Thames Valley Strategic Clinical Network & Clinical Senate: The Road to 2020
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Thames Valley Strategic Clinical Network & Clinical Senate: The Road to 2020
Contents
Introduction: What is the Thames Valley Strategic Clinical Network? 4
Partnership wheel 6
1. Commissioning guidance 7
2. Cancer network 8
3. Children’s network 14
4. Diabetes network 18
5. End of Life network 22
6. Long Term Conditions 25
7. Maternity network 28
8. Mental Health, Dementia and Neurology network 32
9. Stroke network 38
10. Vascular network 40
11. Clinical Senate 42
3
Introduction: What is the Thames
Valley Strategic Clinical Network
and Clinical Senate?
Milton Keynes
Banbury
Bicester
Witney Aylesbury Acute Trusts: 4
Oxford
High
Wycombe
Abingdon
Swindon
Slough
Newbury Reading
Bracknall
GP Practices: 274
Thames Valley Mental Health Community
Population: Trusts: Hospitals:
2.4 million 2 18
4
The Road to 2020
Cancer Diabetes
4,400
Reduce 80% more newly
smoking of cancers diagnosed
d patients
prevalence to staged rreceiving
e structured
10.8% patient
education
(a 30% reduction)
Additional Every GP
1,400 people 450
450
practice in Thames
fewer lower
surviving
s cancer Valley meeting
limb amputations
for 10 years 40% achieving the
across Thames
or more three treatment
Valley
targets
Mental Health, Dementia & Neurology Long Term Conditions
and End of Life
5,000 100% of
more people with all acute hospitals (LTC) - 80%
Serious Mental in Thames Valley have of patients
Illness (SMI) all-age Mental Health having care &
receiving physical Liaison services in support planning
health checks 90% of A&E and inpatient (EoLC) - 10% consultations
individuals with wards increase across
dementia to have Thames Valley of
patient-centred death in place
care & support of usual
plans residence
Stroke
Strok
ke Maternity Children
200 3,000
fewer 1,300 more children
m
strokes
s in TV seen
s in MH
more women n to
o
services in
be seen by Perinatal
Thames
Th Valley
850 Mental Health
additional patients services in TV
in TV experiencing Children
with Eating
stroke symptoms will Reduce
Disorders seen
be taken to a HASU stillbirths
within 4 weeks/
for the first 72 hours by 20% 1 week for
of their stay in (4.1 per 1000
urgent cases
hospital in TV)
5
Partnership wheel
He
alt
hw
atc
tic al
h
ac n
e
Pr tio
NHS England
st na
Specialised Patients
Be ter
In
Commissioning
NHS England
National Clinical Third Sector
Leadership
Public Health
NHS England
England & Local
Medical Directorate
Authorities
TVSCN &
Senate
NHS England Academic Health &
inno mia &
Acad
Assurance Science Network
vatio
e
n
Sustainability &
Transformation Provider Trusts
Plans
NHS England Clinical
GP Forward Commissioning
View Groups
Primary Care
6
Commissioning guidance
Vision
Building on previous iterations of the TVSCN The web portal has allowed a more accessible method of
Commissioning Guidance, we created an intuitive, showing how the priorities would inform and align to
user friendly website version of previous guidance to the strengthened two year CCG operational planning
commissioners, to ensure a comprehensive capture of process (September-December 2016) as well as
benchmarking information across the patch, linked to Sustainability & Transformation Plans (STP).
national and local priorities. The commissioning guidance Due to the further enhancements to the website we have
not only described ‘what’ commissioners should focus on, developed stronger partnerships with arm’s length bodies to
but also ‘how’ to go about achieving this. It linked to best provide commissioners with a more comprehensive offering.
practice guidance, showed quality and financial savings As a result, the public health interventions relating to individual
where available, and linked directly to reports delivered clinical networks now provide calculation and scale of challenge
by the networks on current status and recommendations. and opportunity. Customised data packs are also provided at a
CCG and practice level to quantify potential gains.
NEW: Prevention More in-depth content
section covering
Targeted advice Improved Healthier
tackling unhealthy patient workplace
behaviours pathways
• Quantified scale of challenge/opportunity
on interventions and redesign
• Detailed breakdown of national strategies
and priorities
• Customised data packs per CCG and
practice level
PPrevention
ti Screening
S i
Dynamic
Sessions Users
1,357 916 experience...
Pages / Session New Session
2.44 67.50%
Engaged users
Avg. Session Duration
00:02:27
Pageviews
3,315
Assessment M
Management t
& Diagnostics & Treatment
7
Cancer network Vision Ensuring optimal provision of diagnosis, treatment, care and outcomes for all cancer patients in Thames Valley by increasing early diagnosis, improving outcomes and providing high quality services. Why is it needed? Cancer is the most common cause of premature death (
Accurate staging
More accurate staging data allows for quality improvement initiatives to be targeted appropriately. The SCN worked with
clinicians in primary and secondary care settings to ensure accurate recording of cancer staging during Multi-Disciplinary
Team meetings. The network is aiming to have 80% of all cancers staged by the year 2020.
90
80
70
60
Percentage
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40
30
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2012 2013 2014 Target
Percentage of cancer cases with recorded stage at diagnosis
Source: Public Health England’s National Cancer Intelligence Network: Cancer Analysis System
2014 Additional patients for all CCGs
% recorded No of patients Achieving Achieving Achieving
recorded 70% 75% 80%
England 75.9 225,016
TVSCN 69.7 8,724 332 738 1,282
NHS Aylesbury Vale CCG 66.8 713 34 87 141
NHS Chiltern CCG 66.3 1,148 64 150 237
NHS Milton Keynes CCG 65.9 779 48 108 167
NHS Oxfordshire CCG 77.1 2,551 - - 95
NHS Swindon CCG 76.0 822 - - 44
NHS Newbury & District CCG 67.9 363 12 38 65
NHS North & West Reading CCG 64.2 314 28 53 77
NHS South Reading CCG 65.8 256 16 36 55
NHS Wokingham CCG 68.8 559 10 51 91
NHS Bracknell & Ascot CCG 63.7 403 40 72 103
NHS Slough CCG 64.5 321 28 53 77
NHS WAM CCG 63.4 495 52 91 130
Average staging completeness across Thames Valley
2014 data is based on Public Health England’s National Cancer Intelligence Network: Cancer Analysis System
9
Earlier staging
Diagnosing cancer at an early stage dramatically improves a patient’s survival chances. Recording the percentage of
cancers diagnosed at stages 1 and 2 gives a good overview in order to assess improvements in cancer survival rates,
and allows for the appropriate treatment and care of patients.
