1.30 Chair 2.0 1 - Clinical commissioning group...Draft Redbridge Clinical Commissioning Group Governing Body Meeting 28 January 2016 1.30pm. Boardrooms, Becketts House Present: Dr

NHS Redbridge Clinical Commissioning Group Governing Body meeting 24 March 2016

1.30pm Boardrooms, Becketts House, Ilford, IG1 2QX

Item Time Lead director Attached, verbal or to follow

1.0 1.1 1.2 1.3

Welcome, introductions and apologies Declaration of conflicts of interest Minutes of the meeting held on 28 January 2016 Matters/actions arising

1.30 Chair Attached Attached Attached

2.0

2.1 2.2

Chair and chief officer’s & patient experience reports Chair’s report Chief officer’s report

1.40 1.45

Chair TT

Attached Attached

3.0 3.1 3.2 3.3 3.4 3.5

Governing body assurance Governing body risk assurance framework report BHRUT performance risks Barts Health performance risks Delivery of IAPT operating plan standards Personal Medical services (PMS) review update

1.50 2.00 2.10 2.20 2.30

LM TT LM CO SS

Attached Attached Attached Attached

4.0 4.1 4.2 4.3 4.4

Corporate strategy and planning Operational Planning 2016/17-update on submissions 2016/17 Financial Planning Report Primary care strategy update CCG strategic direction 2016/17 and onwards

2.40 2.50 3.00 3.10

LM TT SS MP

Attached Attached Attached Attached

5.0 5.1

5.2

Service transformation and development Improving patient flow – front of A&E and supporting discharge business case Response Car - London Ambulance Service and Community Treatment Team business case

3.20

3.30

MM

MM

Attached

Attached

6.0 6.1 6.2 6.3

Quality and performance Patient experience report Finance and activity report Quality in commissioning report

3.40 3.50 4.00

MP TT JH

Attached Attached Attached

7.0 7.1

7.2 7.3 7.4 7.5

Development/governance Revisions to committee Terms of Reference and establishment of an auditor panel Use of the Clinical Commissioning Group’s seal Finance & delivery committee chair’s report Audit & governance committee chair’s report Minutes of sub – committees and relevant fora:

• Executive committee• Patient engagement forum• Joint executive team committee• Primary care committee

4.10

4.15 4.20 4.25 4.30

MP

MP KP KP

Attached

Attached Attached Attached

1

Item Time Lead director Attached, verbal or to follow

• Investment committee

8.0

AOB

4.35

9.0 Questions from the public

4.40

10.0 Date of next meeting – 25 May 2016

2

Glossary of terms and abbreviations

Term Explanation

AO Accountable Officer

ACO Accountable Care Organisation

ADL Activities of Daily Living

APC Area Prescribing Committee

ASH Accredited Safe Haven

BCF Better Care Fund

BHR Barking and Dagenham, Havering and Redbridge

BHRUT Barking, Havering and Redbridge University Trust

BPPC Better Payment Practice Code

CAPS Clinical Application Services

CCG Clinical Commissioning Group

CCS Complex Care Service

CDOP Child Death Overview Panel

CEO Chief Operating Officer

CFO Chief Finance Officer

CHC Continuing Healthcare

CHSCS Community Health and Social Care Services

CIL Community Infrastructure Levies

COB Corporate Objectives

COO Chief Operating Officer

CQC Care Quality Commission

CQRM Clinical Quality Review Meeting

CQUIN Commissioning for Quality and Innovation

CSU Commissioning Support Unit

CTT Community Treatment Team

3

CVS Council of Voluntary Services

CYPP Children and Young Person Plan

DI Discovery Interview

DOH Department of Health

DTOC Delayed Transfer of Care

ECG Electrocardiogram

EHC Education, Health and Care

EoI Expression of Interest

EOL End of Life Care

FNP Family Nurse Partnership

FT Foundation Trust

FYE Full Year Effect

GBAF Governance Board Assurance Framework

GP General Practitioner

H4NEL Health for North East London

HCAIs Healthcare Associated Infections

HE NCEL Health Education North Central and East London

HSC Health Scrutiny Committee

HWBB Health & Wellbeing Board

IAPT Improving Access to Psychological Therapies

ICC Integrated Care Coalition

ICM Integrated Case Management

ICSG Integrated Care Joint Health and Social Care Steering Group

IFR Individual Funding Request

IRS Intensive Rehabilitation Service

IST Intensive Support Team

JAD Joint Assessment and Discharge Service

JET Joint Executive Team

JHWS Joint Health & Wellbeing Strategy

JMT Joint Management Team

JSNA Joint Strategic Needs Assessment

4

KGH King George Hospital

KPIs Key Performance Indicators

LAC Looked After Children

LAS London Ambulance Service

LETB Local Education and Training Boards

LMCs Local Medical Committees

LPC Local Pharmaceutical Committee

LSCB Local Safeguarding Children’s Board

LTC Long Term Conditions

MASH Multiagency Safeguarding Assessment Hub

MLU Mid-wife Led Unit

MSRB Maternity Systems Readiness Board

NEL North East London

NELCSU North East London Commissioning Support Unit

NELFT North East London Foundation Trust

NHS National Health Service

NHSE NHS England

NICE National Institute for Health and Care Excellence

OFSTED Office for Standards in Education, Children’s Services and Skills

OD Organisation Development

ONEL Outer North East London

PALS Patient Advice and Liaison Service

PEFs Patient Engagement Forums

PELC Partnership of East London Cooperatives

PMCF Prime Minister’s Challenge Fund

PMO Project Management Office

POD Point of Delivery

POLCV Procedures of Limited Clinical Value

PPGs Patient Participation Groups

PSED Public Sector Equality Duty

PTL Patient Tracking List

5

QIPP Quality, Innovation, Productivity and Prevention

RAG Red. Amber, Green

RTT Referral To Treatment

SAB Safeguarding Adults Board

SCN Strategic Clinical Network

TDA Trust Development Agency

TSCL The Transforming Services – Changing Lives

TUGT Timed Up and Go Test

UCC Urgent Care Centre

UCL University College London

UCLP University College London Partners

VFM Value for Money

WELC Waltham Forest, East London and City

WICs Walk in Centres

YTD Year to Date

6

1

Register of interests 2015/16

Declaration of governing body members

Last updated: August 2015

Name Role Organisation Nature of interest

Amendment and date

Dr Anil Mehta

Chair

Fullwell Cross Medical Centre Metropolitan Police The cleaning company NHS England (Feb 2015) Healthbridge Direct (from September 2014) Fouress Enterprises Ltd

GP Partner Forensic Medical Examiner Owner - Sister in law GP Appraiser Shareholder Director

Dr Sarah Heyes

Clinical director

The Shrubberies Medical Centre Healthbridge Direct (from September 2014)

GP Partner/Principal Shareholder

Dr Muhammad Tahir

Clinical director Forest Edge practice, Hainault Health Centre

GP Partner

7

2


Amendment and date

Dagenham & Redbridge Football Club Redbridge local medical committee Healthbridge Direct (from September 2014)

Medical adviser & club doctor Member Shareholder

Dr Mehul Mathukia

Clinical director Mathukia surgery Cognicare (supported living provider) Valia Consultancy – Healthcare & research consultancy PELC NOCLOR and NIHR Healthbridge Direct (from September 2014)

GP Principal Director/Owner/Shareholder Director/Owner/Shareholder GP Locum GP research champion Share Holder

Dr Shabana Ali

Clinical director

Southdene Surgery

GP Partner/Principal. Daughter is receptionist/admin

8

3


Amendment and date

North East London Foundation Trust Avicenna Ltd Healthbridge Direct (from September 2014) BMA RCGP CVGP NHSE

GP with special interest in cardiology Director. Husband is also a director Shareholder Member Member (applying to become a member) GP appraiser (B&D CCG, Havering CCG)

Dr Samia Azeem Clinical director

Chadwell Heath surgery Redbridge CCG

Salaried GP Locum GP

Dr Chidi Okorie

Clinical director

Ilford Lane Surgery Partnership of East London Co-operative

GP Partner Working GP

Dr Syed Raza

Clinical director Chadwell Heath surgery Raza Syed Medical Ltd

Salaried GP Director

9

4


Amendment and date

(June 2014) Healthbridge Direct (from September 2014) Redbridge Fairness Commission (1 March 2015)

Shareholder Fairness Commissioner

Dr J. Sood

Clinical director Newbury Group Practice Redbridge CCG ESS Wanstead Ealing Hospital NHS Trust DMC Healthcare Soods Limited – Locum agency NHS England London Deanery

GP Partner GPwSI – Diabetes & Dermatology GPwSI – Diabetes & Dermatology GPwSI – Diabetes & Dermatology GPwSI – Diabetes & Dermatology Director. Husband is a partner GP appraiser GP trainer

10

5


Amendment and date

Imperial College Undergraduate GP trainer

Dr Heath Springer

Clinical director Willows Medical Practice Redbridge CCG Redbridge LMC Healthbridge Direct (from September 2014)

GP partner / Caldicott Guardian GP trainer Vice chair Member & Shareholder

Ah-Fee Chan

Secondary care consultant

North Middlesex University Hospital NHS Trust Nadia Medical Services Ltd (March 2015)

Consultant in Anaesthetics and Intensive Care Medicine Director of the company providing consultant services at a range of private facilities in London where practice privileges are given

Charles Beaumont

Associate Independent Lay Voting Member for Audit Committee and Individual Funding Request Panel

North Essex Partnership Foundation Trust

Non-Executive Director

11

6


Amendment and date

Conor Burke

Accountable officer

Your business works (not trading) Redbridge college

Director Former Audit committee member

Accenture UK Consultancy – removed 9/7/15

Louise Mitchell

Chief operating officer Richard House Children’s Hospice, Beckton

Personal interest - former employee

Tom Travers

Chief financial officer

Royal Free Foundation Trust

Wife works in finance department

Jacqui Himbury

Nurse director

Nursing, Midwifery Council

Nurse member – Fitness to Practice panels

Khalil Ali

Lay member

St Francis Hospice, Havering Dr Joseph’s GP practice, Collier Row, Romford

Spouse is donor/contributor Family GP

Spouse a donor to Cancer research – removed 10/8/15

Kash Pandya

Lay member - Governance

Hillcroft College for women, Surbiton Essex Ministry of Justice Advisory Committee Health & Safety Executive

Council Member and Audit Chair Lay Member for appointment magistrates Independent Audit Committee Member

12

7


Amendment and date

Her Majesty’s Inspector of Constabulary Brentwood Citizen’s Advice Bureau Havering CCG Barking & Dagenham CCG PricewaterhouseCoopers North Central London CCGs

Associate Inspector Generalist advisor Lay Member Lay Member Kiren Pandya (son) Management consultant Out of hours and 111 procurement panel chair

Added 25/8/15

13

Draft Redbridge Clinical Commissioning Group Governing Body Meeting

28 January 2016 1.30pm.

Boardrooms, Becketts House

Present: Dr Anil Mehta (AM) Clinical Director/Chair Dr Jyoti Sood (JS) Clinical Director Dr Muhammed Tahir (MT) Clinical Director Dr Chidi Okorie (CO) Clinical Director Louise Mitchell (LM) Chief Operating Officer Dr Heath Springer (HS) Clinical Director Jacqui Himbury (JH) Director of Nursing Conor Burke (CB) Accountable Officer Tom Travers (TT) Chief Finance Officer Khalil Ali (KA) Lay member – PPI Kash Pandya (KP) Lay member – Governance Dr Syed Raza (SR) Clinical Director Dr Ah Fee Chan (AFC) Secondary Care Consultant Dr Shabana Ali (SA) Clinical Director Dr Samia Azeem (SAz) Clinical Director In Attendance: Anne-Marie Keliris Company Secretary Vicky Hobart LBR Director of Public Health John Powell LBR Director of Adult Social Services & housing Cathy Turland Healthwatch Redbridge Apologies: Dr Sarah Heyes (SH) Clinical Director Dr Mehul Mathukia (MM) . Clinical Director Marie Price (MP) Director of Corporate Services Sarah See (SS) Director of Primary care

Item Action 1.0 Welcome and apologies

The Chair welcomed members to the meeting. Apologies for absence were received from

1.2 Declarations of conflicts of interest There were no additional declarations of interest.

1.3 Minutes of the last meeting

14

The minutes of the meeting held on 26 November 2015 were agreed as a correct record.

1.4 Matters/Actions arising The committee noted the actions taken since the last meeting.

2.0 Chair & Accountable Officer’s Reports

2.1 Chair’s report The Chair presented his report covering the following areas:

• Clinical director elections

• Kings Fund clinical leadership programme

• Intermediate Care Changes The governing body noted the report. 2.2 Chief Officer’s report The chief officer presented his report covering the following areas:

• CCG assurance

• CCG development

• Devolution/Accountable Care Organisation (ACO)

• Urgent and emergency care vanguard

• Primary care transformation

KA commented that he was pleased to note the continuing commitment of Redbridge and BHR CCGs to ensure good patient, carer and other stakeholders’ involvement in the various initiatives and projects being undertaken. Patients, carers and users can, and do, make a difference in areas such as service re-designs. The governing body noted the report.

3.0 Governing body assurance 3.1 Governing body assurance framework

LM presented a report which outlined the key risks to the clinical commissioning group in achieving its corporate objectives as identified in the governing body risk assurance framework. There are five risks on the GBAF:-

1. Barking Havering and Redbridge University Hospitals Trust (BHRUT) emergency care performance

2. BHRUT referral to treatment times (RTT) performance 3. BHRUT cancer performance for 2 weeks and 62 days 4. Barts Health (BH) performance against key targets, A&E,

RTT and cancer

2

15

5. BH quality concerns 6. Improved access to psychological therapies 7. Quality, innovation, productivity and prevention (QIPP)

delivery KP reported the audit and governance committee had discussed risk appetite and a risk assurance map which will show how risks are managed within the CCG. The governing body noted the current risks escalated to the GBAF and levels of assurance in the controls and mitigating actions being taken 3.2 BHRUT performance risks CB presented a report which provided a further update on the key actions that the CCG is taking to seek performance improvements at the Trust. It is doing this by both holding the Trust to account through its contract and other mechanisms, as well as providing overall support through wider system initiatives overseen by the Integrated Care Coalition and System Resilience Group (nee Urgent Care Board). It was noted that there are still some major concerns around RTT, A&E and cancer. CB reported there had been a consistent improvement in A&E compared to last year and reported that there had been a director in A&E overnight recently which had made a significant difference and an area that needs exploring further. The Chair requested clarification on urgent care centre usage. CB confirmed it was at the same level across both sites but would still like to see increased utilisation. VH referred to the issues around the somerset database and if there was any update to report. JH responded that she had discussed the issue with the chief nurse who reported that 2700 patients had been assessed and no concerns had been identified to date. She added that this is a priority for the CCG with weekly reviews taking place. SAz suggested that an increase in CTT hours would support the local community and reported on patients that have used the CTT service where A&E admissions have been avoided. CB welcomed the feedback on this service. MT questioned if there are any specific speciality outliers in the cancer RTT. JS confirmed that both lung and colorectal were, adding that the new lung cancer pathway should help improve this. JH reported that as part of recovery work there has been high level analysis of what contributed to delays, which has resulted in a

3

16

reduction of avoidable delays. KA commented that It is good to see some improvement towards the targets over December, alongside the raft of initiatives and projects designed to help keep people safe and well in their homes, patients should be experiencing better health and social care and highlighted the importance of evaluation of the system to test this. KP referred to RTT, an area of ongoing concern and questioned if there is confidence in achieving the recovery plan by March 2017. CB responded that until the plan has been received and reviewed it was difficult to confirm adding it will also depend on other factors ie resources available. The Governing Body noted the action being taken to date to mitigate the performance risks at BHRUT. 3.3 Barts Health performance risks LM presented a report which detailed the performance and quality concerns that Barts Health are facing and the actions being taken by the CCG as an associate commissioner. Currently the Barking and Dagenham, Havering and Redbridge (BHR) CCGs are an associate to the main contract which is led by Newham CCG. The Chair referred to RTT and cancer pathways at Whipps Cross and questioned if the CCG were assured on clinical harm. JH confirmed that the CCG were not assured and reported that the Trust had been advised to accelerate their clinical harm reviews. CT reported that Healthwatch had held a meeting with the Trust chief executive to discuss patient experience with transport at the Trust with assurances being given to resolve issues raised. JH welcomed this feedback, there had been a significant number of serious incidents relating to patient transport following the procurement of the service. It was noted that the CCG has been monitoring the issue closely and holding the Trust to account. KA welcomed the CCG continuing pressure and challenges, despite being the associate commissioner for Bartshealth, and the signs of improvement at Whipps Cross Hospital for the cancer targets, particularly as this impacts on our population in the Wanstead and Woodford Locality. When will the remaining 86 and 9 patients on the respective 62 days and 100 days targets be seen. JH confirmed that patients are being tracked with weekly monitoring and review. JH agreed to circulate this information to members. The Governing Body: • Noted the actions being taken by the lead commissioner to mitigate the performance risks at Barts Health since the last

JH

4

17

report provided at our November Governing Body • Noted that the lead commissioner is holding the Trust to account through the contractual governance framework. 3.4 Delivery of IAPT operating plan standards

CO presented a report which provided an update on actions that are being taken to improve performance against the Improving Access to Psychological Therapies (IAPT) standards. The Chair referred to Newham CCG performance and questioned what they are doing differently in terms of marketing the IAPT service. CO reported that Newham have a one stop marketing service by their provider. CB reported that Redbridge were the lowest performing CCG across London and it was important to treat this as a risk for the CCG. He added that the biggest gain in referrals would be from GPs and suggested that learning could be gained from colleagues in Barking & Dagenham who are delivering the target. VH reported that public health have offered support to look at the impact of patients not choosing this service. SAli questioned how progress against the target is being tracked. CO confirmed there is weekly review of performance. KP questioned how hard to reach groups are being targeted. CO confirmed this is a contractual obligation for the provider. The Governing Body noted the continued under-performance and associated recovery actions being undertaken to address this 3.5 Primary care update SAli, HS and SR declared an interest in the item as holders of PMS contracts at their GP practices. CB presented a report which updated and briefed on the development of the CCG’s Primary Care Transformation Strategy, negotiations on the 2015/16 and 2016/17 Prime Minister’s Challenge Fund GP hub contract, and delegated responsibilities for the commissioning of primary medical services, specifically in regard to: • the proposed (voting) clinical membership of the CCG’s Primary Care Commissioning Committee, and

• the mandated Personal Medical Services (PMS) Review.

SAz highlighted the importance value for money in the review and the impact it could have on the general practice in Redbridge. CB

5

18

recognised that the review could reduce capacity in general practice and the potential increased investment by the CCG. JS highlighted the importance of working with the population to shape the primary care strategy. SAli reported that PPGs have been invited to be involved along with nursing, pharmacy and Healthwatch representatives. KA commented that from a purely patient or user perspective, the vision for primary care over the next 5 years needs to be set out in a compelling and simple way. Discussion ensued on utilising locality meetings to explore place based budgets and more effective integrated care.

The Governing Body noted the update on the development of the Primary Care Transformation Strategy and the update on the negotiations for the Prime Minister’s Challenge Fund GP hub contract for 2015/16 & 2016/17.

4.0 Corporate strategy and planning 4.1 Planning requirements and operational requirements

LM presented a report which summarised the latest information received in respect of the planning round for 2016/17, and takes into account local developments around the Barking and Dagenham, Havering and Redbridge (BHR) Health Economy’s successful bid to develop a business case for an Accountable Care Organisation (ACO). TT reported that following local discussions around the ACO a different approach to 16/17 contracts is being explored. He added that the tariff is not expected to be released until March when contracts will need to be signed which is a risk. KP commented that significant engagement will be required to meet the STP deadline. CB noted the concern around the timeline and reported that guidance was received early in the year and agreed in principle to one STP across north east London and felt positive that the STP would support the pilot for devolution. The governing body:

• noted the described planning requirements and timescales from the newly-published NHS England 2016/17 planning guidance (both in the text below and the attached summary of the guidance)

• noted the emerging workstreams which will require additional consideration for 2016/17

6

19

5.0 Service transformation and development 5.1 Healthy London Partnership 2016/17 and 2017/18

TT presented a report which updated on the the Healthy London Partnership (HLP) that has been in operation since May 2015. As programmes progress in line with the plans agreed by London CCGs and NHS England (London), the Interim London Transformation Group (ILTG) has requested that a longer term commitment is considered by accountable organisations for 2016/17 and 2017/18, i.e. a further two years. The majority of CCGs across London have agreed the proposals outlined. The maximum contribution is 0.15% per CCG and where the budget is not used against agreed programme priorities it is returned to CCGs. This is in line with 2015/16 contributions and arrangements. The Chair reported that CB chairs the urgent and emergency care workstream and questioned if CB could comment on his views on the benefits of this pan-London approach. CB commented that the HLP was set up to support not lead CCGs and shared an example of a recently trialled initiative in health analytics around care plans which has been shared with the 111 service/PELC and LAS. The Governing Body:

• Noted the progress and achievements of the HLP to date

• Agreed to support the HLP in 2016/17 and 2017/18, including the proposed planning process and financial assumptions.

• Agreed to the proposed ongoing governance arrangements

5.2 Enhanced mental health liaison business case CO presented a report which provided a further review of the funding of the Enhanced Mental Health Liaison EMHL) night service, taking in account policy requirements as well as activity data from the service. The paper requests that recurrent funding for the EMHL night service be agreed. This will ensure that patients attending acute hospitals in Barking and Dagenham, Havering and Redbridge (BHR) with urgent mental health needs will have their needs met in a timely way. It will enable the health economy to manage pressures on acute beds. It will enable commissioners and providers to meet the expected minimum standards for liaison mental health services and will enable progression towards providing the appropriate service expected by 2020.

7

20

JS questioned how the service will support CCG transformation plans for mental health and urgent care. CO responded with the following points:

• The EMHL is supported by the national mental health policy/NHS planning guidance – expectation that by 2020 all acute trusts will have effective models of liaison psychiatry in place

• It is recognised as a priority in BHR CCGs mental health commissioning framework approved in 2014 and crisis care concordat action plan

• Mental health is one of the workstreams of the urgent and emergency care vanguard as there is a clear relationship with mental health crisis care

• The development of the crisis services for children and young people are reflected in the concordat action plan and are being taken forward through CYP mental health and wellbeing plans.

KA commented that the EMHL service is saving 17 Beds per week and questioned if this factor has been taken into account for commissioned activity in the 2016/17 contract. TT confirmed it had. HS questioned if funding identified would support a 24/7 service. CO responded that the CCGs have received some pump priming funds for enhanced psychiatric liaison through the vanguard. There is also a national requirement for CCGs to invest additional resources into mental health services in 2015/16 and the BHR CCGs had identified a mental health reserve funds in budgets for 15/16 to be released upon approval of a business case. SAli questioned if Wanstead and Woodford patients would be able to access this service. CO confirmed they would. The Governing Body agreed recurrent funding of £95,369 for the EMHL night service, thus securing a 24/7 service on a recurrent basis. 5.3 Improving Out of Hours End of Life Care in Redbridge LM presented a report which provided an update on the current review and planning work undertaken to improve the out of hours end of life care in Redbridge and a business case for consideration and decision. JH referred to the risk highlighted in the report “that if the service is not provided that this will adversely impact on both the ability to support individuals to die at home or their chosen place of death and in turn on the level of utilisation of acute hospital settings for end of life care” and questioned if there is any service in place. LM

8

21

confirmed there was but not a specialist service. TT reported that the value for money assessment plays into the impact assessment of benefit realisation. CT reported that Healthwatch have an interest in end of life care and sees this as a positive move to improve the quality of the services available for Redbridge patients. She added that it would also be helpful to see the promotion of hospice services across Redbridge. CO agreed, adding that it was important for Redbridge to have equity with other CCGs in the services provided for our patients. The Governing Body

• Noted the gap highlighted in Redbridge against the national requirements in out of hours’ service provision

• Reviewed the proposed four options within the business case • Approved Option 3 as the recommended model for

implementation. • Agreed to receive a report three months post service

implementation

6.0 Quality and performance 6.1 Patient experience report

KA presented a report which provided a summary of the various feedback that has come through to the CCG from patients and stakeholders highlighting the following areas:

• The last patient engagement forum (PEF) meetings and updates re the PEF

• Work on strengthening relationships with the voluntary and community sector.

• Patient Participation Groups (PPGs) • Plans for engagement strategy • Assurance on CCG engagement

The Chair welcomed the assurance report on CCG engagement. The governing body noted the report. 6.2 Finance and activity report TT presented the month 8 finance and activity report highlighting that as reported previously, the CCG has agreed a revised risk assessed forecast outturn of breakeven with NHSE. The revision to the forecast was based on a risk assessed view of the underlying data driving the month 6 year to date and forecast positions. As at the end of November (month 8) the position has remained stable and the CCG has maintained a breakeven position. At month 8 this

9

22

represents year to date slippage of £2,201k against the original year to date plan and £3,302k slippage against the original planned 1% surplus. The main driver behind the reported position is Barts Health, where significant over performance is reported. The latest risk assessed forecast overspend is £4,647k or an 8% contract pressure. Barts Health - The Month 7 data before adjustments indicates a high level of year-end over performance. The Barts Health contract continues to present the largest financial risk to the CCG. The latest data received from the Trust highlights over performance reported across a range of points of delivery, including non-elective, elective care, critical care, maternity pathway, outpatient procedures, high cost drugs and treatments and unidentified QIPP schemes. A number of challenges have been made and the reported position includes assumptions that a number of challenges are successful. Analysis of the data highlights that there is a potential further downside risk in excess of the reported position, if the mitigating actions, data challenges and contract levers are not successfully applied. The CSU have carried out further analysis of the Barts position and are in the process of risk rating the issues identified, to further inform the reported outturn position. BHRUT – A fixed price contract has been agreed with BHRUT for 2015/16, including non-recurrent funding to support the delivery of the QIPP schemes and the achievement of key performance indicators, ensuring system sustainability in the coming years. The fixed price also includes funding to ensure operational resilience during winter and meet the targets set to address the RTT backlog at the Trust. The 2015/16 contract will still be managed under full PbR rules, as at Month 6 there were a number of issues with the Month 7 data and the finance and activity plans. These are being flagged for correction with the Trust through the TSG and SPR meetings. As highlighted in previous reports the CCG faces a number of risks that may impact the financial position. These include: further acute activity growth above planned levels, QIPP delivery, continuing care growth and prescribing growth. A number of mitigations are in place attempting to off-set these risks and include robust contract management, PMO, QIPP process and on-going review of investments. Month 7 QIPP delivery, based on Month 6 SUS data, has delivered £967k actual savings against a target of £1,070k. This represents a year to date saving of £4,640k against a plan of £5,420k. KP expressed concern that the CCG are not going to meet its control target for 15/16 and questioned what the outlook for next year. TT responded that the 16/17 headline allocation was £335m,

10

23

which was a 5.06% uplift, adding that there was no pre commitment or expectation against the headline rate until closed position and agreed QIPP requirement, but agreed that challenges this year will continue into next year. The Chair questioned if allocations are significantly different across London. TT confirmed allocations across London ranged from 1.9-3% uplift. KA commented that whilst there has been general growth across the acute sector what has been done to understand the reasons for this. TT confirmed that this is being actively discussed with lead commissioners. VH was pleased to note the latent TB funding. She added that public health are expecting an 8.4% cut in funding which will need to be factored in as a health economy and pharmacy funding implications might need to be reviewed as a priority. The governing body agreed the financial position and the actions taken to achieve it.

6.3 Contracting report TT presented a report which provided an update on the contract performance for 2015/16 at Month 7 for acute, community and mental health services. BHRUT are failing to meet several of the national standards required in the Operating Framework. Commissioners continue to actively manage performance through a number of forums held on a weekly basis and as a consequence Contract Performance Notices have been served. There are action plans in place to recover the standards for A&E, Referral to Treatment (RTT), Cancer and Diagnostics. The Trust is held to account on actions required with associated penalties enforced in accordance within the contract. Barts’ operational and performance issues are being managed by the Lead Commissioner (Newham CCG) in line with the contractual governance framework. Barts are failing to meet several of the national standards required in the Operating Framework. There are a number of action plans currently in place for 18 weeks, Cancer, serious incident (SI) management and data quality that are being actively managed by the Lead Commissioner. The Trust is held to account on actions required with associated penalties enforced in accordance within the contract. A Care Quality Commission (CQC) report on Whipps Cross hospital was published on 17 March 2015 with a subsequent CQC report on Barts, Royal London and

11

24

Newham, published on 22 May 2015. Poor performance at both acute has led to them being placed in special measures. National reporting of 18 weeks has been suspended for both BHRUT and Barts Health. NELFT are performing to contracted standards in their Community and Mental Health Service contracts with the significant exception of Increasing Access to Psychological Therapies(IAPT) services. PELC are currently the second best performing Out of Hours (OOH) and 111 Provider in London. They are also supporting ambulance re-triage for lower acuity calls. The London Ambulance Service (LAS) continue to be very challenged in their delivery of the 8 minute response standard, with the year to date for the CCG at 61.6% against a standard of 75%. JH referred to the high number of never events reported at Barts Health and that this has been escalated with the lead commissioner. It was noted that the lead commissioner had issued a contract notice and an action plan is now in place with no never events reported in the last two months. AFC referred to the 62 day cancer screening target and questioned what the main issue was and if the process was being robustly managed. TT confirmed the delays were mostly in diagnostics and this was being robustly managed. The governing body agreed the reported M7 position for the two main acute and two main non-acute contracts and; reviewed the performance against standards and requirements and agreed remedial actions being taken. 6.4 Quality in commissioning report JH presented a report which provided assurance that the CCG continues to implement the recommendations and requirements from the Transforming Care Programme (previously referred to as Winterbourne View) recommendations, quality and safeguarding improvement plans, actions to reduce health inequalities along with new initiatives around compliance with Francis. The following specific areas were covered:

• Transforming Care Programme

• Safeguarding

• Special Educational Needs and Disability (SEND)

• Looked after children

12

25

• Maternity commissioning

• Quality of care in Care Homes (with Nursing)

• Reducing health inequalities

• Frances Report – Duty of Candour

The Chair questioned if there was any feedback from unannounced nursing home visits. JH reported that the visits had initially been at homes where quality concerns had been raised. She was pleased to report that there had been less concerns raised and examples of good care in place. CT reported that she is a member of the quality surveillance group which had worked on patient experience around dignity and respect and welcomed the opportunity to support care home visits in the future. JS referred to the SEND code of practice and questioned if patients and carers could be engaged. JH responded that it was a requirement to include engagement and an event is planned in March for this. CT welcomed the opportunity to involve Healthwatch stakeholders in this event. JP reported that this builds on the ongoing work taken by the partnership board and importance of building on this work and not duplicating. The governing body noted the report.

7.0 Development/governance 7.1 Remuneration & workforce report

KP presented a report which provided key highlights of the remuneration & workforce committee held on 1 December 2015. The governing body noted the report. 7.2 Finance & delivery committee report The chair presented a report which provided key highlights of the finance and delivery committee held on 3 December 2015. The governing body noted the report. 7.3 Audit & governance committee report KP presented a report which provided key highlights of the audit and governance committee held on 8 December 2015. The governing body noted the report.

13

26

7.4 Minutes of sub committees: The governing body noted the minutes of:

• Executive committee held on 13 December 2015. • Patient engagement forum held on 24 November 2015. • Joint executive team committee held on 12 November & 10

December 2015. • Primary care commissioning committee held on 7 October &

13 November 2015. • Investment committee held on 17 November 2015.

8.0 AOB

There was no other business.

