Scn cvd-network-meeting-jan-2015

Improving health outcomes across England by providing improvement and change expertise
SCN CVD Network Meeting
Friday 16 January 2015
Chair Huon Gray
National Clinical Director Cardiac

Contents (40 pages)
October 2014

NHS Improving Quality
Hilary Walker
Head of Living Longer Lives
Friday 16th January 2015

Summary (1)
• Local leadership & ‘structured partnership’

Summary (1)
• Single leadership group

Summary (1)
• Single leadership group
• Stable mandate + Mental Health (Parity of Esteem) prioritised
• Emphasis on workforce (LETBs and HEE)
• Prevention (National Prevention Board chaired by PHE)
1. CCG & LG levels of ambition
2. National action (alcohol, fast food, tobacco and others)
3. National diabetes prevention programme
• NHS programmes to help people stay in work (including
healthier NHS workforce)

Summary (2)
• Empowering patients (digital health records, access to GP records,
personal budgets, learning disabilities, choice, Public & Patient Involvement)
• Engaging communities (volunteering, charities, NHSE to reflect diversity)
• New models of care (national New Models of Care Board)
– Multi-specialty community providers (MCPs)
– Integrated primary & acute care systems (PACS)
– Viable smaller hospitals
– Enhanced care in Care Homes
– Expressions of early interest by end January 2015
– Health & Care Garden City (Ebbsfleet and Bicester)
– Innovative technologies & working (AHSN & others partnering), CtE
– Emphasis on Urgent & Emergency, Maternity, Specialised, Cancer
– New National Cancer Strategy

Summary (3)
• New deal for primary care (workforce & infrastructure)
• Strong clinical leadership
• Improving quality & outcomes (National Quality Board)
• National Information Board
– Transparency, paperless NHS
– Electronic prescriptions
– Discharge summaries, e-referrals
– Interoperable digital records
• Patient safety
– Sepsis and AKI as priorities (CQUINs)
– Antibiotic resistance (CCG quality premium)
– Implement at least 5 of the 10 clinical standards for 7 day services
– Diagnostics, pathology & functional genomics

Summary (4)
• Increasing productivity & efficiency
– Narrowing the gap between least and most efficient
– Technology
– Better staff retention
• NHS finances
– 10% reduction in NHSE & CCG admin costs
– Accurate demand & capacity plans by providers and commissioners
– Tariffs (inflation +3.0%, tariff cost uplift +1.93%, provider efficiency
expectation -3.8% so net decrease in tariff of 1.9%)
• Marginal rate above baseline = 50% of tariff
• Up to 2.5% of provider income to come from national CQUINs
– Existing (Dementia & Delirium, physical health in SMI)
– New (AKI, Sepsis, Urgent & Emergency care)

Improvement Programmes
Domain 1: Living Longer Lives
Hilary Walker
Domain 2: Long Term Conditions
Jane Whittome
Domain 3: 7day Services
Ann Driver
Domain 4: Experience of Care
Jane Whittome
Domain 5: Patient Safety
Fiona Thow

Living Longer Lives
• Cardiovascular Disease
• Engaging Primary Care
• Raising Awareness

NHS Health Check
• NHS IQ have facilitated the spread of innovative approaches to
engaging ‘seldom seen, seldom heard’ groups through our case
study and webinar series.
• The work identifies examples of innovative practice, develops and
publishes corresponding case studies and then holds webinars to
support other Local Authorities in applying the learning to their own
local situation
• This approach will be showcased as a Poster at this year’s
International Clinical Microsystems Festival in Sweden (24th-26th Feb
2015)
• NHS IQ have worked with Public Health England to develop a self-
assessment tool aligned to graded levels of support to aid Local
Authorities in implementing the NHS Health Check Programme in
their area.

GRASP update
• 2,723 practices have uploaded GRASP-AF data
• 101 practices have uploaded GRASP-COPD
data
• 59 practices have uploaded GRASP-HF data
• 157 CCGs have uploaded data on at least one
of the GRASP tools in at least one practice

GRASP roll out strategy
• A move to the promotion of audited care rather
than a particular audit tool
• We are gathering intelligence on alternative audit
tools in use
• We would like to identify those CCGs where no
audit tools are in use and promote the use of
GRASP in these CCGs
• If you have any information on the use of
alternatives, or plans to use GRASP in your SCN or
CCG then please contact Ian Robson or your
regional LLL team contact

Date of next meeting
Friday 17th April in London
Focus on rehabilitation

Thank you
Any questions?
Hilary.walker@nhsiq.nhs.uk
@hilarywalkerNHS

The Commissioning Landscape And
Cardiovascular Disease Services
Personal Perspectives
Mark Scott
City and Hackney CCG
23

Summary Of Presentation
• Current Commissioning Landscape
• Developments In City And Hackney
– One Clinical Commissioning Group
– Impact On Commissioning Cardiovascular Diseases
• Discussion Points
– Implications For Strategic Clinical Networks
24

My Background
25
• Initially In Acute Trusts And Clinical Network
– Moved to commissioning
• Worked for London CCGs
– North West London and North East London
– Currently City and Hackney CCG
– Programme Director Integrated And Urgent Care
• Many English CCGs
– Personal perspectives from one CCG

New Commissioning Landscape
• NHS England
- National
- Regional (Strategic Clinical Networks)
- Local
• Clinical Commissioning Groups
– Commissioning Support
• Public Health
26

Clinical GP-Led Commissioning
27
1991 to
1997
1994 to
1997
2005 to
2011
2011 to
present
GP
Fundholding
Total
Purchasing
Pilot
Practice based
commissioning
CCGs and GP
Commissioning

28
2011/12 Changes To The System

Current Structures In Health
• GP Commissioning
• Commissioning support market
• Central commissioning primary care
• Central commissioning specialist services
29

Health And Local Authority Issues
• Public Health
– moved to local authorities
• Better Care Fund
– Small proportion of services jointly
commissioned through BCF
30

City And Hackney CCG
Where Is At Now?
31

Clinical Commissioning Started 2007
32
2005 to
2011
2011 to
present
Practice Based
Commissioning
CCGs and GP
Commissioning

Practice Based Commissioning Focus
on pathways
33
• Focus on pathways
• Linking secondary care and primary care
• GP Education
• Benchmarking performance data
• Demand management
East London
Integrated Care
Success in improving quality and reducing costs