The percentage of cancers diagnosed early (stages 1 and 2) has been steadily increasing, indicating that cancers
are being diagnosed earlier.
2014 Year 2020
TV Range Best CCG % of all % of cancer
cancers staged
Early stage 1 & 2 40% 30-44% 49% 60% 75%
Late stage 3 & 4 30% 25-33% 35% 20% 25%
Unstaged 30% 23-37% 16% 20%
Cancer staging targets to the year 2020
In practice, early staging of cancers such as lung, colorectal and ovarian cancers saves lives and money. By staging lung
cancer early, up to 70 years of life for 1,161 lung cancer patients across Thames Valley could be saved.
Thames Valley (current) Thames Valley (using best in England)
Median % Patient Years of % Patient Years of Years of Months of
survival diagnosed numbers life diagnosed numbers life life gained life gained
(months) at stage at stage
Stage 1 22.5 19.7 229 429 22.2 258 483
Stage 2 10.9 8.8 102 93 11.8 137 124
Stage 3 6.5 19.3 224 121 18.9 219 119
Stage 4 2.6 52.2 606 131 47.1 547 118
Total 1,161 775 1,161 845 70 844
Note: Data in this table is based on the Saving Lives, Averting Costs report by Cancer Research UK
Years of life saved by diagnosing lung cancer at stages 1 & 2
10Staging colorectal cancer early could save £800,790.
Thames Valley* England
Colorectal Cost of No of patients Current % Best in No of aditional Cost
treatment by in 2014 England % patients at stage in difference
stage (including scenario (£)
recurrence) (£)
Stage 1 3,749 212 17.5 18.6 14 51,751
Stage 2 9,812 339 27.9 44.4 200 1,962,557
Stage 3 13,977 351 28.9 21.1 -95 -1,325,663
Stage 4 12,519 312 25.7 15.9 -119 -1,489,436
-800,790
Total 1,214 100 100
savings
* Thames Valley colorectal cancer including colon and rectal cancers
Note: Data in this table is based on the Saving Lives, Averting Costs report by Cancer Research UK
Model limitations: Thames Valley colorectal cancers include both colon and rectal cancers; there are no further breakdown details
of colon staging in Thames Valley. This model excludes unknown or not staged cancers and the resulting cost implications.
Money saved by diagnosing colorectal cancer at stages 1 & 2. Based on Saving Lives, Averting Costs: An analysis of the financial
implications of achieving earlier diagnosis of colorectal, lung and ovarian cancer. A report prepared for Cancer Research UK
(September 2014).
And staging ovarian cancer early could save £764,003 across Thames Valley.
Thames Valley England
Cost of No of patients Current % Best in No of additional or Cost
treatment by in 2014 England % reduced patients at difference
stage (including stage in scenario (£)
recurrence) (£)
Stage 1 6,832 75 33.5 59.6 59 399,699
Stage 2 18,840 12 5.4 9.4 9 170,615
Stage 3 23,483 81 36.2 19.4 -38 -881,646
Stage 4 15,081 56 25.0 11.6 -30 -452,671
-764,003
Total 224 100 100
saving
Note: Data in this table is based on the Saving Lives, Averting Costs report by Cancer Research UK
Model limitations: This model excludes unknown or not staged cancers and the resulting cost implications.
Money saved by diagnosing ovarian cancer at stages 1 & 2. Based on Saving Lives, Averting Costs: An analysis of the financial
implications of achieving earlier diagnosis of colorectal, lung and ovarian cancer. A report prepared for Cancer Research UK
(September 2014).
11Reducing smoking
Smoking rates in Great Britain have halved in the last 35 years, declining steadily since the 1970s. Current smoking rates
are at 18.4% of the population, but smoking remains the leading cause of preventable death and disease in England.1
The Thames Valley area has a smoking prevalence of 15.4%, below the national average, and the network is targeting
a further reduced rate of 10.8% by 2021.
Projection of Thames Valley population in 2021 2,188,200
Projection of number of smokers aged >15 years old in Thames 236,574 Achieving 30% reduction in smoking
valley population to meet 30% reduction target by 2020 prevalence by 2020
Total reduction in number of smokers 110,720
Source: QOF 2015/16 for patients aged 15 or over who are recorded as current smokers and ONS population projection
Improving urological cancer services in Thames Valley
In 2013, the Cancer Peer Review process identified that there were serious concerns with the Thames Valley service
configuration for specialist surgery for prostate, bladder and kidney cancer. The peer review team raised specific
concerns with operations being carried out across two locations: Royal Berkshire Hospital (RBH) and Heatherwood
and Wexham Park (HWP) rather than one location as recommended in the Improving Outcomes Guidance (IOG) for
urological cancer. The review also highlighted problematic working relationships within the Berkshire Specialist Urology
Multi-Disciplinary Team (SMDT).2
The Thames Valley SCN established a project to develop a service model for specialist prostate, bladder and kidney
cancer surgery in Thames Valley that was compliant with the targets outlined by the peer review team.
In order to carry this out, the SCN successfully did the following:
Facilitated mediation
Developed case for Effectively repatriated
to improve working
changing the current radical cystectomy
relationships within
service configuration services to RBHT
the SMDT
Improved data Developed clinical
collection, both Appointed impartial quality metrics to
retrospective and external clinical advisor measure and assess
current impact of repatriation
By April 2014, the Berkshire-wide compliant cystectomy Pre Post
service was in place. The SMDT established a working
Sample size 30 22
environment that operated at a level beyond professional
cordiality and dedication to improvement. Surgeries now Average patient age 65.1 69.6
take place at one location (RBH), and the change has been Surgical technique
a success in terms of both collaboration and ensuring Open 100% 68%
patient care. Robotic 0% 32%
An audit of pre- and post-repatriation shows the Average length of stay 9.8 days 8.9 days
following results: 30 day mortality 7% 5%
90 day mortality (excluding 30 day) 0% 0%
Pre- and post-repatriation audit results
1
Achieving World-Class Cancer Outcomes: A Strategy for England 2015-2020, http://www.cancerresearchuk.org/sites/default/files/achieving_world-
class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf (last accessed 15th December 2016)
2
Peer Review Visit Report for Royal Berkshire Specialist Urology MDT.