9.0 Questions from the public Rosemary Warrington, Green Party London Assembly member

addressed the governing body and welcomed the opportunity to learn more about the relationships between the provider and commissioners of local health services. Andy Walker asked the following questions: Does the CCG agree with me that blood testing for under 7s should come back to King George Hospital? CB noted that the CCG’s communication lead had already responded to Mr Walker which had been acknowledged and published on his blog. He added that no services had been withdrawn and in fact an enhanced service for taking young children’s blood will be coming to the hospital. Will the CCG agree with me that the closure plan for King George A&E should also be closely monitored. April 2015 to November 2015 saw 20 acute beds along with the doctors and nurses to staff them cut from King George Hospital, which amounts to 6.8% capacity cut, which must be a factor in the 80% A&E four hour waits at Queens in November. This puts Queens among the worst performers in the country for November. CB agreed that the closure plan for King George A&E should be closely monitored and reiterated the CCGs view that no changes will take place until it is safe to do so. Whilst the A&E performance isn’t yet at the level that we and the Trust yet want to see, we hope that they and we as a system, have overseen significant improvements when we compare this year to last. Will the CCG agree to conduct an ongoing mortality review to be published monthly on their website of the impact of these past bed cuts and also future ones? My concern is that evidence suggests long waits in A&E increase the risk of poor patient outcomes including increased mortality rates. Evidence supporting bed cuts at KGH leading to increased mortality rates would encourage you to commission the return of beds doctors and nurses to King George

14

27

Hospital. JH responded that the CCG monitor the performance of all our hospital contracts closely and we have regular meetings to hold our providers to account for a whole range of indicators. The Trust already publishes its summary hospital mortality indicator each month as part of the improvement update online. 3) Transparency improves standards, so why can't I record what is said at this meeting and then publish it on the internet? CB responded that although this is not something that NHS boards normally do the CCG would consider this. 4) While 7 day notice of questions improves the quality of replies, will this committee follow the example of BHRUT and allow questions without notice to increase public participation in this meeting? CB responded that the CCG do take questions without notice but it helps us have the information you are requesting if they are submitted in advance.

10.0 Date of the next meeting

24 March 2016.

15

28

1

Actions arising from the Redbridge Clinical Commissioning Group governing body on 28 January 2016 Action reference Action required Lead Progress

3.3

Barts Health performance risks

When will the remaining 86 and 9 patients on the respective 62 days and 100 days targets be seen. JH confirmed that patients are being tracked with weekly monitoring and review. JH agreed to circulate this information to members.

JH Completed.

Item 1.3

29

To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body From: Dr Anil Mehta, Chair Date: 24 March 2016 Subject: Chair’s report

Executive summary The report provides an overview of key activities undertaken by myself and the CCG since the last governing body meeting. As identified on the agenda there are a number of significant risks that we continue to manage, specifically with our acute providers. The reports in the assurance section outline the actions underway to mitigate these risks. I, along with our chief officer and chief operating officer are focussing our own and our respective teams’ efforts in addressing these.

Recommendations The governing body is asked to note the progress report.

1.0 Purpose of the report

1.1 To provide an update on my activities since the last meeting and on key CCG news.

2.0 Clinical director elections

2.1 We held clinical director elections at a member event on 16 March. A full announcement about the elected clinical directors will be shared with members, the governing body and then publicised more widely. I want to thank those CDs who decided not to stand and/or pursue other opportunities. We have been lucky to have a fine complement of CDs who have contributed considerable time and effort with the aim of improving outcomes for local people.

3.0 360 survey

3.1 Our 360 survey process for 2015/16 has begun and I have encouraged all members to share their views with us. The results from last year were helpful in determining how we need to engage with members, partners and stakeholders. I hope that we have a high participation rate and look forward to reviewing the results later this spring.

30

4.0 Kings Fund clinical leadership programme and membership of FMLM

4.1 I attended a useful meeting with my fellow Barking and Dagenham Chair and the King’s Fund OD lead last month. It was a productive session, with further clarification on the proposed programme. There was a wider discussion at the February Joint Executive Team (JET) meeting, with the proposal being well received. The CDs present agreed to the suggestion of a series of two consecutive days a month over 3-4 months. The sessions will include all CDs across BHR, but there would be the opportunity to break into smaller groups based on borough/area of interest or specialty as appropriate.

4.2 The governance team has identified possible dates and our director of corporate services is following up on the outline programme with the King’s Fund OD lead. The sessions will begin in April or May 2016 and will take place at the King’s Fund offices in central London.

4.3 In addition the CCG has secured membership of the Faculty of Medical and Leadership Management (FMLM) for all CDs. The FMLM runs a number of useful events and has a wealth of resources on the website for leaders. I encourage all CDs to make the most of the opportunity.

5.0 Meetings

5.1 In addition to the many committee meetings that I attend, below is a summary of other meetings I’ve been to since the last governing body.

5.2 Members’ meeting: We had a very well attended members’ committee meeting on 27 January. At the meeting I provided a general update while our CDs informed members about their respective work in delivering our strategic priorities. We also heard about the primary care transformation strategy development, an update on the finances of the CCG and information about our local acute trusts’ improvement programmes.

5.3 Health and wellbeing board: At the 25 January meeting we discussed the ‘Early Help’ Needs Assessment, the accountable care organisation (ACO) developments, palliative and end of life care ambitions, and the CCG planning round 2016/17.

At our meeting on 7 March we considered the progress in developing the borough’s sexual health and health protection strategies, as well as the Transforming Services Together programme – led by the inner East London CCGs, but which impacts on some Redbridge residents.

5.4 Informal CDs’ meetings: I have had a number of meetings with my CDs since the last governing body meeting. We’ve focussed on the QIPP challenges that we have and how we plan to address them in the remainder of this financial year and next.

5.5 Joint Executive Team meeting (JET): At the February meeting there was an interesting discussion on diabetes and some thoughts about what we need to do collectively to tackle the growing problem and prevalence of this disease in BHR. I understand that the diabetes leads will be taking this work forward. There was a helpful discussion on the next steps with our broader vision for developing localities and shared transformation programmes and the benefits that the ACO may offer.

It was agreed that a longer session – using the JET time – would be helpful to explore this further with clinical leads and some of their team members from BHRUT and NELFT. This took place on 10 March 2016 and was facilitated by Mike Roberts of UCL Partners. We agreed on a number of ‘quick wins’ that we would like to see and to which partners committed to. We also agreed that there was more to be discussed from a clinical leader

31

perspective and that we should hold joint sessions using the JET time-slot every two months.

5.6 ACO: I have been involved in a number of strategic meetings with clinicians and other colleagues regarding this.

5.7 CD panels: I was happy to support fellow BHR CCGs’ colleagues in being part of the assessment panels in advance of clinical director elections. I understand that the candidates who passed the selection process were duly elected in March.

6.0 Resources/investment 6.1 There are no additional resource implications/revenue or capital costs arising from this

report. 7.0 Equalities 7.1 There are no direct equality implications from this report. 8.0 Risk 8.1 The CCG is managing a number of serious risks which are outlined in further detail in the

assurance section of this agenda. 9.0 Managing conflicts of interest 9.1 There are no conflicts of interest arising from this report. 16 March 2016

32

www.southwark.gov.uk

To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body From: Conor Burke, Chief Officer Date: 24 March 2016 Subject: Chief Officer’s Report

1.0 Devolution/Accountable Care Organisation (ACO) 1.1 Clinical leadership arrangements have been established and discussions are ongoing to help design the model, with considerable engagement with members and stakeholders planned. An update on progress will be provided later on the agenda.

2.0 Urgent and Emergency Care Vanguard 2.1 Extensive work has been undertaken by all partners to develop Value Proposition 2, detailing

activity and financial modelling, and this was submitted to the national team on 8 February. The outcome of this bidding process is expected mid-March. Urgent and emergency care vanguards are expected to accelerate implementation and BHR has been awarded £1.3m of national funding for 15/16 to support this. Engagement and co-design events will be run throughout March. We are on track to deliver the key initial milestones of 24/7 urgent care centre by end of March and the co-design of the overall care model.

3.0 Primary Care Transformation 3.1 Work has progressed on the CCG’s refreshed Primary Care Transformation Strategy. An update

is provided later on the agenda. 4.0 Health and Wellbeing Board update 4.1 The most recent Health and Wellbeing Board meetings were held on 25 January and 7 March.

Discussions focused on End of Life care, development of a Tobacco Control strategy and updates on ACO, Better Care Fund and the Transforming Services Together partnership programme.

5.0 Sustainable Development update 5.1 The CCG continues to progress actions from its two-year sustainable development plan. We have

implemented a staff awareness campaign around energy and waste usage and have promoted national campaigns such as NHS Sustainability Day, which will be held on 24 March. For this we have asked each team in the CCG to make a pledge to change something in the way they work that will contribute to environmental sustainability and encourage Governing Body members to do the same. We have also encouraged staff to join HealthWorks – a new online community to share ideas about staff health and wellbeing in the NHS – which is designed to help us learn from each other about health and wellbeing and to share ideas on how to improve our workplace. A full report on the progress of the current plan will come to the Governing Body later in the year.

Executive summary This report provides an overview of key activities undertaken by the Chief Officer and the CCG since the last meeting.

Recommendations The governing body is asked to:

• Note the progress report

33

6.0 Meeting attendance 6.1 I attended the Members’ Committee on 27 January and was pleased to see such high attendance

from our GP membership. 6.2 I was invited to attend the Healthcare People Management Associate event as a guest speaker on

2 February. I gave a presentation on our local joint plans for the development of an ACO, what that might mean for our workforce and what HR/OD capabilities we will need to make it happen.

6.3 On 17 February I attended the London Chief Officers’ meeting where discussions focused on

business planning for 16/17, updates on ACO and Vanguard and the Healthy London Partnership programme.

7.0 Equalities 7.1 There are no equalities implications arising from this report.

8.0 Risk 8.1 There are no risks arising from this report. 9.0 Managing conflicts of interest 9.1 There have been no conflicts of interest to manage.

34

To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body From: Louise Mitchell, chief operating officer Date: 24 March 2016 Subject: Governing body risk assurance framework report

Executive summary The governing body assurance framework (GBAF) has been reviewed to reflect the current significant risks to the organisation. There are eight risks on the GBAF:-

1. Barking Havering and Redbridge University Hospitals Trust (BHRUT) emergency care performance

2. BHRUT referral to treatment times (RTT) performance 3. BHRUT cancer performance for 2 weeks and 62 days 4. Barts Health (BH) performance against key targets, A&E, RTT and cancer 5. BH quality concerns 6. Improved access to psychological therapies 7. Quality, innovation, productivity and prevention (QIPP) delivery 8. Barts Health contract financial risks

Risks are reviewed on a monthly basis at various meetings and committees at the CCG and across BHR CCGs. This includes continued discussion at our audit and governance committee in common. Recommendations The governing body is asked to: • Note and comment on the current risks escalated to the GBAF and levels of assurance in the

controls and mitigating actions being taken • Raise and discuss other potential risks that may require escalation to the next GBAF.

1.0 Purpose of the Report 1.1 The purpose of the GBAF is to outline the key strategic risks to the Clinical Commissioning Group

(CCG) in achieving its corporate objectives and the controls in place to provide assurance that the risks are being managed.

2.0 Background/Introduction 2.1 The CCG’s governing body has a responsibility to maintain sound risk management and ensure

that internal control systems are appropriate and effective, and where necessary to take appropriate remedial action. The CCG’s risk register consists of risks that are local to the borough and risks that the CCG has in common with its collaborative partners, Barking and Dagenham and Havering CCGs.

35

3.0 Current risks on the GBAF 3.1 There are eight risks on the GBAF. Please refer to appendix 1 for the full details. These fall

under five of the six corporate objectives and are as follows:

Collaborative objective 2: High quality and compassionate and safe care for all commissioned services – delivering better care

Risk 2.4 a, b, and c. Barts Health performance – this risk groups together three performance areas that BH are failing to achieve, referral to treatment times, cancer targets and urgent and emergency care. There are also data quality concerns that present a further challenge for commissioners. The risks could threaten the long-term viability of the Trust and could put patients at risk and cause reputational damage. Risk 2.4 a – 18 weeks referral to treatment times (RTT) - significant issues exist affecting the delivery of this target - key issues with the number of patients on the incomplete waiting list and those waiting over 52 weeks. This position deteriorated further as a result of the Cerner (PAS) implementation issues experienced at Whipps Cross Hospital during July 2014. Mitigation: • RTT recovery is reflected in the improvement plan work being undertaken by BH following

placement in special measures in March 2015 with oversight by our lead commissioners via the RTT and performance monthly meeting with the Trust.

• We retain oversight of Whipps Cross (WX) specific RTT via the WX improvement plan meeting attended by our lead commissioner and BHR CCGs’ representative

• A breakdown of the over 52 weeks waiters has been received and are being reviewed monthly

• BH advise they anticipate resuming full RTT reporting from quarter one 16/17 (RTT is currently excluded from reporting).

Risk 2.4 b: BH have consistently not achieved a number of the cancer waiting time targets with the potential clinical risk to the patient pathway impacting on early detection and survival rates for Redbridge Mitigation: • Cancer recovery is reflected in the improvement plan work being undertaken by BH

following placement in special measures in March 2015 with oversight by our lead commissioners.

• We retain oversight of WX specific cancer standards via the WX improvement plan meeting which we attend with our lead commissioner representative.

• The focus remains on the 52 weeks cancer target (the Trust is achieving the 2 weeks cancer target).

Risk 2.4c: Urgent and emergency care - failure to deliver quality improvements at BH (specifically at Whipps Cross hospital) Mitigation: • Bi-weekly performance meetings including the Trust, commissioners and TDA with regular

updates at the strategic performance review (PR) meetings • Contractual processes being followed in line with the contract query notice (CQN) process • Progress against the remedial action plan (RAP) reviewed jointly by all commissioners • Formal letter to the lead commissioner for BH (WX) from BHR CCGs’ chief officer

requesting clarification regarding governance and decision making arrangements concerning all aspects of performance concerns from an associate commissioner assurance perspective

36

• Serious incident issues being addressed via the CQR (attended by the nurse director on behalf of BHR CCGs).

• BH exception report to each CCG GB meeting detailing progress since the last meeting. Risk 2.6 - Risk that patients fail to receive the required quality of care whilst under the care of BH. The Trust is failing their quality standards in respect of Clostridium Difficile, Methicillin Resistant Staphylococcus Aureus (MRSA) and friends and families test (FFT). Mitigation: • Attendance at the Barts Health Clinical Quality meetings • BH developed a quality improvement plan that will support reduction in HCAI and improve

the FFT scores. • Strengthened internal monitoring governance and established a formal escalation process

with the lead commissioner • Continued active engagement in our supporting role as an associate and seeking assurance

with escalation as required through our governance routes where non-compliance remains • Quality and Safety are specifically detailed in the overarching BH Trust Improvement plan,

the delivery of which is overseen by NHSE and the TDA.

Risk 3.1: Continued concerns with urgent and emergency care at BHRUT - risks to patient care and viability of the trust. Frailty: Operational resilience plans - non delivery of additional initiatives and support to maintain performance over the winter period

Mitigation: • BHRUT being held to account via weekly operational performance monitoring meetings,

escalated to monthly strategic review, reporting to the CCG governing body, quality and safety committee and CCG executive committee

• Improvement plan agreed (with Trust Development Agency (TDA)/ Care Quality Commission (CQC) / NHS England (NHSE) and CCGs) with monthly whole system Oversight and Escalation Group (OEG) to review progress against the plan.

• System Resilience Group (SRG) is leading the work to support improvement • Friends and family scores recovery plan and performance monitored through Clinical Quality

Review Group (CQRM) • Trust performance improved significantly over the past year and is most nearer to the national

standard • On-going performance monitoring to ensure delivery and SRG planning 'winter' resilience for

15/16.

Collaborative objective 4: Improved mental health services so that they deliver proactive and responsive care. Risk 4.1: Improved access to IAPT operating plan targets may not be met due to insufficient referrals into the service and insufficient capacity to meet recovery and waiting time targets. Mitigation: • Joint recovery action plan being implemented with focus on increasing referrals into the

services from practices. Referrals are being reported weekly to target interventions • Redbridge is significantly below plan and additional capacity has been identified to help with

practice support • An interim project manager has been recruited (three days/week) to strengthen PMO

approach • Communications plan finalised and being implemented to raise awareness

37

• Plans are monitored monthly through joint meetings with provider with performance oversight at the weekly JMT meetings (identified as one of the CCG’s top five risks) and bi-monthly governing body meetings

• Twice weekly teleconferences with NHSE to report on progress

Corporate objective 5: Ensuring that planned care is appropriate, timely and of high quality.

Risk 5.2: BHRUT 18 weeks referral to treatment times (RTT) – failure to meet the national standards for RTT and data reporting.

Mitigation: • Monthly joint OEG with the TDA to hold Trust to account for implementation and recovery

reporting to the CCG governing body, quality and safety and executive committees. • The agreed RTT ‘admitted’ recovery plan being implemented with a significantly reduced

backlog • The full ‘non-admitted’ plan reviewed with full RTT plan signed off by OEG in October 2015 • Trust update weekly at Performance Assurance Group (PAG) on progress • The clinical harm process and outcomes reviewed through the external harm panel chaired

by Angela Lenox, associate medical director NHS England with BHR CCGs’ nurse director on the panel.

Risk 5.3: BHRUT has failed to deliver the national 62 days cancer performance standard with potential impact on cancer diagnoses, treatment and clinical harm. Mitigation: • Implementation of the full revised RTT recovery plan and trajectory (admitted and non-

admitted) agreed in October 2015 at the Joint Oversight and Escalation Group. • Recovery monitored through PAG • Detailed forward booking reviewed at weekly meeting to assess risk. • Full contract levers applied. • Risk managed through Performance Management Framework.

Collaborative objective 6: Continued focus on our development as an organisation that delivers

Risk 6.1: Failure to identify QIPP schemes presents a risk to the achievement of planned surpluses 15/16 - 16/17 Mitigation: • Review and escalation to the finance and delivery committees based on four specific trigger

criteria; finance, activity, milestones and risk • Confirm and challenge sessions implemented • London and national horizon scanning to supplement locally developed schemes • Linking to transformational activities and ensuring QIPP benefits trackers are applied

through transformational projects governance • QIPP detailed review held with clinical directors/Governing Body members in August 2015

and BHR CCGs’ QIPP summit held in October 2015, with subsequent plan developed.

Risk 6.2: Barts Health contract financial risks – acute contracts, particularly Barts 15/16 contract has been signed by the lead commissioner and the CCGs are working with the collaborative to

38

jointly manage the contract. The issues include; specialist commissioning movements, over performance risks and data quality risks.

Mitigation:

• BHR CCGs engaged proactively in the commissioning collaborative and London wide arrangements to map specialist commissioning movements.

• BHR reserves the right of sign off to commitments of associates and continued strong application of contract management processes.

• Support and advise the lead commissioners and CSU in their engagement with Barts Health (BH)

• Through lead commissioner arrangements enforce the accountability of Waltham Forest CCG and East London (WEL) under the lead commissioner contract

• BHR involvement and agreement in all finance decisions relating to the BH Contract

4.0 Resources/investment 4.1 There are no additional resource implications/revenue or capital costs arising from this report.

The cost of operating effective risk management arrangements is met from within existing resources.

5.0 Equalities 5.1 There are no equalities considerations arising from this report.

6.0 Risk 6.1 This report also links to the following GB papers being presented at this meeting which provide

greater detail on key risks mentioned above and how they are being mitigated by the organisation

GBAF ref. 3.1, 5.2 and 5.3 relates to item 3.2 - BHRUT exception report GBAF ref. 2.4a, b and c and 2.6 relates to item 3.3 – Barts Healthcare exception report GBAF ref. 4.1 relates to item 3.4 – IAPT recovery

7.0 Managing conflicts of interest 7.1 There are no conflicts of interest considerations arising from this report.

Attachments: Appendix 1 - Governing body assurance framework and summary Author: Pam Dobson, deputy director, corporate services, BHR CCGs Date: 11 March 2016

39

Page 1 of 13

Appendix 1 – NHS Redbridge CCG Collaborative objective 2: High quality and compassionate and safe care for all commissioned services – delivering better care

Risk Description: Barts Health (BH) performance. BH continues to fail a number of operational standards including a) referral to treatment times (RTT), b) cancer targets and c) A&E, (specifically Whipps Cross). There are also data quality concerns that present a further challenge for commissioners. This could: A) Threaten the long-term validity of the Trust, B) Put patients at risk and cause reputational damage.

Lead director: Louise Mitchell Risk ref: 2.4 a, b, & c – (groups the three performance risks together)

Initial Risk

Rating 7/2014

Controls Assurances I = internal

E = external

Current risk

rating

Evidence for assurance

Gaps Proposed actions

Target Risk – 31/3/16 Control Assurance

Like

lihoo

d (4

) x Im

pact

(5)

= S

ever

e 20

1. Bi- weekly performance

meetings with the Trust development agency (NTDA), led by the lead commissioners Newham CCG as part of the collaborative arrangements

2. Contract query notice issued

3. Remedial action plan developed

4. Contractual meetings – s performance review (WEL SPR) - and levers fully utilised.

5. Weekly reporting to the joint management team (JMT) meetings

6. Monthly executive committee meetings

7. BH system resilience group led by Newham CCG and attended by a CCG Director

8. Weekly system escalation and assurance route from BHR CCGs (Redbridge as lead) to the Lead Commissioners AO – Newham.

1. Minutes of the bi-weekly

meeting (E) 2. Contract notice issued (I) 3. Agreed remedial action

plan implemented( I) 4. Minutes of contractual

meetings – SPR (I)

5. Notes of the JMT meeting (I)

6. Minutes of the executive committee meetings (I)

7. Minutes of the BH system resilience group (E)

Like

lihoo

d (4

) x

Impa

ct (

5) =

Sev

ere

20

Item 3.1.3 on the agenda – Barts Health performance risks report provides greater detail regarding how the CCG is managing this risk

1. Development

of a valid RTT trajectory.

1. Full use of the

appropriate contractual levers to deliver the RRT trajectory to the required quality assurance levels.

BHR CCGs in attendance at Barts Health improvement plan meetings for Whipps Cross as associated commissioner

Li

kelih

ood

(3)

x Im

pact

(4)

= H

igh

12

40

Page 2 of 13

Risk Description: Quality concerns at Barts Health (BH) - Risk that patients fail to receive the required quality of care. The Trust is failing their quality standards in respect of Clostridium Difficile, Methicillin Resistant Staphylococcus Aureus (MRSA) and friends and families test (FFT). As well as concerns regarding the quality of record keeping and staffing levels.

Lead director: Jacqui Himbury Risk ref: 2.6

Initial Risk

Rating 2/2015


E = external

Current risk

rating




Like

lihoo

d (4

) x

Impa

ct (

5) =

Sev

ere

20

1. Bi- weekly performance meetings with the Trust and Trust development agency (NTDA), led by the lead commissioners Newham CCG as part of the collaborative arrangements

2. Contract query notice issued 3. Remedial action plan

developed 4. Contractual meetings –

service performance review (WEL SPR) - and levers fully utilised.

5. Weekly reporting to the joint management team (JMT) meetings

6. Monthly executive committee meetings

7. BH system resilience group led by Newham CCG and attended by a CCG Director

8. Weekly system escalation and assurance route from BHR CCGs (Redbridge as lead) to the Lead Commissioners AO – Newham.

9. Barts Health Clinical Quality Review Meetings (CQRM).

1. Minutes of the bi-weekly

meeting (E) 2. Contract notice issued

(I) 3. Agreed remedial action

plan implemented( I) 4. Minutes of contractual

meetings – SPR (I)

5. Notes of the JMT meeting (I)

6. Minutes of the

executive committee meetings (I)

7. Minutes of the BH

system resilience group (E)

8. Letters of escalation to

lead commissioners (E) 9. Minutes of the WX

CQRM (E)

Like

lihoo

d (4

) x

Impa

ct (

5) =

Sev

ere

20

Item 3.1.3 on the agenda – Barts Health performance risks report provides greater detail regarding how the CCG is managing this risk

1. Record keeping

audit and review to address the concern regarding the quality of record keeping in nursing documentation

1. Audit report and

recommendations

BHR CCGs in attendance at Barts Health improvement plan and CQRM meetings for Whipps Cross as associated commissioner

Li

kelih

ood

(3)

x Im

pact

(4)

= H

igh

12

41

Page 3 of 13

Collaborative objective 3: Developing a system wide urgent care strategy and redesigning the urgent care pathway

Risk Description: Failure to deliver quality improvement in urgent and emergency care at BHRUT could: a) threaten the long-term viability of the Trust and b) put patients at risk, cause reputational damage and delay the implementation of acute reconfiguration programmes.

Lead director: Alan Steward Risk ref: 3.1

Initial Risk

Rating 6/2013


E = external

Current risk

rating



Target Risk – 31/03/1

6 Control Assurance

Like

lihoo

d (4

) x

Impa

ct (

4) =

Sev

ere

16

1. Agreed BHRUT original improvement plan with TDA/ NHSE monitored at monthly Oversight and Escalation meeting. Now replaced with phase two plan

2. Weekly Performance

Assurance Group (PAG) and Operational Resilience Board

3. Contractual meetings – SPR / CQRM – and levers used fully

4. Monthly strategic review (MSR) meetings with senior leadership for overarching assurance and escalation of risk

5. System Resilience Group (Urgent Care Board) focused on system resilience with priorities focused on front door integration.

1. Minutes of the monthly

oversight and escalation meeting (I)

2. Minutes of PAG and

Operational Resilience Board (I)

3. Minutes of contractual

meetings – SPR / CQRM (I)

4. Minutes of strategic review

meeting (I) 5. Minutes of the monthly

System Resilience Group (urgent care board) (I)

Like

lihoo

d (4

) x

Impa

ct (

4) =

Sev

ere

16

Item 3.2 on the agenda – BHRUT exception report provides greater detail regarding how the CCG is managing this risk

Continued monitoring and management through local performance management framework arrangements including weekly Operational Resilience Board, Performance Assurance Group, SPR and System Resilience Group. Continued liaison with NHS England and TDA to monitor arrangements and impact and ensure leading role for CCG SRG leading transformation programme (Vanguard) over next 2 years to transform urgent care. This will further assist the hospital to deliver the 4 hour target and improve quality.

Like

lihoo

d (4

) x

Impa

ct (

3) =

Hig

h 1

2

42

Page 4 of 13

Collaborative objective 4: Improved mental health services so that they deliver proactive and responsive care.

Risk Description: Improving access to psychological therapies (IAPT): Failure to deliver improved access to IAPT services could: 1) restrict people who would benefit from a service in accessing it and 2) threaten delivery of an operating plan commitment for a national mental health standard which will impact on CCG assurance ratings.

Lead director: Louise Mitchell Risk ref: 4.1

Initial Risk

Rating 9/2014


E = external

Current risk

rating



Target Risk –

31/06/16 Control Assurance

Like

lihoo

d (1

) x

Impa

ct (

3) =

Low

3

1. Monthly review of activity plan and improvement actions by CCG

2. Teleconference with NHSE

Assurance Team every two weeks to monitor progress and review of progress each month via activity return and assurance process.

3. Contractual meetings – SPR

/ CQRM – and levers fully utilised.

4. Delivery of improvement plan

actions as discussed at the September 2015 GB meeting monitored through the governing body committee and relevant committees...

1. Monthly performance report

minutes (I) 2. Minutes of NHSE

assurance meetings (E) 3. Minutes of contractual

meetings – SPR / CQRM (I) 4. Minutes of the Executive

and Finance and delivery Committees and the GB meeting.(I)

Like

lihoo

d (4

) x

Impa

ct (

5) =

Sev

ere

20

Item 3.3 on the agenda – IAPT recovery plan and report provides greater detail regarding how the CCG is managing this risk.

1. Action plan to

be strengthened with additional interventions around marketing and communications

2. Weekly tracking of referrals going into the service

1. External

assurance of plans and IAPT model

2. Weekly tracker introduced in December 2015.

NHS England Intensive Support Team reviewed the CCG plan and report in September 2015. Comments incorporated into the CCG plan. Continued liaison with NHS England to monitor arrangements and impact.

Like

lihoo

d (2

) x

Impa

ct (

4) =

Hig

h 8

43

Page 5 of 13

Corporate objective 5: Ensuring that planned care is appropriate, timely and of high quality.

Risk Description: BHRUT 18 Week RTT – a system upgrade exposed significant issues around RTT PTL management and reporting and therefore failure to meet the national standards for RTT and reporting for 12 – 24 months.


Initial Risk

Rating 5/2014


E = external

Current risk

rating


Gaps Proposed

actions

Target Risk –


Like

lihoo

d (5

) x

Impa

ct (

5) =

Sev

ere

25

1. Monthly joint assurance meetings with TDA.

2. Weekly operational

performance meeting with the Trust

3. Contractual meetings – SPR / CQRM – and levers used fully

4. Monthly Strategic review

(MSR) meetings with senior leadership for overarching assurance and escalation of risk

5. Detailed clinical harm review

framework and process including external panel

6. Implementation of the full

RTT recovery plan and trajectory (admitted and non-admitted) agreed in October 2015 at the Joint Oversight and Escalation Group.

1. Minutes of the TDA

meetings (E) 2. Minutes of the

operational performance meetings (I)

3. Minutes of contractual

meetings – SPR / CQRM – contract notice issued (I)

4. Minutes of strategic

review meeting (I) 5. Detailed clinical harm

review framework and process – progress monitored through PAG with outcomes monitored at CQRM (I).

6. Minutes of the joint

oversight and escalation group for reporting process against plan

7. Intensive Support Team

(IST) providing support to Trust (E)

Like

lihoo

d (4

) x

Impa

ct (

5) =

Sev

ere

20

Item 3.2 on the agenda - BHRUT exception report provides greater detail regarding the management of this risk

1. Return to

national RTT reporting expected in February 2015

2. Demand management plan to address significant mismatch of demand over capacity

1. Independent

report on PTL and pathway management

2. Demand management plan agreed by CCG

The BHRUT exception report contains details of the issues, risks and mitigating actions. The CCG will review the independent assurance report on the systems, process and data quality necessary to return to reporting. Delivery programme board established with system director appointed reporting to Trust and CCGs. Clinical Reference Group developing demand management plan by February 2016.

Like

lihoo

d (4

) x

Impa

ct (

3) =

Hig

h 1

2

44

Page 6 of 13

Risk Description: BHRUT cancer standards: failure to deliver national performance standards on cancer pathways for 62 day waits (now delivering on the 2 week standard) with potential impact on cancer diagnoses and treatment and clinical harm.


Initial Risk

Rating 5/2015


E = external

Current risk

rating



Target Risk –


Like

lihoo

d (4

) x

Impa

ct (

4) =

Sev

ere

16

1. Weekly Performance Assurance Group (PAG) meeting with the Trust.

2. Contractual meetings –

SPR / CQRM and Cancer CQN meeting – with levers used fully

3. Monthly Strategic review

(MSR) meetings with senior leadership for overarching assurance and escalation of risk

4. System wide assurance to

NHS England

5. BHRUT 62 day cancer improvement plan and trajectory.

6. Implementation of the

eight cancer high impact initiatives.

1. Minutes of the PAG (I) 2. Minutes of contractual

meetings – SPR / CQRM / cancer CQN meeting – and associated remedial action plans. (I)

3. Minutes of strategic

review meeting (I)

4. Minutes of NHS England assurance calls (E)

5. Minutes of the system-

wide (NHSE / TDA / CCG) bi-weekly scrutiny (at PAG) (E)

6. Minutes of the PAG and

SPR meetings for reporting progress against plan (I)

Like

lihoo

d (4

) x

Impa

ct (

4) =

Sev

ere

16

Item 3.2 on the agenda – BHRUT exception report provides greater detail regarding the management of this risk

Like

lihoo

d (2

) x Im

pact

(2) =

Med

ium

4

45

Page 7 of 13

Collaborative objective 6: Continued focus on our development as an organisation that delivers

Risk Description: Failure to deliver the CCG QIPP could: 1) adversely impact on the contractual activity agreements with relevant providers, 2) threaten delivery of an operating plan commitment which will impact on CCG assurance and 3) threaten the overarching year end budget delivery required for 15/16

Lead director: Tom Travers Risk ref: 6.1

Initial Risk

Rating 8/2015


E = external

Current risk

rating




Like

lihoo

d (4

) x

Impa

ct (

5) =

Sev

ere

20

1 Monthly review of QIPP delivery ( finance and activity)

2 Monthly review of mitigating actions and risks per scheme where off plan

3 Formal escalation route to Finance and Delivery committee in place as due governance for all schemes that are off plan

4 Confirm and Challenge

model in place for all new innovation / QIPP pipelines to ensure continual identification of schemes

5 Dedicated PMO in place as part of QIPP delivery infrastructure

6 Clinical Director QIPP and innovation meetings held monthly to embed clinical leadership and accountability and identification of required rectification plans

1 Minutes of Monthly QIPP

review meetings (I)

2 Risk log and mitigations for all schemes (I)

3 Minutes of Confirm and Challenge Sessions (I)

4 Minutes of Executive Committee and Governing Body (I)

5 Minutes of finance and Delivery Committees (I)

6 Monthly QIPP delivery summary reports against year trajectory (I)

Like

lihoo

d (4

) x

Impa

ct (

4) =

Sev

ere

16

Continued liaison Instigate JMT level monthly deep dive on QIPP as part of overarching finance and activity review. Dedicated QIPP dashboard instigated to inform review.