Historical Performance For CVD
Outcomes Prior To PBC
• One of worst performing areas for CVD outcomes
• Poorly performing on intermediate outcomes
– Blood pressure control
– Glycaemic control
– Cholesterol
• High premature mortality and high referral rates
34

City And Hackney Vs Other CCGs
• Rank Achievement For All 211 CCGs
• 50 Long Term Conditions QOF Indicators
– City and Hackney
– Top for 10 indicators
– In the top 10 for 12 indicators
– In top quartile for 14 indicators
• Low Referral Rates
– 2.3% reduction in referral rates (09/10 - 10/11)
– Challenge benchmarking CVD since changes in local
clinical networks
35

Quality And Outcomes Framework
Data For 2013/14
36

Long Term Conditions Locally Enhanced Service
Implemented March 2013
Percent Patients Treated Increased Patient Numbers
1
10
100
1000
BP ≤ 150/90 Cholesterol
≤ 5
CHD annual
review
AdditionalPatients
37
0%
30%
60%
90%
65+ pulse
rhythm
recorded
Cholesterol
<5
BP <150/90
PercentPatients
2013 2014

Variations In GP Practice Performance
Comparing Measuring Cholesterol and BP
38
0
10
20
30
40
50
0 10 20 30 40 50
CholesterolMeasures
BP Measures
GP Practices successful in one indication are successful in all

Increased Role Of Private Sector?
39
• Tendering contracts
– CVD contracts frequently re-commissioned
– Circle, Serco, Virgin situation
• Local experience
– Focus on collaboration and integration

Current Key Organizational Issues
40
• Primary Care Co-commissioning
– Conflicts of interest
• Commissioning Of More Specialized Services
– Capacity within CCGs
– Organizational memory
– Collaboration across CCGs
– Links with acute clinicians and clinical networks

41
Fine, Problem Or Bigger Problem
CCG 2
CCG 1

Finances Impacting Performance
42
• A&E Performance
• Delayed transfer of care
• Cancer waiting times
• 18 week waiting times
• Cardiovascular specific waiting times

Key Factors And Quality Gap
43
1. Funding
2. Reconfiguration and service change
3. Integrated health and social care economy
These three factors key to creating culture of
clinically-led quality improvement

A&E Performance and Emergency Activity
44
Overall Performance
1. 2013: 96.0%
2. 2014: 95.8%
Activity Reductions comparing Q1 and
Q2 14/15 with 13/14 periods
A&E Activity Reductions
1. Activity Down: 4.9%
2. Costs Down: 8.5%
Emergency admission Reductions
1. Activity Down: 5.4%
2. Costs Down: 0.93%
Percent Seen Within 4 Hours
Target
07/03/13
15/06/13
23/09/13
01/01/14
11/04/14
20/07/14
28/10/14
91% 93% 95% 97% 99%

Beyond May 2015
45
Five Year Forward
View
New Models of
Care
• Multi-specialty community providers
• Integrated primary and acute care systems
What could this mean for the role of commissioners and
quality improvement?

Alliance Contracting
New Zealand Example
• Moved From Competition To Collaboration
– Networks and partnerships as guiding principles
for health care delivery
• Removes Health Care Institutional Divides
– Sector-led governance arrangements
– Facilitate ‘whole of system’ approaches to care
design and delivery
• Promoted clinical governance and leadership
47

Alliance Membership
Leadership And Chair
• Independent chair
• Leadership skill based
– Health professional and
managerial
• Capacity to:
– lead/influence/understand
perspectives of professional
colleagues
• General Practice, nursing,
hospital specialty
Members
• DHB and PHO CEOs and
managers
• GPs, specialists, nurses,
allied professionals
• Ambulance and aged care
residential services
• Måori/Pacific leaders
• Patients/community
representatives
48

49
Alliance South
leadership
team

Comparison Of Contracts
Traditional Contract Alliance Contract
50

Healthcare Alliances
• Shared goals/objectives
• Clinically led
– Whole of system approach
• Decisions based on:
– Best for patient
– Best for system
• Pooled budgets
• Allocation of services
• High degree of trust
– Competition undermines
alliances
• Joint accountability for
results
• Innovation and flexibility
– Promotes transformational
change
– Replaces business as usual
amongst providers
51

One Hackney Alliance
HOMERTON ELFT CHUHSE CHUSE+
LBH
PROVIDER
TAVISTOCK
& PORTMAN
VOLUNTARY
SECTOR

One Hackney Challenge
•Providers set up services, with payment
linked to outcome targets they set and agree
with commissioners
•An £800k performance fund which will be
paid to the One Hackney provider
community if agreed metrics are achieved
by 31 March 2015
•A further £800k performance fund linked to
achievement of metrics during 2015/16

One Hackney Performance Metrics – Payment Basis
l
METRIC MEASURE/PAYMENT BASELINE TARGET
March 2015
TARGET
September 2015
TARGET
March 2016
1 Increase effectiveness of
reablement/rehabilitation
12 month period to target month.
Payment based on % achieved.
Payment baseline 90.4% (12 month period)
90.5% still at home
91 days after
discharge
1 additional
patient still at
home
90.5% - 100% paid
90.7% still at home
91 days after
discharge
8 additional
patients still at
home
90.6% - 50% paid
90.7% - 100% paid
91.2% still at home
91 days after
discharge
13 additional
patients still at
home
90.9% - 50% paid
91.2% - 100% paid
2 Increase proportion of people
dying outside hospital
43% deaths outside hospital
(2010-2012)
(461 deaths outside hospital out of 1082 total
deaths [EOLC Profiles])
Payment baseline 43% (12 month period)
43% deaths
outside hospital
(464 deaths outside
hospital out of 1085 total
deaths)
3 more deaths
outside hospital
43% - 100% paid
44% deaths outside
hospital (480 deaths
outside hospital out of 1088
total deaths)
19 more deaths
outside hospital
43% - 50% paid
44% - 100% paid
46% deaths outside
hospital (503 deaths
outside hospital out of 1091
total deaths)
42 more deaths
outside hospital
45% - 50% paid
46% - 100% paid
3 Emergency admissions for
over 75s to reduce to the
London average
(all emergency admissions excl maternity,
sickle dental and MH)
38 admissions per 1,000 population
over 75 per month (Apr 2011 – Jan
2014)
335 admissions per month [HES] for 8855
population [ONS 2013]
Payment baseline 335
Performance to be based on 12 month
average
Reduce admissions
by 5 per month to
330 admissions
335 - 50% paid
330 – 100% paid
Reduce admissions
by 15 per month to
320 admissions
Payment scale:
335 (no payment) –
320 (100% paid)
Reduce admissions
by 30 per month to
305 admissions
Payment scale:
305 (100% paid)