12The future for the cancer
network
Demand on cancer services is increasing due to the steady
rise of both new diagnoses and the number of patients
who survive. Whilst the workforce has absorbed these
increases so far, service quality has dropped which has
been reflected in the increasing delays in delivering test
results to patients. Across the country, more than a third of
radiologists are aged 50 or over, and around a quarter will
be approaching retirement age in the next ten years.3 The
cancer network is planning to undertake an assessment
of the Thames Valley workforce to understand the current
situation, and develop plans to manage the recruitment
and retention of fully-trained staff.
3
Guidance Summary: National Reports Focused on Cancer 2014-2015.
13Children’s network
Vision Why is it needed?
The aim for Thames Valley is to create an environment The impact of mental wellbeing problems in the early years is
where children and young people have the opportunity to highlighted by the evidence that 75% of adults with mental
grow up happy, safe and healthy within resilient families. ill health will have started to experience issues before the age
Good mental health is a vital part of that. The vision is for of 18 years old. Despite this evidence, as a health service we
children and young people to grow up resilient, have good may be reaching as few as one in four children and young
mental health and if they need help know how to access people with problems that could be helped.
high quality, timely services.
50% of lifetime mental illness (excluding dementia) starts by age 14
Started mental illness Not started mental illness
The onset of lifetime mental illness1
In addition to the ethical and moral reasons for better services, there is also a powerful economic impetus given that
children with serious conduct disorders are twice as likely to leave school without any qualifications, three times more
likely to become a teenage parent, four times more likely to become dependent on drugs and 20 times more likely to end
up in prison; the monetary cost to the health service, the benefits system and the justice system is high.2
The Future in Mind report3 articulates how we need to set about tackling the problems to create a system that brings
together the potential of the internet, schools, social care, the NHS, the voluntary sector, parents, and children and
young people themselves.
1
Kim-Cohen J, Caspi A, Moffitt TE et al. Prior Juvenile Diagnoses in Adults With Mental Disorder: Developmental Follow-Back of a Prospective-
Longitudinal Cohort. Arch Gen Psychiatry. 2003;60(7):709-717; Kessler RC, Berglund P, Demler O et al. Lifetime Prevalence and Age-of-Onset
Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602; Kessler RC, PG Amminger,
Aguilar-Gaxiola S et al. Age of Onset of Mental Disorders: A Review of Recent Literature. Curr Opin Psychiatry. 2007 July; 20(4): 359-364.
2
Five Year Forward View for Mental Health. https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf
(last accessed 16th December 2016)
3
Future in Mind: Promoting, Protecting and Improving our Children and Young People’s Mental Health and Wellbeing. https://www.gov.uk/government/
uploads/system/uploads/attachment_data/file/414024/Childrens_Mental_Health.pdf (last accessed 16th December 2016)
14There are five core themes:
• Promoting resilience, prevention and early intervention;
• Improving access to effective support: a system without tiers;
• Care for the most vulnerable;
• Accountability and transparency, and;
• Developing the workforce.
Seeing more children in mental health services
In Thames Valley an additional 3,000 children and young people will be able to access evidence-based treatment by 2020/21.
Estimated 2016/17 2017/18 2018/19 2019/20 2020/21
prevalence *
England 711,674 21,000 35,000 49,000 63,000 70,000
Thames Valley 29,866 881 1,469 2,056 2,644 2,938
NHS Milton Keynes CCG 3,964 117 195 273 351 390
NHS Aylesbury Vale CCG 2,456 72 121 169 217 242
NHS Chiltern CCG 3,824 113 188 263 339 376
NHS Oxfordshire CCG 7,874 232 387 542 697 774
NHS Bracknell & Ascot CCG 1,753 52 86 121 155 172
NHS Slough CCG 2,377 70 117 164 210 234
NHS Windsor, Ascot & 1,652 49 81 114 146 163
Maidenhead CCG
NHS Wokingham CCG 1,706 50 84 117 151 168
NHS North & West Reading CCG 1,231 36 61 85 109 121
NHS South Reading CCG 1,593 47 78 110 141 157
NHS Newbury & District CCG 1,437 42 71 99 127 141
* Estimated prevalence of any mental health disorder, aged 5-16 in 2014 (source: PHE Fingertips - Children’s and Young People’s Mental
Health and Wellbeing)
Seeing how the service is working
The SCN is working with the CYP mental health system to understand not only the number of children and young people
being seen, but also if the services are improving.
1. Reduced waiting times
A key priority for the SCN is to ensure that the waiting times for children and young people are reducing, and to understand
where there are common themes; within Thames Valley, this means focusing attention on the number of CYP with autism.
Autism - Waiting Q2 2016-17 Trajectory 2020
times to diagnosis
Waits W Berks Bucks Oxon E Berks MK
average wait (days) 259 107 128 awaiting awaiting
info info
Number of patients % % % %
waiting
0 - 4 weeks 171 12.3 34 10 54 10 100%
4 - 6 weeks 77 6.4 15 4 22 4
6 - 8 weeks 12 3 22 4
8 - 10 weeks 157 13.0 27 8 31 6
10 - 12 weeks 23 7 25 5
> 12 weeks 795 66.3 235 68 367 70
152. Timely intervention for eating disorder interventions
The aim is for 95% of children and young people with eating disorders to be seen within four weeks, or one week for
urgent cases, and ultimately reduce the number of tier 4 eating disorder admissions. A national minimum data set will
be released in April 2017 and will form the basis on which progress will be monitored and a trajectory agreed.
3. Improving experience
The SCN needs to hear from children and young people and their carers to understand if the experience is improved,
and defining what an improved experience consists of. All CCGs to have in contract with providers a young person’s
forum/ group.
4. Referral to acceptance rates
Improving transparency and accountability across the whole system to ensure children are referred to the right service
at the right time, improving the area’s referral to acceptance rates. This baseline data will be released in the data set.
Improving quality of care during transition
from children to adult services
Transitioning from children to adult Outcomes
services can lead to poor quality of care
and condition management
Greater collaboration
across Local Authority,
Health & Social Care
Taking learning from...