Like

lihoo

d (3

) x

Impa

ct (

4) =

Hig

h 1

2

46

Page 8 of 13

New: Risk Description: Barts Heath contract financial risks - Acute contracts, particularly Barts 15/16 contract has been signed by the lead commissioner and the CCGs are working with the collaborative to jointly manage the contract.

Lead director: Tom Travers Risk ref: 6.2

Initial Risk

Rating 5/2015


E = external

Current risk

rating




Like

lihoo

d (3

) x

Impa

ct (

3) =

Hig

h 9

1 Lead Commissioner contract governance arrangements in place to manage contractual performance

2 Detailed contract variance drivers analysed and provided to Commissioners

3 Commissioning Support Unit (CSU) claims & challenges process in place and monthly engagement with Barts Health (BH) with status progress reports provided to Commissioners.

4 Waltham Forest and East London (WEL) and BHR finance leads engaged in joint management of risk.

1 Minutes of Clinical

Commissioning Committee and Contract Review Group monthly meetings (E)

2 Minutes of NHS England assurance meetings and stocktakes (E)

3 Minutes of Executive Committee and Governing Body (I)

4 Minutes of Finance

and Delivery Committee (I)

5 Monthly QIPP delivery

summary reports against year trajectory (I)

Like

lihoo

d (5

) x

Impa

ct (

4) =

Sev

ere

20

Support and advise the Lead commissioners and CSU in their engagement with BH Through lead commissioner arrangements enforce the accountability of WEL under the Lead Commissioner Contract BHR involvement and agreement in all finance decisions relating to the BH Contract

Like

lihoo

d (3

) x

Impa

ct (

3) =

Hig

h 9

Risk Summary Number Total risks last report 7 New risk(s)escalated 1 Risks de-escalated this report 0 Total GBAF risk this report 8

47

Page 9 of 13

NHS Redbridge CCG Governing Body Assurance Framework - overall summary (2015 – 2016)

Lead / GBAF ref. Risk Description

Previous risk ratings Current

risk rating

End of year forecast Target

risk level May 2015

Aug 2015

Oct 2015

Dec 2015

Feb 2016

This time

Last time

L Mitchell 2.4, a, b

& c

Failure of Barts Health (BH) to meet a number of operational standards, RTT, cancer, A/E, data quality and others.

4 x 5 = 20

4 x 4 = 16

4 x 5 = 20

4 x 5 = 20

4 x 5 = 20

3 x 4 = 12

4 x 4 = 16

3 x 4 = 12

J Himbury 2.6

Quality standards not being met at BH - for C.Diff, and MRSA and FFT

4 x 5 = 20

4 x 5 = 20

4 x 5 = 20

4 x 5 = 20

4 x 5 = 20

4 x 4 = 16

4 x 4 = 16

3 x 4 = 12

A Steward 3.1

Failure to deliver quality improvement in urgent and emergency care at BHRUT

4 x 4 = 16

4 x 4 = 16

4 x 4 = 16

4 x 4 = 16

4 x 4 = 16

4 x 3 = 12

4 x 3 = 12

4 x 3 = 12

L. Mitchell 4.1 Failure to deliver improved access to IAPT services 4 x 5

= 20 4 x 5 = 20

4 x 5 = 20

4 x 5 = 20

4 x 5 = 20

2 x 4 = 8

4 x 4 = 16

A Steward 5.2

Failure to meet the 18 weeks referral to treatment times targets at BHRUT

4 x 5 = 20

4 x 5 = 20

4 x 5 = 20

4 x 5 = 20

4 x 4 = 16

4 x 3 = 12

4 x 3 = 12

4 x 3 = 12

A Steward 5.3

Failure to deliver national performance standards on cancer at BHRUT

4 x 4 = 16

4 x 5 = 20

4 x 4 = 16

4 x 4 = 16

4 x 4 = 16

2 x 2 = 4

2 x 2 = 4

2 x 2 = 4

T Travers 6.1 Risk of failure to deliver the CCG QIPP plans 4 x 5

= 20 4 x 5 = 20

4 x 5 = 20

3 x 5 = 15

4 x 3 = 12

4 x 3 = 12

4 x 3 = 12

T Travers 6.2

New: Barts Health contract and financial risk 3 x 3

= 9 4 x 5 = 20

4 x 5 = 20

4 x 5 = 20

4 x 5 = 20

4 x 5 = 20

N/A 3 x 3 = 9

48

Page 10 of 13

NHS Redbridge CCG Governing Body Assurance Framework - overall summary (2013 – 2015)

Lead / GBAF ref. Risk Description Initial rating

(June 2013)

Previous risk ratings End of year forecast Target

risk level Sept

2013 Jan

2014 Mar 2014

June 2014

Sept 2014

Nov 2014

Dec 2014

Feb 2015

This time

Last time

L Mitchell 2.4, a, b

& c

Failure of Barts Health (BH) to meet a number of operational standards, RTT, cancer, A/E, data quality and others.

4 x 5 = 20

4 x 5 = 20

4 x 4 = 16

4 x 5 = 20

3 x 4 = 12

4 x 4 = 16

3 x 4 = 12

J Himbury 2.6

Quality standards not being met at BH - for C.Diff, and MRSA and FFT 4 x 4

= 16 4 x 4 = 16

4 x 4 = 16

3 x 4 = 12

A Steward 3.1

Failure to deliver quality improvement in urgent and emergency care at BHRUT

4 x 4 = 16

4 x 4 = 16

4 x 5 = 20

4 x 5 = 20

4 x 5 = 20

4 x 5 = 20

5 x 5 = 25

5 x 5 = 25

5 x 5 = 25

4 x 3 = 12

4 x 3 = 12

4 x 3 = 12

L. Mitchell 4.1

Failure to deliver improved access to IAPT services

4 x 5 = 20

2 x 4 = 8

4 x 4 = 16

A Steward 5.2

Failure to meet the 18 weeks referral to treatment times targets at BHRUT

5 x 5 = 25

5 x 5 = 25

5 x 5 = 20

4 x 4 = 16

4 x 4 = 16

4 x 3 = 12

4 x 3 = 12

4 x 3 = 12

A Steward 5.3

Failure to deliver national performance standards on cancer at BHRUT 3 x 4 =

12 3 x 3 = 9

3 x 3 = 9

3 x 3 = 9

2 x 2 = 4

2 x 2 = 4

2 x 2 = 4

T Travers 6.1

Risk of failure to deliver the CCG QIPP plans

4 x 3 = 12

4 x 3 = 12

4 x 3 = 12

49

Page 11 of 13

NHS Redbridge de-escalated risks from the GBAF

Lead / GBAF Ref. Risk description

Initial risk

rating

Target risk level and

date

Risk rating when

de-escalated

L Mitchell 5.7 (R13.14/15)

De-escalated in May 2015: The CCGs are significantly concerned about the impact on management capacity from recent significant leadership changes during this critical and challenging period when improvements in patient care need to be delivered at pace.

3 x 5 = 15 Feb 2015

J Himbury 4.1a & b (2 & 45)

De-escalated in January 2015: a) A backlog of continuing health care reviews and outstanding initial assessments, inherited from the PCT, does present a clinical and financial risk to the CCG. b) Outstanding appeals and claims predating April 2014

5 x 5 = 25 June 2013

1 x 3 = 3 31 Dec 2014

3 x 4 = 12 Dec 2014

J Himbury 4.2 (10)

De-escalated in June 2014: Assurance process of care homes. The CCG has not inherited a robust system for assuring quality of all providers the risk is that there is not a culture of sound monitoring.

3 x 5 = 15 June 2013

1 x 3 = 3 1 April 2014

1 x 3 = 3 June 2014

M Sheldon 3.3 (22)

De-escalated in June 2014: Commissioning organisations are not able to run patient level validations for the first quarter to validate non contract activity which will present a financial risk

3 x 5 = 15 June 2013

1 x 3 = 3 1 April 2014

1 x 3 = 3 June 2014

S Morrow 3.2 (21)

De-escalated in June 2014: Financial and operational pressures on practices associated with the transition of GP contracts to NHSE will impact adversely on practice engagement in QIPP delivery. The key risk is that we will fail to deliver our QIPP plan as a result of the issues.

3 x 5 = 15 June 2013

1 x 3 = 3 1 April 2014

1 x 3 = 3 June 2014

M Sheldon 3.1 (4)

De-escalated in January 2014: Central allocation funding issue / specialised commissioning unexplained changes to the LSG calculations resulting in potential additional financial pressure to CCG

3 x 5 = 15 June 2013

1 x 3 = 3 1 April 2014

1 x 3 = 3 Sept 2013

50

Page 12 of 13

51

Page 13 of 13

How to interpret the CCG governing body assurance framework (GBAF):

Risk refThis is a risk identifier attributed to the risk by the CCG risk lead

Lead directorThis is the executive lead with responsibility for:- managing the risks to the corporate objectives and- liaising with the risk lead to ensure the GBAF is up to dateReporting to the CCG governing body or other committee on progress

Risk ratings:The risk rating is derived from conversation between the lead director (or nominated deputy) and the risk lead. The risk score is calculated using the risk grading matrix. There are three types of risk rating used in the CCG GBAF.- initial risk rating: this grades the risk as if there were no remedial measures in place. This is called the ‘inherent risk’. - current risk rating: this grades the risk taking into account the remedial measures. The remedial measures should aim to 1, reduce the likelihood of the risk materialising, 2, reduce the impact of the risk if it does happen and 3, reduce both.- target risk rating: this is the level of risk that the CCG is prepared to accept and the level of risk that must be aimed for.

Risk descriptionFor each risk note down:Who can be harmed and how can they be harmed if the risk materialises.Areas to consider are: harm/injury, objectives, claims or litigation, service disruption, staffing and competence, morale, financial, external assessment and adverse media interest

ControlsWhat is being done to reduce the likelihood and severity of the risk.One specific risk may be mitigated by a number of controls

AssuranceAssurances are inevitably ‘bits of paper’ that act as evidence the controls are in place. Examples include:Job descriptions /organisation chartsRegular reportsContracts / service level agreementsPolicies and proceduresMinutes / agendas / terms of reference

Gaps in controlsWhat more can be done to control the risk and what controls could be improvedGaps in assuranceWhat associated documentation will demonstrate that the controls are in place?

Proposed actionsWhere gaps have been identified, list the actions required to put them into place. Ensure they have a named lead and target date

wisk wef

Lead Director

wisk Description

Lnitial wisk

wating (Wune 13)

/ontrols Assurances /urrent

risk rating

Gaps troposed

actions

Target wisk – 1/4/1

4

/ontrol Assurance

3.3 aS

/ommissioning organisations are not able to run patient level validations for the first quarter to validate non contract activity which will present a financial risk

15 • hur current control is we have issued instructions to the /SU not to pay un-validated invoices. Where we have a contract we will pay in line with the contract and monitor activity.

• Where there is no contract we will develop an alternative validation process. Until the process is developed we will not pay the invoices.

• A regular weekly report is being developed with the /SU to report on the progress.

• The audit committee will be updated on performance to only pay validated invoices.

15 • A detailed process for non contract invoicing requires urgent development.

• A regular report will be produced for the audit and governance committee

• Develop new validation process

3

52

To: Meeting of NHS Redbridge Clinical Commissioning Group (CCG) Governing Body From: Conor Burke, Chief Officer Date: 24 March 2016 Subject: BHRUT Performance Risks Executive summary The CCGs are continuing to manage a number of performance issues at Barking, Havering and Redbridge University Trust (BHRUT) around A&E, Referral to Treatment (RTT) and Cancer access standards. These issues are all included in the CCG’s Risk Register and Governing Body Framework. This report provides a further update on the key actions that the CCG is taking to seek performance improvements at the Trust. It is doing this by both holding the Trust to account through its contract and other mechanisms, as well as providing support through wider system initiatives overseen by the System Resilience Group. The CCGs are working closely with the Trust Development Agency (TDA) and NHS England (NHSE), as well as local partners as the “system leader” to ensure that performance is recovered and then sustained. Recommendations The Governing Body is asked to: • Note the action being taken to date to mitigate the performance risks at BHRUT • Suggest any further actions that the CCG should consider to address the performance and

quality risks for local people. 1.0 Purpose of the Report 1.1 The CCG’s Governing Body Assurance Framework and the risk register identify a number of

areas where the CCG is concerned about performance issues at BHRUT. This report provides an update on the actions that the CCG is taking to seek performance improvements at the Trust on A&E, RTT and Cancer.

2.0 A&E 2.1 A&E performance at BHRUT has not achieved the national standard (95%) from August 2015 to

date. Provisional performance in January was 83.3% compared to 83.0% in 2015 continuing a trend of year on year improvement. However February performance has dropped to 80.4% (provisional) and is significantly below 2015 (92.57%).

2.2 Comparative data for the year to date (April – February) demonstrates a 5.6% (13,102) growth in attendances compared to the same period in 2015/16. However significant growth has been experienced of over 18% for the consecutive months January and February compared to the same period in 2015. This has continued a significant growth trend in attendances since Quarter Three. Ambulance conveyances have increased significantly during the winter period; while as a proportion of total attendances they remain consistent with prior year trends, the actual numbers each week have increased with an average of 1020 per week to Queens Hospital in January compared to 880 in January 2015 and significantly 367 to King George Hospital (KGH) compared to 307. This growth is consistent with wider London trends.

53

2.3 The Trust has reported that the high attendance rates coupled with clustering of attendances

especially during out of hours’ periods coupled with challenged staffing levels have resulted in increased numbers of breaches. Commissioners continue to assess the A&E performance on a daily and weekly basis to hold the Trust to its contractual obligations. There have been daily calls across the sector to review issues affecting performance and flow and agree any further actions that are required.

2.4 The CCGs issued a Contractual Performance Notice (CPN) in July due to the failure of the Trust

to consistently deliver the 95% standard. Through the Systems Resilience Group, it was agreed to develop a joint action plan focusing on how A&E performance can be assured and delivered through the winter, with a focus on the front door of A&E. This has improved performance compared to last year as highlighted above. Performance remains very fragile however driven by the following key issues:

• Significant surge in A&E attendances compared to prior year both “walk-in” and ambulance

conveyance • ED staffing shortages, in particular low proportion of medical rotas that are filled • Poor performance during night shifts, related to access to access to senior decision making

and surges of patients during the evening and night • Reduced throughput in the Queen’s UCC • Multiple services at the front door of A&E that can be confusing to patients

2.5 The following actions are being taken to address these issues: • Medical rotas are reviewed to ensure all mitigating actions are taken to prevent staffing

issues. The Trust has appointed three emergency department (ED) consultants to commence in Quarter Four.

• The Trust is negotiating with the GP Federation to improve UCC utilisation at Queen’s and to increase operational hours. The CCGs continue to challenge the increased A&E activity until this issue has been resolved.

• Review of Intelligent Conveyancing (IC) with London Ambulance Service (LAS) • Commissioners are monitoring and seeking assurance through the CCGs’ weekly

Performance Assurance Group (PAG) that all actions are being taken and escalation processes are in place. The ED improvement plan is the basis for monitoring progress through PAG.

2.6 Through the System Resilience Group (SRG) there is continued support to Emergency and

Urgent Care through schemes implemented in 2014/15 and funded by 15/16 Winter resilience monies; these include GP Federation primary care hubs, care home schemes, rapid access to mental health service (RAID) and Frail Older Peoples Liaison Service (FOPAL), Community Treatment Teams (CTT) and Intensive Rehabilitation Service (IRS) and the Joint Assessment and Discharge team (JAD). In addition, the Trust continues to implement Majors-Light, A&E Urgent Care Triage, improving the Medical Receiving Unit and Elderly Assessment Units and improving earlier discharge.

2.7 The SRG Winter Resilience Plan 2015/16 builds on the measures introduced last year with an additional focus on mental health liaison, support around care packages and discharge to assess. There are separate reports on the agenda looking to extend funding for a number of these initiatives.

2.8 The CCGs will continue to hold the Trust to account through its existing arrangements including

the weekly PAG and the monthly contractual Service and Performance Review (SPR) meeting. 3.0 Referral to Treatment Targets (RTT) 3.1 In December 2013, the Trust identified significant RTT issues following the implementation of its

upgrade to a new Patient Administration System (PAS) including internal system and capacity issues that have affected RTT performance. As a consequence of this, the Trust has suspended national reporting on RTT performance.

54

3.2 Due to the failure to report on these standards, commissioners issued a Contractual

Performance Notice (CPN) that required a detailed recovery plan to be developed.

3.3 The resolution of the RTT data quality issues and the need to reduce the admitted and non-admitted backlogs has been given high priority by the CCG. The CCG has met with the Trust weekly through its formal Performance and Assurance Group (PAG) to review progress to recover RTT standards (as well as A&E and Cancer). A monthly Oversight and Escalation Group with membership from the Trust, CCGs, NHS England and Trust Development Agency (TDA) to oversee and provide assurance on the recovery of the national standard.

3.4 In November 2015 – with the detailed recovery and implementation plan nearing completion –

the CCGs established a joint Programme Board with the Trust to implement the recovery plan and ensure issues and risks are mitigated. A system director for RTT was appointed in January 2016 reporting directly to the Trust Chief Executive and CCG Accountable Officer. The recovery plan will be submitted to the Trust Board and CCG Governing Bodies for approval. The System Director and Programme Board will report formally through the CCG’s governance to the Governing Bodies.

3.5 The core elements of the recovery plan are: improving internal trust productivity, outsourcing to secure additional capacity and demand management. To improve internal productivity the Trust has implemented additional weekend and evening theatre lists and clinics, commenced recruitment processes for consultants across a range of specialties who will be in post from April 2016.

3.6 To support the ongoing validation of the waiting list, all patients who have waited greater than 52

weeks have been contacted by the Trust by phone to confirm their current waiting list status (circa 1,000 patients). 230 patients of those contacted have confirmed that they no longer require the appointment. The Trust will continue to call long wait patients with a further cohort of >45 week waiters to be called. The Trust will also be writing to patients who have waited >18weeks but <45 weeks to request confirmation of their waiting list status. An initial sample of 300 patients has been written to gauge the response rate and assure that potential risks are being managed.

3.7 An external analysis of theatre utilisation and productivity has been undertaken to identify

process and practice developments that could improve theatre productivity. The Trust has appointed a project manager to lead development of the productivity plan to commence in February.

3.8 The Trust commenced outsourcing of patients requiring admitted treatment in July 2015; the

conversion rate from offer of alternative provider to actual treatment is 31%. Factors affecting increased activity are patient choice and clinical exclusion preventing transfer.

3.9 A Clinical Reference Group (CRG) has been established to develop the demand management

plan and is meeting fortnightly. The group has prioritised specialties where it is felt a greater impact can be made on wait times through referral management, clinical protocols or establishment of alternative pathways and new technologies; these include dermatology, ENT, Orthopaedics and Gastroenterology. The CCG has engaged with the national Behavioural Insights Team to support development of demand management plans to understand how to influence the behaviour of patients.

3.10 It is anticipated that the earliest recovery of the standard will be March 2017; however there

remains substantial risk to achieving this due to the volume of patients who have already breached their 18 week wait. Priority is given to any patient that has waited over 52 weeks to make sure that they are treated as soon as possible.

55

3.11 The Commissioners and the Trust have agreed additional resources for increased activity in

Quarter Four to bring forward outpatient attendances and treatment for patients with >52 week waits. An additional 757 outpatient attendances will be booked in February/March with an additional 114 surgeries to be undertaken.

3.12 The IST reviewed the Trust’s RTT data quality, systems and processes in October 2015. The

report from this review on the data quality is awaited and is a key requirement for the Trust to return to reporting. Despite escalation through NHSE to the IST, this report has yet to be received. Given the delay in receiving this report, the CCGs are commissioning an independent review of the Trust’s system and processes.

3.13 The Trust has agreed a clinical harm process drawing on good practice developed elsewhere.

This is being implemented with both an internal and external harm review panel meeting to review progress and outcomes. No significant or moderate harm has been identified from the cases reviewed for the admitted pathway. Locally the progress of clinical harm reviews is reported to the weekly PAG with the outcomes reviewed at the Clinical Quality Review Meeting (CQRM).

4.0 Cancer 4.1 Cancer performance is one of the eight national priorities for delivery. While performance overall

on cancer pathways has improved at the Trust over the last six months with seven of the national standards being met until December, the 62 day standard has consistently been failed.

4.2 In December the Trust reported that the 2week wait, 2week wait breast and 31 Day First Definitive Treatment and 31 Day Subsequent Surgery standards. Provisional data for January shows the Trust has not recovered the standards. The Trust has indicated that patient choice over the holiday period, theatre and capacity issues in December and January have resulted in the breaches. The Trust is working to recover the 2week and 31 day standards by February reporting and have implemented additional activity to address capacity and backlog.

4.3 A CPN was issued against the 62 Day Cancer standard in 2014/15, which remains open due to

the lack of improvement in performance.

4.4 The Trust has failed the 62 day standard (85% target) since June 2014. The Trust developed a Cancer Action plan which has been signed off by the CCGs, TDA and NHSE with a planned recovery of the standard by January 2016, with a trajectory provided showing how performance would improve month on month. The Trust did not achieve this trajectory and have presented a revised trajectory with recovery of the standard now expected in May 2015.

4.5 A significant increase in the number of patients waiting with or without a decision to treat (DTT)

was reported in February. These patients were known and were being tracked but were not being correctly reported through weekly submissions to the TDA. The Trust has - as required - reported this as an SI. The continued failure of the 62 Day Standard has resulted in escalation to weekly monitoring of planned and actual activity and the booking of patients who have waited greater than 62 days for treatment from referral against a weekly trajectory.

4.6 Recent deliverables that the Trust and Commissioners have implemented and continue to

develop include: • Increased activity in February – May above run-rate to reduce the number of patients

waiting, • Tumour site specific plans with the implementation of straight to test pathways for some

specialties and a focused change programme for urology with the continued implementation of the London prostate cancer pathway,

• Improving the tracking of patients on the suspected cancer waiting list and the analysis and reporting of the trends,

• Completing pathway mapping with the support of NHS Elect – a national NHS improvement agency. Five pathways out of the nine have been completed, and

56

• Improving compliance on transferring tertiary cases by day 42.

4.7 Due to the issues reported in February with regard to data and the failure to recover the trajectory in January, the CCG is looking to commission an independent review of the cancer pathway and process management.

4.8 Commissioners continue to monitor the number of over 100 days’ treatment breaches and have agreed with the Trust that from February patients who have waited >62 days are to be reviewed by Divisional Directors and reported to the External Harm Review Board. The Trust has issued guidance and timelines on the completion of these ham reviews. Harm reviews are expected to be complete and recorded within the second month after treatment.

5.0 Resources/investment 5.1 The CCG Chief Financial Officer and other senior leaders are working with NHSE, TDA and

other partners to secure the required resources to deliver the changes. 6.0 Equalities 6.1 The implementation of the Trust improvement plan and the associated remedial action plans

identified above will improve quality and reduce health inequalities. 7.0 Risk 7.1 This report highlights the key risks around each of these issues. These risks are included in the

Governing Body’s Assurance Framework and this report provides further detail to the Governing Body on the issues and action being taken to mitigate them.

Author: Conor Burke, Accountable Officer

Date: 2 March 2016.

57

To: Meeting of the NHS Redbridge CCG Governing Body From: Louise Mitchell, Chief Operating Officer

Date: 24 March 2016 Subject: Barts Health Exception Contract Report 2015/16 Executive summary The CCGs continue to manage a number of performance and quality issues with their key providers, most notably at Barts Health around A&E, Referral to Treatment Times (RTT) and Cancer 62 day waiting times. These issues are all fully captured in the CCG’s Risk Register and Governing Body Assurance Framework. This report provides a further update on the key actions that the CCG is taking to seek assurance, through the lead commissioner arrangements, that performance improvements are being taken forward at the Trust. Redbridge CCG, on behalf of BHR CCGs, continues to operate as an associate to the lead commissioner arrangements.

Recommendations The Governing Body is asked to: • Note the actions being taken by the lead commissioner to mitigate the

performance risks at Barts Health since the last report provided at our January Governing Body

• Note that the lead commissioner is holding the Trust to account through the contractual governance framework.

• Advise of any further actions that the CCG should consider to address the performance and quality risks for local people.

1.0 Purpose of the Report

The purpose of this report is to inform the Governing Body of the performance and quality concerns that Barts Health is facing and the actions being taken by the CCG as an associate commissioner. Currently the Barking and Dagenham, Havering and Redbridge (BHR) CCGs are an associate to the main contract which is led by Newham CCG.

58

2.0 Background/Introduction

The following section of this report outlines the current areas of escalation that are of significant concern for BHR CCGs and are reflected as noted in the Governing Body Assurance Framework.

3.0 Performance

Barts Health continues to fail a number of operational standards, as set out in detail below. BHR CCGs remain engaged through the contractual governance framework established by the lead commissioner and are in attendance at the relevant forums. 3.1 A&E performance The required national operational standard continues to remain unmet. Whilst the Trust is working on improved management of bed occupancy, A&E performance remains variable. As noted in January’s Exception Report, Whipps Cross site level performance data (A&E All Types) for November indicated that Whipps Cross attained 81.69% against the standard. Performance data for December indicated a further deterioration, with the Trust reporting 80.92%. Provisional data for January indicates a slight improvement, to 81.75%, on the December position. The Trust reports continued themes of deterioration against Type 1 performance at site level; as noted in January’s Exception Report, for Whipps Cross, Type 1 performance for November was 72.92%. December performance further deteriorated to 70.56%. Provisional data for January indicates a slight improvement, to 71.95%, on the December position. It is important to note that A&E performance is now reported monthly and data for January is provisional, as at the date of this report. January data will be published by NHSE after 10 March. The Trust did not meet the 4 hour wait standard on any day in January. Trust level performance trajectories (agreed between the Trust, Commissioner and TDA) have been confirmed for the remainder of the year; for Quarter 4, the agreed trajectories are 91.20% for the Trust as a whole, and 88.50% for Whipps Cross. The Whipps Cross site has failed to achieve the A&E Trajectory from the week ending 17 November through to the week ending 21 February (with one exception being the week ending 17 January). Based on current performance projections (as at week ending 21 February), the Trust are predicted to achieve 86.00% for Quarter 4, and on the Whipps Cross site, 80.58%.

59

Due to the consistent failure of each site to meet the agreed trajectories further work is under way at site level to ensure the existing actions on the current RAP remain the most appropriate actions and to consider whether there is any further action that can be taken. In the event that there are no further actions, further discussion will be required to understand what is preventing the required level of performance improvement. It has been the recommendation of the Barts Health CCC that site level Exception Reports are raised to this effect, subject to CCG agreement and sign-off. Further tripartite meetings with NHSE are expected to be held in the coming weeks. A reporting pack is currently in the process of being developed for this to include, an overview of performance against trajectory, out-of-hospital plans, as well as an overview of Operational Resilience schemes and the outputs of the McKinsey diagnostic work (the three key areas being; Emergency Department process including minors/UCC streaming; discharge process including complex discharge; and Paediatric pathways). The table below highlights the Whipps Cross site Emergency Department trajectory, actions and agreed impacts in Quarter 3 and Quarter 4:

Site Workstream Delivery Date

Q3 Impact Q4 Impact Total Impact to Year End

Whipps Cross

Reconfiguration of front door 30-Nov-15 0.5% 1.6% 1.1% Triage direct to EGU 11-Dec-15 0.1% 0.2% 0.2% Triage direct to SAU 18-Dec-15 0.1% 0.5% 0.4% Triage direct to Ambulatory Care 30-Nov-15 0.4% 1.3% 0.9% Increase % Paeds s/b primary care 30-Nov-15 0.0% 0.2% 0.1% Establishment of PCDU 30-Dec-15 0.1% 0.5% 0.4% Establishment of PASU 30-Dec-15 0.1% 0.2% 0.1% ED Sit Reps and ED Breach Reviews In place 0.2% 0.5% 0.4% Early Discharge from CDU and AAU to enable timely admission from ED

23-Nov-15 0.7% 1.1% 1.0%

DTOC Reduction to cap 07-Dec-15 0.4% 0.7% 0.6%

A number of actions have been taken by the Trust including the recruitment of nurse posts and implementation of new clinical leadership and programme of clinical engagement supported by ECIP. However, the PASU and PICU funded via OR have not been implemented on a consistent basis due to unavailability of locum Paediatric nurses and therefore has not had the impact anticipated. Other mitigating actions at the Whipps Cross site include:

• Emergency Sit reps completed 2 hourly to inform decisions and actions. • Continued ED and UCC integrated streaming and assessment of ambulant

patients. • CDU flow prioritised to enable full use by ED consultants. • Treat and Transfer Nurse for paediatrics remains in place.

60

• PCDU supported by additional ENP and SHO, ED senior registrar cover to ensure safety of children requiring extended observations within the Emergency department.

Actions and progress is monitored on a daily and weekly basis with exceptions reported by the Trust where standards are not met. Compliance against Remedial Action Plans, with a particular site focus, is discussed with the lead commissioners at fortnightly Emergency Department performance meetings and the monthly Urgent Care Working Group. BHR CCGs are kept informed on the position and engaged in actions undertaken on our behalf as part of monthly Clinical Commissioning Collaborative meetings with the lead commissioner. 3.2 Referral to Treatment (RTT) As noted at January’s Governing Body meeting, national reporting on RTT for Barts Health is currently suspended. In response to the Contract Performance Notice issued in June 2015 the Trust has provided a number of iterations of its Remedial Action Plan and a trajectory to clear backlog of 52 + and 40 + week waiters.

The Trust continues to report separately to commissioners and report non-compliance with the incomplete standard. The Trust met the agreed trajectory for backlog (with the exception of ‘pop-ons’ 1 in November) and total waitlist clearance as at the end of November 2015. December saw an increase in the backlog due to cancellations that took place in the month. The overall waiting list however, continues to reduce. The 52+ week position, as at end of December, is 50 with a further 65 ‘pop-ons’, totalling 115 patients waiting longer than 52 weeks. This remains higher than the trajectory, however, of the 50 patients, 12 are patient choices, and another 3 due to patient cancellations/DNAs. The key reason for the rise in ‘pop-ons’ is due to the conclusion of the first patient contact exercise of the raw PTL, leading to 270 patients being identified as genuinely waiting. ’Pop-ons’ will continue until completion of Phase 2 of the data quality exercise. Patients waiting 40+ weeks rose by 26 between December and January but remain below the trajectory. The rise is due, in part, to ‘pop-ons’ and patient choice but also as a result of elective cancellations as a result of the recent strikes and reduction in bed occupancy prior to Christmas. Long waiters are managed robustly by the Trust with individual review of patients over 38 weeks, to ensure a plan is in place and the next events are clear. These are managed at site level at director-led meetings which are attended by the CSU.

1 ‘Pop-ons’ refers to patients previously not seen on the PTL and are usually due to validation of the pathway, through the data quality processes

61

The RAP has now been signed off by CCGs. However the inclusion of patient choice in the 52 week wait trajectory is being reviewed. The CCGs will continue to monitor delivery against this plan. The first stage of the data quality plan for the circa 310,000 raw PTL is complete. Potential cohorts of patients for exclusion were identified, in consultation with IST, and 10% of each of these were sampled. 194,580 (out of 310,000) pathways were identified with 95% confidence as non RTT. Phase 2 of the data quality plan has resulted in a further circa 18,000 requiring patient contact to confirm the status of their pathway. The lead CCG agreed in December that patients would be contacted by letter, with a return card or email response to confirm whether or not the patients are still waiting for treatment. Letters began to be sent out in January, with a view to completion by the end of March. Letters have been sent directly to patients and those patient’s GPs, resulting in a number of concerns raised by BHR GP practices regarding both the content of the letters and communication of the process to GP practices. The CCG has escalated these concerns via the lead CCG. The lead CCG has been requested to obtain an explanation directly from the Trust. The expectation, as at 3 March, is that the Trust will be writing directly to CCGs on this matter. Once this data quality process is complete, a decision will be made with the support of the Intensive Support Team (IST) with regard to recommencing national reporting. 3.3 Cancer The Trust has consistently achieved the cancer 2 week wait National Operational Standard since April 2015 at Whipps Cross. Performance for December remains to be validated (96.4%), but provisional data indicates that Whipps Cross Hospital will continue to meet the target. A Contract Performance Notice was issued to the Trust in June 2015. A revised Remedial Action Plan was signed off by commissioners in September 2015. This is a ‘live’ document and progress will be updated monthly to commissioners via the Cancer, Diagnostics and RTT National Performance Standards Assurance Group and Contracting Reference Group. Although the Trust met the 62 day standard in October (86.18% - the first time since September 2013), the Trust failed to meet the standard in November (84.34%). However, data for December indicates achievement of 87.14% against the standard. The Trust achieved eight of the nine cancer standards for the month of December. In addition, the Trust has also:

• Reduced the number of patients who have been on cancer pathways for more than 62-days to 98 (as at 15 February)

62

• Reduced the number of patients who have been on cancer pathways for more than 104-days to 6 (as at 12 February)

These improvements will put the Trust in a good position to sustain 62 day performance. The RAP includes a trajectory for specialty level 2WW and 62 day GP performance The Trust was compliant with the latter during Quarter 3 and anticipates being compliant within all 2WW specialties in January 2016. As noted in the last report to the Governing Body, The Trust has successfully recruited four Urology Consultants, all of whom have now commenced employment. The Trust has also recruited two further Cancer Nurse Specialists, one at Whipps Cross, and another at Royal London Hospital. There is an ongoing review of the Histopathology staffing case mix and capacity, and there is additional recruitment underway for another colorectal surgeon to assist in patient throughput and to bolster service delivery across the specialty. RAPs for RTT, Diagnostics and Cancer are reported to the BH National Standards Performance Committee/Contract Review Group (CRG) where senior level representation from WEL CCGs, the TDA, NHSE Specialised Commissioning and NEL CSU hold the Trust to account. 4.0 Resources/investment There are no additional resource implications, revenue or capital costs arising from this report. 5.0 Equalities There are no equalities implications arising from this report. 6.0 Risk There are particular challenges facing the local health economy around the financial position of Barts Health NHS Trust and work is currently being undertaken by the Trust, lead commissioner and the NHS Trust Development Authority (NTDA) to understand more fully both the underlying financial position of the Trust and how the local health economy can work together to ensure future viability. BHR CCGs remain particularly concerned at the progress against improvement plans for the Whipps Cross Hospital site. BHR CCGs continue to escalate matters formally with the lead commissioner, seeking clarification in respect of actions taken where appropriate. 7.0 Managing conflicts of interest

63

There are no conflict of issues relevant to this report.