One Hackney Performance Metrics – Payment Basis
l
METRIC MEASURE/PAYMENT BASELINE TARGET
March 2015
TARGET
September 2015
TARGET
March 2016
4 Emergency admissions all ages to
remain lower than London average
(all emergency admissions excl maternity, sickle
dental and MH)
6.1 admissions per 1,000 population per
month (Apr 2011 – Jan 2014)
1735 admissions per month [HES] for 282,000
population [ONS 2013]
Payment baseline – London average
No increase in
admission rate
compared with
London total
Below London 12
month average – 100%
paid
No increase in
admission rate
compared with
London total
Below London 12
month average –
100% paid
No increase in
admission rate
compared with
London total
Below London 12
month average – 100%
paid
5 Reduce emergency bed days 3000 bed days per month for over 75s
(Apr 2012 – March 2013)
Payment baseline 3000 bed days per month for
over 75s
Performance based on 12 month average
Reduce bed days
by 15 to 2,985 per
month in over 75s
3000 - 50% paid
2985 – 100% paid
Reduce bed days
by 75 to 2,925
per month in over
75s
Payment scale:
2925 (100% paid)
Reduce bed days
by 150 to 2,850
per month in over
75s
Payment scale:
2850 (100% paid)
6 Reduce excess bed day costs £220k per month (Apr 2012 – March
2013)
Payment baseline £220k per month
Performance based on 12 month average
Reduction of £5k
per month to
£215k
£220k - 50% paid
£215k – 100% paid
Reduction of
£20k per month
to £200k
Payment scale:
220k (no payment) –
£200k (100% paid)
Reduction of £40k
per month to
£180k
Payment scale:
220k (no payment) –
£180k (100% paid)
7 Reduce % of admissions readmitted
within 30 days
19% of admissions readmitted within 30
days (Apr 2012 – November 2013)
Payment baseline 19% (rounded)
Performance based on 12 month period
19%
19% or below - 100%
paid
17%
Payment scale:
19% (no payment) –
17% (100% paid)
15%
Payment scale:
19% (no payment) –
15% (100% paid)
NB. One Hackney informed that baseline values being verified for more recent performance to ensure that targets still relevant.

Conclusions
• Clinical commissioning effective in City and
Hackney – improving quality/reducing costs
• Step-change in improvements in cardiovascular
outcomes
• Current trends reducing A&E attendances and
emergency admissions
• Alliance approach key to quality improvement
for integrated services
• Collaboration or competition - key dividing line
56

Lessons from Ants for Networkers
Muir Gray CBE
Better Value Healthcare

The future is not like the Isle of Man, a
destination awaiting our arrival, it is like
the Forth Bridge, something we have to
imagine, design, plan and construct

We have had two healthcare revolutions, with
amazing impact
• Antibiotics
• MRI
• CT
• Ultrasound
• Stents
• Hip and knee replacement
• Chemotherapy
• Radiotherapy
• Randomised controlled
trials
• Systematic reviews
• Richard Doll in Gower street
The First The Second

However, all health services, everywhere, still face 5
major problems one of which is unwarranted
variation which reveals the other four
• FAILURE TO PREVENT DISEASE &DISABILITY eg stroke and vascular
dementia from AF
• WASTE OF RESOURCES through low value activity
• HARM, from overuse even when quality is high
• INEQUITY, from underuse by groups in high need
And new, additional, challenges are developing
• RISING EXPECTATIONS
• INCREASING NEED
• FINANCIAL CONSTRAINTS
• CLIMATE CHANGE Variation in utilization of health
care services that cannot be
explained by variation in patient
illness or patient preferences.
Jack Wennberg

After 67 years we cannot answer key
questions such as
1.Is the service for people with seizures & epilepsy in
Manchester of higher value than the service in
Liverpool?
2. Who is responsible for service for all the women
with pelvic pain in Birmingham
3.How many liver disease service s are there in
England and how many should there be?
4.Which service for people at the end of life in
London provides the best value?
5. Is the service for people with seizures & epilepsy
in asthma of higher than the service in Somerset ?

If we could manage AF as well as they
do in Bradford there would be 5000
less strokes a year”
1.Is the service for people with atrial fibrillation in Manchester
better than the service in Liverpool?
3.How many atrial fibrillation services are there in England and
how many should there be?
4.Which service for frail elderly people wih atrial fibrillation in
the London provides the best value?
1.Is the service for people with atrial fibrillation in Nottingham
better than the service in Sheffield ?
5.Which service for people with atrial fibrillation improved
most in the last year ?

The Healthcare Archipelago
GENERAL MENTAL
PRACTICE HEALTH
COMMUNITY HOSPITAL
SERVICES SERVICES
PUBLIC
HEALTH
SERVICES

JURISDICTIONS INSTITUTIONS
PROFESSIONS
REGULATORS AND INSPECTORS
Complexity is the dynamic state between order and
chaos
Kieran Sweeney, Complexity in Primary care

Chaos…..….Complexity……...Order
Services for homeless
people
Screening for cervical ca
Immunisation
Services for people
With physical and mental
Co-morbidity
People with atrial fibrillation
People with hip pain
People who are
elderly and frail
People with pelvic pain
People with dizziness
People with multiple morbiditiy
who are alert and online

More of the same is not the answer ,
not even better quality, safer, greener
cheaper of the same
we need to design, plan and build a
new paradigm

The Aim is triple value & greater equity
• Allocative, determined by how the
assets are distributed to different sub
groups in the population
– Between programme
– Between system
– Within system
• Technical, determined by how well
resources are used for all the people
in need in the population
• Personalised value, determined by
how well the decisions relate to the
values of each individual

CVD
Respiratory
Gastro-
intestinal
Mental
Health
Between Programme
Marginal Analysis and
reallocation is a
commissioner
responsibility with public
involvement

CVD
Respiratory
Gastro-
intestinal
Between Programme
Marginal Analysis and
reallocation is a
commissioner
responsibility with public
involvement