TVSCN Guidelines & process
supported ensures safe transition
from paediatric to
adult services
with Transition Nursing
capacity to implement
For patients aged
13-18 to support Ensures vulnerable
readiness for transition patients stay visible in
to adult services the system
16Ready Steady Go is a transition tool system, developed The feedback for the trial has been very positive:
by Southampton Children’s Hospital, and is designed to
encourage collaboration between clinicians, patients,
and parents to establish the patient’s needs and to “The RBFT Transition Plan means
communicate these clearly between children and adult
long term condition services (e.g. diabetes, endocrinology,
there are clear guidelines to allow
cardiology etc). us to safely transfer patients from
The transition from children to adult services is currently paediatric to adult services…I have
not standardised across the country, and young patients found the Transition Nurse to be a
can fall through the gaps when they become the sole point very valuable resource.”
of contact for arranging and attending appointments.
Epilepsy Clinical Nurse Specialist
Self-management of long term conditions can decline in
the late teens; diabetes management in particular can “The RBFT Transition Nurse has
become poor when a young person becomes responsible provided a wealth of information,
for managing their own food and medication intake, and
emergency presentations of diabetes increase during this time. support and advice.”
CHC Paediatric Nurse Assessor
The TV SCN funded a three year, two phase project to set
up a transition steering group, publish a transition policy,
“The appointment of the RBFT
and implement Ready Steady Go.
Transition Nurse has resulted in an
1. Set up a transition steering group explosion of joint working with the
The TV SCN Transition Nurse created a transition steering Local Authority, health and social
group that began in February 2015 and meets every two
months to map transition pathways, write policy, and ensure
care in the west of Berkshire.”
that new specialities are complying with those policies. Special Educational Needs (SEN) Team Manager
2. Publish a transition policy
The policy was completed in January 2016, published
on the SCN website, and will be used for rolling out the
transition principles across the Thames Valley area.
The scheme has reduced instances of missed appointments
and encouraged attendance at adult clinics, helped
3. Implement Ready Steady Go
vulnerable patients to stay visible in the health and social
The TV SCN Transition Nurse based in RBFT identified care system, ensured correct and needed diagnostic
60 patients with a long term condition aged 13-18 who procedures to take place, and ensured adult services had
attended one of eight clinics and worked with them to a better understanding of patient needs.
implement the Ready Steady Go system.
The progress of the project was measured against a
Commissioning for Quality and Innovation (CQUIN)
The future of the network
Indicators: The network plans to continue its work by creating a
system that is transparent, accountable and competent,
Indicator Target End of Q2 and that always has the child and their family at the centre
audit results of everything it does.
(16/17)
This system will be run by a resilient and competent
Patients to have a transition 50% 83% workforce who not only know how to identify a child’s
plan in their notes presenting issues but also respond in good time and
prevent escalation to crisis services. The staff will know
Patients to have a 50% 73%
what interventions to use, who to call and how to access
named transition worker
further help when needed, so that a child, with the right
documented in their notes
support can develop the tools and resilience needed for
CQUIN indicators for the Transition Project better mental health and wellbeing, and take these with
them into adult life.
The system will also be built on good practice examples, and
will create learning and development environments that will
bring about long-term, sustainable cultural change.
17Diabetes network
Vision Why is it needed?
To deliver a step-change in diabetes care for the patients of In Thames Valley just under 1,000 people will die early
Thames Valley through prevention, patient education and from type 2 diabetes; a disease which has been shown
delivery of diabetes care standards. By 2020, the network to be preventable in many cases. At present, we have
plans to have every GP practice in the area reaching the 42,000 people with diabetes whose HbA1C (long-term
target of at least 40% of patients achieving the three blood sugar) isn’t controlled; 30,000 whose cholesterol
treatment targets (controlled blood pressure, controlled isn’t controlled; and 30,000 whose blood pressure isn’t
cholesterol level, controlled long-term blood sugar level) controlled. Type 2 diabetes also accounts for 9% of the
on a regular basis. total NHS spend.
The National Diabetes Audit (NDA) is an annual national
clinical audit, which measure the effectiveness of diabetes
healthcare against NICE Clinical Guidelines and NICE
Quality Standards. Thames Valley outperforms the national
rate for audit completion, with 94% of TV GP practices
completing the audit compared to 81% across England,
which means that the data on which the network can
base improvements is strong.
Three treatment targets
By 2020, at least 40% of patients with diabetes in every
GP practice in Thames Valley will receive the three
treatment targets on a regular basis. Achieving this
ambition will mean that 54,343 people in Thames Valley
will have their diabetes better controlled, which will
improve outcomes and reduce complications.
CCG No of Average CCG Percentage of No of people
practices performance % practices achieving required to
submitted less than 40% reach 40%
NHS Aylesbury Vale 19 44.4 26 4780
NHS Chiltern 34 44.8 12 7724
NHS Oxfordshire 68 38.8 66 14195
NHS Milton Keynes 24 38.8 58 5562
NHS Bracknell & Ascot 15 44.2 13 2866
NHS Slough 16 42.6 31 5164
NHS Windsor, Ascot & Maidenhead 16 42.0 50 2859
NHS Wokingham 13 37.8 62 3337
NHS North & West Reading 10 37.5 80 2472
NHS South Reading 15 37.1 60 2751
NHS Newbury & District 10 34.0 80 2633
Total 54343
Note: For patientsDiabetic structured patient education
By 2020, at least 50% of all newly diagnosed patients with diabetes will receive structured patient education. Based on an
assumption that the Thames Valley diabetes prevalence will grow a further 6% by 2020, with our population size growing
a further 5.4%, we anticipate having over 4,400 newly diagnosed diabetes patients who will require structured patient
education. The network will also monitor patients with prevalent diabetes who are offered structured patient education.