Author: NEL CSU Contract Team Date: 3 March 2016

64

Appendix 1 - Abbreviations and Acronyms A&E - Accident and Emergency AAU - Acute Admissions Unit CCC - Clinical Commissioning Collaborative CDU - Clinical Decision Unit CPN - Contract Performance Notice CQRM - (Executive) Clinical Quality Review Meeting CRG - Contract Review Group DNA - Did Not Attend DTOC - Delayed Transfer of Care ECIP - Emergency Care Improvement Programme ED - Emergency Department EGU - Emergency Gynaecology Unit ENP - Emergency Nurse Practitioner IST - Intensive Support Team NHSE - NHS England OR - Operational Resilience PASU - Paediatric Assessment and Short Stay Unit PCDU - Paediatric Clinical Decision Unit PTL - Patient Tracking List RAP - Remedial Action Plan RTT - Referral to Treatment Times SAU - Surgical Assessment Unit SHO - Senior House Officer SSU - Short Stay Unit TDA - Trust Development Authority UCC - Urgent Care Centre

65

To: Meeting of the NHS Redbridge CCG Governing Body meeting From: Dr C Okorie Date: 24 March 2016 Subject: Delivery of IAPT operating plan standards Executive summary CCGs are required to deliver two mental health standards related to Improving Access to Psychological Services (IAPT) in the 2015/16 operating plan - 15% of adults with relevant disorders will have timely access to IAPT services with a recovery rate of 50%. From 1 April 2016 CCGs are required to meet a waiting time access standard so that 75% of people referred to IAPT are treated within six weeks of referral and 95% will be treated within 18 weeks of referral. The BHR CCGs have all committed to meeting these targets for 2016/17 in their Operating Plan submissions of February 2016.

Redbridge CCG has not achieved the access standard to date in 2015/16. A recovery action plan is in place which resulted in slightly improved performance in January 2016 (0.88% against target of 1.25%) compared to November. Additional actions have been identified for Redbridge to recover performance however it is extremely unlikely that Redbridge will meet the target before end Q4 2015/16. Redbridge CCG has seen under-performance against the recovery standard in 15/16. Current waiting times for Redbridge are between two-to-four weeks on average and the service is meeting the national waiting time target of at least 75% of patients entering treatment within six weeks.

Recommendations

The Governing Body is asked to:

• Note the recent performance against the IAPT standards.


1.1 This report provides an update to the Governing Body on actions that are being taken to

improve performance against the Improving Access to Psychological Therapies (IAPT) standards.

2.0 Background/Introduction 2.1 The Governing Body has received reports in November 2015 and January 2016 notifying

of the performance against the IAPT access target and actions in place to recover this performance where necessary.

66

2.2 CCGs are required to deliver the access standard for IAPT which is that 15% of adults

with relevant disorders will have timely access to IAPT services and the recovery standard of a 50% recovery rate.

2.3 By 1 April 2016 CCGs are expected to deliver a waiting time standard for IAPT so that 75% of people referred to IAPT are treated within six weeks of referral and 95% will be treated within 18 weeks of referral.

2.4 Barking and Dagenham, Havering and Redbridge CCGs have contracted with NELFT to provide the IAPT service and have agreed additional investment to ensure that the capacity is in place to deliver these targets.

2.5 Delivery of the IAPT access and recovery standards was a component of the CCG operating plan in 2014/15 and continues to be so in 2015/16. BHR CCGs are some of the few in London not attaining the required access targets.

3.0 IAPT performance - access 3.1 Redbridge CCG did not achieve the monthly target in November, December or January.

Data for the neighbouring BHR CCGs is included in the table and figure below for comparative purposes.

Please see table 1 and fig 1 below. Table 1: Access performance report

(HSCIC Monthly figures Apr - Oct 15) (Provider monthly

figures)

April May June July Aug Sept Oct Nov Dec Jan

Target 1.25% 1.25% 1.25% 1.25% 1.25% 1.25% 1.25% 1.25% 1.25% 1.25%

B&D Actual 0.39% 1.37% 1.32% 1.08% 1.08% 1.20% 1.37% 1.38% 1.28% 1.24%

Havering Actual 0.22% 1.14% 1.32% 0.97% 0.99% 1.12% 1.24% 1.05% 0.73% 1.06%

Redbridge Actual 0.21% 1.15% 1.25% 1.17% 0.70% 0.86% 1.01% 0.81% 0.57% 0.88%

67

Fig 1: Graph showing CCG performance against target (Provider data)

3.2 Year-end projected access rates (see table 2 below)

Redbridge CCG – Current forecast rate of 11.49% access rate for full year 2015/16 (a slightly improved position from the previous Governing Body report) and a trajectory that sees achievement of the 3.75% access rate from Q1 2016/17.

Table 2: Expected performance 2015/16

15/16 forecast

access rate (full year)

Barking and Dagenham CCG 14.22%

Havering 12.53%

Redbridge 11.49%

3.4 The CCG is implementing a Recovery Action Plan to improve performance. CCG actions

since January have focused on:

• Delivering a programme of practice visits to increase GP referrals to IAPT. Additional clinical capacity has been secured to carry out extra practice visits in Redbridge, with a total of 45 visits having been carried out since July 2015.

• Introduced a new/simplified GP referral form to support direct referrals • Developing a BHR marketing strategy and campaign, based on evidence and

research gathered over the past few months, which has resulted in rebranding of the service (currently underway).

• Close monitoring of activity, including requesting GPs to consistently code referrals with the same input code, and develop weekly reports of activity to drive recovery actions.

• Monitoring telephone response to callers to IAPT service (including “mystery shopper” exercise.

68

4.0 IAPT performance – recovery

4.1 The recovery standard is that 50% of people who complete treatment are moving to recovery. NELFT is currently reporting a BHR average recovery rate of 47.54% for Q3 which needs to be increased to 50% to meet the recovery targets. NELFT has established an IAPT Clinical Task Group to oversee the remedial actions being taken to assist the Redbridge IAPT service to meet its recovery targets.

5.0 IAPT Performance – waiting times 5.1 Achievement of the waiting time standard is required from 1 April 2016. The standard is

(i) the proportion of patients that wait six weeks or less for referral to entering a course of IAPT treatment against the number of people who finish a course of treatment in the reporting period (ii) the proportion of patients that wait 18 weeks or less for referral to entering a course of IAPT treatment against the number of people who finish a course of treatment in the reporting period.

5.2 Preparation for the delivery of the waiting time standard has been included in the Service

Development and Improvement Plan as part of the NELFT contract. Delivery of this plan is on target.

6.0 Resources/investment 6.0 CCGs have identified additional dedicated project management support from within

existing resources.

7.0 Equalities

7.1 Disparity in the quality and availability of mental health services is a long standing issue. The introduction of access standards for mental health is one step to ensuring that mental health is treated on a par with physical health.

8.0 Risks

8.1 The key risk is that patients are not receiving access to the care and support that they

need. Non-delivery of the IAPT action plans will lead to failure to deliver the IAPT targets by CCGs. This will impact on the annual CCG assurance rating from NHSE which determines whether the CCG can be considered to be a competent commissioner.

9.0 Managing conflicts of interest

9.1 There are no conflicts of interest considerations arising from this report

Author: Gemma Hughes, Deputy Chief Operating Officer Barking and Dagenham CCG Date: 26 February 2016

69

To: Meeting of the NHS Redbridge CCG Governing Body From: Sarah See, Director of Primary Care Transformation Date: 24 March 2016 Subject: Personal Medical Services (PMS) Review - update Executive summary The purpose of this paper is to brief the Governing Body on the latest position regarding the Personal Medical Services (PMS) Review, namely:

• the ‘London offer’ agreed between NHS England (London) and London’s Local Medical Committees; and

• the draft commissioning intentions and the overall funding position for the CCG.

Recommendations The Governing Body is asked to:

• Note the agreed ‘London offer’ for PMS agreements; • Comment on the draft commissioning intentions for the CCG, and overall funding; and • Agree that review and discussion on these matters including the impact at individual practice

level take place at the Primary Care Commissioning Committee. Particularly noting that the planned increase in PMS/GMS contract values for 2016/17 and 2017/18 will be funded through Primary Care Growth funding.


The purpose of this paper is to brief the Governing Body on the updated position regarding the Personal Medical Services (PMS) review, namely: • the ‘London offer’ agreed between NHS England (London) and London’s Local Medical

Committees and • the draft commissioning intentions and the overall funding position for the CCG. • advise that a Equality Impact Assessment (EIA) is being completed

2.0 Introduction 2.1 In January 2015 the Governing Body received an update paper outlining progress on the

nationally mandated review of PMS agreements. The paper reminded the governing body of the national and London principles underpinning the review and how the work was being taken forward across London and locally within the CCG.

2.2 Since then NHSE London have confirmed that the London offer has now been agreed with

London’s LMCs to ensure a consistent service offer for all Londoners.

70

3.0 The new PMS contract 3.1 It is confirmed that the ‘main body’ PMS contract and Schedule 13 will form what will be

referenced as the core PMS contract. The mandatory / non-mandatory key performance indicators (KPIs) and the premium service specification also form part of the ‘London Offer’ and attracts funding above the core ‘main body’ offer i.e. premium funding.

3.2 The funding associated with each of the above components is outlined below: Figure1. New PMS contract components / funding

Premium funding

Core funding (assumed GMS equivalent)

3.3 To remind governing body members, the ‘main body’ of the contract largely comprises national

PMS regulations and includes details such as contract holder, a definition of essential services, information on who can perform services, the management of patient records, termination clauses, etc. The contract can be viewed at https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/06/pms2015-16.pdf

3.4 Schedule 13 of the core contract sets out a list of services that patients can expect to be provided

by a PMS contractor. Payment for this schedule is assumed as part of the main contract and therefore does not attract any additional payment above core funding. The requirements set out in this schedule are designed to be equivalent to the GMS contract but provide greater definition than corresponding elements in the GMS contract.

3.5 The proposed KPI schedule has been updated following discussions with all London LMCs;

breast screening has now been removed from the mandatory KPI list. The following areas are now finalised as the mandatory KPI’s:

• Cervical Screening, • Vaccinations and Immunisations, i.e. childhood Immunisation, flu and

Pneumococcal immunisations, and • Patient Voice – a selection of indicators that are sourced from the national GP Patient

Survey - CCGs need to select two from a number of suggested indicators.

1 This includes Saturday morning opening - cost £4 per raw registered patient based on an average practice of 6000

patients and improving access through the use of technology £1pwp for full achievement. Additional capacity has not been included as the price is to be determined locally.

PMS Contract

Optional Premium Service Specification £5.001 prp

Mandatory KPIs

Optional KPIs

£3.04 pwp

£1.36 pwp

Schedule 13 – Service Requirements

£75.77 pwp

+

£2.18 prp

‘Main body’ contract-Regulations

71

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/06/pms2015-16.pdf


Optional KPIs -

• Breast Screening and • Capacity & Access measures e.g. attendance at local Walk in Centres, Urgent Care

Centres and A&E.

The mandatory KPIs should be commissioned by all London CCGs/NHSE - although there is some local determination as to which patient voice indicators CCGs wish to commission. The capacity and access measures and breast screening are optional KPIs.

3.6 Performance and payment against the KPIs will be measured against 4 bands:

• Band A - Optimal Performance level • Band B- Acceptable Performance Level • Band C- Minimum Performance Level • Band D- KPI Failure

3.7 The optional premium service specification describes services that will support implementation of

the Strategic Commissioning Framework (SCF). NHSE have developed three areas which facilitate delivery on patient choice, contacting the practice, routine opening hours and same day access.

3.8 There are three premium provisions within this specification:

• Flexing Capacity – sets out a requirement that practices extend core hours to include four hours on a Saturday morning (09:00 – 13:00); this attracts a payment of £4.002 per registered patient (prp);

• Additional Capacity – sets out a requirement for practices to offer additional appointments; cost to be determined locally; and

• Improving Access through Use of Technology – incentivises practices to increase access to online services such as booking and cancelling appointments, access to patient records, ordering repeat prescriptions and electronic consultations. Maximum payment available is £1.00 pwp.

4.0 Financial implications 4.1 As outlined previously a number of key principles are in place, that is:

• Any released PMS funding should be reinvested in general practice; • CCGs, with NHSE may choose to commission locally specific services with released

PMS funding or use additional funding at a CCG level; • The review will establish as a minimum an agreed cost per weighted patient for the

delivery of the agreed specification across all PMS providers at CCG level; • The review will ensure equality of opportunity across all GP practices - PMS, GMS

and APMS - provided they are able to satisfy locally determined requirements; and • Funding not invested in core PMS requirements should be reinvested in general

practice for CCG or SPG specific services via PMS contracts or other commissioning mechanisms.

4.2 There are 13 PMS practices in Redbridge with a PMS premium of c£1m invested; there is variation between individual practice’s premiums, the minimum being -£1.75 to a maximum of £28.09 per patient.

2 Based on a list size of 6000 registered patients.

72

4.3 The affordability of the London PMS contract has been modelled against the PMS premium available for each CCG. (see Table 1 below).

Table 1 – London PMS offer

Contract type

Mandatory KPIs

(£)

Optional KPIs

(£)

Saturday opening

(£)

Use of technology

(£)

Additional capacity3

(£)

Total London Offer Cost

(£)

PMS 257,181 115,055 377,708 84,599 834,544

GMS 502,296 224,711 736,920 165,229 1,629,156

Overall 759,477 339,766 1,114,628 249,828 2,463,700

4.4 Commissioning the entire ‘London offer’ in Redbridge, for both PMS and GMS practices will cost

in excess of c£2.4m, as the additional capacity element is to be costed locally. This would mean a cost pressure for the CCG amounting to in excess of £1.4m (given the premium available is c£1m);

5.0 Draft Commissioning Intentions 5.1 The CCG was required to submit draft commissioning Intentions to NHSE by 19 February 2016.

These were submitted noting that they were draft intentions and further work would need to be completed once the CCG’s financial baseline position was known and validated. These intentions also need to be discussed with the LMC, agreed by NHS England and final approval sought from the Primary Care Commissioning Committee (PCCC).

5.2 Initial work has been completed on the basis that the current level of PMS funding will continue to

be invested in PMS practices, this equates to £11.18 premium per weighted patient. From July 2016 the CCG proposes to commission4 the following from all PMS practices: • Mandatory KPIs; • Use of technology – from April 2015 practices were contractually required to offer online

services to patients and all practices are technically able to do this. However this provision and associated patient communication is variable. There is a national drive to improve the usage of on-line services and increase the number of appointments offered on-line to patients. This shift is expected to improve practice productivity. It is therefore proposed that this is commissioned to drive improvement further and encourage practices to actively offer these services to patients. It will also support implementation of the SCF; and

• Additional Capacity – this is an area which should be prioritised, subject to the outcome of negotiations and formal CCG approval. Patient survey (GPPS) results for Redbridge are below the London and national average and it is felt that commissioning additional capacity in-hours would have a positive benefit on patients as well as support implementation of the SCF. Currently in Havering and Barking and Dagenham, a number of PMS contracts require practices to offer 100 appointments per 1000 patients per week.

5.3 The CCG does not plan on commissioning the flexible capacity premium specification. This

would not be cost effective, nor do all practices have the resources to offer Saturday opening. However Saturday opening is already commissioned for the whole population via GP Access Hubs (3 currently operational in Redbridge). Currently the Hubs vary their opening hours and

3 To be determined locally

4 Subject to approval from PCCC, agreement from NHSE and discussions with the LMC and local practices.

73

capacity to meet demand, but from 1 April 2016, the CCG will need to, as a minimum, ensure 1 Hub is commissioned to open for 4 hours on Saturday mornings.

5.4 The CCG also intends to commission the GMS equalisation on a staggered basis from 2016/17

as outlined below: • 2016/2017 Improving access through use of technology • 2017/2018 Mandatory KPIs • 2019/2020 Additional capacity

5.5 Delegated responsibility from NHSE for Primary Care Co-Commissioning has identified a number

of reporting and information risks leaving the CCG’s with a degree of uncertainty. It is planned that the increase in PMS/GMS contract values for 2016/17 and 2017/18 will be funded through Primary Care Growth. In future years the local offer requires significant investment and will need to be reviewed in line with the transformation plans and the medium term financial plans. The table below sets out the cost of the local offer and the borough impact. The impact on individual practices will be reviewed at the PCCC.

Contract type 2016/2017 2017/18 2018/19 2019/20 2020/21

PMS - Transition Cost 189,298 192,840 0 0 0 PMS - Contract Premium Offer 869,418 869,418 869,418 869,418 869,418 GMS 172,132 695,414 695,414 1,926,158 1,926,158 Overall 1,230,848 1,757,672 1,564,832 2,795,576 2,795,576 Current Redbridge PMS Premium 1,046,251 1,046,251 1,046,251 1,046,251 1,046,251 Change in funding 184,597 711,421 518,581 1,749,325 1,749,325 Note:- The figures shown above are based on 2015/16 list sizes are at 2016/17 prices. Future years will be subject to growth and inflationary increases.

5.6 Overall the new offer would mean six PMS practices became financially better off and seven PMS practices would see a reduction in funding. Based on the draft London transition policy six of these practices would be entitled to transition funding. All GMS practices would financially gain over the 4 year period. As a result by 2019/2020 all patients would have the same level of services available to them at their GP practice, regardless of the type of contract in place.

6.0 Gap and Impact Analysis of decommissioning current services 6.1 The CCG has undertaken an impact (gap) analysis. Unfortunately despite the best efforts of

NHSE and CCG staff the data and information available was limited due to some practices not completing a return. The CCG has identified 5 service specifications relating to the PMS premium but hasn't been able to ascertain levels of activity. These services include additional capacity (similar to the extended hours DES), phlebotomy (also provided at community clinics), insulin initiation (also provided at community clinics under a block contract), palliative care, dermatology and heart failure. Given the variation in PMS premium payments not all PMS practices currently provide the full range of these services, therefore, not all patients registered at a PMS practice have access to the same services. In addition, following a review of a former PMS practice’s activity some time ago (the practice submitted a business case in October 2015 to revert to a GMS contract) the CCG was able to ascertain at that time very low levels of activity which did not demonstrate VfM for that particular practice.

7.0 Resources 7.1 The provisional resource implications of the PMS review are outlined in section 4 and 5 above.

74

8.0 Equalities 8.1 A draft equality impact assessment has been undertaken as part of the review following

engagement and communication with key stakeholders. This shows that there will be no negative or adverse impact for any of the equalities groups.

9.0 Risk 9.1 The CCG’s Primary Care Commissioning Committee reviews the risk register relating to the

delegated responsibilities (including the PMS review) on a monthly basis; high-level risks are escalated to the corporate risk register. Below are some of the key risks.

Risk and impact Prob Imp Severity Mitigating Action

There is a risk that this may not be able to be delivered by the expected deadline in March 3 3 9

Local working group meeting monthly. Project Plan and Communications Plan in place.

Presentations and briefings currently underway at HOSC/HASS.

Relationship between practices / members may be challenged if difficult decisions have to be made, leading to resistance and poor relationships with practices

3 3 9

Member drop in sessions held in January and communication to practices on-going.

Individual practice meetings planned between April-June 2016.

All PMS practices give notice of terminating their contract / retire from contract

3 5 15


The CCG is currently arranging to meet respective LMCs to discuss draft commissioning intentions.


10.0 Managing conflicts of interest 10.1 This paper is for information only so that the Governing Body is kept updated on progress with

and understands the construct of the proposed PMS contract and its implications for the CCG in terms of supporting the CCG’s commissioning intentions and overall affordability.

Author: Natalie Keefe, Head of Primary Care Transformation Date: 3 March 2016

75

To: Meeting of NHS Redbridge Clinical Commissioning Group (CCG) Governing Body From: Sarah See, Director of Primary Care Transformation Date: 24 March 2016 Subject: Personal Medical Services (PMS) Review - update Executive summary The purpose of this paper is to brief the Governing Body on the latest position regarding the Personal Medical Services (PMS) Review, namely:

• the ‘London offer’ agreed between NHS England (London) and London’s Local Medical Committees and

• the draft commissioning intentions and the overall funding position for the CCG.


• Note the agreed ‘London offer’ for PMS agreements; • Comment on the draft commissioning intentions for the CCG, and overall funding; and • Agree that review and discussion on these matters including the impact at individual practice

level take place at the Primary Care Commissioning Committee. Particularly noting that the planned increase in PMS/GMS contract values for 2016/17 and 2017/18 will be funded through Primary Care Growth funding.


The purpose of this paper is to brief the Governing Body on the updated position regarding the Personal Medical Services (PMS) review, namely: • he ‘London offer’ agreed between NHS England (London) and London’s Local Medical

Committees and • the draft commissioning intentions and the overall funding position for the CCG. • advise that a Equality Impact Assessment (EIA) is being completed.

2.0 Introduction 2.1 In January 2015 the Governing Body received an update paper outlining progress on the

nationally mandated review of PMS agreements. The paper reminded the governing body of the national and London principles underpinning the review and how the work was being taken forward across London and locally within the CCG.

2.2 Since then NHSE London have confirmed that the London offer has now been agreed with

London’s LMCs to ensure a consistent service offer for all Londoners.

76

3.0 The new PMS contract 3.1 It is confirmed that the ‘main body’ PMS contract and Schedule 13 will form what will be

referenced as the core PMS contract. The mandatory / non-mandatory key performance indicators (KPIs) and the premium service specification also form part of the ‘London offer’ and attracts funding above the core ‘main body’ offer i.e. premium funding.

3.2 The funding associated with each of the above components is outlined below: Figure 1. New PMS contract components / funding

Premium funding

Core funding (assumed GMS equivalent)

3.3 To remind governing body members, the ‘main body’ of the contract largely comprises national

PMS regulations and includes details such as contract holder, a definition of essential services, information on who can perform services, the management of patient records, termination clauses, etc. The contract can be viewed at https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/06/pms2015-16.pdf

3.4 Schedule 13 of the core contract sets out a list of services that patients can expect to be provided

by a PMS contractor. Payment for this schedule is assumed as part of the main contract and therefore does not attract any additional payment above core funding. The requirements set out in this schedule are designed to be equivalent to the GMS contract but provide greater definition than corresponding elements in the GMS contract.

3.5 The proposed KPI schedule has been updated following discussions with all London LMCs;

breast screening has now been removed from the mandatory KPI list. The following areas are now finalised as the mandatory KPIs:

• Cervical Screening; • Vaccinations and Immunisations, i.e. childhood Immunisation, flu and

Pneumococcal immunisations; and • Patient Voice – a selection of indicators that are sourced from the national GP Patient

Survey - CCGs need to select two from a number of suggested indicators.

1 This includes Saturday morning opening - cost £4 per raw registered patient based on an average

practice of 6000 patients and improving access through the use of technology £1pwp for full achievement. Additional capacity has not been included as the price is to be determined locally.

PMS Contract

Optional Premium Service Specification £5.001 prp

Mandatory KPIs

Optional KPIs

£3.04 pwp

£1.36 pwp

Schedule 13 – Service Requirements

£75.77 pwp

+

£2.18 prp

‘Main body’ contract-Regulations

77



Optional KPIs - • Breast Screening and • Capacity & Access measures e.g. attendance at local Walk in Centres, Urgent Care

Centres and A&E.

The mandatory KPIs should be commissioned by all London CCGs/NHSE - although there is some local determination as to which patient voice indicators CCGs wish to commission. The capacity and access measures and breast screening are optional KPIs.

3.6 Performance and payment against the KPIs will be measured against 4 bands:

• Band A - Optimal Performance level • Band B- Acceptable Performance Level • Band C- Minimum Performance Level • Band D- KPI Failure

3.7 The optional premium service specification describes services that will support implementation of

the Strategic Commissioning Framework (SCF). NHSE have developed three areas which facilitate delivery on patient choice, contacting the practice, routine opening hours and same day access.

3.8 There are three premium provisions within this specification:

• Flexing Capacity – sets out a requirement that practices extend core hours to include four hours on a Saturday morning (09:00 – 13:00); this attracts a payment of £4.002 per registered patient (prp);

• Additional Capacity – sets out a requirement for practices to offer additional appointments; cost to be determined locally; and

• Improving Access through Use of Technology – incentivises practices to increase access to online services such as booking and cancelling appointments, access to patient records, ordering repeat prescriptions and electronic consultations. Maximum payment available is £1.00 pwp.

4.0 Financial implications 4.1 As outlined previously a number of key principles are in place, that is:

• Any released PMS funding should be reinvested in general practice; • CCGs with NHSE may choose to commission locally specific services with released

PMS funding or use additional funding at a CCG level; • The review will establish as a minimum an agreed cost per weighted patient for the

delivery of the agreed specification across all PMS providers at CCG level; • The review will ensure equality of opportunity across all GP practices - PMS, GMS

and APMS - provided they are able to satisfy locally determined requirements; and • Funding not invested in core PMS requirements should be reinvested in general

practice for CCG or SPG specific services via PMS contracts or other commissioning mechanisms.

4.2 There are 15 PMS practices in Havering with a PMS premium of £1.1m invested; there is little variation between individual practice’s premiums, the minimum being £10.73 and the maximum £12.02 per patient.

4.3 The affordability of the ‘London PMS offer’ contract has been modelled against the PMS premium

available for each CCG (see Table 1 below)

2 Based on a registered list size of 6000 patients

78

Table 1 - London PMS offer

Contract type

Mandatory KPIs

(£)

Optional KPIs

(£)

Saturday opening

(£)

Use of technology

(£)

Additional capacity3

(£)

Total London Offer Cost

(£)

PMS 310,093 138,726 419,556 102,004 970,379 GMS 466,205 208,565 610,852 153,357 1,438,979 Overall 776,298 347,291 1,030,408 255,361 2,409,358

4.4 Commissioning the entire ‘London offer’ in Havering, for both PMS and GMS practices will cost in

excess of c£2.4m as the additional capacity element is to be costed locally. This would therefore be a cost pressure for the CCG amounting to in excess of £1.3m (given the premium available is c£1.1m).

5.0 Draft Commissioning Intentions 5.1 The CCG was required to submit draft commissioning Intentions to NHSE by 19 February 2016.

These were submitted noting that they were draft intentions and further work would need to be completed once the CCGs financial baseline position was known and validated. These intentions also need to be discussed with the LMC, agreed by NHS England and final approval sought from the Primary Care Commissioning Committee (PCCC).

5.2 Initial work has been completed on the basis that the current level of PMS funding will continue to

be invested in PMS practices, this equates to £11.18 premium per weighted patient. From July 2016 the CCG proposes to commission4 the following from all PMS practices: • Mandatory KPI’s • Use of technology – from April 2015 practices were contractually required to offer online

services to patients and all practices are technically able to do this. However this provision and associated patient communication is variable. There is a national drive to improve the usage of on-line services and increase the number of appointments offered on-line to patients. This shift is expected to improve practice productivity. It is therefore proposed that this is commissioned to drive improvement further and encourage practices to actively offer these services to patients. It will also support implementation of the SCF.

• Additional Capacity – this is an area which should be prioritised, subject to the outcome of negotiations and formal CCG approval. Currently in Havering a number of PMS contracts require practices to offer 100 appointments per 1000 patients per week, should this not be commissioned as part of the new offer this would have a detrimental impact on patient access in the borough.

5.3 The CCG does not plan on commissioning the flexible capacity premium specification. This

would not be cost effective nor do all practices have the resources to offer Saturday opening. However Saturday opening is already commissioned for the whole population via GP Access Hubs (twp currently operational in Havering). Currently Hubs vary their opening hours and capacity to meet demand, but from 1 April 2016, the CCG will need to, as a minimum, ensure 1 Hub is commissioned to open for 4 hours on Saturday mornings.

5.4 The CCG also intends to commission the GMS equalisation on a staggered basis from 2016/17

as outlined below: • 2016/2017 Improving access through use of technology

3 To be determined locally

4 Subject to approval from PCCC, agreement from NHSE and discussions with the LMC and local practices.

79

• 2017/2018 Mandatory KPIs • 2019/2020 Additional capacity

5.5 Delegated responsibility from NHSE for Primary Care Co-Commissioning has identified a number

of reporting and information risks leaving the CCG’s with a degree of uncertainty. It is planned that the increase in PMS/GMS contract values for 2016/17 and 2017/18 will be funded through Primary Care Growth. In future years the local offer requires significant investment and will need to be reviewed in line with the transformation plans and the medium term financial plans. The table below sets out the cost of the local offer and the borough impact. The impact on individual practices will be reviewed at the PCCC.

Contract type 2016/2017 2017/18 2018/19 2019/20 2020/21

PMS - Transition Cost 0 0 0 0 0 PMS - Contract Premium Offer 1,141,429 1,141,429 1,141,429 1,141,429 1,141,429 GMS 153,357 619,561 619,561 1,716,063 1,716,063 Overall 1,294,785 1,760,990 1,760,990 2,857,491 2,857,491 Current Havering PMS Premium 1,140,870 1,140,870 1,140,870 1,140,870 1,140,870 Change in funding 153,915 620,120 620,120 1,716,621 1,716,621 Note:- The figures shown above are based on 2015/16 list sizes are at 2016/17 prices. Future years will be subject to growth and inflationary increases.

5.6 Overall the new offer would mean nine PMS practices became financially better off and six PMS

practices would see a reduction in funding. Based on the draft London transition policy no practices would be eligible to transition funding as they would all see a reduction of less than 1% from the current contract value. All GMS practices would financially gain over the four year period. As a result by 2019/2020 all patients would have the same level of services available to them at their GP practice, regardless of the type of contract in place.

6.0 Gap and Impact Analysis of decommissioning current services 6.1 The CCG has undertaken an impact (gap) analysis. Unfortunately despite the best efforts of

NHSE and CCG staff the data and information available was limited due to some practices not completing a return. The CCG has been unable to ascertain levels of activity against any of the services identified. A meeting was convened recently with a small group of PMS practices to go through the information, agree what is now in the core contract, what might be covered in the new contractual arrangements and where there may be gaps in provision. This discussion generated ideas to support QIPP and transfer services to a primary care setting e.g. 24 hour BP, 24 hour ECG and Spirometry. It was also agreed the gaps that were identified are likely to relate to low levels of activity and therefore represent a low risk/impact.

7.0 Resources 7.1 The provisional resource implications of the PMS review are outlined in section 4 and 5 above. 8.0 Equalities 8.1 A draft equality impact assessment has been undertaken as part of the review following

engagement and communication with key stakeholders. This shows that there will be no negative or adverse impact for any of the equalities groups.

80

9.0 Risk 9.1 The CCG’s Primary Care Commissioning Committee reviews the risk register relating to the

delegated responsibilities (including the PMS review) on a monthly basis; high-level risks are escalated to the corporate risk register. Below are some of the key risks

Risk and impact Prob Imp Severity Mitigating Action

There is a risk that this may not be able to be delivered by the expected deadline in March. 3 3 9

Local working group meeting monthly. Project Plan and Communications Plan in place.