CVD
Respiratory
Gastro-
intestinal
Mental
Health
Many people
have more than
one problem ;
GP’s are skilled in
managing
complexity

CVD
Respiratory
Gastro-
instestinal
Rhythm
Failure
Coronary
Within Programme,
Between System
Marginal analysis is
a clinician
responsibility

Cancers
Respiratory
Gastro-
instestinal
Apnoea
COPD
(Chronic
Obstructive
Pulmonary
Disease)
Asthma
Triple Drug
Therapy
Rehabilitation
O2
Stop Smoking
Imaging
2. Carry out Within
System
Marginal Analysis

Technical Value (Efficiency) = Outcomes / Costs
Outcome= Benefit (EBM +Quality) – Harm (Safety )
Costs (Money + time + Carbon)

Added value
from doing
things right
(quality
improvement)
Higher
Value
Higher
Value
High
Value
Lower
Value
Lower Value
THE INSTITUTIONAL
APPROACH
Hellish Decisions in Healthcare

After a certain level of
investment, health gain
may start to decline
Benefits
Investment of resources
Harms
Benefits - harm
Point of optimality
1. Reduce lower or negative value activities

4 Increase High Value Innovation by
Disinvestment from Lower Value
Interventions and ensure that any
innovation without strong evidence of
high value is introduced using the IDEAL
method to ensure evaluation
ESR

Population healthcare focuses primarily on
populations defined by a common need which
may be a symptom such as breathlessness, a
condition such as arthritis or a common
characteristic such as frailty in old age, not on
institutions , or specialties or technologies. Its
aim is to maximise value and equity for those
populations and the individuals within them
It will be delivered not only by commissioners
but also by clinicians practising population
medicine

BetterValueHealthcare
PrimarySecondaryAcuteCommunityManagerOutpatientHubandSpoke
Introduce new language
A SYSTEM is a set of activities with a common set of objectives and outcomes; and an annual report. Systems can focus on symptoms,
conditions or subgroups of the population
(delivered as a service the configuration of which may vary from one population to another )
A NETWORK is a set of individuals and organisations that deliver the system’s objectives
(a team is a set of individuals or departments within one organisation)
A PATHWAY is the route patients usually follow through the network
A PROGRAMME is a set of systems with ha common knowledge base and a common budget
STEWARDSHIPto hold something in trust for another
Ban old language

SELF CARE
INFORMAL CARE
GENERALIST
SPECIALIST
SUPER
SPECIALIST

This is an example of a national service set up
as a system

Hierarchy Network

Dr Jones is a respiratory physician in the Derby
Hospital Trust and last year she saw 346 people
with COPD and provided
evidence based, patient centred care, and to
improve effectiveness, productivity and safety

Dr Jones estimated that there are 1000 people with COPD in South Derbyshire and
a population based audit showed that there were 100 people who were not
referred who would benefit from the knowledge of her team

Dr Jones is given 1 day a week for Population Respiratory
Health and the co-ordinator of the South Derbyshire COPD
Network and Service has responsibility, authority and
resources for
Working with Public Health to reduce smoking
Network development
Quality of patient information
Professional development of generalists, and
pharmacists
Production of the Annual Report of the service
She is keen to improve her
performance from being 27th out
of the 106 COPD services, and of
greater importance, 6th out of the
23 services in the prosperous
counties

Three levels of command
STRATEGIC
OPERATIONAL
TACTICAL
Single national
specification
1XX networks,
1,000,000 consultations
and self care

YEAR 1 1. prepare system specification through knowledge harvesting
YEAR 2 2.Recruit the first cohort of population based services
3.Support the preparation of the first annual reports of the First Cohort
Services
4.Facilitate sharing and learning, involving patient organisations
YEAR 3 5.Recruit the Second Cohort of populations
6.Support the preparation of the annual reports of the First and Second
Cohort services
7.Facilitate sharing, learning & improvement involving patient organisations
YEAR 4 8.Recruit the third and final Cohort of populations
YEAR5 9.Support the preparation of the National Annual Report
10.Facilitate sharing and learning, involving patient organisations

We are now in the thirdhealthcare revolution
• Antibiotics
• MRI
• CT
• Ultrasound
• Stents
• Hip and knee
replacement
• Chemotherapy
• Radiotherapy
• RCTs
• Systematic
reviews
The First The Second the Third
Citizens
Knowledge Smart
Phone

NHS Confed/ AoMRC
AoMRC
Future Focused Finance
Dalton Oldham
RCGP Kings Fund
Five Year Forward View + Personalised Care 2020

Map of Medicine - COPD
Work like an ant colony; Neither markets
nor bureaucracies can solve the challenges
of complexity

Map of Medicine - COPD
Work like an ant colony ; Proverbs 6;6
go to the ant, O sluggaard
study her ways and learn wisdom ,
for though she has no chief,
no officer or ruler
,she secures herfoo in the summer,
she gathers her provisions in the harvest

Huon Gray
CVD Update
16 January 2015

BHF Heart Stats (2012) http://www.bhf.org.uk/publications/view-publication.aspx?ps=1002097
CVD Mortality in England (all <75 yrs)

Source: www.statistics.gov.uk/ statbase/Product.asp?vlnk=6725
Causes of Death (England, <75 yrs)
(Source: ‘Living Well for Longer’ [ONS data], 2013)

Global Burden of Disease Study. Lancet 2013;381:997-1020
DALYs Attributable to top 20 (of 67) Risk Factors (UK)

CVD Risk: Future trend Obesity
England – Impact of Rising Trend in Obesity - Predicted Increase in
Cardiovascular Disease Prevalence over & above Impact of Ageing
Diabetes Coronary Heart Disease Hypertension Stroke
2010 2% 1% 1% 1%
2020 15% 8% 5% 5%
2030 38% 20% 13% 11%
2040 68% 33% 23% 18%
2050 98% 44% 34% 23%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Predicted%IncreaseinDiseasePrevalence
2010
2020
2030
2040
2050
Source: National Heart Forum. A Prediction of Obesity Trends for Adults & their Associated
Diseases (NHF. February 2010)

