCT will need to ensure there is robust focus and assurance with respect to performance management. EAST SUSSEX DOWNS AND WEALD PCT

20. Adding life to years and years to life 20 20 Potential for Improvement Commentary PCT trajectory The panel acknowledges that the PCT has made significant improvements over the past 12 months, including achieving financial balance and making inroads into improved relationships with primary care. The panel acknowledges that the PCT has potential for improvement. The panel would expect the PCT to build on the foundations for World Class Commissioning over the coming year. Areas for organisational development The panel acknowledges the unique challenges faced by the joint management board. The relationship with Hastings and Rother also provides opportunities and potential benefits which should be further developed (e.g. through the pending management and governance review) to improve the effectiveness of the PCT. The PCT will need to continue to develop its capability and capacity to deliver World Class Commissioning. This will include ensuring the PCT is able to address gaps at both executive and commissioning delivery levels. In light of the challenges faced by the PCT, the PCT should ensure that they are planning an appropriate Board development programme to meet the needs of the future. EAST SUSSEX DOWNS AND WEALD PCT