Presentations and briefings currently underway at HOSC/HASS.

Relationship between practices / members may be challenged if difficult decisions have to be made, leading to resistance and poor relationships with practices.

3 3 9

Member drop in sessions held in January and communication to practices ongoing.


All PMS practices give notice of terminating their contract / retire from contract.

3 5 15


The CCG is currently arranging to meet respective LMCs to discuss draft commissioning intentions.


10.0 Managing conflicts of interest 10.1 This paper is for information only so that the Governing Body is kept updated on progress with

and understands the construct of the proposed PMS contract and its implications for the CCG in terms of supporting the CCG’s commissioning intentions and overall affordability.

Author: Natalie Keefe, Head of Primary Care Transformation Date: 3 March 2016

81

To: Meeting of the NHS Redbridge CCG Governing Body From: Louise Mitchell, Chief Operating Officer, Redbridge CCG Date: 24 March 2016 Subject: Operational Planning 2016/17: update on submissions Executive summary This paper provides an update to the Planning Round briefing submitted to the January Governing Body and provides further detail regarding:

• Draft CCG Operating Plan submissions made in February and March • Requirements for the final Operating Plan submission to be made on 11 April • Requirement for the Better Care Fund (BCF) Plan Submissions in March and for the

final BCF Plan submission to be made on 25 April • The process required to sign off the final Operating Plan submission and BCF Plan

submission.

Recommendations • To note the information given below regarding the draft Operating Plan submissions

already made, and the final 11 April submission • To note the information given below regarding the draft BCF Plan submission already

made, and the second draft due on 21 March and the final 25 April submission • To give delegated authority to the BHR CCGs’ Chief Finance Officer and Accountable

Officer to sign off the final submissions ahead of the 11 April and 25 April submission dates.


This report provides a narrative summary of the draft Operating Plans submitted on the CCG’s behalf on 8 February and 2 March 2016 and describes next steps required to develop plans for the full and final submission on 11 April. It also provides an update on the Better care Fund Plan submissions in March and the next steps required to develop plans for the final submission on 25 April.

2.0 Summary of requirement for 2016/17 Operating Plans 2.1 The NHS England 2016/17 Planning Guidance confirms that for 2016/17, CCGs are

required to compile and submit a single-year Operating Plan which covers finance, activity, capacity and key performance standards. The Operating Plan then represents year one of the five year Sustainability and Transformation Plan; a final version of which is to be submitted in June. These plans must demonstrate how local health economies

82

will accelerate their rate of transformation and deliver the vision of the Five Year Forward View by 2020.

3.0 Draft Operating Plan submissions 8 February and 2 March 2016 3.1 The first draft Operating Plan was submitted on behalf of the CCG on 8 February. A

second draft Operating Plan was then submitted on behalf of the CCG on 2 March. The second draft refined the activity and finance elements of the submission first made in February. No changes were made to the Constitutional Standards or mental health trajectories between the two submissions.

3.2 In activity terms the Operating Plan commits Redbridge CCG to reducing activity by

3.62% (15,852 units of activity across all acute activity types). This is the net effect of 1.8% growth for demographic and seasonality factors and a reduction of 5.42% for the anticipated effect of transformational/demand management schemes.

3.3 For the NHS Constitutional Standards and mental health standards, the draft plans

commit the CCG to: • Full achievement of RTT, diagnostics and dementia diagnosis standards • Achievement of the IAPT access standard by the second quarter of 2016/17.

IAPT recovery and waiting times standards will be met throughout the year • Achievement of all cancer standards with the exception of 62 day, which will be

achieved by July • Achievement of the A&E standard by September

3.4 NHS England reviewed the CCG’s Operating Plan to ensure the CCG is committing to

act within its resources, to act in accordance with NHS Business rules, and has alignment with provider plans. A ‘stocktake’ meeting was held between NHS England and the CCG on 22 February and the CCG is subsequently required to:

• Ensure subsequent submissions show alignment with provider (BHRUT) plans • Ensure that two-thirds of QIPP schemes are developed in detail and are

understood by relevant providers • Identify the impact of Right Care wave one projects and work these through into

savings which should feed into the CCG’s financial plan • Work with BHRUT to support delivery of the 95% waiting time standard by

September 2016 (and mitigating actions if the assumptions do not support delivery by this date)

• Work with BHRUT to develop a jointly owned plan that reduces the RTT backlog and supports a run-rate to ensure sustained delivery of the standard

• Work with BHRUT to address the shortage of diagnostic capacity (particularly endoscopy) and understand how extra capacity will be sourced

3.5 The CCG’s £9.8m high level QIPP target has been built into the plan. Detailed Business

cases are being ratified through the agreed confirm and challenge process. Current plans in development total £6.8m which is 69% of the target.

4.0 Next steps – final Operating Plan submission 11 April 4.1 The next (and final) Operating Plan submission is on 11 April. 4.2 Work will continue to develop the plan (and supporting items) in respect of the NHS

England feedback (above) and any feedback received relating to the second draft submitted on 2 March.

83

4.3 The final submission will also incorporate C.Difficile objectives for 2016/17, which NHS

England are expected to publish imminently. 4.4 The 2016/17 Quality Premium measures are expected to be published in early March. In

previous years CCGs have been required to submit Quality Premium trajectories/choices as part of Operating Plan submissions and this may recur for the 11 April submission.

4.5 The Governing Body is requested to give delegated authority to the BHR CCGs’ Chief

Finance Officer and Accountable Officer to sign off the final submission ahead of the 11 April submission date.

5.0 Better Care Fund (BCF) Plan 5.1 The BCF Planning guidance was only published by NHSE in the last week of February,

and the Local Authority and CCG were given a week to produce a draft finance & activity template which was submitted on 2 March.

5.2 The next step is to submit a second draft of the finance & activity template, with a Plan

narrative, on 21 March. 5.3 The final plans have to be submitted on 25 April, having been formally signed off by the

Health & Wellbeing Board. 5.4 The Governing Body is requested to give delegated authority to the BHR CCGs’ Chief

Finance Officer and Accountable Officer to sign off the final submission ahead of the 25th April submission date.

5.5 It should be noted that CCG officers have worked in close partnership with Local

Authority officers through the Joint Executive Management Group to produce the first draft finance & activity template submission on 2 March, and will continue to work closely to produce the second draft submissions and the final submission.

5.6 The 2016-17 guidance states that the BCF planning and assurance process will be

integrated as fully as possible with the core NHS operational planning and assurance process

5.7 The Plan will go through an assurance process however; unlike for 2015/16 when there

was a national assurance and resubmission process, for 2016/17 the assurance process will be owned by NHS England and local government regional teams.

5.8 There are a number of Plan requirements to be met before assurance will be given.

These include a number of national conditions such as level of financial contributions for the CCG into the pooled fund; confirmation of agreement on how plans will support progress for seven-day services; better data sharing between health and social care based on the NHS number; a joint approach to assessments and care planning; agreement of a local action plan to reduce delayed transfers of care.

5.10 There is also a requirement to set national metric targets locally. 6.0 Resources/investment 6.1 A separate financial planning paper has been submitted to the March Governing Body,

which details the financial allocations for the CCG.

84

7.0 Equalities 7.1 This paper does not identify any specific equalities issues. 8.0 Risk

8.1 There are currently no specific risks identified through this paper.


9.1 There are no conflicts of interest considerations arising from this report

Author: James Colley, Planning and Programme Manager, North East London Commissioning Support Unit

Date: 7 March 2016

85

To: Meeting of the NHS Redbridge CCG Governing Body From: Tom Travers, Chief Finance Officer Date: 24 March 2016 Subject: 2016/17 Financial Planning Report Executive summary The purpose of this report is to present the draft 2016/17 Financial Plan to the CCG for approval. The draft plan sets out a break even position in line with 2015/16 outturn with the CCG planning not to achieve the 1% surplus - the required business rule. The paper identifies key assumptions and risks to achievement of the CCG’s financial targets in 2016/17. The current draft of the plan is not compliant with the 1% surplus requirement and the holding of a 1% uncommitted non recurrent reserve. It is compliant with the holding of the 0.5% contingency. The plan currently includes a significant level of financial risk as highlighted in Section 5 of this report. The main risk factors include:

• Acute activity growth above the planned demographic levels. • The current significant gap between CCG and provider positions in the 16/17 contract

negotiations. • Current business rules limit the scope to apply contract levers. • The risk of QIPP schemes not delivering to the expected and planned levels. • Additional costs associated with Constitutional Standards. • Other risks include potential for Prescribing and Continuing Care costs to exceed planned

levels.

The only reserve mitigation to these risks is the 0.5% contingency within the plan. The QIPP requirement in the plan is £9.8m (3.1%).

Recommendations The Governing Body is asked to note the high level of financial risk and approve the draft financial plan for 2016/17 which is consistent with the latest Operating Plan submission to NHS England (NHSE). A further Operating Plan submission will be sent to NHSE in early April. An updated set of financial plans/budgets will be presented to the next Governing Body meeting. These will be consistent with the updated Operating Plan.

86

1.0 Purpose of the Report 1.1 The purpose of this report is to update the CCG Governing Body on the 2016/17 Financial Plan.

2.0 Background/Introduction

2.2 The CCG is currently planning to deliver a break even position in 2015/16. This was reduced in

year from a 1% surplus. It faces ongoing financial challenges in order to maintain this break-even position in 2016/17.

The Department of Health announced a £3.8bn real terms increase for the NHS in 2016/17 in the

December Spending review which informed the allocations CCGs receive for 2016/17. Despite the increased allocations, however, the CCG continues to face significant pressures on

its budgets due to:

• Growth in population. • Increasing life expectancy and prevalence of long term conditions • Growth in prescribing and continuing care costs • Financial pressures at BHRUT and Barts Health • Access standards for Mental Health • Inflationary pressures

The above factors mean that even with baseline funding growth, the CCG still needs to make significant Quality Innovation Productivity and Prevention (QIPP) savings to meet the financial targets outlined in this plan.

3.0 Report Content 3.1 The Planning Guidelines

CCGs are required to submit plans reflecting Department of Health financial rules that assure the delivery of the CCG’s commissioning objectives, including the key NHS constitution targets of: • Maximum referral to treatment waiting times • Access to cancer services • Maximum wait times in A&E

For 2016/17, NHSE guidance is that CCGs should set and deliver financial plans within NHS business rules. These rules would equate to the following budget requirements;

Currently the CCG’s plan does not achieve the planned surplus nor uncommitted non-recurrent reserve requirements.

% £mSurplus 1.0% 3.4Contingency 0.5% 1.9Uncommitted Non-recurrent Investment 1.0% 3.4

NHS Business Rules

87

Plans have been produced to include the following key assumptions:

3.2 Draft 2016/17 Budgets The CCG’s draft 2016/17 budget is based on an allocation of £376m which includes:

3.3 Growth The confirmed allocation includes a 5.42% recurrent uplift on 2015/16. This incorporates differential growth for elements of the budget;

1) A programme growth of 5.06%. 2) A Primary Care Co-Commissioning growth of 10.22%. Primary Care Co-Commissioning

budgets for 2016/17 will be separately presented to the Primary Care Commissioning Committee for approval. It has been assumed that this budget will achieve a balanced position.

3) A running cost growth of 0.69%.

The programme growth is constituted from the following factors:

The increased growth allocation is to achieve a greater equity of access through accelerating

alignment of allocations so that in 2016/17 all CCG’s are no more than 5% under target for CCG

Tariff Change - Acute 1.10%Tariff Change - Acute CNST 0.40%Tariff Change - Non Acute 1.10%Demographic Growth (Based on ONS data) 1.80%Non Demographic Growth - Acute 0.50%Non Demographic Growth - MH & Community 0.50%Prescribing 5.00%

Key Planning Assumptions

Redbridge £000Baseline Allocation 319,524Programme Growth 16,164Primary Care Co-Commissioning 33,553Return of 2014/15 Surplus 0Running Cost Allocation 6,445Total Resource 375,686

£000Per capita growth 8,655Population growth 6,041GP IT & CAMHS 1,468Total 16,164

Programme Growth

88

commissioned services and for the total commissioning streams for their population. The increased funding to Redbridge make its distance from target below by -1.2% for programme allocations and under by -9.4% for Primary Care Co-Commissioning allocations.

3.4 The increased funding for the CCG has been more than offset by pressures on the CCG’s

underlying financial position, which include;

• Parity of esteem investment levels in mental health • Funding GP IT and CAMHS recurrently

• Tariff uplift of 1.5% for acute and 1.1% for all other services.

The remaining growth funding is required to fund demographic / non demographic growth, already agreed investments and cost pressures and for the CCGs to meet its business rules.

The CCG running costs have been reviewed and will be contained within the allocation of

£6.5m.

3.5 Bridge Analysis A ‘bridge’ from the 2015/16 plan (Programme spend only) to the 2016/17 Programme spend

plan identifying key movements is summarised within the table below. This includes the change in baseline funding, business rules, and generic assumptions outlined in section previous sections.

Programme Baseline 319,524 Calculation£000 %

Total Growth 16,164 5.1 %

Underlying Position 2015/16 (1,333) (0.4%)Total Funds available 14,831 4.6 %

Reinstate ETO funding 764 0.2 %GPIT 956 0.3 %CAMHS 512 0.2 %Tariff Uplift 1.1% 3,047 1.0 %Prescribing 5% 1,898 0.6 %Demographic Growth (ONS) 1.8% 5,068 1.6 %Non-Demographic (0.5%) 1,182 0.4 %0.5% Contingency 1,878 0.6 %1% Non Recurrent Risk Reserve 3,357 1.1 %CNST 0.4% 775 0.2 %CQUIN Change 1,131 0.4 %Investments & cost pressures 4,061 1.3 %Change year on year in surplus 0 0.0 %

QIPP (9,797) (3.1%)

Total Increase in Expenditure 14,831 4.6 %

2016/17 Planned Surplus 0 0 %

Redbridge

89

The financial plan includes a number of cost pressures, some of which are the calls on growth

monies described in section 3.3. The cost pressures include;

• Acute Over-Performance and RTT pressures • Mental Health new targets investment • Continuing Care • Prescribing • Tariff uplifts of 1.5% for acute and 1.1% for other services • Demographic growth of 1.80% based on ONS population projections.

Furthermore, the plan includes the financial impact of achieving business rules including 0.5%

contingency and 1% non-recurrent funds, although the non-recurrent 1% has not been held uncommitted in planning.

3.6 Proposed Budgets The table below summarises the proposed budgets for the CCG in 2016/17.

Annual Allocation£000's

Acute NHS SLA 186,049Acute Other 19,325Acute Sub-total 205,375Mental Health and LD 28,482Community Healthcare 23,391Continuing Care 20,273Programme Spend 15,247Services Provided in a Primary Care Setting 42,922Healthcare Provision Sub-total 130,313CCG Running Costs 6,445Running Costs 6,445Primary Care Co-Commissioning 33,553Primary Care Co-commissioning 33,553

Total Expenditure 375,686

Resource Limit 375,686

Surplus / (Deficit) 0

Redbridge CCG Base Budgets 2016/17

Commissioner Function

90

3.5 QIPP The CCGs £9.8m high level QIPP target has been built into the plan. Detailed business cases are

being ratified through the agreed confirm and challenge process. Current plans in development total £6.8m which is 69% of the target. Further details are in Appendix A.

4.0 Equalities 4.1 N/A

5.0 Risk 5.1 A high level of financial risk has been identified within the operating plan. The currently identified

risks are highlighted in the table below.

Risks

Full Risk

Value £'000

Probability of risk being

realised %

Potential Risk Value £'000

Acute activity growth (3,981) 50.0% (1,990) Other contracting variances (3,000) 50.0% (1,500) Contract Levers (2,498) 50.0% (1,249) Continuing Care SLAs (720) 50.0% (360) QIPP Under-Delivery (6,512) 60.0% (3,907) CCG's use of 1% funds (3,356) 50.0% (1,678) Potential additional acute pressure (2,241) 50.0% (1,121) Other Risks (971) 53.0% (517) TOTAL RISKS (23,278) 53% (12,322) Contingency Held 2,046 100.0% 2,046 NET RISK / HEADROOM (21,232) 48.4% (10,276)

5.2 The table shows the full risk identified and a potential risk assessed value. The risk assessed

value after mitigating reserves totals £10.3m. 5.3 The main risk factors include:

• Acute activity growth above the planned demographic levels. • The current significant gap between CCG and provider positions in the 16/17 contract

negotiations (for example there is an NHS contract gap in excess of £40m across all BHR CCG’s)

• Current business rules limit the scope to apply contract levers. • The risk of QIPP schemes not delivering to the expected and planned levels. • Additional costs associated with constitutional standards. • Other risks include potential for Prescribing and Continuing Care costs exceeding planned

levels.

91

5.4 The only reserve mitigation to these risks is the 0.5% contingency within the plan.

5.5 The CCG will take responsibility for commissioning Bariatric Surgery in 2016/17. This transfer will be reflected in future iterations of the plan. Currently it is assumed that sufficient resource will be transferred from NHSE to ensure that this does not create an additional risk. Assurance will be sought and required from NHSE on this issue.

5.6 Impact upon statutory duties The plan includes a high level of financial risk. The materialisation of any of these key risks could result in the CCG posting a deficit position in 2016/17. There is a similar risk profile across the BHR CCG’s. Agreement would be required from NHSE to move one or more of the CCGs to a deficit plan.

6.0 Managing conflicts of interest 6.1 N/A

7.0 Recommendations 7.1 The Governing Body is asked to note the high level of financial risk and approve the draft

financial plan for 2016/17 which is consistent with the latest Operating Plan submission to NHS England (NHSE).

A further Operating Plan submission will be sent to NHSE in early April. A final set of financial plans/budgets will be presented to the next Governing Body meeting.

These will be consistent with the updated Operating Plan.

Attachments: 1. Appendix A – QIPP Target

92

Appendix A

Development of QIPP plans for 2016/17 Current plans in development total £6.8 which is 69% of the £9.8m target. Work is continuing on closing the gap and the process has resulted in the development of the following QIPP projects.

QIPP Initiative PID Status Gross Saving Investment Total

£000 £000 £000

QIPP TARGET 9,797

Vanguard Draft 676 - 676 MSK Draft 569 - 569 CHC Draft 900 - 900 Medicines Management Draft 471 (99) 372 Estates Draft 341 - 341 Chronic Kidney Disease Draft 245 - 245 BCF Draft 1,303 - 1,303 RTT demand management Draft 324 - 324 Right Care Draft 927 (196) 731 Contract Efficiency Draft 1,340 - 1,340 Current Total 7,096 (295) 6,801

% of target

69%

QIPP Gap

2,996

Gap as % of target

31% The projects listed above are being progressed through the QIPP PMO review sessions. Additional QIPP projects will need to be developed in the first quarter of 2016/17. To close the QIPP gap, there is continued effort to identify and work up new opportunities. Failure to identify the £3.0m QIPP gap will present the CCG with a significant financial pressure in 2016/17. However steps are being taken to mitigate this risk through the additional opportunities identified, including:

• Review of current contracts and spend • Scrutiny of other BHR CCG project implementation documents (PIDs) for implementation by

Redbridge CCG • Review of other CCG QIPP ideas, web based or through contact with other CCGs.

93

To: Meeting of the NHS Redbridge CCG Governing Body From: Sarah See, Director of Primary Care Transformation Date: 24 March 2016 Subject: Primary Care Strategy – Update Executive summary The CCG is developing a strategy for the transformation of primary care over the next five years. The work is framed by national and London policy, the Barking & Dagenham, Havering and Redbridge (BHR) system commissioning challenges and takes account of substantial input gathered from local GPs, their teams and wider local stakeholders.

The vision emerging is of primary care leading the provision of joined-up care in localities, with sustainable and productive practices at its foundation. This builds on the concept of place-based care and wider evidence from places where this approach has been implemented.

Extensive discussions with and between local clinical leaders are continuing about how this model will facilitate the development of local schemes which will deliver better care for local people and what the implications and opportunities will be for individual GP practices, their autonomy and sustainability.

The transformation programme for 2016/7 will be primarily about provider development – strengthening individual practices, progressing collaborative working amongst GP practices in localities and developing extended locality teams, bringing together GPs with all local health and social care professionals to provide the majority of care for patients. The plan is to draw on the CCG’s strategies for planned, mental health and urgent and emergency care and identify specific local schemes, which can be used to inform development of collaborative governance and working arrangements in localities and as a proving ground in localities, ensuring they are wholly grounded in the business of local providers and the care needs of local people.

An investment of additional time is needed in order to complete this dialogue properly, and we are now aiming to complete the strategy in time for formal review by the governing body in May 2016.

At the same time, detailed plans and an investment strategy are being developed in order to secure the resource needed to assist primary care leaders with the transformation of primary care in their localities and underpin development of our local Sustainability and Transformation Plan. Recommendations The governing body is asked to:

• Note the contents of this progress report; • Agree the programme of stakeholder engagement planned to review and refine the strategy

proposals so that the strategy can be finalised; and • Receive the final strategy at its meeting in May 2016.

94

1.0 Purpose of the Report 1.1 The purpose of this report is to advise the governing body of progress with the primary care

transformation strategy, the timetable for its completion and enable it to assure itself that there is sufficient stakeholder engagement in the review and refinement of the strategy prior to formal governing body review in May 2016.

2.0 Background/Introduction 2.1 The CCG is developing a strategy for the transformation of primary care in Redbridge over the

next five years. The work is framed by national and London policy, the Barking & Dagenham, Havering and Redbridge-wide (BHR) system commissioning challenges and takes account of substantial input gathered from local GPs, their teams and wider local stakeholders.

2.2 The governing body received a report on progress in January 2016. This paper provides a

further report on progress ahead of a formal review of the completed strategy now scheduled for May 2016. It briefly describes the emerging vision, benefits, implications and proposed implementation approach in addition to setting out the programme of stakeholder engagement to review and refine the proposals.

2.3 Further information on the proposals is provided in the attached primary care strategy

communications slide pack, which is current as of 1 March 2016. 3.0 Emerging Vision 3.1 The strategy proposes step-by-step migration to a place-based primary care-led delivery model

for care out of hospital in each Redbridge locality. The model has at its foundation stronger GP practices and involves effective collaborative working across groups of practices and an extended team of community, social care, pharmacy, dental and ophthalmology professionals and the voluntary sector.

3.2 Primary care, strengthened and extended, will have the collective capacity and funding to take on

the majority of patient care, as well as prevention services. 3.3 Evidence advanced by the King’s Fund, drawing on examples from New Zealand, Chen Med and

elsewhere, is that place-based care works best with a population of 50-70,000 people, and clinical leaders in the borough are assessing the suitability of existing commissioning clusters as the starting point for deciding on the geographic footprints for localities.

3.4 Practice productivity and collaborative provision and administration will be enhanced through

better exploitation of available information, IT and digital solutions. 3.5 A BHR approach to the development of the primary care workforce will create the right staff mix

for locality-based working, and localities will be empowered to co-design and deliver locally appropriate solutions for the recruitment and retention of staff.

4.0 Benefits for Patients and Implications for Practices 4.1 The benefits envisaged for patients from the primary care strategy are:

• Personalised, responsive, timely and accessible primary care, provided in a way that is both patient-centred and coordinated

• An integrated service that supports and improves their health and wellbeing, enhances their ability to self-care, increases health literacy, and keeps them healthy

• More treatment closer to home where previously provided in secondary care, and • Involvement in the co-design of services with professionals in their locality.

95

4.2 The key implications for practices of the strategy are envisaged to be: • Retention of practice autonomy, with GPs playing leading roles in locality-based care • Improved financial sustainability through the pooling of resources to reduce costs and the

creation of new opportunities to generate income • Better practice productivity through improved team working and better use of IT, reducing

administration and freeing up GP time for patient care, and • The potential to develop more attractive career offers to recruit and retain primary care

clinicians.

5.0 Implementation Approach 5.1 The King’s Fund’s framework for implementing place-based models of care will be used as the

starting point from the implementation of primary care-led locality-based care in Redbridge. 5.2 It is proposed to work with a single locality within the borough as a pilot to design collaborative

governance and working arrangements while working on selected prevention, planned care, mental health and/or urgent and emergency care schemes. This will enable initial lessons from locality-based working to be properly understood and the learning to be reflected in the designs and planning for the other localities.

5.3 A parallel programme of work will be put in place to help practices improve their productivity,

make better use of information and IT systems and better understand their financial sustainability. 5.4 There is a 12-18 month target timescale for all localities to be operational and effective.

6.0 Resources and investment 6.1 Resources will be needed to help primary care leaders in localities establish organisational and

governance arrangements for collaborative working and operate these effectively and to assist with specific initiatives to strengthen practice productivity and enable wider use of information, IT and digital solutions. Resource will also be needed to run the transformation programme at the BHR level. A review of CCG organisational arrangements may identify some individuals with the right skills and experience from programme roles.

6.2 An investment strategy for primary care is currently under development. This will enumerate the

funding required for the transformation programme.

7.0 Stakeholder Engagement 7.1 The following table shows the extensive programme of engagement planned for the socialisation

of the primary care strategy proposals. Governing body members are asked to consider whether any changes or additions are necessary before the strategy is finalised.

Meeting level Meeting

Date(s)

Redbridge Health & Wellbeing Board workshop 7 March Redbridge Primary Care Working Group 12 April BHR Primary Care Commissioning Committee 9 March BHR JET 10 March Redbridge Overview Scrutiny Committee 14 March BHR Primary Care Transformation Programme Board 14 March Redbridge Patient Engagement Forum 15 March Redbridge Practice Learning Event 16 March Redbridge Local Medical Council 17 March

96

Meeting level Meeting

Date(s)

Redbridge Locality meetings

22 March (Seven Kings), 30 March (Cranbrook & Loxford), 31 March (Fairlop), 6 April (Wanstead & Woodford)

8.0 Equalities 8.1 By delivering common standards of prevention, planned care, mental health and urgency and

emergency care across the BHR system and organising delivery in localities, the CCG’s overall approach aims to both reduce health inequalities and optimise services to meet the needs of local populations in Redbridge.

9.0 Risk 9.1 A detailed risk analysis is being undertaken, which will be included with the final version of the

strategy document 10.0 Managing conflicts of interest 10.1 This paper is for information only so that the governing body is kept updated on progress with the

development of the Primary Care Transformation Strategy; the invest / resource required will be considered by the non-conflicted investment committee of the CCG.

Attachments:

1. Primary Care Strategy Communications Slides – current at 01/03/16

Author: Sarah See, Director, Primary Care Transformation Date: 1 March 2016

97

March 2016

Primary Care Transformation

98

The emerging Primary Care Strategy for Redbridge

The Primary Care Strategy sets out: • The drivers of primary care transformation

– National policy – London policy – Feedback from GP’s and other local stakeholders – The system challenges

• The points we to address in our solution • A vision of primary-care led locality-based care, founded on strong practices • Localities make sense for place based care • How locality-based care would work within the BHR system • Delivery levels – the BHR perspective • The benefits for practices • Implementation approach and timescales

99

What is the national and local policy context for Primary Care Transformation?

• Policy at a national and regional level is focusing on ensuring a sustainable high quality primary care landscape – NHSE Five Year Forward View – London Health Commission – Strategic Framework for Primary Care in London – Think tanks (Kings Fund, Nuffield Trust) – Care Quality Commission

• Move funding from acute to primary care • New incentives and models of care – networks • Expand primary care workforce • Ambitious quality standards

100

Three areas of care form the basis of a vision for General Practice in London

Accessible Care

Better access primary care professionals, at a time and through a method that’s convenient and with a professional of choice.

Coordinated Care Greater continuity of care between NHS and other health services,

named clinicians, and more time with patients who need it.

Proactive Care More health prevention by working in partnerships to reduce

morbidity, premature mortality, health inequalities, and the future burden of disease in the capital. Treating the causes, not just the

symptoms.

Patients and clinicians alike have told us about the importance of three areas of care; thhis forms the basis of the new patient offer (also called the specification)

101

Local GPs and their teams have identified issues with primary care as it is now…..

102

Practices have provided their perspective on these challenges based on feedback from locality discussion

I value my autonomy and the freedom to run my practice

in a way that works for my

patients and me.

My practice isn’t

financially sustainable

The current workload in general practice is unsustainable - GPs are seeing patients,

coordinating care, chasing others for information and doing too much admin and

not enough of the pro-active patient care that make being a GP rewarding

We are facing a crisis in recruitment and

retention of GPs and nurses, with many

people about to retire too

103

Healthy life expectancy; female

55.5 years

63 years

65.8 years

62.7 years

63.4 years

male

61.1 years

HAV

RED

B&D

HAV

B&D RED

3rd

119th 166th

Ranked in order of most deprived in England

63.4 London average

63.8 London average

Barking & Dagenham Child poverty 30.2%

vs London 23.5% Havering

Largest net inflow of Children in London

Redbridge Highest rate of stillbirths

in London

What are the key challenges across BHR?

Alcohol abuse

7% harmful

17% high risk

14% binge drinkers

Barking & Dagenham

vs

17% London

23%

Barking &

Dagenham

Health and wellbeing challenges

24% Obese adults 23.1% Obese children

19.6% Obese adults 22.4% Obese children

vs London

BHR

Care and quality challenges Funding and efficiency challenges

40+ 40+ 40+ 40+

1+ LTC

75+ 75+

1+ LTC

1 in 4 People over 40 are living with at least

1 LTC

1 in 2 People over 75 are

living with at least 1 LTC 50%

60%

Against national target of 67%

Barking and Dagenham one-year survival rate:

64% vs 69% London

of cases diagnosed

BHRUT

Local Authority funding

reduction

Public Health budget

reduction

£

£

BHR system wide budget

gap of over

£400m

Jobs section - - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - -

Out of work benefits BHR

12.2% (B&D 16.7%)

vs London 11.6%

2015 population 750,000

2025 +15% increase

+110,000

NB: The figures do not include Barts Health currently but the final plan will take account of this

104

In summary, we need to find a solution that addresses the following points

Good career offer and working environment for GPs - retain existing GPs and attract new recruits The GP & their teams

Productive GP practices can retain their autonomy and have a financially sustainable future GPs have the time they need to provide quality patient care Minimise the time spent by GPs and practice colleagues on administration Respective roles and responsibilities of all local care providers in delivering care are clearly defined and consistently applied

day-to-day by all parties

GP Practices

GPs and colleagues can rely on IT to present the information about their patients that they need to make the best decisions for patients at each point of care

Care is delivered in premises that are fit for purpose in a way that makes the best use of existing assets

Infrastructure / enablers

Our patients can continue to benefit from a relationship with their local GP Our patients receive a joined-up cost-effective care service with unnecessary duplication avoided

Patient experience

We meet the health needs of our diverse local communities We contribute substantially to the improvement of health outcomes for our populations We meet, as a minimum, national and regional quality standards for primary care We work together with other locally-based providers to deliver the majority of patient care – planned, mental health and

urgent – with a focus on prevention, reducing demand for acute care and enabling savings

Delivery

105

Locality level 50,000 – 70,000 per locality

Picture is representative of possible localities

Borough level B&D: 200,000

Localities make sense for Place Based Care - Redbridge

Havering

Redbridge

Barking and Dagenham

BHR Level 750,0000

NEL Level 1,800,000

London Level

8,500,000

Interface with HLP on agreed plan London initiatives

The commissioning and provider landscape in BHR can be layered into locality level, borough level, BHR level, North East London level and London level, allowing services to be commissioned for specific groups, achieving a degree of local autonomy at the same time as achieving economies of scale where appropriate.

Evidence advanced by the Kings Fund, drawing on examples from New Zealand, is that place-based care works best with a population of 50-70,000 people Redbridge has a history of working in

localities which contain populations of this size, and it is proposed that place-based care be established within these boundaries

Overall Sustainability and Transformation plan strategy – clinical and financial sustainability

Issues needing a plan

NEL approach: 1. Acute reconfiguration /

pan NEL flows 2. Mental Health 3. Cancer 4. Urgent and Emergency

Care (incl. LAS) 5. Maternity 6. Specialised 7. Estates and workforce

coordination of enablers and interface with HEE/HLP etc.

8. Transformation funding

Local plans to address local gaps and challenges

Devolution test/ACO development

Delivery via contracts (lead commissioner)

Local enabler plans Local out of

hospital plans

HWB strategy and challenges

HWBB leadership Local

consultation and engagement

Provides integrated health and social care services through Local Accountable Care Organisations. Includes the right level of service consolidation that maximises value for money

106

Care provision Prevention Administration

Patients

Co-producing their care Registered with a local practice, with treatment, referral and care oversight from their GP When needed, receiving personalised, joined-up care and support, mostly near home

Baby

.