CVD Risk: Ageing Population
England – Population Projections (Principal) –
% Growth to 2012, 2017 & 2022
1% 1%
2%
7%
3%
6%
2%
5%
2%
6%
20%
10%
22%
6%
10%
4%
7%
21%
31%
44%
10%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
0-19 20-44 45-64 65-74 75-84 85 plus All Ages
Projected%IncreaseinPopulation
2010-2012 % Increase
Source: ONS Population Projections. 2010-Based
65-74 to grow
By 20% 2010-2017
85 plus to grow
By 44% 2010-2022

Long Term Conditions: Heart
Failure Prevalence
Men Women Men Women Men Women Men Women Men Women
0-44 45-54 55-64 65-74 75 plus
England 0.0% 0.0% 0.2% 0.1% 0.9% 0.4% 3.1% 1.6% 13.7% 12.5%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
PrevalenceofHeartFailure(%)
England – Heart Failure – Prevalence (%) by Age & Sex - 2009
General Practice Research Database 2010
Source: General Practice Research Database 2010, reported in British Heart Foundation
Coronary Heart Disease Statistics . 2010 Edition

Long Term Conditions: Heart
Failure - Future Prevalence
2012 2017 2022
45 Plus
Women 371,156 398,461 453,129
Men 344,728 387,815 450,342
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,000
EstimatedPrevalentCasesofHeartFailure
Women
Men
England – Heart Failure – Prevalence Cases – Projected Numbers
to 2022 – Based on General Practice Research Database 2010
Source: General Practice Research Database 2010, reported in British Heart Foundation Coronary Heart Disease Statistics . 2010 Edition
Heart Failure rates by Age/Sex applied to ONS Population Projections.
Up 10%
Over 2012
Up 26%
Over 2012715,884
786,276
903,470

CVDOS Recommended Actions (10)
• Seeing CVD as one condition (‘family of diseases’)
• Integration of services
• Risk factors, NHS Health Check
• Case finding in 10 care
• Better management in, and support for, 10 Care
• Inherited cardiac conditions (incl. FH)
• Improve survival from OHCA (CPR, AEDs, First Responders,
Education, Registry)
• Raising awareness
• 24 x 7 CV Services
• Care planning (phys & psych support, self care, EOL care)
• Information (CVIN, Service Level Markers, Clinical Audit)
• Research
https://www.gov.uk/government/publications/improving-cardiovascular-disease-outcomes-strategy

Stroke Update
Tony Rudd
16th January 2015

Areas for presentation
• Acute organisational audit
• Clinical audit data
• CCG audit
• Telemedicine commissioning guidance
• Stroke service toolkit
• Single level markers

Stroke News
• Publication of SSNAP organisational audit and
June – Sept clinical data
• MR CLEAN trial of intra-arterial treatments
• MHRA review of alteplase

SSNAP organisational data
Thrombolysis Provision
Source: SSNAP Organisational Audit, October 2014
1%
1%
0%
0%
8%
8%
83%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
No provision at all
No onsite service and less than 24/7 service provided
including local arrangements
Less than 24/7 service provided overall including local
arrangements
Less than 24/7 service provided on-site, with no local
arrangements
No on-site service but a 24/7 service provided involving local
arrangements
Less than 24/7 service provided on-site but a 24/7 service
provided overall involving local arrangements
24/7 service provided on-site

Decision making for thrombolysis – Normal
Hours
National My Site
Consultant physician in person 99% Yes/No
Consultant physician via telemedicine 8% Yes/No
Consultant physician via telephone 17% Yes/No
Registrar 11% Yes/No
Lower grade doctor 2% Yes/No
Stroke nurse band 8 0% Yes/No
Consultant as most senior 99% Yes/ No

Decision making for thrombolysis – Out of Hours
National My Site
Consultant physician in person 50% Yes/No
Consultant physician via telemedicine 61% Yes/No
Consultant physician via telephone 32% Yes/No
Registrar 10% Yes/No
Lower grade doctor 0% Yes/No
Consultant as most senior 94% Yes/ No

Interventional Neuroradiology results
*on site or by referral to another site
Interventional Neuroradiology All sites (167) My Site
% of sites currently using intra-arterial
treatment (e.g. thrombectomy) to treat
patients with acute stroke*
54%

Nursing levels
Registered nurses usually on duty at
10am
National – total
stroke units
My Site
Median per 10 beds Per 10 beds
Weekdays 1.9
Saturdays 1.8
Sundays/Bank Holidays 1.8
Registered nurses usually on duty at
10pm
National – total
stroke units
My Site
Median per 10 beds Per 10 beds
Weekdays 1.3
Saturdays 1.3
Sundays/Bank Holidays 1.3

6 or 7 day therapy working
34% of sites have 6 or 7 day working for at least two of: physiotherapy,
occupational therapy, and speech and language therapy.
Source: SSNAP Organisational Audit, October 2014
35%
44%
8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Occupational therapy Physiotherapy Speech and Language therapy

Prevention of venous thromboembolism
First line treatment for preventing venous
thromboembolism
National My site
Short or long compression stockings 1% (1)
Intermittent pneumatic compression device 42% (77)
Low molecular weight heparin 35% (64)
None of the above 22% (41)

East of England and West Midlands

North of England/Yorkshire/Humber

South West/Thames Valley/Wessex
But don’t get too depressed......

Clinical Audit
Thrombolysis: Changes over time
D3 Level
Number of teams achieving each level
Oct – Dec 2013 Jan – Mar 2014 Apr – Jun 2014 Jul – Sep 2014
A 10 teams (6%) 12 teams (8%) 9 teams (6%) 18 teams (12%)
B 20 teams (13%) 26 teams (16%) 31 teams (20%) 26 teams (17%)
C 35 teams (22%) 39 teams (25%) 40 teams (25%) 33 teams (22%)
D 49 teams (31%) 42 teams (27%) 42 teams (27%) 44 teams (29%)
E 46 teams (29%) 39 teams (25%) 35 teams (22%) 31 teams (20%)

Clinical Audit
Speech and Language therpay: Changes over
time
D7
Level
Number of teams achieving each level
Oct – Dec 2013 Jan-Mar 2014 Apr – Jun 2014 Jul – Sep 2014
A 5 teams (3%) 1 teams (1%) 11 teams (5%) 21 teams (10%)
B 16 teams (9%) 15 teams (8%) 19 teams (9%) 26 teams (13%)
C 34 teams (19%) 35 teams (18%) 48 teams (24%) 40 teams (20%)
D 19 teams (10%) 26 teams (13%) 24 teams (12%) 22 teams (11%)
E 109 teams (60%) 120 teams (61% 101 teams (50%) 93 teams (46%)