2013/2014 2014/2015 Additional
patients to attend
Area % of patients % of patients Number of
course to reach
who attended who attended newly diagnosed
50% by 2020/21
structured structured patients
education course education course
2013/2014 2014/2015
England 5.6 5.7 144,352 75,000
TV SCN 4.6 4.8 8,287 4,400
NHS Milton Keynes 0.5 0.5 389 200
NHS Aylesbury Vale 13.7 9.3 863 460
NHS Chiltern 6.1 3.9 1,445 770
NHS Oxfordshire 5.1 4.9 1,845 970
NHS Bracknell & Ascot 0.0 1.7 470 250
NHS Slough 1.3 0.2 873 470
NHS Windsor, Ascot & Maidenhead 1.4 2.5 518 270
NHS Wokingham 4.5 5.9 461 240
NHS North & West Reading 2.0 10.4 461 250
NHS South Reading 4.3 11.5 541 290
NHS Newbury & District 0.5 2.1 421 230
2020 target for structured patient education, broken down by CCG. Based on 2013/14 & 2014/15 National Diabetes Audit
16 % of patients who attended structured education course 2013/2014
14 % of patients who attended structured education course 2014/2015
12
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19Diabetic footcare
By 2020, the network plans for the amputation rate across Thames Valley to match that of the best CCG in England,
which is a rate of 0.6 amputations per 1,000 people with diabetes. This would result in 450 fewer people in TV
undergoing amputation as a result of this improvement. The target is ambitious (over 50% fewer amputations for all
CCGs), but Thames Valley is well placed having established a Good to Great footcare pathway that has been accepted
across the system and is now being rolled out across the area.
April 2012 – March 2015 Achieving the best CCG within Thames Achieving the best CCG within
Valley (1.3 per 1000 people) England (0.6 per 1000 people)
Rate per Number of Number of Number of % reduced Number of Number of % reduced
1000 cases cases to be cases cases to be cases
people reduced reduced
Lowest CCG
0.6
in England
Highest CCG
4.9
in England
England
2.6
average
NHS Aylesbury
2.7 74 38 36 51.9 58 16 77.8
Vale CCG
NHS Bracknell
1.3 22 0 22 0.0 12 10 53.8
& Ascot CCG
NHS Chiltern
2.1 94 36 58 38.1 67 27 71.4
CCG
NHS Milton
2.9 101 56 45 55.2 80 21 70.3
Keynes CCG
NHS Newbury
2.0 25 9 16 35.0 18 8 70.0
& District CCG
NHS North &
1.8 21 6 15 27.8 14 7 66.7
West Reading
NHS
Oxfordshire 1.9 153 48 105 31.6 105 48 68.4
CCG
NHS Slough
2.0 53 19 34 35.0 37 16 70.0
CCG
NHS South
2.1 30 11 19 38.1 21 9 71.4
Reading CCG
NHS Windsor,
Ascot &
1.4 27 2 25 7.1 15 12 57.1
Maidenhead
CCG
NHS
Wokingham 2.0 33 12 21 35.0 23 10 70.0
CCG
TVSCN 633 236 397 37.3 450 183 71.1
Amputations per 1,000 people aged 17+ with diabetes
Source: Diabetes Footcare Profile
20Thames Valley footcare pathway
Diagnosis of diabetes
Manage diabetes and
Book in to have formal foot
cardiovascular risk as per
Specific foot related education (A) examination (C) at surgery
local policy and initiate care
within 12 weeks
planning process
Refer for Formal Structured
Education according to local Immediate footcare examination
policy which will include (B) if a problem is noted
footcare advice
Assign risk status, and follow
appropriate pathway.
Give leaflet corresponding
with contact details
Thames Valley diabetic footcare pathway
The Thames Valley diabetic footcare pathway has been
successfully integrated into GP IT systems across the area.
Diabetes Transformation
The TV footcare best practice work that led to the creation
of the pathway has been recognised by the Vascular All
Programme
Party Parliamentary group.1 Buckinghamshire CCG developed a Diabetes
Transformation Programme which aimed to increase
the numbers of uncomplicated patients with diabetes in
primary care rather than secondary care. Also implementing
the Care and Support planning and the House of Care
models, Buckinghamshire developed their work further and
created a mentorship programme across practices, set up
nurse specialist-led virtual clinics, and has begun work on
targeting patients who present at accident and emergency
with undiagnosed diabetes, specifically those with active
foot ulceration.
The future for the network
In order to put Thames Valley on the map with regards to
quality standards, the network will be focusing on diabetes
prevention, treatment standards, footcare and inpatient
care and will be supporting each with NHS England
Reporting to the Vascular All Party Parliamentary group
transformation money (available 2017).
1
http://appgvascular.org.uk/media/events/2016-02-meeting/APPG%20Vascular%20Disease%20Feb%201%20-%20Meeting%20Minutes.pdf
(last accessed 19th December 2016)
21End of Life (EoL) Network
Vision
Our vision is for people at end of life to receive optimal care. We will achieve this by promoting the needs of people
at end of life, to all health and social care providers and by supporting Thames Valley commissioners to be expert
commissioners of End of Life Care (EoLC).
The network aims are to ensure that:
CCGs have robust plans for EoLC based on Ambitions for Palliative
and End of Life Care1
CCGs measure improvements in EoLC:
Choice in place of care and death Provision of advanced care plans
Decisions around Do Not Attempt Cardio Pulmonary Use of Electronic Palliative Care Coordination Systems
Resuscitation (DNACPR) (EPaCCS)
Provision of 24/7 services Specialist palliative care services
Acute providers engage in the enablers identified in the Transform2 programme:
Advance Care Planning (ACP) Electronic Palliative Care Coordination Systems (formerly
known as end of life care locality registers)
AMBER care bundle Rapid Discharge Home
Priorities of Care from ‘One Chance to Get it Right’*
*One Chance to Get it Right: Improving People’s Experience of Care in the Last Few Days and Hours of Life.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/323188/One_chance_to_get_it_right.pdf
(last accessed 20th December 2016)
CCGs integrate EoLC into other work programmes:
Frail elderly Urgent and emergency care
Long term conditions New models of care
Out of hospital care Transforming primary care
Personalisation 24/7 services
1
http://endoflifecareambitions.org.uk/ (last accessed 20th December 2016)
2
Transforming End of Life Care in Acute Hospitals: The Route to Success ‘How To’ Guide (revised December 2015). https://www.england.nhs.uk/wp-
content/uploads/2016/01/transforming-end-of-life-care-acute-hospitals.pdf (last accessed 20th December 2016)
3
Actions for End of Life Care: 2014-16. https://www.england.nhs.uk/wp-content/uploads/2014/11/actions-eolc.pdf (last accessed 20th December 2016)
4
Actions for End of Life Care: 2014-16. https://www.england.nhs.uk/wp-content/uploads/2014/11/actions-eolc.pdf (last accessed 20th December 2016)
5
Dying Without Dignity. http://www.ombudsman.org.uk/reports-and-consultations/reports/health/dying-without-dignity
(last accessed 20th December 2016)
6
Our Commitment to You for End of Life Care: The Government Response to the Review of Choice in End of Life Care. https://www.gov.uk/government/
uploads/system/uploads/attachment_data/file/536326/choice-response.pdf (last accessed 20th December 2016)
22CCGs to have local measures to capture patient and Previous work has demonstrated the need for a focused
carer experience. approach on end of life care. In particular, ‘Dying without
Dignity’ report5 and the geographical variation in patient
CCGs implement routine reporting at board level to
experience of care as evidenced in VOICES surveys and data
monitor progress with service initiatives including local
on CHC funding for patients in the last months of life.
measure which capture patient and carer experience.