.

.

.

A team of around 100 professionals, with trusted relationships, working together to design

and deliver a high quality locality care service that meets local needs cost-effectively

Pharmacy

Social Care

Other services to be agreed

Community Nursing

Voluntary Sector

Dental

GP Practices High quality care

Productive Financially sustainable

GPs with time for patients

Network arrangements

The emerging vision is primary care-led locality-based care, founded on strong practices

Digitally-enabled scheduling and administration

Patient-level information sharing at point of care

Business intelligence: Ops management, Outcomes

Smart use of available Locality estate

Workforce

development, recruitment

and retention Optometry

Outpatient services

Redbridge

107

SPG / Borough

Delivery

Individual GP practices

GP Network and extended team: ‘Locality’ development

Primary care-led locality team forms and develops (framework in development)

Locality team sets outcomes and priorities to best meet local health needs

Pharmacy

Social Care

Optometry

Community Nursing

Voluntary Sector

Dental

Locality team defines local pathways and division of workload across practices,

practice networks and extended locality team

Delivery Improvement

OUTCOMES

Havering

Redbridge

Barking and Dagenham

Locality-based care would be designed and delivered within a wider set of standards and priorities

SPG / Borough level plan and priorities – supporting implementation of BHR transitional

programmes and CCG assurance measures

Other services to be agreed

Outpatient services

108

The vision would have positive benefits for practices

• Retain autonomy - allow step-by-step change with GPs leading • Working together help to ease financial pressures - pooling resources to reduce costs and

creating new opportunities to generate income • Partnership working - GPs have confidence to devolve routine work to other members of

the primary care team (e.g. repeat prescriptions) i.e. reduce workload & free up GP time • Integrated IT will help reduce duplication of work in the wider primary care team, including

chasing information • Integrated IT allows new ways of working that save time (e.g. e-consultations or multi-

disciplinary team meetings) • Attractive career offer to retain and recruit staff:-

• Model will allow for more diverse job roles within the extended primary care team • Enable new ways of working • More rewarding work focusing on patients • Create opportunities for career development for both clinical and non-clinical staff

109

Our Implementation Approach King’s Fund framework to develop place-based care

• Define the population served and the system boundaries. • Identify the partners and services that need to be included. • Create a shared local vision and objectives, based on local need and the priorities and

preferences of the population. • Develop an appropriate governance structure which must include patients and the public

in decision-making. • Identify the right leaders to manage the system, and develop a new form of system

leadership. • Agree how conflicts will be managed and resolved. • Develop a sustainable financial model for the system across three levels:

– the combined resources available to achieve the aims of the system – the way that these resources will flow down to providers – how these resources are allocated between providers and the way that costs, risks and rewards will be shared.

• Create a dedicated team to manage the work of the system. • Develop ways to allow different members of the group to focus on different parts of the

group’s objectives. • Develop a single set of measures to understand progress and use for improvement

110

Proposed Support for the set-up of Locality Teams

Programme Manager Change Manager helping the locality team get up and running: - Governance set-up - Teambuilding - Practice productivity initiative - Exploitation of IT & digital - Specification and use of BI

Operations Manager in place once the locality team is established (each covering 3 localities) Support required: Local manager Finance Business intelligence Administrator

111

The Programme builds locality-based working. Led by primary care, localities deliver outcomes

Workforce future model• Roles• Offer

Recruitment, development and retention programme established

ACO business case

Executing:• Fewer leavers• More recruits• Right staff mix for

PCL-PB model

Prepare shadow Shadow Full, live

Care City, CEPN

Productive practice development

Collaborative workingCore: forming OD

Operational management

Admin/back office

Able to deliver and cement working in:a) Individual practicesb) Extended teamc) Discharge

First admin collaboration

Fully operational localities:• Setting local outcomes• Defining pathways• Delivery as single team• Productive practices• Financially sustainable

First locality strategy

Move to joint delivery

Further admin collaboration leading to reduced operating cost

2016

Practice technology exploitation

• Implementation, training, new working arrangements, interoperability and user governance• Info for operational management

2017 2018

Themes from emerging preventative, planned, mental health, urgent & emergency care strategies feeding into locality pathway development

Prim

ary

care

tran

sfor

mat

ion

stra

tegy

Rela

ted

stra

tegi

es

PatientsRegistered with a local practiceTreatment, referral and care oversight from their GP

Receiving personalised, joined-up care and support for self-care, with the majority of care near home.Involved in the design of local pathways

Digitally-enabled scheduling and administration

Network arrangements- Care and prevention- Administration

Click, Call, Come In

Urgent Care

Community Nursing

Social Care

Pharmacy

Dental

Ophthalmology

Voluntary Sector

planned, mental health, urgent & emergency care, designed locally to best meet

local population needs

Acute Care

Interoperability: patient-identifiable information sharing at point of care

Business intelligence: (1) Locality-level operational management (2) Monitoring outcomes, informing improvement

Workforce The right mix of clinical and administrative roles in practices and across locality team

Compelling career and employment offer and a locality/system programme to recruit, develop and retain professionals

Referral & discharge protocols

Team of circacirca 100 professionals, with trusted working relationships, sharing workload and delivering continuity of care…

GP Practices- High quality care- Productive- Financially sustainable- GPs with time for

patients

112

To: Meeting of NHS Redbridge Clinical Commissioning Group (CCG) Governing Body From: Conor Burke, Chief Officer Date: 24 March 2016 Subject: CCG strategic direction 2016/17 and onwards Executive summary While we have achieved much as a CCG over the past three years, we are entering a particularly challenging period from 2016/17. This means that we need to act radically to drive change resulting in better health outcomes for local people. We have a history of ambition and innovation, having bid and piloted a number of initiatives to deliver greater access to GPs, a complex care practice and urgent and emergency care improvements through the Vanguard to name just a few. Through our recent work on the primary care transformation strategy we are looking to develop primary care-led localities, providing integrated services for populations of 50-70k people. At the same time we are working within the Barking and Dagenham, Havering and Redbridge (BHR) CCG collaborative on system wide initiatives to transform mental, health, planned care and urgent/emergency care. We are exploring whether developing an accountable care organisation (ACO) across BHR would enable us to deliver better and faster results. The case, being developed by the CCGs with our local authority and provider colleagues will outline the resource opportunities and requests, proposed flexibilities and freedoms and identify the support that we may need to become a full pilot site for devolution. We will be considering the case as a governing body later this summer. Our proposals for the ACO will feed into the north east London (NEL) sustainability and transformation plan (STP) which we are required to produce across the wider geography.


• Note the strategic update

1.0 Purpose of the report 1.1 To provide the governing body with a brief overview of the overall strategic direction for

the coming years, both for the CCG and the wider BHR health and social care economy.

2.0 Strategic direction 2.1 There has been considerable progress in developing and defining the CCG’s plans for

the next 1-5 years. Work is underway on the operating plan submission for each CCG,

113

as referred to in paper 4.1 on this agenda. Given the challenges that we face as a system in terms of quality, finances and overall outcomes for patients, we have been working with colleagues within boroughs, across BHR and where appropriate across the NEL footprint.

2.2 It is a complex picture and we need to ensure that our leaders, staff, members and

wider stakeholders understand and fully own the vision and plans for the years ahead. So we have been working to develop a simple ‘narrative’ that explains clearly what our challenges are and how we plan to address them. The summary is attached as appendix 1.. We are also developing set of slides to support engagement.

2.3 We are also exploring the creation of a ‘rich picture’, which would be a graphic

representation of our vision. Rich pictures are developed by engaging key leaders and stakeholders, and can be an effective tool for communication. It is a tool that has been used in BHR previously to positive effect.

2.4 The following section provides a summary of the key elements of our strategy from

2016/17 onwards. 3.0 Primary care and development of localities 3.1 The engagement and work to date on the primary care strategies in each of the BHR

boroughs includes a proposal to develop primary care localities for populations of between 50-70,000 people. The localities in time, if the model is agreed, will provide fully integrated health and social care services to people, based on local need and priorities. There is an update paper on the agenda at 4.3 that provides further detail, outlining the emerging vision and wider proposals.

4.0 Transformation programmes 4.1 While developing localities within each borough will be key to improving quality and

experience for communities in neighbourhoods, there are benefits to working with our partners at scale across the entire BHR health and social care economy. By negotiating arrangements with our fellow CCGs, local authorities and major providers we can manage contracts and risk across the wider patch. We can also develop consistent clinically led and agreed standards for pathways and the care that people receive.

4.2 Programmes for mental health and urgent care (including the Vanguard) have been

running for several months now and work on developing a programme for planned care is underway. To support the running and resourcing of the programmes a ‘portfolio management office’ (PMO) is being established. This will help to ensure that all the initiatives are fully joined up given the cross cutting nature of each programme.

5.0 Accountable care organisation 5.1 Work in progressing the business case is well underway. Our local plan, as an individual

and collaborative of CCGs will be fed into the business case to ensure that the proposal is fully aligned to our strategic direction. The ACO is not about creating a new vision but is about exploring whether having full devolution could enable us to deliver better results and/or more quickly. We have a strong track record in working in partnership with local authorities and providers (through our Integrated Care Coalition), sharing an overall aim of commissioning/delivering better care for local people with a diminishing pot of resources and rising demand.

114

6.0 Sustainability and transformation plans 6.1 National NHS planning guidance issued in December 2015 outlined the requirement to

develop sustainability and transformation plans (STP) by June 2016. These plans are to cover all health services, (and public health and social care services) over an agreed footprint. They are expected to set out an ambitious five year vision and programme to ensure that health and care services are sustainable into the future.

6.2 We are working in an STP footprint of north east London and work in developing the

plan is underway. We have made it clear that our element of the plan will largely be derived from the ACO business case, but that we recognise the need for collaboration on key issues such as maternity services and acute reconfiguration because of the flows of patients between the BHR and WEL systems. Governance and planning arrangements are currently being finalised and the details will be shared as they emerge.

7.0 Resources/investment 7.1 As part of the business case process we will identifying the resources and support that

we believe would enable us to develop as a devolution pilot area. We are also looking at how we make most effective use of our staff resources to ensure that we deliver our ambitious vision.

8.0 Equalities 8.1 Plans will be developed in line with equalities considerations with the aim of addressing

health inequalities across our borough and BHR. 9.0 Risks 9.1 We cannot carry on without making radical changes to the way health and social care is

delivered within our borough and across BHR. Our plans outline our ambition for trying something new to enable is to deliver the care that we think local people should receive.

10.0 Managing conflicts of interest 10.1 There are no conflict of interest issues in relation to this report. Author: Marie Price, director of corporate services Date: 2 March 2016 Appendix 1: Our vision – draft narrative

115

Appendix 1 Our vision – draft narrative

Through our strong clinical leadership and partnership working over the past three years, we have begun to make significant improvements in the quality of care for local people. But we have more than our fair share of challenges too – money, some very poor health outcomes, workforce challenges – to name just a few.

The current and inherited old ways of commissioning and the boundaries between organisations, people, commissioners/providers just won’t enable us to deliver a sustainable system in the future, and it certainly won’t enable us to deliver the care that we know local people need and have a right to expect.

Primary care is the bedrock of any effective healthcare system. We are considering whether by developing primary care led localities or neighbourhoods; we could deliver the change we need. It is a model that has been emerging through the primary care transformation strategy engagement process.

Each locality would self-organise and manage a significant chunk of the overall budget in line with their population - driving innovation and responsiveness to need at a local level, but could have a set of common characteristics.

The initial focus would be on primary care, but the localities could develop to include wider health and social care input – providing fully integrated and seamless services.

To make it work though we would need to invest considerable set-up resources and look at running pilots – perhaps as early as April 2016 if some patches feel ready. We would support each area to go at its own pace and ensure that the learning is shared across all.

We have fantastic pockets of innovation within our three CCGs and across BHR. We have taken opportunities to gain national funding and opportunities to test and try new models of care. We have all heard about initiatives such as the Prime Minister’s Challenge Fund, vanguard and accountable care organisation (ACO), but these are just ways of getting freedoms and flexibilities to deliver what we think is best for patients.

As we develop our vision for improving services – possibly through this locality model if GP colleagues agree – we will at the same time be testing whether an ACO could help us to achieve better and or faster results. An ACO could enable us to have different payment mechanisms, greater collaborative working and where appropriate, shared leadership and governance arrangements. We think there is a chance that it could help, but if it becomes clear that it won’t, then we won’t be recommending the model.

We also don’t want to lose sight of the great work that clinicians have led together across our health economy – big improvements in urgent and emergency care performance, intermediate care services that are keeping thousands more people well and through our current proposals for better stroke rehabilitation services. By working and investing together we have also begun to make real progress in helping people to access the mental health services that they need.

116

Through clinically led standardised pathways for key areas of care – urgent/emergency, mental health and planned treatment – as well as an agreed approach to managing risk with major contracts/providers across the BHR footprint, we can be effective by working together as three boroughs.

The individual boroughs/CCGs will continue to be accountable. They will ensure that the democratic focus remains, and seek assurance that the required outcomes are being delivered at the locality and BHR levels, with appropriate governance designed for each.

This is an approach that has emerged from some early discussions with clinical and political leaders and through the primary care transformation work. We want to test whether it is a model that GP leaders and practitioners believe could work and whether / how we should take it forward.

117

To: Meeting of the NHS Redbridge Clinical Commissioning Group (CCG) Governing Body

From: Dr Mehul Mathukia, Clinical Director Date: 24 March 2016 Subject: Improving patient flow – front of A&E and supporting discharge Executive summary

This paper puts forward the business case to recurrently fund additional nursing and occupational therapy support that has been funded to date through non-recurrent operational resilience (winter pressures) money, and which have demonstrated system benefits since they commenced in November 2014. The operational resilience money was used to fund additional nursing staff to work with Emergency Department in Queen’s hospital to support achievement of the 4 hour wait target by identifying patients who are appropriate for community support and safely discharging them from A&E, and for additional nurses and occupational therapists to in-reach into wards to reduce length of stay. The business case indicates that the enhancement of support in the front of A&E has led to 402 avoided admissions (with an estimated saving of £366k). The in-reach service has achieved a reduction in the the total length of stay equivalent to a saving of 46 beds (compared to 2014). If funding was ceased for these services then length of stay may increase and directly impact on patient flow and A&E performance. The business case sets out a preferred option to maximise benefits and minimise cost.

Recommendations:

• To continue to fund these services in 2016/17. 1.0 Purpose of the Report

1.1 The purpose of this report is to set out the rationale for continued funding for the front of

A&E and discharge support services.

2.0 Background/Introduction 2.1 Operational resilience funding was received by the Barking, Havering & Redbridge

system in the summer of 2014/15 and schemes for funding were prioritised, through the System Resilience Group, in line with the Barking Havering and Redbridge University

118

Page 2 of 4

Hospitals Trust (BHRUT) Service Improvement Plan and identified gaps in existing provision.

2.2 £300k funding was agreed to extend support in A&E at Queens’s hospital and pilot an in-

reach Intensive Rehabilitation Service to the orthopaedic and geriatric wards on both the Queens and King George hospital sites.

2.3 The service is provided by NELFT. The initial funding was agreed to cover the period

from 1st November 2014 to 31st March 2015 and then in March 2015 the CCGs agreed to extend the pilot into Q1 of 2015/16 and in June 2015 it was extended again for £164k for Q2 and £409k for Q3/Q4.

3.0 Service description

3.1 The following sets out how the operational resilience funding has been used to develop capacity in the services.

• Emergency Department based Treatment Team Identifies patients who are suitable for discharge (with support) directly from

A&E to avoid the need for admission. Only based in Queen’s ED not in community – this is a separate team to the

community based CTT. This was piloted in KGH but was not viable due to small numbers of suitable patients.

Currently provided from 8am to 10pm for 365 days per year. Original service staffing includes 3 therapists and 1 social worker (funded by

LB Havering) and the current team are also supported by 2 JAD social workers.

Operational resilience funding has paid for 2 additional Band 6 nurses which has increased caseload capacity.

• Intensive Rehabilitation Service (IRS) in-reach Identifies patients from orthopaedic and geriatric wards, on both hospital sites,

who are suitable for intensive support to reduce length of stay. This improves outcomes for patients and reduces bed usage

Currently provided from 9am to 5pm 365 days per year. Operational resilience funding pays for three band 6 nurses and two band 6

occupational therapists, who make up the full in reach team Team supports the flow of patients from Queens and KGH and also supports

Redbridge patients being discharged from Whipps Cross Hospital.

4.0 Recurrent funding proposal rationale The business case sets out the rationale for recurrently funding the additional service capacity based on avoiding admissions, reduced length of stay leading to bed savings and supporting the hospital to meet A&E 4 hour target as follows:

Admissions – Treatment Team The service effectively targets the most appropriate patients in A&E and has access to services in the community to safely discharge patients with the appropriate support. As a result no patient seen by the service has needed to be admitted to hospital. The case

119

Page 3 of 4

assumes that all of the patients seen by the service might otherwise have been admitted to hospital and the intervention has saved approximately 402 short stay admissions with an estimated saving of £366k for the last 12 months.

The Treatment Team service has contributed to delivery of the ED access targets, all patients are seen within an hour of referral. This is further supported by the views of ED clinicians.

Bed savings - IRS The bed saving assumption in the pilot was that a patient seen by the A&E team would save 1 day and a patient seen by IRS would save 3 days – this was on the assumption that admissions avoided by treatment team are likely to have short stays anyway and for IRS this would bring us to the benchmark linked to our ‘Commissioning for Value’ comparator group. A caseload of 5-6 patients per day equates to a saving of 13 beds. The bed saving divided by the service cost would equate to £59k (compared to £60k average for a hospital bed).

For IRS admissions the total length of stay (LOS) for patients admitted to the Geriatric Medicine, Orthopaedics and General Medical wards were compared for April – October 2014 against April - October 2015. The total length of stay for patients admitted actually reduced by 9587 days in 2015 compared to 2014 and this equates to a saving of 46 hospital beds compared to the 12 bed target. While this does not have any direct cost savings for CCGs at this time this does support the system requirement to reduce acute bed usage and support the closure of hospital beds.

A reduction in LoS expedites a patient’s recovery as it minimises any loss of independence, risk of infection and longer term effects. Patients spending longer time in hospital could result in poor outcomes and excess bed days. The business case includes a case study that demonstrates the positive patient outcomes.

5.0 Resources/investment

The total cost of the preferred option is £766,735 which is broken down by CCG:

Treatment Team

CCG Investment Estimated A&E saving

Barking & Dagenham £ 82,622 £ 84,180 Havering £ 247,866 £ 252,540 Redbridge £ 28,738 £ 29,280 £ 359,226 £ 366,000

120

Page 4 of 4

Intensive Rehabilitation Service CCG Investment Bed saving

Barking & Dagenham £ 93,727

46 beds Havering £207,830

Redbridge £105,953

£407,510

6.0 Recommendation

The business case sets out a number of options for recurrently funding the elements of the Treatment Team and IRS service described above.

The preferred option (Option 4) attempts to get best value by matching service delivery to seasonal need as follows:

To continue to fund the Treatment Team in A&E from 8am-10pm 365 days per year, and IRS 9am-5pm for 7 days per week from November to March and 5 days per week from April to October.

7.0 Equalities

There are no equalities issues raised by this paper. 8.0 Risks

The risks associated with not implementing the proposed option are identified as:

• increased length of stay, • increased admissions, • poorer flow through ED and the hospital, • increase in breaches of the four hour waiting time standard, • delayed medical reviews risking clinical safety of patients in ED and wards The risks associated with implementation of the preferred option ; • Failure to maintain current levels of performance • Ability of provider to recruit permanently to posts increasing service cost


There are no conflicts of interest considerations arising from this report. Author: Sarah D’Souza, Deputy Chief Operating Officer Barking and Dagenham CCG Date: 24 February 2016 Attachment 1: Business Case CTTIRS

121

Business case TTIRS 110116 1/11 Version 10

BUSINESS CASE

This template should be completed for business cases up to £2m. This document should be completed following approval of the Business Justification. Note 1 Guidance notes are incorporated into each section – please delete them when no

longer required. Note 2 Some sections may not be relevant to your business case. Please do not delete the

section, but indicate accordingly. Note 3 Please remember to update the ‘footer’ version number at the bottom of the page

each time you update your case. Contents

1. Approval

2. Summary of project

3. Purpose

4. Current situation

5. Case for change a. Business needs b. Benefits c. Risks d. Interdependencies

6. Strategic context

7. Procurement

8. Activity implications

9. Workforce implications

10. Funding and affordability

11. Options considered & preferred option

12. Management arrangements

13. Governance arrangements

14. Consultation/communication

15. Timelines and deliverables

16. Other Organisational Involvement

17. Environmental considerations

18. Equality/ Diversity

122


1. Approval This document must be approved by the following: Name Signature Title / Responsibility Date Version

CCG CFO

Quality

Corporate

CSU Commissioning Support Director

2. Summary of project Project Name Treatment Team (TT)/

Intensive Rehabilitation Service (IRS)

Date 22/2/16

Executive Summary Treatment Team (TT) support in A&E at Queens hospital and an in-reach Intensive Rehabilitation Service (IRS) to the orthopaedic and geriatric wards on both the Queens and King George hospital sites.

Cost of Business Case The cost of the preferred option is £766,735 for a full year if the service is recurrently funded. This is based on 2015/16 payscale rates. If the business case is agreed will be added to the NELFT contract baseline for 2016/17 and the appropriate business rules applied

Confirm physical capacity already exists/included in costs

Yes – physical capacity already in place

Impact Average of equivalent of 13 beds saved per month in the last quarter (October to December 2015). Cost per bed (based on cost savings) - £59k

3. Introduction

Operational resilience funding was received by the Barking, Havering & Redbridge system in the summer of 2014/15 and schemes for funding were prioritised, through the System Resilience Group, both in line with the Barking Havering and Redbridge University Hospitals Trust (BHRUT) Service Improvement Plan and identified gaps in existing provision. £300k funding was agreed to extend Treatment Team (TT) support in A&E at Queens’s hospital and pilot an in-reach Intensive Rehabilitation Service to the orthopaedic and geriatric wards on both the Queens and King George hospital sites. The service is provided by North East London Foundation Trust (NELFT). The initial funding was agreed to cover the period from 1st November 2014 to 31st March 2015 and then in March 2015 the CCGs agreed to extend the pilot in to Q1 of 2015/16 and in June 2015 it was extended again for £164k for Q2 and £409k for Q3/Q4. This paper summarises the development of the service and makes the case for continuation of funding. The cost for continuation of the service for 2016/17 is £766,735.

123



Treatment Team (TT) • The TT service is provided from 8am to 10pm for 365 days per year. • This part of the TT service is based in ED and the focus is to identify patients who are

suitable for discharge, with support, directly from A&E to avoid the need for admission. These staff only work in ED and do not cover the community – community staff do also not in reach to ED.

• There was a TT service in ED at Queen’s hospital prior to Operational Resilience funding. The service was staffed by 3 therapists and 1 social worker (the latter post is funded by London Borough of Havering) who supported setting up social care packages in the community and ED for patients of TT.

• The operational resilience funds were used to recruit two band 6 nurses to increase the caseload capacity of TT.

• In addition, the TT team have had support from two social workers from the JAD team. These staff are not included in the costs stated above and the arrangement for inclusion in the team will be picked up as part of JAD discussions at the System Resilience Group.

Intensive Rehabilitation Service (IRS) • The IRS service is currently provided from 9am to 5pm 365 days per year. • The IRS team attend orthopaedics and geriatric wards on both of the BHRUT sites to

identify patients suitable for intensive support with the objective of reducing length of stay and therefore improving outcomes for patients and reduce bed usage.

• There was no baseline funding for IRS although a pilot of therapy in reach at KGH had been undertaken. The Operational Resilience funding enabled recruitment of three band 6 nurses and two band 6 occupational therapists

• During times of peak pressure the IRS team support rapid assessment and discharge

into the rehabilitation pathway from acute, and from community beds, to home in some cases. This level of intensive support managed, during peak time, to discharge from acute and admit into the whole bed base of intermediate care beds in a 10 day period - maximising support of flow in BHRUT.

• The team also virtually support the flow of Redbridge patients out of Whipps Cross

Hospital. The extension of the services meant that a minimum of five new patients per day could be seen across the two teams. The table below shows the number of patients seen by month and the conversion to beds saved: CTT/IRS service - activity and bed savings by month

Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16

Pts seen 98 86 143 129 116 106 123 126 139 143 143 175 133 132 165

Bed target 6 8 12 12 12 12 12 12 10 10 10 12 12 12 12Proxy beds saved (average) 9 8 10 12 10 10 9 11 10 12 12 14 12 12 9.6

Activity and resource allocation is split 25% CTT and 75% IRSProxy measure is based on 1 day saved for CTT and 3 days saved for IRS The bed savings are based on a proxy measure agreed for operational resilience, but the quantified bed savings are shown under section 5b below.

CCG split of activity The following table shows the split of the activity by CCG:

CCG TT % of total IRS % of total Barking & Dagenham 23% 23% Havering 69% 51% Redbridge 8% 26%

124


5. Case for change

a) Business Needs When the Operational Resilience schemes were developed in 2014/15 they were all focused on reducing length of stay and admission avoidance to reduce the bed usage on the acute hospital sites. As part of their Service Improvement Plan, BHRUT identified a 72 bed gap between expected need and actual bed stock. This scheme aimed to release capacity equivalent to 12 beds.

b) Benefits

The combined TT/IRS services have focused on the release of inpatient bed days as the key measure of success and, in addition, the TT service has focused on admissions avoided in A&E. A case study as attached at appendix 4 which demonstrates the improved outcomes for patients of the IRS service. Admissions and total length of stay (LOS) for patients admitted to the Geriatric Medicine, Orthopaedics and General Medical wards were compared for April – October 2014 against April to October 2015. The total length of stay for patients admitted reduced by 9587 days in 2015 compared to 2014 and this equates to a saving of 46 hospital beds. TT have avoided admissions for 100% of the patients that they see in A&E at Queens Hospital.

It is important to reduce LoS as it limits the time that a patient is in hospital and expedites recovery to minimise loss of independence, longer term effects and risk of infection. Without LoS reduction, patients could end up with longer LoS resulting in poor outcomes and excess bed days.

The average LoS for April to October 2015 has been compared to that for the same period in 2014, and for the same wards as stated above. The average LoS has reduced from 10.1 days to 8.5 days, a reduction of 1.6 days (16%). The majority of the bed savings are attributable to the IRS as they have been proactively identifying patients in orthopaedic and geriatric wards and reducing length of stay. The in-reach IRS has supported rapid access to the rehabilitation pathway for community IRS and beds.

In addition to bed savings, the TT service has contributed to delivery of the ED access targets, all patients are seen within an hour of referral. They have managed to avoid 402 admissions in the last 12 months. This is because they target the most appropriate patients and have access to the services in the community in order to safely discharge patients with the appropriate support. The average price for a 0/1 day LoS is £910 and therefore the TT service alone has saved £366k. The in reach service provided by TT / IRS has supported BHR wide organisations to move to a discharge to assess pilot. This model of discharge has excellent benefits for the patients who are assessed for their needs in their home environment maximising recover, reducing bed occupancy and patient deconditioning which will lead to system benefits of reduced longer term health and social care need.

In support of the case Dr Dan Harris, ED Consultant at BHRUT, stated that “TT has been hugely helpful with facilitating discharge home directly from ED. They are now increasingly discharging patients from the Observation bay thereby preventing admissions into MRU and ERU beds. Their view is that the service has been critical to delivery of the 4 hour target. The TT team speed up assessment, work alongside medical teams to ensure timely and safe discharge home with required packages of care, where appropriate. They see/ treat and discharge from A&E before patients are admitted. They reduce admissions thereby freeing up on call teams to focus on people who need to be in hospital.”

125


c) Risks BHRUT have highlighted that if the services were not in place then the risks would be: • increased length of stay, • increased admissions, • poorer flow through ED and the hospital, • increase in breaches of the four hour waiting time standard, • delayed medical reviews risking clinical safety of patients in ED and wards Admission avoidance is vital as there is strong evidence that once a patient is admitted they can deteriorate as a result of loss of independence and risk of infection and each admission can affect their recovery rate and future ability to self-care.

Without IRS in-reach patients maybe in hospital longer than required and delays in rehabilitation could affect the speed of their recovery and their long term health and result in excess bed day costs as a result of longer lengths of stay.

d) Interdependencies

The TT is one of the services that would be part of a proposed Urgent and Emergency Care Vanguard programme to streamline provision at the front end of A&E. It is acknowledged that some of the services overlap, and the range of services can present a complex number of options for staff based in ED to navigate when trying to find the most appropriate pathway for patients but that there has been a positive impact on the system as a whole by having these services in place. It is not yet known what the impact of this would be and whether any savings would result from this work. For TT, it is essential to ensure good communication between the team and social services across all the local boroughs so that assessments don’t have to be repeated and information can be passed on and acted upon with a single call. For IRS, relationships with the wards has been built which has supported greater awareness of discharge pathways. The links are essential with the community team and community beds.


The TT and IRS service are just two of a number of initiatives that have been developed across BHR to bring care closer to home, reduce pressure on the acute trust, support to achieve ED waiting time targets and improve outcomes for patients.

7. Procurement

Not applicable.

8. Activity Implications Activity will continue in line with the table in section 4 above. TT will see approximately 36 patients per month and IRS will see approximately 104 although there is some seasonal variation for the latter figures.


The posts are filled by agency staff currently so contracts would need to be extended or ideally recruitment to posts would be undertaken. There are two social workers who support the team, who are not part of the costs, who are seconded from JAD and would be essential to continuation of the service. As noted previously this will be picked up as part of the JAD discussion at the System Resilience Group.


Option 1: Stop both services on 31/3/16 (No cost) Option 2: Fund TT 8am-10pm and IRS 9am-5pm for 365 days per year (£847,195) –

appendix 1

126


Option 3: Fund TT 8am-10pm 365 days per year and IRS 9am-5pm for weekdays only (£666,277) – appendix 2

Option 4: Fund TT 8am-10pm 365 days per year and IRS 9am-5pm for 7 days per week from November to March and 5 days per week from April to October (£766,735) – appendix 3


The options are set out in section 10 above. The preferred option is option 4 as this reflects the additional demand over the winter months and will provide a responsive service to manage patients out of hospital as quickly as possible. The cost by CCG for option 4 is set out below: Barking & Dagenham £176,349

Havering £455,901 Redbridge £134,485 12. Management Arrangements

The service is provided and managed by NELFT and the arrangement has been in place since November 2014. This would continue.


Scheme performance is monitored through the System Resilience Group on a monthly basis and will also be reviewed through the monthly SpR that it is place with NELFT.


No consultation or communication is required unless the service is ceased. If the decision was taken to not continue funding the service then A&E and the wards would need to be informed as this would mean a change to the pathways that have been in place since November 2015. The impact would also need to be feed through the capacity modelling that BHRUT will be required to undertake in preparation for resilience planning.

15. Expected timelines and deliverables

Service is in place currently and the case is being made for continuation. 16. Other Organisational Involvement

The services are provided in A&E at Queens and in-reach to both Queens and King George hospital sites and therefore there are significant links in place with BHRUT. The TT service is part of the proposal for streamlining A&E services (see 5d above) and links to the Urgent Care Vanguard development. The IRS service would need to be part of the discharge planning review.


Not applicable 18. Equality/ Diversity Not applicable Notes on submission process:

1. The Head of Finance or Deputy Chief Finance Officer are available to assist and advise

on the preparation of business cases. 2. Approval will be sought from JMT, CCG Executive, and/or CCG Board as determined by

the business case approval process.