CCG audit
• >99% participation of CCGs in England
– Services Commissioned
• Stroke specific services and generic
• Who they are commissioning
• Location of services
– CCG organisation
• Clinical lead
• Do they require participation in SSNAP
• Any joint commissioning
• Consortium commissioning
• Provisional reports for validation Jan, Final report
February and public report march
• Start provider data collection March

Key Elements of a stroke service
+ Includes stroke performance standards, repatriation pathways,
workforce guidelines, competency framework, education & training
and telemedicine
Commissioning Assurance Framework
+ Includes agreement templates such as collaborative working,
confidentiality and conflict of interest
Assessing Need
+ Includes Health Impact and equality impact assessments, as well as
cost benefit analysis
Programme Governance
+ Includes pre-consultation and high level projects plans, engagement
template and Terms of Reference
Option Appraisal Process
• Includes factors to consider for rural and urban areas
Stroke Reconfiguration Toolkit
Contents

Travel and Activity Modelling – How to guide
for the data modelling
+ Health datasets which can be used:
+ how to source these
+ how to use these
+ linking datasets to understand patient pathways
+ Understanding and forecasting changes
+ Modelling drive time & activity volumes
Toolkit Contents Continued

Financial Modelling
+ Template providing financial analysis & costing for
stroke service reconfiguration
+ Includes provider and commissioner finance
templates, with guidance around use
+ Detail around payment-by-results framework and
best practice
+ Overall process map to guide project delivery
Toolkit Contents Continued

Via Stroke SCN per area
+ Propose initial contact with Clinical and Managerial Leads to discuss
toolkit
+ Then host local workshops with SCNs and their contacts
Via CCGs
+ Target Identified CCGs with Stroke as a priority in their area plans
+ Teleconference or local meetings
+ Add to Learning Environment
Proposed Dissemination

Action Date
Final Draft completion January 2015
BSCS Communications department to complete document
layout and compilation
Mid - February
2015
Contact clinical and managerial; leads per SCN area to
introduce toolkit and host meetings/workshops
January – March
2015
Contact CCGS to introduce toolkit – avoiding duplication February – March
2015
Upload document to Learning Environment February – March
2015
Complete Dissemination March 2015
Planned Timescales

Telemedicine
Telemedicine National My Site
Use of Telemedicine 70% Yes/No
If YES:
• Remote viewing for brain imaging is used 97% Yes/No/NA
• Video enabled clinical assessment is used 71% Yes/No/NA
• Telemedicine rota in operation with other hospitals 60% Yes/No/NA
Types of patients assessed by telemedicine National My Site
Only patients potentially eligible for thrombolysis 68%
Some patients (regardless of eligibility for
thrombolysis)
21%
All patients (who require assessment during times
when telemedicine is in use)
10%
Telemedicine Commissioning
guide to be sent to all SCNs

National Action Plan commitment
“Overarching clinical indicators - For ten new clinical
areas (including cancer, children’s services, mental health
and stroke), data will be made available to tell the public
how well services are performing and meeting their
needs; the first of these will be available by summer 2014
with more available over the following 12 months. Once
it is available, we will be able to use the care.data
information service outlined above to support the
development of this information.”
Service Level Markers: What is being
asked?

Phase 1a
• Cancer
• Stroke
• cardiac
What areas have been considered?
Phase 1b
• Learning disabilities
• Mental Health
• Children
Phase 2
• Diabetes ?
• Maternity ?
• Respiratory ?
• Kidney ?
• Liver
• Other ?

Stroke Service Level Marker
• Using SSNAP performance
• Team centred data not patient level
• Adjusted for data quality and ascertainment
• Aim to deliver by March 2015
• Likely to be highly publicised

NCD Update
(Renal)
Richard Fluck
Date: 15th January 2015

Think Kidneys
www.thinkkidneys.nhs.uk

System levers
• Forward view: into action 2015/16
NHS England is proposing to introduce new national
CQUIN indicators to tackle sepsis and acute kidney
injury; and a new quality premium indicator to tackle
resistance to antibiotics. 04/02/2015
Safety collaboratives: AHSN/SCN
Sign up for safety
Health Foundation

‘AKI warning
score’
Patient
management
system
Alert Response
Local systems
Message
Master
patient
index
Other data
systems
AKI
Registry
Regional
National
Research
QI
Measurement

Engaged,
informed
individuals
& carers
Commissioning
Organisational
& clinical processes
Person-
centred,
coordinated
care
Health & care
professionals
committed to
partnership
working
Plan
Study
Do
Act
CKD Identify patient-reported
outcomes measures
(PROMs)
Baseline data and
analysis
Multiprofessional
steering committee
Interventions to
increase PAM
Advice from
stakeholder groups
Joint work with
voluntary sector
organisations
Advice from
stakeholders
Test at CCG level
PROMs and patient/
carer stories influence
CCGBoards
Commissioning tools
and resources for
CCGs
Opportunities for
innovative
commissioning
Test and measure
PAM
PROM reporting
Use of RPV
Improved quality
reduces demand for
urgent and
unplanned care
Five Year Forward View: Patient Participation

‘Valuing Individuals – Transforming Participation in CKD’
An Introduction for interested CCGs
The NHS Five Year Forward View sets out how the health service needs to change,
arguing for a more engaged relationship with patients.
The UK Renal Registry working with NHS England, the NCD for renal and the renal
patient community have recently held a series of teleconference calls with CCGs
who’ve expressed an interest in getting involved in this work.
Please find the questions the programme will answer through this process:
• Routine collection of patient measures across a ‘joined up’ pathway of
care – PAM (Patient Activation Measure) and PROM (Patient Reported
Outcome Measure) is possible.
• Increasing patient activation in CKD is associated with better clinical and
person centred outcomes. (Linking PAM to PROM)
• Person centred interventions can be put in place to increase patient
activation.