It is recognised that the impact on the wider healthcare
Workforce education in EoLC is available and accessible
system is considerable; suboptimal end of life care
for all health and social care staff and offered through
contributes to inappropriate health costs due to poor
workshops based on the principle that ‘end of life care
care planning, and in addition can contribute to potential
is everybody’s business’.
long term morbidity for those important to the patient,
i.e. family and carers.
Why is it needed? The Government’s response to the Choice review6 will
Providing high quality end of life care is an important require ongoing work in end of life care and the network
priority for the NHS, defined as ‘improving the is in a strong position to influence those changes.
effectiveness, safety and experience of care for adults
approaching the end of life and the experience of their
families and carers’.3
Key metrics
Data is not collected at a local office or SCN level. This is
In 2013, overall quality of care across all services in the last
now being driven by the network and will form the metrics
three months of life was rated as outstanding or excellent
for future evaluation.
by 43% of respondents,4 highlighting that there is an
opportunity for improvement in 57% of cases.
Leading good End of Life care
TVSCN End of Life Care Vision - To enable Thames Valley
commissioners to become expert commissioners of End of Life Care
Commissioning Guidance highlightshts
national evidence and best practice on the
importance and gains of delivering 24/7
palliative and end of life care
National data AWC 2013 Bradford Bradford City GSF/Gold Line
England 2013 District 2013 2013 Year 2013/14
All deaths in hospital 48.3 36.0 45.9 50.4 14%
All deaths at home 22.4 20.1 24.5 23.1 41%
All deaths in care homes 21.6 33.2 19.0 19.7 22%
All deaths in hospice 5.5% 8.8 8.3 4.6 23%
Bucks CCG East Berks CCG
Local
Specific EOLC workstream in Wholesale adoption of guidance
Generalist
2 year Operating Plan: in 2 year Operating Plan:
✓ Incentive Schemes on Place of Death
Support
✓ 24/7 access service
✓ Provider Capacity Review ✓ Coordination hub
✓ Outcome based specification in
Local
✓ Community integrated team
development ✓ Provider Capacity Review
Specialist
✓ Patient Experience Support
23The Network has developed comprehensive guidance
for commissioning and delivering high quality end of
The future for the network
life care, which has been made available. The network The network is in a prime position to influence and
provides impartial, expert guidance via the Thames Valley support CCGs to develop and put in place local metrics
Commissioners Forum, and through direct contribution for assurance of services, including a focus on patient and
to locality groups. The network leads the Commissioner carer experience. There is also a need to collect data about
Forum for CCGs to share their local opportunities and specialist palliative care provision in response to the loss of
challenges and explore the possibility of implementing national data collection from 2017.
similar innovations. For example, Oxfordshire is now
Also, the network is looking to recommend routine
evaluating the possibility of a palliative care coordination
implementation of the Voices survey across all CCGs as
service and has implemented an anticipatory prescribing
a mechanism for assessing patient experience of quality
initiative for end of life medication aimed at all patients
of care, as measured by the carer which would allow for
in last year of life. The analysis of projects such as this can
benchmarking and highlighting the areas to be improved.
then be shared with other CCGs.
This would also allow evidence to be collated about service
The provision of 24/7 palliative and end of life care is a central provision which included the patient experience, which has
tenant of comprehensive care with two thirds of all end of so far been difficult to obtain at CCG level.
life requests for advice and support being out of hours. The
The network is in a prime position to influence the
SCN used the Commissioner’s Forum to debate and discuss
implementation of the national choice offer in end of life
this, and the commissioning guidance emphasised the clear
care, such as the six commitments that the government
benefits of providing such a service. Areas which provide
has made to the public to end variation in end of life care
this service drive up the percentage of people dying at home
across the health system by 2020.7
from a national average of 23% to 40%.
Successes
There have been a number of service innovations
improving EoL care in Thames Valley, in response to the
EoL focus promoted and maintained by the network,
as described below:
• East Berkshire CCG used the format and principles
within the network guidance to create the basis for their
operating plans;
• Advice and guidance on local incentive scheme for EoL
for Bucks, the Directed Enhanced Services (DES+) which
has enabled service improvements with better metric
and reporting for EoLC;
• Berkshire West and East developing service initiatives
with palliative coordination hubs;
• East Berks recently launched a 24/7 rapid response
nursing service alongside the hub, hosted by Thames
Hospice, to deliver a flexible, responsive face-to-face end
of life service that supports the whole community.
East Berkshire is also looking to launch a local
enhancement scheme to improve end of life care along
similar lines to the Bucks DES+.
7
Our Commitment to You for End of Life Care: The Government Response to the Review of Choice in End of Life Care. https://www.gov.uk/government/
uploads/system/uploads/attachment_data/file/536326/choice-response.pdf (last accessed 20th December 2016)
24Long term conditions
Vision
For the population of Thames Valley with long term conditions (LTCs) to experience a person-centred approach in their
care, through CCGs adopting Care and Support Planning (CSP), based on the House of Care framework.
Organisational and
supporting processes
Engaged, Health and care
informed professionals
individuals committed to
and carers partnership
working
Person-centred
coordinated care
Commissioning
The House of Care framework
For this to be truly effective, four aspects require equal
attention which the SCN has been working to achieve in
Why is it needed?
different areas of long term condition management: There are around 15 million people in England with long
1. Patients are engaged and informed; term conditions; this section of the population has the
greatest healthcare needs (50% of all GP appointments
2. Health professionals are committed to partnership
and 70% of bed days), and 70% of acute and primary
working;
care budgets are spent on their treatment and care. This
3. Organisational and supporting processes; situation is not expected to change, as the number of
4. Commissioning. people with three or more long term conditions is set to
increase to 2.9 million by 2018.1
By 2020, 80% of patients with a LTC will
experience a Care & Support Planning The NHS will need to adjust to this new demand by
consultation and 60% of patients will be working to introduce more joined up services, develop
predictive rather than reactive services, and increase the
confident in managing their own health.
amount of emotional and psychological support and
information for patients.