127


Appendix 1 Option 2: Fund TT 8am-10pm and IRS 9am-5pm for 365 days per year (£847,195)

Band Rota Headcount Mon-Friday Saturday Sunday WTE needed

Total (inc sickness

and AL)

CTT Pay -Rota 8am-10pmNurse Band 6 2.00 164,291 40,960 50,413 2.61 306,796

IRS Pay -Rota 9am -5pmTherapist Band 6 5.00 225,056 58,515 72,018 7.47 426,706

Total Pay Costing 7.00 10.08 733,503

Total Non-Pay @ 5% 36,675

Overheads 10% 77,018

Total Cost CTT/IRS 847,195

* Sickness/Annual leave at 20%

Option 2 - KGH & Queens A&E Liaison Serviceboth CTT and IRS running 7 days per week for 365 days per year

128


Appendix 2 Option 3: Fund TT 8am-10pm 365 days per year and IRS 9am-5pm for weekdays only (£666,277)


Total (inc sickness

and AL)

CTT Pay -Rota 8am-10pmNurse Band 6 2.00 164,291 40,960 50,413 2.61 306,796

IRS Pay -Rota 9am -5pmTherapist Band 6 5.00 225,056 7.47 270,067






Option 3 - KGH & Queens A&E Liaison Service 7 days per week for CTT and 5 days per week for IRS

129


Appendix 3 Option 4: Fund TT 8am-10pm 365 days per year and IRS 9am-5pm for 7 days per week from November to March and 5 days per week from April to October (£766,735)


Total (inc sickness

and AL)CTT Pay -Rota 8am-10pmNurse Band 6 2.00 164,291 40,960 50,413 2.61 306,796

IRS Pay -Rota 9am -5pmTherapist Band 6 5.00 225,056 29,257 36,009 7.47 348,387




Agency costs 10,000



Option 4 - KGH & Queens A&E Liaison Service7 days per week for CTT 5 days per week for IRS (April - October) and 7 days IRS (November - March)

130


Appendix 4 – Case study Intensive Rehabilitation Service – Patient Case Study Miss J.B (seen from 21/12/15- 13/1/16) Patient Background: 92 year old female, admitted to acute on background of falls, increasing in numbers over a 2 week period. Diagnosed in acute with UTI, and treated with antibiotics. All falls occurred overnight, when patient was transferring to the toilet. The acute therapists felt that the falls were predominantly due to environmental hazards due to the location and nature. Patient was in acute environment for approx. 4 weeks prior to IRS intervention. Patients PMH:

IRS In-Reach Experience: DAY ONE: IRS In reach therapist was asked to review patient as she was borderline for inpatient therapy vs IRS at home. Patient was transferring independently and mobilising independently with a rollator frame approx. 8m. On assessment IRS therapist concluded: - Current function level she appears at her baseline and is limited only by her anxiety around returning home.

- Suggested that the ward complete a home visit with patient to try and reduce some anxiety around returning home - patient declined and reported she just wanted rehab.

- Suggested a d/c home with full POC and IRS support - patient declined and reported she just wanted rehab // patient then became very tearful.

-Reassured ++ and explained that no decision has been made currently but that feed back to ward staff would be expressed.

131


- Explained the above to ward staff and reported that we cannot clinically reasoning with ease this lady being admitted to a rehab bed - suggested they investigate her anxiety around returning home further. DAY 2: Patient’s daughter was then informed by the ward staff of the above conclusions made by the in-reaching therapist. Patient’s daughter contacted the IRS team and spoke to the in reaching therapist to express her concerns regarding; what felt to her; the sudden change in plans around her mums discharge. IIRS in reaching therapist explained the findings of the assessment and reassured the patient’s daughter. DAY 3: The ward staff, based on IRS recommendations completed a home visit with the patient and patient due for discharge the same day. DAY 4: IRS therapy started. IRS Intervention: This patient received 2-3 visits daily during her 21 day stay with the IRS team- from PT, OT and RA. On point of initial assessment patient was: - Mobilising with rollator frame independently but ++ anxious - Transferring independently - Requiring assistance one to complete washing and dressing in shower - Requiring assistance one to complete all kitchen tasks - She had an initial TUG of 44 secs On point of d/c patient was: - Completing all standing exercises independently and mobilising with

rollator frame around her house independently. - Patient was independent with hot drink prep - Patient was able to independently wash in shower but continued to require

assistance one to access secondary to steps. - She had a final TUG of 38.6 secs. Patient was also supported at home with a QDS POC and district nursing. Outcomes: Due to the input received from the IRS service the patient was able to be safely discharged from hospital, and regain her independence and confidence at home. The Acute hospital was able to receive advice and facilitation to an otherwise ‘complex’ discharge, due to the IRS in reach service provided. This patient has had no further falls and no further admissions to acute services since her d/c home with IRS support.

132

To: Meeting of the NHS Redbridge Clinical Commissioning Group (CCG) Governing Body

From: Dr Mathukia, Redbridge CCG Lead Date: 24 March 2016 Subject: Response Car - London Ambulance Service and Community Treatment Team Executive summary

The service was established in October 2014 and was funded from 2014/15 Operational Resilience Funding (the cost of the car was covered by the London Ambulance Service (LAS) from October to December 2014). It was set up by LAS and the Community Treatment Team (CTT) from NELFT to support the reduction in admissions/attendances and conveyances to an Emergency Department. Funding was agreed for 2015/16 through the System Resilience Group. The service consists of an ambulance car, staffed by a paramedic and a CTT nurse and responds to appropriate falls calls (criteria including the patient being over 65) identified by the LAS Control Centre. The team then do a full assessment of the patient in their own home and where possible keep the patient at home and avoid unnecessary conveyance. From April 2015 to January 2016 the team visited 1,150 patients and managed to keep 818 of these at home (71%) avoiding the need for an emergency ambulance, A&E attendance and admission (where that would have been appropriate) and it is estimated that there is a net saving of £390,827 as a result of the service being in place.

Recommendations

• To continue funding for this service in 2016/17.


1.1 The purpose of this report is to set out the rationale for the continuation of funding for the

LAS/ CTT response car service.

2.0 Background/Introduction 2.1 Operational resilience funding was received by the Barking, Havering & Redbridge

system in the summer of 2014/15 and schemes for funding were prioritised, through the System Resilience Group, in line with the Barking Havering and Redbridge University Hospitals Trust (BHRUT) Service Improvement Plan and identified gaps in existing provision.

133

Page 2 of 3

2.2 The LAS/CTT service was established in October 2014 and was funded from 2014/15

Operational Resilience Funding (the cost of the car was covered by LAS from October to December 2014). It was set up to support the reduction in admissions/attendances and conveyances to an Emergency Department.

2.3 This paper summarises the development of the service and makes the case for

continuation of funding. The cost for continuation of the service for 2016/17 is £473,377 and represents a 14% reduction (£66,202) on the cost of the scheme in 2015/16.

3.0 Service description

3.1 An Ambulance car, staffed by a paramedic and a CTT nurse responds to appropriate falls calls (criteria including the patient being over 65) identified by the LAS Control Centre. The team then undertake a full assessment of the patient in their own home.

If the patient requires support in order to stay at home then the team contact CTT in the

community and hand the patients care over, ensuring continuity and reassurance for the patient.

The team are able to provide and, where appropriate, fit some small items of equipment

e.g. chair raisers, walking frames to address any immediate patient needs. 3.2 The service aims to enable the identified cohort of patients to be safely assessed, treated

at home and discharged from care, without the need to convey to A&E. This supports reduction in attendances, admissions and ambulance conveyances to an ED. The service operates seven days a week, between the hours of 07:00 and 19:00.

3.2 From April 2015 to January 2016 the team visited 1,150 patients and managed to keep 818 of these at home (71%) avoiding the need for an emergency ambulance, A&E attendance and admission (where that would have been appropriate). The forecast for a full year, on this basis is 1,380 patients visited and 982 kept at home. This forecast has been used for the estimated cost saving in appendix 1 of the business case.

4.0 Recurrent funding proposal rationale 4.1 The business case sets out the rationale for recurrently funding the service based on

reducing admissions, attendances and ambulance conveyances to an ED and the fact that 71% of people are kept at home and the excellent patient experience and outcomes. Patient case studies and patient experience surveys are included in the business case. 98% of patients completing the survey were seen within 2 hours and would recommend the service.

4.2 The total cost of the service across BHR is £473k and it is estimated that the total annual savings, based on the current service performance, would be approximately £864k, if we assumed that 80% of patients would have been admitted, and therefore the net savings are £391k. Appendix 1 also shows the forecast savings, if either 100% or 60% of patients were admitted, and all forecasts show a net saving after fully funding the service.

5.0 Resources/investment 5.1 The service costs £473k per annum and this is split between £281k for LAS and £192k for CTT.

134

Page 3 of 3

5.2 The cost and net savings by CCG are set out below:

Service cost Total savings Net savings

Barking & Dagenham £147,972 £270,140 £122,168

Havering £245,058 £447,381 £202,323

Redbridge £ 80,347 £146,683 £ 66,336

TOTAL £473,377 £864,204 £390,827

6.0 Recommendation

6.1 To fund the service for 2016/17 to ensure continuity of this service which has demonstrated the ability to manage patients in their own home and is forecast to save more than it costs. 7.0 Equalities 7.1 There are no equalities issues raised by this paper. 8.0 Risks 8.1 If the service was not in place then the risks would be:

• Increase in ED admissions and ambulance conveyances in an already significantly challenged system.

• Carers may end up in hospital which could have an impact on the person they are caring for.

• Once a patient is admitted they can deteriorate as a result of loss of independence and are at risk of infection which can affect their recovery rate and future ability to self-care.

9.0 Managing conflicts of interest 9.1 There are no conflicts of interest considerations arising from this report. Author: Sarah D’Souza, Deputy Chief Operating Officer Barking and Dagenham CCG Date: 24 February 2016 Attachment: Business Case CTTLAS

135

Business case CTTLAS 240216 1/13 Version 1

BUSINESS CASE

This template should be completed for business cases up to £2m. This document should be completed following approval of the Business Justification. Note 1 Guidance notes are incorporated into each section – please delete them when no

longer required. Note 2 Some sections may not be relevant to your business case. Please do not delete the

section, but indicate accordingly. Note 3 Please remember to update the ‘footer’ version number at the bottom of the page

each time you update your case. Contents

1. Amendment History


3. Purpose


5. Case for change a. Business needs b. Benefits c. Risks d. Interdependencies


7. Procurement

8. Activity implications




12. Management arrangements



15. Timelines and deliverables

16. Other Organisational Involvement


18. Equality/ Diversity

136


1. Summary of project Reviewers This document must be reviewed by the following: Name Signature Title / Responsibility Date Version

Project Manager (Owner)

Executive Sponsor

Project /Senior Management Accountant The Project Manager (Owner) is the person who will be responsible for delivering the benefits arising from this project. They would usually be a senior manager or clinician. The Executive Sponsor must be an Executive Director. They would usually be expected to present the case to the CCG Joint Management Team / CCG Executive Committee. Approval This document must be approved by the following: Name Signature Title / Responsibility Date Version

CCG CFO

Quality

Corporate

CSU Commissioning Support Director


Project Name Community Treatment Team (CTT)/ London Ambulance Service falls car scheme

Date 24/02/16

Executive Summary A response vehicle provided by the London Ambulance Service (LAS) crewed by a registered nurse and a registered LAS paramedic tasked to attend an identified group of patients within the geographical area of Barking & Dagenham, Havering and Redbridge Clinical Commissioning Groups (CCGs). This joint clinical response has the aim of enabling this cohort of patients to be safely assessed, treated at home and discharged from care, without the need to convey to A&E.

Cost of Business Case £473,377 (LAS - £280,709, NELFT - £192,667)

Confirm physical capacity already exists/included in costs

Yes – physical capacity already in place

Impact

Average of 82 patients kept at home per month from April 2015 to January 2016. From April 2015 to January 2016 the team visited 1,150 patients and managed to keep 818 at home (71%) avoiding the need for an emergency ambulance, A&E attendance and admission (where that would have been appropriate). The potential net savings for the scheme are £390,827 and this is set out in appendix 1.

137


3. Introduction

Operational resilience funding was received by the Barking, Havering & Redbridge system in the summer of 2014/15 and schemes for funding were prioritised, through the System Resilience Group, both in line with the Barking Havering and Redbridge University Hospitals Trust (BHRUT) Service Improvement Plan and identified gaps in existing provision. The LAS/CTT service was established in October 2014 and was funded from 2014/15 Operational Resilience Funding (the cost of the car was covered by LAS from October to December 2014). It was set up to support the reduction in admissions/attendances and conveyances to an Emergency Department. An Ambulance car, staffed by a paramedic and a CTT nurse responds to appropriate falls calls (criteria including the patient being over 65) identified by the LAS Control Centre. The team then undertake a full assessment of the patient in their own home. The service operates seven days a week, between the hours of 07:00 and 19:00. This paper summarises the development of the service and makes the case for continuation of funding. The cost for continuation of the service for 2016/17 is £473,377 and represents a reduction of £66,202 on the cost of the scheme in 2015/16.


From April 2015 to January 2016 the team visited 1,150 patients and managed to keep 818 at home (71%) avoiding the need for an emergency ambulance, A&E attendance and admission (where that would have been appropriate). The table below shows the number of calls attended each month from April 2015 and the number of patients kept at home:

Table 1:

Month: Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sept 15 Oct 15 Nov 15 Dec 15 Jan 16 Total

Calls attended 98 112 105 121 104 114 145 111 107 133 1,150

Patients kept at home (Plan): 80 100 80 100 80 80 100 80 80 100 880

Patients kept at home (actual): 57 72 79 97 76 81 106 76 79 95 818

Variance: -23 -28 -1 -3 -4 +1 +1 -4 -1 -5 -62

5. Case for change

a) Business Needs

When the Operational Resilience schemes were developed in 2014/15 they were focused on reducing length of stay and admission avoidance to reduce the bed usage on the acute hospital sites. As part of their Service Improvement Plan, BHRUT identified a 72 bed gap between expected need and actual bed stock. This scheme aimed to keep 20 patients at home, per week to reduce attendance / admissions / ambulance conveyances to an ED.

b) Benefits

The CTT/LAS team have patient experience at the forefront of the service and the focus continues to be keeping patients at home, wherever possible, to maintain independence and prevent further deterioration of ill health. Two patient case studies have been included at appendix 1, which demonstrate the benefit of the service to patients.

138


Achievements:

• The Team won the international poster competition at the National Patient Safety Congress awards on 7th July – against over 200 other entries.

• The Team were shortlisted for an HSJ award

• The Team were asked to present their work to the executives and Trust board of

LAS and to the commissioners in Essex with a view to replicate the model.

c) Risks

If the service was not in place then the risks would be: • Increase in ED admissions and ambulance conveyances in an already

significantly challenged system • Carers may end up in hospital which could have an impact on the person they are

caring for (See case study, appendix 2) • Once a patient is admitted they can deteriorate as a result of loss of

independence and are at risk of infection which can affect their recovery rate and future ability to self-care.

d) Interdependencies

The service is closely linked with LAS and the community CTT team. Appropriate calls are sent to the car from the LAS control centre as well as the car having a Geotracker which enables them to identify suitable patients. Patients who can be kept at home with support are passed on to the local CTT team.


The CTT and LAS service has been developed across BHR to reduce pressure on the acute trust and improve outcomes for patients by keeping them independent in their homes wherever possible

7. Procurement

Not applicable.

8. Activity Implications

The car will aim to keep at least 20 patients at home per week. 9. Workforce implications

Paramedic and CTT nurse seconded into post on a rotation basis. 10. Funding and affordability

The service costs £473k per annum and this is split between £281k for LAS and £192k for CTT. The breakdown of costs is attached at appendix 2.

We have created a full year forecast based on the activity from April 2015 – January 2016. This would give a forecast of 1380 calls attended and 982 patients kept at home. The service cost equates to a cost of £343 per call attended or £482 per patient kept at home. The cost of an ambulance conveyance is £236; the cost of an A&E attendance is £152 and the cost of a 0/1 day admission is approximately £910. Appendix 1 includes a comparison of service cost against savings and the net savings for the service are approximately £391k.

139


11. Options considered & preferred option The cost and net savings by CCG are set out below:

Service cost Net savings Barking & Dagenham £147,972 £122,168 Havering £245,058 £202,323 Redbridge £ 80,347 £ 66,336 TOTAL £473,377 £390,827

12. Management Arrangements

The service is provided by NELFT and LAS and the arrangement has been in place since October 2014. This would continue.


Scheme performance is monitored through the monthly SPR that is in place with NELFT and separate monitoring arrangements would be established with LAS.


No consultation or communication is required unless the service is ceased. If the decision was taken to not continue funding the service then NELFT and LAS would need to be informed as this would mean a change to the pathways that have been in place since October 2015. The impact would also need to be fed through the capacity modelling that BHRUT will be required to undertake in preparation for resilience planning.

15. Expected timelines and deliverables

Service is in place currently and the case is being made for continuation. 16. Other Organisational Involvement

No other organisational involvement. 17. Environmental considerations

Not applicable. 18. Equality/ Diversity

Not applicable. Notes on submission process:

1. The Head of Finance or Deputy Chief Finance Officer are available to assist and advise

on the preparation of business cases. 2. Approval will be sought from JMT, CCG Executive, and/or CCG Board as determined by

the business case approval process.

140


Appendix 1 – Service cost breakdown CTT Cost Summary Pay costs £162,064 Non pay costs £ 30,603 Total Cost £192,667 LAS Cost Summary Pay Costs £189,867 Vehicle Costs £ 29,826 Other Non-Pay Costs £ 61,016 Total Cost £280,709 2016/17 - LAS/CTT COSTS AND SAVINGS

Service costsCTT £192,667LAS £280,709

£473,376

Service activity Annual Forecast (based on April 2015 - Jan 2016 actualCalls attended 1380Admissions avoided 982

A B CSavings Unit price 100% 80% 60%Ambulance conveyance £236 £0 £0 £0A&E attendance £152 £149,480 £149,480 £149,480Admission (0/1 day) £910 £893,404 £714,723 £536,042

Total £1,042,884 £864,203 £685,522

Net savings £569,508 £390,827 £212,146

A - assumes an admission saving for 100% of people kept at home

B - assumes an admission saving for 80% of people kept at home

C - assumes an admission saving for 60% of people kept at home

The following have been developed as it may be incorrect to assume that everyone conveyed to hospital would be admitted

141


Appendix 2 - Patient Case Studies / Patient Survey Results Patient – 1 84 year old female – lives with her husband in warden controlled accommodation. Visited & assessed by CTT/LAS car K466 following a fall. Access to property gained as warden on site. On arrival of K466 patient found to be laying on the floor in the living room. PC – fall, rib pain. HPC – patient had a fall at home this morning, states she caught her foot on the edge of a rug which caused her to fall. Unable to get herself up off the floor. Husband was present but suffers with dementia & was unable to help her up. O/E – Patient alert & orientated. Complaining of right sided rib pain & skin tear laceration noted to right forearm. Denies any other pain. Assisted up into armchair. Some distress due to rib pain. Pain worse on deep inspiration & movement. No chest pain. No radiation of pain. No obvious shortness of breath although states she is having slight DIB. No obvious swelling / bruising to rib area. Tender on palpation but no obvious bony crepitus felt. Chest auscultation – chest clear & good air entry heard in all lung fields. Good colour. Not sweaty. No nausea or vomiting. PEARL. Denies hitting head. No LOC. Denies dizziness. No palps. Patient very anxious & upset at the thought of having to go to hospital & leaving her husband. Co-codamol 8/500mg x 2 given to the patient. SH – lives with her husband in warden controlled accommodation. Carers BD for her husband as he suffers with dementia. Patient independent with ADL’s. Mobilises using a walking stick. Able to cook etc. Has a wet room / walk in shower. Has a perching stool in kitchen. Feels that they usually manage when she is well. PMH – hypertension, high cholesterol, under active thyroid, OA. Observations – BP 148/78, P 82 reg, RR 20, O2 sats 97% on air, T 36.8, BM 5.6mmols, GCS 15/15. Imp – fall secondary to tripping up rug. Rib pain. ??# rib. Skin tear laceration. Plan – advised the patient to take regular analgesia. Spoke to patient’s GP who will carry out a home visit tomorrow to review the patient & prescribe more analgesia if required. Husband’s care package increased to QDS as the patient may require more support in the short term to care for her husband. Skin tear laceration cleaned & dressed using mepitel one & mepilex border – CTT to refer to DN for ongoing wound care. Rug removed with the patient’s permission. Patient happy with the plan. The patient’s husband suffered with dementia & becomes increasingly agitated & anxious if his wife is not about to help him. The patient was very reluctant to go to hospital as she was so worried about leaving her husband & stated he would never cope going into respite care if she were to go to hospital. By enabling the patient to be kept at home she was able to remain with her husband which made them both very happy & not only saved money from her not attending the ED & potentially being admitted but it also stopped her husband having to go into short term respite care which also would have been very costly.

142


Patient 2 76 year old female – Lives with her husband in a house, privately owned. Visited and assessed by CTT\LAS car K466 following a fall and head injury. On arrival met by husband, patient in the living room sitting up holding blood stained cloth to head. PC: Fall, Head injury. HPC: Patient had a fall approx 30 minutes ago in the garden. Patient was feeding the birds bent down and fell backwards, hit head on the fence and sustained 3cm full thickness laceration to back of head. Nil LOC, alert and orientated GCS 15/15. Patient got herself up from the floor and mobilised to the living area. Husband called 999. O/E: Observations recorded and stable (see chart), patient alert and orientated, denies LOC, GCS 15/15 PEARL size 3, patient able to recall events, c/o mild headache pain score 4/10. Denies any other pain, nil sob, nil chest pain, nil palpitations, nil dizziness, nil sweating, nil nausea or vomiting. Cap refill < 2 seconds, looks well, pink and perfused. Sustained 3 cm full thickness laceration to back of head, currently not taking any anti coagulants, nil other injuries. Chest Auscultation- chest clear & good air entry heard in all lung fields. 12 lead ECG recorded, normal sinus rhythm. Wound cleaned with normal saline, closed with tissue glue. 1 gram paracetamol given. Head injury advice given to patient, head injury leaflet given. Husband will be with patient for next 72 hours. CTT leaflet given to patient and explained. SH: Lives with her husband in a house independent of ADL’s. Wife is main carer for husband following a CVA 1 year ago. Patient states she is coping well and declined any further support from social services. Telecare leaflet given for patient to consider pendant alarm for her and her husband. PMH: palpitations and anxiety Medication: Sotalol Hydrochloride IMP: Fall, head injury Plan: Advised the patient to take regular analgesia. Husband will be with patient over the next 72 hours to observe. Head injury leaflet given and explained to patient. Advised to contact CTT if concerned or 999 in the case of an emergency. CTT to follow up tomorrow for neuro observations. This patient would have been conveyed to the ED if k466 wasn’t in operation as the paramedics are unable to use tissue glue, and would not have the expertise to safely leave a patient who has sustained a head injury at home. The CTT followed the patient up the next day with a visit from a nurse and the following day with a telephone call and she was subsequently discharged.

143


Appendix 3 - Patient Survey results This report was generated on 11/12/15, giving the results for 40 respondents. What year is this survey being undertaken? 2015 (40) 2016 (-) What month is this survey being undertaken? January (9) February (5) March (7) April (6) May (-) June (-) July (-) August (5) September (3) October (-) November (-) December (5) Borough patient resides in Barking & Dagenham (10) Redbridge (18) Havering (12) Are you happy for your comments to be used? Yes (40) No (-) How quick was the service in responding to you? Within 2 hours (39) Within 12 hours (1) Within 24 hours (-) 24-28 Hours (-) Over 48 Hours (-) How likely are you to recommend this service to friends and family if they needed similar care or treatment? Extremely likely (39) Likely (-) Neither likely nor unlikely (-) Unlikely (-) Extremely unlikely (-) Don't know (-) What do you think is the best thing about this service?

• Can’t fault he service it was quick and put my mind at rest

• Professional, quick response, excellent service

• Everything- Kind ,Efficient

• I think it is absolutely terrific I think it is brilliant that Stan and I are both in our 80’s

and you are there for us

• The service is essential for keeping the elderly in their own home

• It is brilliant

• That they come quick and look for everything

144


• Could not wish for a better service, both the nurses and paramedics are excellent.

• Both extremely efficient and both had a “bedside manor”

What do you think is the best thing about this service?

• Listen to the patient, concerned for the patient and made mum feel at ease

• That they look after people in their own home and it isn’t easy. Excellent service

• The fact that my father was able to stay at home and be checked over instead of

going into hospital, which he was desperate not to do

• Thoroughness

• Quick service and preventing her from going to hospital. Being assessed thoroughly

• It seems to be a good thing if it helps the patient to stay at home and to get care

• Support for older patients

• Saves the patient from going into hospital, if not need be.

• Very helpful in assessing the needs and treatment of the patient very thorough

• Doing everything at home rather than taking us to hospital

• The service could not have been better

• Being treated at home by such lovely girls

• I think this service is brill

• The amazing capability and patience of the paramedics

• The service provided by lea and Vikki was excellent. Keeping us informed as to the

steps to be taken regarding my wife’s problem. Very professional

• Quick professional care that can prevent hospital visit

• Quick, efficient, very friendly here within 10mins amazing

• As a busy professional it was nice for CTT/LAS to take over, saved time and helped

individual that needed assistance.

• Spend a long time investigating and explained everything. Marvellous service

• Rapid response, friendly staff Able to speak with GP and leave me at home.

• Efficient, friendly, spoke to the resident

• It was absolutely brilliant; they work in a team and explain everything

• Speed of the service, friendliness, excellent team work

• The speed and efficiency

• Reassurance that patient care comes first treating the patient with respect

• Home attendance

• Came to visit me at home and looked after me rather than going to hospital

• Friendly, caring, understands needs

• The speed efficiency and pleasantness of the staff

How do you think we can make it better?

• Don’t think it could be any better

• Wish all services were as good as this service

145


• I don’t think you could make the service any better

• I do not think it can

• The service we have received has been fantastic and could not be any better from my

point of view

• Couldn’t wish for it to be better

• More protection from

• Could not be made better

• More cars, paramedics, nurses

• By making more people aware of the service

How do you think we can make it better?

• Very satisfactory

• Not sure it could be better very caring people

• First time used, looks like a good service

• Nothing else

• Increase in this service

• It is the first time we have used this service. but I must say the two ladies that

attended were lovely and done a brilliant job and I could not think of any improvement

that would be needed

• Make people more aware of the service

• Marvellous service, couldn’t be better

• It could not be better

• No need to make it better

• Not at all, it is very good

• It seem, from my point of view that no improvement is necessary

• I cannot think of any improvement to the team’s service

• Nothing, they were brilliant

• From what I saw today, it was very quick and reliable

• Fantastic anyway

• No, the service received was marvellous

• They can’t make it any better

• All nurses being nurse prescribers

• Our experience of the service has been very good

• Could not be better

• I can’t think of anything that would better the service

What do you think would happen if you did not get support from this service?

• Had another fall and kill myself

• Without the help of the service would not have been able to cope

• Paralysed in bed and ended up in A+E

146


• I would still be sitting on the floor with a numb bum

• It would involve myself and my 88 year old father, who has very limited mobility,

sitting in A&E for hours with him getting distressed.

• I would have had to go to hospital

• I would be ready to die

• I believe I would be in serious pain

• Patient would have been taken to hospital

• It would be awful

• My father would have spent hours in A+E

• Patient would have got worse and left on floor for longer

• Would have felt a lot worse

• Hospitalization, lack of support given when coming out

What do you think would happen if you did not get support from this service?

• My father would have been sent to hospital, as he had had a fall

• Would have been sitting waiting for the ambulance service to attend

• Would have been taken to hospital

• The procedure would have taken much longer

• A long wait in A+E

• Would have been up the hospital for hours waiting

• The patient may well have deteriorated to a life threatening state

• My wife would still be in server pain and worry

• An all night visit to A+E for cases that do not require it but need early medical

attention.

• My 89 year old client would have spent 5-6 hours in A+E waiting to be seen

• Would have needed to stay for long period with client on the floor, which can cause

him/her more

• stress.

• dial 999 for hospital

• Would have gone to the doctor

• Probably taken to hospital by an ambulance

• Pressure on other services

• I would not survive

• Ambulance would have been called and would have been taken to A+E

• Would have been on the floor a lot longer than ended up in hospital

• I feel the patient would have a further fall and possibly develop an infection

• I would have had to wait until help arrived to lift me off the floor

• Leg would have got worse as she couldn’t get to the hospital or doctors

• Back to hospital

• Suspect that I would have had to go to A+E

147


On a scale of 1-10, how satisfied were you with the service? With 1 being not satisfied and 10 being extremely satisfied. 1 (-) 2 (-) 3 (-) 4 (-) 5 (-) 6 (-) 7 (1) 8 (1) 9 (1) 10 (36) Do you have any other comments you would like to make?

• A big thank you

• I can’t praise you enough

• Yes, Thank you girls for coming so quickly otherwise I would have been sat there for

ages,

• I feel this service is essential to the elderly community, it retains their dignity and their

sense of

• wellbeing is preserved

• This service was amazing

• We are impressed and feel there and feel there is somebody out there if needed

• Very good

• Thank you

• More money to support this service in the future and expand it

• More people should be made aware of this service, to take the pressure off the

ambulance service

• These girls made my day, I was in such terrible pain, they helped me so much

• Just keep on going- you are doing wonderfully

• I cannot think of any better service we have received

• This service should be in place. Great idea, great service and would save lots of

elderly patients from

• enduring A+E for hours

• Explained themselves to client, did appropriate checks

• very helpful and caring

• The service is excellent even 9am and patient states we have arranged everything

• Lovely, lovely people

• I am very pleased that I have found help

• No, good service

• Friendly and reassuring paramedics

• Wonderful service

• Feel comfortable and relaxed that I have been treated in my own home

148

To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body

From: Khalil Ali, Lay Member (PPI)

Date: 24 March 2016 Subject: Patient Experience report

Executive summary Patient and public engagement is critical to informing the work of the CCG as a commissioner of health services on behalf of Redbridge residents.

There are a wide range of sources from which the CCG can draw valuable and insightful feedback from the public including, but not limited to; its members who as GPs engage with the public on a daily basis, directly from patients themselves via our established patient engagement forum and from a vast range of stakeholders with whom we engage, for example, voluntary sector organisations and local authority colleagues.

This report reflects the on-going engagement activities that have taken place with the public since our last governing body meeting as well as other sources of feedback.

The report includes a summary of:

• The last patient engagement forum (PEF) meetings and updates re the PEF • Work on strengthening relationships with the voluntary and community sector • Progress with patient participation groups (PPGs) • The stroke rehabilitation consultation • The CCG’s engagement strategy • Progress on Equality and Diversity Standard 2 (EDS2) work


• Note the range of feedback from the PEF (and other stakeholders), and that there is a process in place to ensure that appropriate responses are communicated to them

1.0 Purpose of the report 1.1 To provide a summary of the range of feedback that has come through to the CCG from

patients and stakeholders. 2.0 Redbridge CCG Patient Engagement Forum (PEF) 2.1 Our meeting on 19 January focussed on the CCG’s commissioning intentions and a

helpful discussion followed. The PEF also considered the wider work on primary care improvement, being led by the CCG’s Director of Primary Care Transformation, Sarah

149

2

See. The meeting also received a presentation about the borough’s progress in reducing the incidence of TB in Redbridge.

2.2 We also had a meeting on 15 March, where we discussed the primary care transformation strategy and received a regular report from Healthwatch Redbridge which included their support for the ongoing stroke consultation, a survey of Redbridge residents' suggestions for their work programme, ongoing interviews with patients about local urgent and emergency care services, a follow up on GP practices' PPGs, and a local celebration of the Dignity Action Day.

Amongst the issues raised by the four PPG localities, and considered by the CCG and PEF, were the anticipated implementation of the Redbridge Diabetes Strategy, the long waits for leg ulcer clinics, referrals of Redbridge patients by the BHRUT Urgent Care Centres out of the borough (for example to Dagenham), an update on the new Kenwood Gardens Practice and Spearpoint Practice, an issue with Barts Health about patient transport for relatives/carers of people with disabilities, the current uptake of BCG vaccinations, confirmation about phlebotomy services at the Wanstead Hospital site, the problems associated with the use of syringes to collect urine samples, the use of e-referrals to hospital, and online access for GP appointments.

2.3 Redbridge Youth Council (RYC) provides regular reports to our PEF. Young people are

actively involved in the children and young people mental health transformation work. A focus group was held with RYC on 1 February. The session was led by Vicky Mason, Joint Commissioner for Children’s Services. The session generated helpful feedback from young people and they are considering forming a new group for members who have special interest in local health services and NHS in general.

2.4 As requested by the PEF last year a written report is provided at each meeting which

outlines how issues raised by the PEF are addressed, summarising each issue and the action taken. This process is working well.

2.5 A number of PEF members have continued to work with the CCG on developing

proposals for improvement to phlebotomy services in Redbridge.

3.0 Community and voluntary sector 3.1 Liaison with the community sector continues with further visits planned in the coming

months. This work is supported by Redbridge Council for Voluntary Service (CVS), in part through the CCG’s funded community liaison post-holder, Swati Vyas.

3.2 A number of us had a very interesting visit to St Francis Hospice in Havering-atte-

Bower. We met with Cathy Mansfield, Contracts Commissioning Manager and the ‘Hospice at home’ team. We also viewed all facilities. We provided relevant information about our CCG work, including the PEF, out-of-hours clinics, PPGs and other primary care projects. The St Francis Hospice Manager attended our PPE event on 3 February and invited us to re-visit the hospice in future.