Co-Design event for this programme will be held on the
3rd February 2015 in Birmingham
Please also find the criteria each CCG needs to meet to be involved:
• Broad commitment to the programme vision - increasing patient
activation and support for self management
• Has or expects to have Renal Unit/satellite unit engagement – (units will
need to commit to using the PAM other tools and relevant interventions)
The UKRR may be able to help with engagement
• Has a long term commitment to move this work forward beyond the 2
years of the programme/aligns with other strategic priorities.
• When responding, it would be helpful to indicate what you as a CCG hope
to achieve from this work. We can then build this aspect into the
measurement work stream and evaluation.
There is significant support and expertise available via the programme and work
streams: Measurement, Intervention and Commissioning.
For further information please contact: Sue Shaw - sue.shaw@renalregistry.nhs.uk
Karen.thomas@renal.registry.nhs.uk or p.muramatsu@nhs.net

• Convene group to discuss and lead
implementation of CG182
– NCD Renal
– NCD Pathology
– Clinical Lead, CG 182
– Primary care GP
– CKD expert
– Patient
– Pathology expert
Five Year Forward View
CKD: Prevention

11. NHS England has recommended
to the Prescribed Services Advisory
Group that the following services
currently commissioned by NHS
England should in future be
commissioned by CCGs:
renal dialysis (excluding
encapsulating sclerosing peritonitis
surgery)
surgery for morbid obesity

Level 1
Centralised – full national control of budgets and contracting
• e.g. highly specialised services that are low incidence and high cost
Level 2
NHS England + CCG co-commissioning
• e.g. neonatal intensive care; many specialised surgeries
Level 3
CCGs collaborating, potentially employing a ‘lead commissioner’
• e.g. renal dialysis
Level 4
Full local commissioning
• e.g. chemotherapy
Commissioning of Renal Dialysis is changing
Consultation finished – decision awaited
A new CRG structure is required for this model
Level 2
Level 3

Possible role for a new ‘Renal Disease CRG’ assurance
Advise on renal dialysis at a national level via:
Exemplar service
specifications
National service
specifications that will
have:
• Core elements common across
CCGs to ensure that services
are of high quality in all regions
• Other elements optional to allow
CCGs freedom to do alterations
to meet the local population
needs
The CRG will add
valuable specialist
input to the local
expertise of the CCG
consortia:
• CRG to provide
strategic planning
advice to CCGs
Coordination and liaison
with other bodiesQuality improvement
By Utilising data
collection and
reporting:
• Define quality indicators that can
be used to monitor provider
performance
• Collect national data on these
indicators for comparison
• Publish public “State of the Nation”
reports at national, regional and
CCG level
• Inform and advice CCG consortia
regarding low performing providers
Via financial levers
and service
improvement
Renal Dialysis is only
one part of the renal
pathway.
• ESRF has many causes and
treatments
• Different parts of the pathway are
commissioned in different levels
• Extremely important to
collaborate with Renal
Transplantation CRG and NHS
Blood and Transplant
• Many bodies have an
interest/responsibility for parts of
the pathway
• Coordination is necessary to
ensure best possible outcomes
The Renal Disease
CRG would be able
to coordinate all
relevant bodies on
renal disease

National Diabetes
Prevention
Programme
Joanna Clarke,
Medical Directorate,
NHS England
16 January 2015

“We also need to make different investment decisions - for example, it
makes little sense that the NHS is now spending more on bariatric
surgery for obesity than on a national roll-out of intensive lifestyle
intervention programmes that were first shown to cut obesity and
prevent diabetes over a decade ago. Our ambition is to change this
over the next five years so that we become the first country to
implement at scale a national evidence-based diabetes prevention
programme modelled on proven UK and international models, and
linked where appropriate to the new Health Check. NHS England and
Public Health England will establish a preventative services programme
that will then expand evidence-based action to other conditions.”
Five Year Forward View

“We are today inviting those local areas that have made
greatest strides in developing preventative diabetes
programmes to register their interest at
england.fiveyearview@nhs.net by the end of January
2015 in joining with us as partners to co-design a new
national programme led by Public Health England, NHS
England and Diabetes UK. By March 2015 we will publish
our agreed approach, and a nationwide implementation
plan from 2016/17 onwards. A national Prevention Board,
chaired by PHE and bringing together NHS, local
government and other stakeholders will oversee delivery
of these commitments.”
FYFV into action

• That those who are at high risk of developing diabetes are referred
onto intensive lifestyle management programmes which will
support them to lose weight, improve their diet, and be more
physically active, and so, in line with the evidence base, reduce
their risk of developing Type 2 diabetes.
• That these referrals could be made by GPs, via a personalised care
and support plan, through the NHS Health Check programme, or
through other routes (e.g. Diabetes UK risk assessments, or through
assessments in the workplace).
• That these programmes are supported by marketing campaigns on
obesity and Type 2 diabetes prevention, commissioned by Public
Health England and local authorities.
Proposition

• The burden of obesity and Type 2 diabetes on the NHS is
growing. The FYFV clearly makes the case for shifting the
NHS’ focus from treating obesity to reducing it and
preventing the development of Type 2 diabetes.
• It is now well established that Type 2 diabetes can be
prevented or delayed in high-risk adults. At least 5 major
randomised controlled trials, conducted in China, Finland,
USA, Japan and India, have documented 30-60% reductions
in Type 2 diabetes incidence in adults at high risk of
developing diabetes through intensive lifestyle change
programme interventions.
• The clinical case for is therefore well established, but has
not been trialled at scale in England.
Rationale

• More people at high risk of developing diabetes will receive lifestyle
interventions to support them to lower their risk; and
• The incidence of Type 2 diabetes will reduce over the longer term;
and
• The incidence of heart, stroke, kidney, eye and foot problems (and
mortality) related to diabetes will reduce over the longer term.
Key success measures:
• [5-7%] weight reduction in participants of the programme
• Risk reduction in participants of the programme
• Reduction in the incidence of Type 2 diabetes and associated
diseases (heart attacks, strokes, etc)
Benefits

• Review the national and international evidence on diabetes
prevention.
• Seek to identify existing good practice service delivery models,
including previous roll out of similar national programmes, and
assess approaches to targeting and tailoring of programmes to both
increase effectiveness and ensure that take-up does not widen
inequalities.
• Work up two or three prototypes for local delivery of referral
systems and intensive lifestyle management programmes, based on
the evidence and NICE guidance on clinical pathways, with ‘real
world translation’, collaboratively with local commissioners,
clinicians, and patients. These would be implementation
prototypes rather than testing proof of concept (which has been
established in international RCTs). These prototypes would
conform to core criteria to be defined centrally, to ensure
consistency with the clinical evidence base.
Approach (1)