1
https://www.england.nhs.uk/ourwork/ltc-op-eolc/ltc-eolc/house-of-care/ (last accessed 14th December 2016)
25The Year of Care introduced Care and Support Planning
Care and support planning training in 2011.3 Since then, the Thames Valley SCN
Care and Support Planning recognises that people who LTC programme, in conjunction with HEETV, has been
live with long term conditions make the majority of the working to support CCGs to introduce CSP training to
decisions that affect their lives themselves, spending GP practices and integrated teams across the area. In 14
relatively little time with a health and/or social care months, 350 community healthcare practitioners (including
practitioner.2 CSP seeks to transform the brief contact practice nurses, family doctors, and community nurses)
that does occur into a meaningful and useful discussion - have completed the course. The breakdown of training
enabled by preparation of the patient and with a focus on completion is as follows:
looking forward and planning.
Chiltern 94%
Over the course of an individual’s lifetime the nature of
Aylesbury Vale 84%
these conversations may well change as their health profile
and their needs change. The aim is for CSP to become the Berkshire West 90%
usual approach to normal care, understood as a continuous
Bracknell & Ascot 100%
process - not a one-off event while supporting continuity
and planning to meet the changing needs of people. Berkshire East 86%
Note: All areas listed now have coordinators in post
Implementing Care and Support Planning
Care and Support Planning –
Training
TVSCN has provided Training to
enabling both the patient & 386 professionals across 136
the professional GP practices in the region
Prepared
Care and
Support Planning
Active Banbury
84%
Practices
– in CCG 2
year Operating
Penetration
A lesb
bur
ury
ry
Aylesbury
Informed Oxford Plan and STP
94%
Practices commitments
High
Hig
Hii h across region
+ 90%
Practices
Wycombe
Slough
100% Slo
ou
* 100% Bracknell &
Ascot CCG penetration
Newbury
New
ewb
ew bur
bur
uryy Reading
diinPractices*
g rate – Slough & WAM
CCGs in development
Continuity
Sustainability
Normal Care
TVSCN is working to deploy
coordinators to support
Adaptive Care
implementation, evaluation
and ownership at CCG level
2
Interpersonal Education in Person-centred Care for Long Term Conditions
3
www.yearofcare.co.uk (last accessed 19th December 2016)
26The SCN has developed from scratch the LTC programme, 3. Organisational and supporting
combining Care and Support Planning roll-out across
Thames Valley, with expert advice and guidance informing,
processes
shaping and leading in each area to ensure sustainability The SCN provides expert input directly to GP practices
and demonstration of impact and effectiveness. and teams post-training, and, in addition, mentoring
support to local CCG care planning coordinators. The
1. Patients are engaged and informed majority of CCGs have local coordinators in place to
support the implementation and evaluation of Care
The LTC programme provided a review and guidance on
and Support Planning.
patient education; it describes the current situation for
diabetes patient education and sets out the challenges of
a new perspective to help create a shift for diabetes self-
4. Commissioning
management education. It also provides current thinking The SCN is advising CCGs on sustainability and evaluation
with regards to modelling and provision of a range of of CSP. It has assisted in the development of incentive
education provision. schemes, provided guidance on evaluation and measures
of success, and advised on local sustainability plans.
2. Health professionals are committed
to partnership working The future for the network
The SCN has delivered a programme of training in care The network will work to realise the potential of the
and support planning for GP practices and integrated care principles of Care and Support Planning, by targeting the
teams to improve collaboration between patients and adoption of CSP across all CCGs in Thames Valley and
clinicians. The SCN has achieved the following: working towards allowing all patients with long term
• Between December 2014 and December 2016, 22 conditions to have CSP consultations as part of their
courses have been run, where each course includes an routine care. As well as benefitting patients, the network
initial one day training programme, with a follow-up that wants to enable healthcare practitioners from all settings to
lasts a day and a half. The courses have provided training ensure collaborative conversations are delivered as part of
for 386 healthcare professionals and 136 GP practices; standard care.
• This equates to over half of all practices having taken
up the offer of training for some of their staff;
• Four CCGs have over 90% of their practices
completing training;
• In terms of staff groups, this includes 133 GPs and
175 nurses who have received training.
27Maternity network
Vision Why is it needed?
The SCN vision for maternity services across Thames The network is developing maternity services that are safer,
Valley is the provision of excellent, evidence-based care more personalised, kinder, professional and more family
for women which will effect a positive, life-changing friendly.1 Two important aspects of this are reducing the
experience for women and their families. To do this, the number of stillbirths, and increasing access to perinatal
network will bring together people who have influence in mental healthcare.
their local area and their professional background who will
The Better Births report set out a vision for better postnatal
contribute to solving identified gaps in service provision
and perinatal healthcare, to address historic underfunding
and developing equitable and robust perinatal mental
and provision in these two vital areas which have a
health services across Thames Valley.
significant impact on the life chances and wellbeing of
women, babies, and their families.2
Reducing stillbirth rates are a key target for maternity
services across the country; in November 2014, the
Secretary of State for Health announced a new ambition
to reduce the rate of stillbirths by 20% by 2020.3
1
Better Births: Improving Outcomes of Maternity Services in England. A Five Year Forward View for Maternity Care. https://www.england.nhs.uk/wp-
content/uploads/2016/02/national-maternity-review-report.pdf (last accessed 16th December 2016)
2
Better Births: Improving Outcomes of Maternity Services in England. A Five Year Forward View for Maternity Care. https://www.england.nhs.uk/wp-
content/uploads/2016/02/national-maternity-review-report.pdf (last accessed 16th December 2016)
3
https://www.england.nhs.uk/ourwork/futurenhs/mat-transformation/saving-babies/ (last accessed 15th December 2016)
28Better access to perinatal mental health services
There is a national drive for 30,000 additional women in England to be seen by perinatal mental health services.
This equates to an increase of 1,338 women to be seen in the Thames Valley area.