• Develop information systems (including on GP systems) to record
those at high risk and track referrals to intensive lifestyle
management programmes (including those referred through the
NHS Health Check programme), in the context of the prototype
development work. GP support for the programme is key, and we
will need to work with the GP community to ensure they are
bought into the programme from the beginning.
• Establish a robust evaluation framework for the delivery
prototypes, to be embedded from the start, to measure local
incidence of Type 2 diabetes, and whether it is positively affected
by the presence of a diabetes prevention service. This would be
based around an operational research approach to evaluation.
• Assess benefits of linking evaluation metrics to payment
mechanisms.
Approach (2)

• Test prototypes for local delivery, with a view to a phased roll-out in a
staged approach across the country.
• Develop national health marketing strategies on Type 2 diabetes and
obesity prevention to support and encourage local delivery of
programmes.
• Develop a cohort of local clinical champions and support the development
of local collaboratives/communities of interest to enable dissemination of
learning and to coordinate local efforts.
Approach (3)

• International evidence review initiated
• First Prevention Programme Board Jan 20th
• Meetings of interested commissioners /
providers and stakeholders in February to
kickstart thinking on delivery models?
• First cohort of people going through the
programme in 2015/16?
Timing

• Prevention Programme Board to sign off high-
level approach
• Workstreams initiated in next few weeks
• By end of March, publish agreed approach
Next steps

Partnership working is delivering a regional FH
service for the North East and North Cumbria - How
might this provide a template for similar initiatives?
Dr Séamus O’Neill , Chief Executive, AHSN
Alison Featherstone, CVD Network Manager

Clinical Network & AHSN
164
North East, North Cumbria, and the
Hambleton & Richmondshire districts of
North Yorks
Greater Manchester,
Lancashire and south
Cumbria
Cheshire & Mersey
West Midlands
East Midlands
South West
Thames Valley
East of England
Wessex
Yorkshire & The
Humber
South East Coast
London

Scale of our problem
• 3.1 million people
• 5,000 people living with FH mutations
• Only 15% known
• Perhaps 50 preventable cardiac deaths per year
– Small numbers per CCG

North East FH Service and History
• Adult specialist lipid clinics well established in 6 Trusts - Durham, Gateshead,
Hartlepool, Newcastle, Northumbria, Sunderland
• Adult FH patients also seen in outpatients in Carlisle, Middlesbrough
• Paediatric Lipid clinics in 2 Trusts contributing to RCP Paediatric FH Register
• Regional expertise in FH Diagnosis and Cascade Testing - National Pilot ‘05 – ‘08
• Regional Genetic Service agree to continue support for FH mutation testing
• Specialist Lipid Clinics Network created ‘08 - NICE CG71 compliant FH pathway
agreed
• NECVN Lipid Specialists Advisory Group (LSAG) established 2009
• NECVN proposal to implement NICE CG71 rejected by commissioners ‘09, ‘10
• FATS Primary Care Guidelines for Identification of FH (Agreed but not fully
implemented)
• NECVN Standards for identification of FH in Acute Cardiology patients (launched
‘09)

FH: can we deliver the new NICE
Quality Standard?
Hilton Newcastle Gateshead Hotel
Bottle Bank, Gateshead,
Newcastle upon Tyne NE8 2AR
Northern Lipid Forum
in association with

FH Services in the North East – Gap Analysis
• No centralised disease register for Adult FH probands and families in North
East
• No Specialist nurses in Adult or Paediatric FH Clinics
• No regional infrastructure for FH Family cascade testing available to support
Clinics
• No access to DNA mutation testing for new FH probands
• No clinical management database software (e.g. PASS) available to FH Clinics
• Adult specialist lipid clinics capacity shortfall, particularly in the south of the
Region
• Paediatric Lipid clinics not available in south of the Region
• FATS/NECVN Primary Care FH Guidelines not fully implemented in south of
Region
• No access to LDL Apheresis

FH: can we deliver the new NICE
Quality Standard?
Plan
1. Discussions with CCG
2. Discussions with AHSN
3. Continue bid to BHF
4. Regional Approach
Northern Lipid Forum
in association with

Northern CCG Forum
• GP Champion
• 13 CCGs
– One of the SCN CCG’s is not part of the forum
• Long history of collaboration across the area
– E.g. Clinical Innovation Teams
• Selling Idea To The CCGs
– Prevention
– Innovation
– Implementing best practice
– Finance – collectively shares the investment

AHSN remit
• Adoption and dissemination of best practice
at scale and pace
• Regional integration of a fragmented system
• Forum for collaboration across provider,
commissioner academic and commercial
organisations
• Working in partnership

AHSN pump-priming
• Project call December 2013
• Strategic priorities included integrated care
• Proposal submitted as partnership between CCGs,
Newgene Ltd and Newcastle Hospitals
• £120k awarded (the maximum available)
• Supporting a local SME; partnership with SCN;
addressing CCG priority; delivering a quantifiable
return on investment

Resource
• British Heart Foundation (approx. £160k)
– Nursing team for running regional FH cascade testing service
• AHSN (£120k)
– Next generation chip and sequence genetics
• AstraZeneca (in-kind)
– PASS software licence
• Northern Forum CCGs
– Year 1 £134,122 Year 2 £294,277 Year 3
£368,520
• SCN (in-kind)
– Admin support
– Access to clinical networks

Current Status
• Steering Group
• Interviewed and recruited to nursing posts
– But still have vacancy interviews 27th Jan
• Regional MDT is in place – virtual
– Currently managed by SCN until admin in place
• Numbers tested have been small
– Nurses not in place
• Developing education for primary care

The Challenges
• Keeping the coalition together
• Dealing with bureaucracy – appointments of
BHF-funded nurses
• Rolling out across other regions
– Any volunteers?

Contact Details
Any queries to:
Rachel Tomlin
Network Delivery Lead
Northern England Strategic Clinical Networks
NHS England
Tel no: 01138 251629 Mobile: 07980729760
Email: racheltomlin@nhs.net

Presentations for this event will be
available on Slideshare:
http://www.slideshare.net/NHSIQ
Follow us on Twitter @NHSIQ

Scn cvd-network-meeting-jan-2015

More Related Content

What's hot

Viewers also liked

Similar to Scn cvd-network-meeting-jan-2015

More from NHS Improving Quality

Recently uploaded

Scn cvd-network-meeting-jan-2015