Area 2015 live 2016/2017 2017/2018 2018/2019 2019/2020 2020/2021
births
England 664,399 500 2,000 8,000 20,000 30,000
TVSCN 29,638 22 89 357 892 1,338
Milton Keynes 3,882 3 12 47 117 175
Buckinghamshire 6,139 5 18 74 185 277
Oxfordshire 7,893 6 24 95 238 356
Berkshire West 6,029 5 18 73 181 272
Berkshire East 5,695 4 17 69 171 257
Targets for additional women to access perinatal mental health services by 2021, separated into CCG areas
Source: ONS births for England local authorities, 2015
Improving stillbirth rates
An audit into stillbirth in England found that half of all term, singleton, normally-formed antepartum stillbirths had at least
one element of care that required improvement and that may have made a difference to the outcome. The network is
looking to reduce stillbirth rates from 5.2 per 1,000 live births to 4.1 per 1,000 live births in the Thames Valley area.4
CCG 2014 stillbirths 2014 rate per 20% reduction of stillbirths
1,000 live births by 2020, per 1,000 births
England 3,047 4.6 3.7
TVSCN 152 5.2 4.1
NHS Milton Keynes CCG 15 4.0
NHS Aylesbury Vale CCG 7 3.0
NHS Chiltern CCG 27 7.4
NHS Oxfordshire CCG 33 4.3 The network will work
with partners to reduce the
NHS South Reading CCG 13 6.9
variation across the geography
NHS North & West Reading 10 8.3 to achieve this target.
NHS Newbury & District CCG 6 4.6
NHS Wokingham CCG 13 7.2
NHS Bracknell & Ascot CCG 3 1.8
NHS Slough CCG 14 5.4
NHS Windsor, Ascot & Maidenhead CCG 11 6.8
Present stillbirth rates in Thames Valley, and target stillbirth rates for 2020
Based on 2014 ONS still births
Establishing Local Maternity systems
The SCN is bringing together commissioners, providers and partners in designing and delivering maternity care in line
with “Better Births”.
4
Better Births: Improving Outcomes of Maternity Services in England. A Five Year Forward View for Maternity Care. https://www.england.nhs.uk/wp-
content/uploads/2016/02/national-maternity-review-report.pdf (last accessed 16th December 2016)
29Providing the care bundle
Saving Babies’ Lives is a care bundle designed to support providers, commissioners and professionals to take action to
reduce stillbirths. The SCN assessed each Trust in its jurisdiction to understand how much progress had been made in
providing the elements of the care bundle:
Buckinghamshire Frimley Health Milton Keynes Oxfordshire Royal Berkshire
NHS Trust Foundation Trust Foundation Trust Foundation Trust Foundation Trust
Element 1: Reducing smoking in pregnancy
Element 2: Risk assessment and surveillance for fetal growth restriction
Element 3: raising awareness of reduced fetal movement
Element 4: Effective fetal monitoring during labor
Progress of Trusts in implementing the four elements of the care bundle
Key: Completed and ongoing
Partially completed and action plan
The care bundle delivers four elements of care that are recognised as evidence-based and/or best practice:
• Reducing smoking in pregnancy;
• Risk assessment and surveillance for fetal growth restriction;
• Raising awareness of reduced fetal movement;
• Effective fetal monitoring during labour.
Delivering through the Perinatal Mental Health Network
Taking a lead for the Thames Valley in Perinatal Mental
Health Awareness & Additional Capacity aims of 2020 Training
Secured funding
to deliver regional
Bolstered Regional Perinatal Mental
Clinical Leadership Health programme
(Nursing & Psychiatry) in 2017
Wide-reaching network During 2015/2016 – Waiting
with members from Focus on
Data & Audit to Times have improved
service user, health
deliver national
professionals and
objectives
organisations
Bi-annual events to share Based on Bucks & Oxon service - OHFT 2015 data reported
mean wait 5 weeks, median wait 4 weeks.
National Thought Leadership
2016 data reports mean wait 3 weeks, median wait 2 weeks
to more than 250 attendees Source: Perinatal Data 2016 Thames Valley
across Thames Valley - NHS Benchmarking Network
30In January 2015, the SCN published the results of their aligns to the national agenda and to the draft perinatal
audit of perinatal mental health services in Thames Valley. competency framework. It will continue to support further
The report set four key recommendations: rounds of funding applications.
1. Develop training and specialisms in perinatal mental The collection of data and audit has been central to
health across different services; the network. The Thames Valley has developed a self-
2. Commission perinatal mental health services in assessment tool to audit against NICE quality standards for
accordance with NICE guidance; perinatal mental health, including perinatal IAPT (Improving
3. Establish a regional network of professional Access to Psychological Therapies), which is being
stakeholders; developed across the South of England.
4. Improve data collection relating to perinatal mental
health by all NHS providers.5 The future of the network
In the last 18 months, the SCN has made significant The network has clear ideas about the next steps for
progress in all these areas. maternity services.
The Thames Valley SCN Regional Perinatal Mental Health
Implementation of a regional maternity
Network was established in June 2015, working to support
the development of equitable access to specialist perinatal dashboard
mental health services across Thames Valley. To provide accessible, high quality and up to date
information about the quality and safety of perinatal
There has been significant investment and development
mental health services in Thames Valley.
of services in the perinatal locality networks since 2015,
ensuring that the region is working towards the national
commitment of increased access to 30,000 women by
A Thames Valley labour line
2020 across England. A 24/7 phoneline staffed by midwives to provide advice
and support to women who think they are in labour.
The regional network has been successful in bringing
to the table a wide range of professionals and services Diabetes in pregnancy
from each locality perinatal network and has supported
Benchmarking the management of diabetes in pregnancy
working together across Thames Valley with partner and
using NICE guidelines, and subsequently directing the SCNs
neighbouring organisations.
focus on service development.
It has hosted two conferences with national speakers
delivered to over 250 individuals. The network has recently Perinatal education
been successful in securing a bid for £100,000 for regional Developing and implementing a perinatal education
training in perinatal mental health, and has developed a programme for specialist perinatal mental health
training plan for 2017 to deliver this to specialist perinatal professionals across Thames Valley.
leads and to the wider audience working with or likely to
come into contact with women in the perinatal period. This
5
Thames Valley Children and Maternity SCN Perinatal Mental Health Report (March 2016). http://tvscn.nhs.uk/wp-content/uploads/2016/03/Final-
Thames-Valley-Perinatal-Mental-Health-Network-Report-2016.pdf (last accessed 15th December 2016)
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