3.3 We visited Redbridge Jewish Community Care on 17 February. A guided tour of two sites

in Redbridge demonstrated an excellent provision of health and social care to their older clients. One site also provides facilities for family use.

4.0 Patient Participation Groups (PPGs) 4.1 The CCG, through the engagement / borough teams will continue to link with GP

practices in order to identify which practices need more support with their PPG meetings.

150

3

4.2 An updated list of practices in Redbridge shows that only one practice does not have a

PPG. The PPE Advisor met with the practice manager from this practice on 1 February. Information and guidance was provided in order to support the establishment of a successful new PPG. Our PPE Advisor will attend their first meeting.

4.3 We will continue with the visits and the liaison with practices in order to ensure that both

staff and patients have all the support and guidance they need in order to successfully run their PPGs.

5.0 Stroke rehabilitation consultation 5.1 The consultation is going well, with over 200 responses across BHR so far and still a

month to go. The feedback on our approach to developing and managing this consultation has been positive, which is welcome.

5.2 In Redbridge we’ve engaged with a number of organisations and groups in addition to

our PEF. These have included the local stroke club, the Pensioner’s Forum and the Older Carer’s Group. We’ve also discussed the proposals and sought the views of the Health Scrutiny Committee and the Health and Wellbeing Board. A further reminder to stakeholders encouraging their participation and response will be issued in the next week or so.

6.0 Engagement strategy development 6.1 Patient and Public Involvement (PPI) Solutions, who are leading this work for the CCG

have had several meetings with a range of stakeholders, both individuals and groups over the past month.

6.2 On 3 February the BHR CCGs held a well-attended engagement event with more than

fifty attendees. All three PEFs/PERF sent members, a GP lead; CCG staff, Healthwatches, voluntary sector organisations and other stakeholders were in attendance. The workshop was an excellent opportunity to share experience of engagement with the three CCGs, hear a summary of what stakeholders have said to PPI solutions and look at how we develop our strategy and all work together more positively together in future. Over 80% of participants provided positive feedback about the event.

6.3 Even more positive were the numerous pledges from individuals and groups as to how

they could help us to better engage from here-on. All of the information was captured in a report and a set of the slides circulated to all who attended.

6.4 Our PEF Chair and Vice Chair, along with their equivalents in our fellow BHR CCGs sent

a helpful letter to the Director of Corporate Services outlining feedback and suggestions for the strategy document. The director thanked those involved for the input and responded to the suggestions, most of which are being picked up in the strategy drafting.

6.5 A first draft of the strategy will be available by the end of the month and shared with

stakeholders for their views. The strategy, once refined, will come to the next governing body meeting for agreement.

7.0 Resources 7.1 There are no resource issues relevant to this report.

151

4

8.0 Equalities 8.1 The work on engagement in our borough, through the CCG’s patient engagement forum structure, and through collaboration with patients; the voluntary sector and other

key stakeholders, should contribute to reducing inequalities in access to healthcare and support the CCG in meeting its equality objectives.

8.2 We have recently attended two equalities workshops organised by the London

Leadership Academy. On 26 January the Pan London Equality and Diversity meeting took place. Our work on developing a Workforce Racial Equality Standard (WRES) has begun, with an initial report on workforce race data and outcomes. This work will be reported through to the Remuneration and Workforce Committee.

8.3 The CCG is required to monitor and oversee the implementation of the EDS2 and WRES

of our local health service providers. We are assured of progress through information provided through the NELFT organised EDS2 Working group.

9.0 Risks 9.1 There are no identified risks in relation to this report. 10.0 Managing conflicts of interest 10.1 There are no conflicts of interest relevant to this report. Author: Boba Rangelov, Patient and Public Engagement Advisor, BHR CCGs Date: February 2016

152

To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body From: Tom Travers, Chief Finance Officer Date: 24 March 2016 Subject: Finance and Activity Report Month 10

Executive Summary As reported previously, the CCG has agreed a revised risk assessed forecast outturn of breakeven with NHSE. The revision to the forecast was based on a risk assessed view of the underlying data driving the month 6 year to date and forecast positions. As at the end of January (month 10) the position has remained stable and the CCG has maintained a breakeven position. At month 10 this represents year to date slippage of £2,752k against the original year to date plan and £3,302k slippage against the original planned fully year 1% surplus.

Further mitigating actions will be required and implemented over the rest of the financial year. Trends of activity are being closely monitored to inform the on-going management of this risk assessed position, and the recurrent impact upon the 2016/17 position.

In previous months a risk range including a downside scenario has been presented to the Governing Body. Risks identified have spread across a number of areas including acute activity, prescribing and continuing care. The main driver behind the reported position is Barts Health, where significant over performance is reported. The latest risk assessed forecast overspend is £4,543k or an 8% contract pressure.

The resource limit for 2015/16 is now £365,838k. The Month 10 budgets have been increased to reflect four allocation changes this month totalling £3,379k.

Reported figures are based on the Month 9 monitoring data from providers and adjusted for outstanding challenges, contract penalties and fixed price contract agreements.

Barts Health - The Month 9 data before adjustments indicates a high level of year-end over performance. The Barts Health contract continues to present the largest financial risk to the CCG. The latest data received from the Trust highlights over performance reported across a range of points of delivery, including non-elective, elective care, critical care, maternity pathway, outpatient procedures, high cost drugs and treatments and unidentified QIPP schemes. A number of challenges have been made and the reported position includes assumptions that a number of challenges are successful. Analysis of the data highlights that there is a potential further downside risk in excess of the reported position, if the mitigating actions, data challenges and contract levers are not successfully applied. The CSU have carried out further analysis of the Barts position and risk rated the issues identified, to further inform the reported outturn position.

BHRUT – A fixed price contract has been agreed with BHRUT for 2015/16, including non-recurrent funding to support the delivery of the QIPP schemes and the achievement of key performance indicators, ensuring system sustainability in the coming years. The fixed price also includes funding to ensure operational resilience during winter and meet the targets set to address the RTT backlog at the Trust. The 2015/16 contract is being managed under full PbR rules, as in previous months there were a number of issues with the Month 9 data and the finance and activity plans. These are being flagged for correction with the Trust through the TSG and SPR meetings.

As highlighted in previous reports the CCG faces a number of risks that may impact the financial position. These include: further acute activity growth above planned levels, continuing care growth and prescribing growth. A number of mitigations are in place attempting to off-set these risks and

153

include robust contract management, PMO, QIPP process and on-going review of investments.

Month ten QIPP delivery, based on Month nine SUS data, has delivered £1128K actual savings against a target of £1053K. This represents a year to date saving of £6.61M against a plan of £7.59M.


1. Agree the financial position noting the action taken to achieve it.

1 Purpose of Report

The purpose of this report is to brief the Governing Body on the overall financial position as at the end of January 2016 (Month 10).

2 Background/Introduction

As at the end of Month 10 the CCG achieved breakeven against a year to date planned surplus of £2,752k. It is forecast the CCG will achieve a year end outturn of breakeven.

3 Report Content Resource limit The CCG has a resource limit of £365,838k, there has been four changes to the resource limit at Month 10 relating to 2015/16 Charge Exempt Overseas Visitors (CEOV) and non-rechargeable services allocation adjustment, delegated CCGs benefit, Healthy London Partnership and Vanguards: UEC- BHR.

Redbridge CCGOpening Resources 2015-16 £'000Recurrent Programme Baseline Allocation 294,076Growth Uplift 20,071BCF Allocation 5,115ETO Additional Funding 764Primary Care Co-Commissioning 30,373GP IT 956London Transformation Fund (471)Waiting list validation and improving operational processes 10Eating Disorders & Planning 2015-16 146Tier 3 Neurology Commissioning Responsibility Transfer - NHS England 262CCG cost of Pharmacy Hub -11Vanguard: UEC - Barking & Dagenham, Havering and Redbridge 150Liaison Psychiatry - Mental Health 62UEC Vanguard sites - Liaison Psychiatry 58UEC Network allocation 40Latent TB Funding 88Vanguards: UEC - Barking and Dagenham, Havering and Redbridge 150Liaison Psychiatry 63UEC Vanguard sites 58Mental Health CAMHs - Transformational Allocation 366Vanguards: UEC - Barking and Dagenham, Havering and Redbridge 1,3102015-16 CEOV and non-rechargeable services allocation adjustment -179Delegated CCG benefit 215Healthy London Partnership 2,033Return of 2015/15 Surplus 3,732Programme Resources 359,437Running Costs Allocation 6,401Total Resources 2015-16 365,838

154

Cash Draw Down The CCG is required to draw down cash from the DoH on a monthly basis to pay invoices and staff salaries. To date £236,595k of a full year Predicted Year End Value of £300,036k has been drawn down. The CCG is predicting to utilise all cash made available by year end. The closing cash position as at 31st January 2016 was £2,507k. The large closing cash balance is due to forecasted payments to the local authority in respect of Better Care Fund which could not be made due to the late raising of invoices by the Local Authority. A summary of Predicted Year End Value receipts and payments for the year is provided for information at Appendix 5. The cash to income and expenditure reconciliation at Appendix 4 reconciles the actual cash received and paid out by the organisation to the total charge within the income and expenditure account. Throughout January the CCG continued to operate within its expected cash envelope and was not overdrawn on any of its bank accounts at any time. The CCG is working closely with the CSU to ensure accurate and robust cash predicted year end values are in place, and that there continues to be appropriate cash and treasury safeguards.

Month 10 Reported Position The CCG revenue financial position is summarised in the table below. A more detailed summary can be viewed in Appendix 1. As at the end of January (Month 10) the CCG achieved a break even position against a year to date planned surplus of £2,752k. The year-end forecast outturn is to break even.

Commissioner Function Annual YTD YTD YTD Predicted Year PYEV

Allocation Budget Actual Variance End Value (PYEV) Variance

£000's £000's £000's £000's £000's £000's

Acute

Acute Clinical SLA 164,409 137,007 144,887 (7,880) 171,929 (7,520)Acute Other 27,310 22,078 21,948 130 27,271 39

Acute sub-total 191,719 159,085 166,835 (7,750) 199,200 (7,481)

Services Provided in a Primary Care Setting 71,839 60,392 61,049 (657) 72,385 (546)Mental Health & LD 28,419 23,683 23,300 383 28,022 398Community Healthcare 22,461 18,536 18,493 43 22,359 102Continuing Care 18,911 15,533 17,114 (1,581) 20,592 (1,681)Programme Spend 22,786 17,216 10,406 6,810 16,879 5,907

Healthcare Provision sub-total 164,416 135,360 130,362 4,998 160,237 4,179

CCG Running Costs 6,401 5,334 5,334 0 6,401 0

Running Costs 6,401 5,334 5,334 0 6,401 0

Total Expenditure 362,536 299,779 302,531 (2,752) 365,838 (3,302)

Resource Limit 365,838 302,531 302,531 0 365,838 0

Surplus/Deficit 3,302 2,752 0 (2,752) 0 (3,302)

Redbridge CCG Financial Position 2015/16

Month 10 - 31st Jan 2016

155

Acute contracts Barts Healthcare

The contract for 2015/16 with Barts Health has been agreed, including challenging targets for QIPP delivery and productivity. A full PbR contract has been agreed ensuring full adherence to the NHS Standard contract, the claims and challenges processes, assessment of the achievement of productivity targets and CQUIN standards, and the levying of performance penalties where the Trust fails to meet national KPIs.

Month 9 data received from the Trust and lead commissioner, before adjustments indicates a high level of year-end over performance for Redbridge CCG. In addition to the increase in non-elective activity, there are also adverse movements in electives, critical care, maternity pathway, outpatient procedures, high cost drugs and treatments and unidentified QIPP schemes.

Further analysis of the Barts data has been carried out by the CSU. The CSU are continuing to risk rate the issues identified to further inform the reported outturn position.

The lead commissioner made adjustments to the forecast position for the items listed below:

- Updated calculations for readmissions, productivity metrics and non-elective threshold. - A prudent risk adjusted view of claims expected to year end based on the Trust’s responses to

date. - Penalties at Month 8 have been calculated. However, the lead commissioner has assumed that

virtually all metrics will be reinvested with the Trust. - Misattributed patient transport and pathology costs were redistributed to CCGs on the basis of

14/15 outturn for these items. - Critical care costs that were automatically extrapolated in the forecast position have been

adjusted to address the extrapolation for unusually high cost patients. A view of uncharged critical care work in progress has also been included in the forecast.

- A view of CQUIN achievement at 80% based on Q2 information (95% in 14/15).

This risk assessment has resulted in a predicted year-end over performance of £4,543k for Redbridge. Discussions have been on-going between the lead commissioners in WEL and Barts Health in relation to a fixed year end deal. The reported figures are in line with the potential year end agreement. In informing Redbridge position, BHR has instructed the lead commissioner that all contractual fines and penalties should be applied and a risk assessed view of CQUIN applied. Analysis of the numbers provided by Barts Health indicate that there are further potential downside risks in excess of the reported position, if the mitigating actions, data challenges and contract levers are not successfully applied. If a yearend position is agreed at the reported level then the downside risk is removed. BHRUT

A fixed price contract has been agreed with BHRUT for 2015/16, including non-recurrent funding to support the delivery of QIPP schemes and the achievement of key performance indicators, ensuring system sustainability in the coming years. The fixed price also includes funding to ensure operational resilience during winter and meet the targets set to address the RTT backlog at the Trust.

156

The planned activity underpinning the 2015/16 fixed price has been rigorously tested and approved independently by NHS England.

As in 2014/15, the 2015/16 contract is being managed under full PbR rules to enable a sustainable and robust activity and Finance baseline going forward. This includes full adherence to the NHS Standard Contract and the claims and challenges processes, assessment of the achievement of productivity targets and CQUIN standards, and the levying of performance penalties where the Trust fails to meet national KPIs.

As in Month 8 data submitted by the Trust included a finance and activity plan that has not been agreed by the CCGs and does not reflect previous discussions with the Trust. Issues identified last month remain in the Month 9 data, including the treatment of non-recurrent RTT, operational resilience and quality premium funding, the majority of which has been assigned to Havering CCG. Issues around incorrect POD mapping, counting and coding changes (including maternity), misattributed specialist commissioning activity and the contract split by CCG, persists. These have all been flagged to the Trust through the TSG and SPR.

To aid the monthly analysis, the CCGs’ view of the plan was overlaid against the Trust’s submission.

A number of adjustments have been made to the Trusts position to comply with PbR rules and to extrapolate the year to date position to year end. They include;

- Forecasting CQUIN achievement based on 2014/15 performance - Calculating the impact of penalties based upon performance data provided by the trust. Penalties

include A&E and cancer waits, ambulance handovers, 52 week waits, and 18 week RTT. Penalties are expected to exceed the 2.5% contractual threshold.

- Claims and challenges raised by the CCG on the activity received from the trust. These include the on-going coding challenge of non-elective and A&E unit prices. The Trust has failed to adequately respond to outstanding claims to date resulting in a high level of open claims. The expectation is that this will be resolved through the quarterly reconciliation process.

- PbR technical adjustments including non-elective threshold adjustments. Work is underway to jointly agree the 2015/16 non-elective threshold baseline with the Trust.

The significant increase in ambulatory care activity has continued and there remains evidence that ambulatory care is being double counted as non-elective admissions. This is being challenged through the claims process. In year financial risk remains around additional funding requirements for RTT/Cancer targets. The significant level of underlying over performance is under further investigation by the Informatics and Contract teams. Non-elective and A&E activity remain key drivers of over performance with the trend of lower than expected UCC attendances continuing. The plan for day cases and elective activity was increased non-recurrently to allow for RTT backlog clearance. These points of delivery remain significantly under plan to date.

Associates and other acute providers

The contract with Homerton still continues to be an issue and the over spend is due to IVF Treatments, Maternity, T&O and Gynaecology. Princess Alexandra still has data issues and the contract has not been agreed. The contracts team have met the Trust to discuss the activity and the contract data. We will be meeting again to resolve before next month. The Royal Free has moved in month due to Urology, Gastroenterology & Drugs expenditure. Data and invoices received from Care UK, Spire and BMI highlight YTD over performance. At Month 10 spending continues to increase in the same specialties relating to T&O, Audiology, Ophthalmology,

157

Endoscopy, MRI, Other Diagnostics, and Gynaecology. There does not appear to be a corresponding reduction in the NHS Acute Trust’s spending patterns. This has caused some adverse movements and a wider piece of work to understand activity trends affecting several providers in the health economy is ongoing.

Healthcare Provision

A summary analysis of the Month 10 position is provided as detailed in the table below:

REDBRIDGE CCG2015/16 REPORTING - MONTH 10 - JANUARY 2016

Annual Budget

Month 10 Budget

Month 10 Position

Month 10 Variance

Forecast Outturn

15/16

Variance

ACUTE TRUSTSBARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST 89,268 74,390 74,390 0 89,268 0BARTS HEALTH NHS TRUST 55,957 46,631 51,620 (4,989) 60,500 (4,543)BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 204 170 192 (22) 230 (26)CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST 310 258 292 (33) 331 (21)GREAT ORMOND STREET HOSPITAL FOR CHILDREN NHS TRUST 534 445 591 (146) 681 (148)GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 1,928 1,606 2,341 (734) 2,693 (765)HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST 2,762 2,301 3,176 (874) 3,764 (1,002)IMPERIAL 527 439 521 (81) 597 (69)KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST 316 263 436 (173) 501 (185)MID ESSEX HOSPITAL SERVICES NHS TRUST 1,171 976 945 31 1,134 37MOORFIELDS EYE HOSPITAL NHS FOUNDATION TRUST 3,436 2,863 3,141 (278) 3,768 (332)NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST 601 501 567 (66) 663 (62)NORTH WEST LONDON HOSPITALS NHS TRUST 385 321 308 13 369 16ROYAL BROMPTON AND HAREFIELD NHS FOUNDATION TRUST 362 302 250 52 297 65ROYAL FREE HAMPSTEAD NHS TRUST 705 588 725 (138) 824 (119)ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST 1,073 894 996 (102) 1,146 (73)ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 179 149 137 12 156 22THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST 880 734 908 (175) 1,016 (135)THE ROYAL MARSDEN NHS FOUNDATION TRUST 123 103 88 14 106 17THE WHITTINGTON HOSPITAL NHS TRUST 168 140 152 (12) 183 (14)UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST 3,520 2,933 3,088 (155) 3,704 (184)

TOTAL ACUTE TRUSTS 164,409 137,007 144,864 (7,856) 171,929 (7,520)

TOTAL OTHER ACUTE 24,404 20,337 21,692 (1,356) 26,127 (1,723)RESERVES 1,796 1,497 35 1,462 35 1,762WINTER RESILIENCE 1,110 245 245 0 1,110 0

TOTAL ACUTE 191,719 159,085 166,835 (7,750) 199,200 (7,481)

Healthcare Provision Annual Budget £000s

YTD Budget £000s

YTD Actual £000s

YTD Variance £000s

Predicted Year End

Value £000s

Predicted Year End Value

Variance £000sServices Provided in a Primary Care Setting 71,839 60,392 61,049 (657) 72,385 (546)Mental Health &LD 28,419 23,683 23,300 383 28,022 398Programme Spend 22,786 17,216 10,406 6,810 16,879 5,907Community Healthcare 22,461 18,536 18,493 43 22,359 102Continuing Care 18,911 15,533 17,114 (1,581) 20,592 (1,681)Healthcare Provision Total 164,416 135,360 130,362 4,998 160,237 4,179



158

Services Delivered in a Primary Care Setting

The total predicted year end value is an over spend of £546k. The main drivers behind this are: Prescribing The first six months of 2015/16 prescribing data have been received. Forecasts have been issued and show a predicted year-end over-performance of £563k. The total overall unfavourable variance reported also includes the 2014/15 adverse cash charge received for the end of the financial year which totalled £173k and non-recurrent income receipts of £136k. Given the historic volatility of the prescribing budget close monitoring will continue during the last few months of this financial year. Primary Care Co-Commissioning Following full delegation, January is the tenth month of reporting co-commissioning expenditure. NHS England have posted actuals and advised accruals against this area for Month 10. Currently an in month cost pressure is being shown with breakeven at year-end. This is mainly due to NHSE QIPP savings taken during the budget setting not yet being fully met by CCG implemented QIPP plans.

Continuing Care Continuing Care was an area of significant pressure in 2014/15 and information received to date suggests this trend has continued in 2015/16. This area is shown as a projected year-end overspend of £1,403k, which is based on 2014/15 outturn plus 5% growth. The forecast also includes additional costs for 1 to 1 Nursing Care of £299k previously shown against the Mental Health budget. Further analysis of the CAPS system and invoices received is ongoing to inform the financial position. The CHC Assessment and Support team is forecasting a year-end overspend of £439k. The total forecast outturn for CHC is an over spend of £1,681k.

Community Services This area shows a predicted year-end underspend of £102k. The main element of this is the growth reserve that will be used to fund contractual pressures in the system. Mental Health & Learning Disabilities This area shows a predicted year-end underspend of £398k. This is mainly made up of underspends against the ELFT cost and volume contract of £152k and £357k against the Care UK contract which is mainly due the 1 to 1 nursing costs now being shown against the Continuing Heath Care area. A predicted underspend of £148k is shown against the NCA budget Programme Spend (Other – Non Acute Services) Better Care Fund All of the Better Care Fund spends and budgets have been reconciled and coded within the accounts according to NHSE instruction. The budgets and spend still sit within the relevant categories (Community, Mental Health and Programme) for monthly reporting purposes. CCG Running Costs

Directorate

2015/16 Annual Allocation

£000's

M10 YTD Budget £000's Pay £000's

Non Pay £000's

M10 Total Costs £000's

M10 YTD Variance

£000's

M10 Annual Forecast

£000's

M10 Annual Variance

£000'sRunning costsCSU SLA 2,958 2,465 0 2,621 2,621 (156) 3,082 (124)Corporate Costs & Services 959 799 236 259 495 304 618 341Operations Management 857 714 753 8 761 (47) 927 (70)CEO / Board Office 473 394 350 8 358 36 443 30Chair and Non Execs 442 368 377 1 378 (10) 453 (11)Finance 168 140 135 0 135 5 161 7Non pay Inc Audit Fees 156 130 0 266 266 (136) 244 (88)Innovation Fund 141 118 85 0 85 33 126 15Strategy & Development 117 98 80 1 81 17 100 17Clinical Support 75 63 39 0 39 24 37 38Nursing Directorate 55 45 115 0 115 (70) 210 (155)Total Running Costs 6,401 5,334 2,170 3,164 5,334 0 6,401 0Corporate Costs 6,576 5,815 1,662 4,114 5,776 39 6,558 18Grand total Running & Corporate Costs 12,977 11,149 3,832 7,278 11,110 39 12,959 18

Redbridge CCG Running & Corporate Costs as at 31st January 2016

159

All running costs are showing a forecast overall breakeven positon at Month 10. Corporate costs are showing a forecast underspend of £18k. The main drivers behind this relates to a forecast over spend of £278k in CHC Assessment & Support, which is offset by forecast underspends in Recharges from NHS Property Services Ltd £177k, Medicines Management £28k, Safeguarding £6k, Primary Care IT £75k and Non Recurrent Programme Projects £10k.

Statement of financial position

The statement of financial position (SoFP) summarises the CCG’s assets, liabilities and tax payers’ equity at a specific point in time. The CCG’s statement of financial position as at 31st January 2016 can be seen at Appendix 2. The cash and cash equivalent balance within the statement of financial position as at 31st January 2016 was £1,190k. This was £1,317k less than the cash position shown within the actual cash and Predicted Year End Value cash position (Appendix 5) due to un-cleared payables orders currently outstanding and the release of BACS run on 28th January which cleared the bank account on 2nd February. The clearance of these funds was after receipt of the main cash drawdown in January. The statement of financial position shows the general ledger balance based upon un-cleared cash items, whereas the actual cash and the predicted year end value cash position only shows cleared items. Trade and other payables totalling £42,981k include £31,578k worth of outstanding invoices to NHS and Non NHS Organisations, as well as £11,403k worth of net manual adjustments most noticeably £5,784k in terms of Prescribing which contribute to the estimated financial position as at 31st January 2016. Predicted Year End Value of closing balances are based upon full utilisation of the CCG’s cash limit in the financial year.

Invoice payment performance measure – Better Payment Practice Code (BPPC)

The BPPC requires the CCG to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later. A summary of the year to date results can be found at Appendix 3 BPPC figures for the CCG as at the end of January 2016 show that 87.8% was achieved on the number of invoices paid and 94.2% was achieved on the value of invoices against the target of 95% on both indicators.

The CCG is working closely with the CSU to ensure all valid invoices are being cleared in line with this target.

QIPP The CCG governing body has agreed a QIPP plan of £11.1M for 15/16. Month ten QIPP delivery, based on Month nine SUS data, has delivered £1128K actual savings against a target of £1053K, this includes £276K of benefit from the BHRUT fixed value SLA, which is not attributed to any schemes. This represents a year to date saving of £6.61M against a plan of £7.59M (inclusive of the BHRUT fixed SLA). Four schemes have been escalated to the Finance and Delivery committee as a result of underperformance (Cardiac Diagnostics, Calprotectin, Pathology and Unplanned Care). Escalation reports have been developed for each scheme, which includes a detailed recovery plan.

160

QIPP Scheme NameTarget saving/

Planned Activity 15/16

Actual Saving/Activity YTD

Target Saving/Activity YTD

Simon JamesDr Mehul MathukiaLouise Mitchell

Gulsen GungorDr Chidi OkorieLouise Mitchell

Gulsen GungorDr Shabana AliLouise Mitchell

Carol HoggDr M. TahirLouise Mitchell

Simon JamesDr M. TahirLouise Mitchell

Jeremy KiddDr Jyoti SoodLouise Mitchell

Yvonne BrowneDr M TahirLouise Mitchell

Sanjay Patel/Vicki KongDr Chidi OkorieBelinda Krishek

Jeremy Kidd

Gulsen GungorDr Shabana AliLouise Mitchell

Tracy WelshN/ALouise Mitchell

Finance (£000) 145.5 145.5 145.5

1,000.0Finance (£000) 465.4

Finance (£000) 41 25.5 0

0

0.0

2,061.6

159429

18.0

388.3

2,544

90.3

4,318

51.8

3,872

42.8

42,975

0.0

Other QIPP

Fixed BHRUT benefit

3308.0

Project Leads

Finance (£000) 128.6 113.3

1,972Activity -1,438

Cardiac DiagnosticsProject Lead:

CD Lead:Exec Lead:

Activity 5,717 4,922

CalprotectinProject Lead:

CD Lead:Exec Lead:

Finance (£000) 74.7 5.3

Community DiagnosticsProject Lead:

CD Lead:Exec Lead:

Activity 7,985 5,898

Finance (£000) 42.6 -85.8

Finance (£000) 1,778.9 1,145.2

3,964Activity 4,908

MSK TriageProject Lead:

CD Lead:Exec Lead:

Activity 0.0 37,269

Unplanned CareProject Lead:

CD Lead:Exec Lead:

Integrated Care3,631

1,324.9

Finance (£000) 0.0 -346.1

Finance (£000) 24.3 15.7

Anticoagulation

Meadow CourtProject Lead:

CD Lead:Exec Lead:

Primary Care

Project Lead:CD Lead:

Exec Lead:

Medicines ManagementProject Lead:

CD Lead:Exec Lead:

Activity 8,035

Finance (£000) -320.5

15.7 0

07,725Activity

Identified QIPP 4540.6

TOTAL - ALL SCHEMES Finance (£000) 3,251.3 1163.5

Unidentified QIPP

0.0

OsteopathyProject Lead:

CD Lead:Exec Lead:

Planned Care

PathologyProject Lead:

CD Lead:Exec Lead:

Activity 267,707 154,976

Finance (£000)

Everyone CountsProject Lead:

CD Lead:Exec Lead:

Financial Summary As at the end of January (Month 10) the CCG achieved a break even position against the revised control total and is forecast achieve the revised break even position at year end. A number of risks have been identified within the reported position. These are being managed and it is expected that the mitigating actions identified will allow the CCG to deliver the break even position. 4 Resources/Investments

n/a

5 Equalities n/a

6 Risk As reported to the Governing Body in month 6, the current forecast projects slippage against Redbridge CCGs planned surplus of £3,302k. A number of risks are factored into the reported position which means that the CCG control total has been moved to a planned break even. The

161

main risks reported in the financial position relate to Barts Health. There are however, additional risks and mitigations that could impact on the reported outturn. The table below sets out the key financial risks associated with the current reported position and actions that can be taken to mitigate these. This table includes risks that are deemed to have a significant increase or decrease in planned expenditure. Redbridge CCG Key Risks

Area Risk Assumption in Forecast

Action taken to mitigate risk

Downside Reported Up Side£'m £'m £'m

Acute Contracts Barts and other costs over performance and QIPP delivery risk

Contract values are delivered

8.0 7.5 7.3 Finance and performance monitoring. Robust contract challenges process in place. Activity / cost will be identified at practice level where possible and a proposed clinician and officer working group established to identify options for activity flows which mitigate the financial pressures

Primary Care Prescribing 1.2 0.6 0.6 Delivery plans monitored through QIPP process faciliated by Medicine Management team. Downside is a risk assessed view of the data available.

Co-Commissioning 0.0 0.0 0.0 FOT co-commissioning reported as break even in the ledger. Downside assumes no QIPP overspend. Upside mitigated by NHSE 1% funding

Continuing Care Continuing care placements exceed growth in budget

14/15 spend plus 5% growth

2.3 1.7 1.7 Review of packages and process by placement teams. Further analysis of CAPS system and invoices.

Other Programme Projects, and unidentified QIPP

1.0 1.0 1.0 Upside and downside of QIPP slippage and investments.

12.6 10.8 10.6

Value Of Risk

The table shows a range of risk that faces the CCG and without mitigating actions would impact the CCG’s ability to deliver its planned financial position. Although possible, it is not expected that all of the adverse or favourable risks will occur in full. Monitoring of these risks and actions will continue throughout the year, and where necessary further actions implemented.

7 Managing conflicts of interest n/a

162

Appendix 1

Commissioner Function Annual YTD YTD YTD In month In month In month Predicted Year Predicted Year Allocation Budget Actual Variance Budget Actual Variance End Value End Value Variance

£000's £000's £000's £000's £000's £000's £000's £000's £000's

Acute Healthcare

Acute Commissioning 164,409 137,007 144,887 (7,880) 13,701 14,628 (928) 171,929 (7,520)Acute Commissioning Other 8,936 7,447 6,448 999 745 615 130 7,819 1,117Urgent Care 1,177 981 981 0 98 98 0 1,177 0Winter Resilience 1,110 245 245 0 4 4 0 1,110 0High Cost Drugs 110 91 91 0 9 9 (0) 110 0Ambulance Services 8,833 7,361 7,361 0 736 736 0 8,833 0Clinical Assessment and Treatment Centres 4,037 3,364 4,233 (869) 336 395 (58) 5,115 (1,078)NCA 3,108 2,590 2,590 0 259 259 0 3,108 0

Acute sub-total Acute sub-total 191,719 159,085 166,835 (7,750) 15,888 16,744 (856) 199,200 (7,481)

Mental Health & LD

IAPT 1,385 1,154 1,164 (10) 115 130 (15) 1,374 11Mental Health Contracts 22,025 18,354 18,232 122 1,835 1,827 8 21,887 138Mental Health Services Other 4,761 3,967 3,657 310 397 255 141 4,363 397Mental Health Services - NCA 249 207 247 (39) 21 137 (116) 397 (148)

Mental Health 28,419 23,683 23,300 383 2,368 2,349 19 28,022 398

Community Healthcare

Community Services 21,067 17,374 17,241 133 1,761 1,724 37 20,884 183Hospices 476 397 405 (8) 40 32 7 492 (17)Wheel chair service 918 765 847 (82) 77 130 (54) 983 (65)

Community 22,461 18,536 18,493 43 1,877 1,887 (10) 22,359 102

Continuing Healthcare

CHC Adult 14,123 11,543 12,926 (1,383) 1,104 1,129 (25) 15,499 (1,376)CHC Adult Full Fund Pers Hlth Bud 282 235 163 72 24 18 6 196 86CHC Assessment and Support 781 651 837 (185) 65 90 (25) 1,059 (278)CHC Children 2,106 1,755 2,136 (381) 176 402 (226) 2,545 (439)Funded Nursing Care 1,618 1,349 1,052 297 135 108 27 1,292 326

Continuing Healthcare Sub-total 18,911 15,533 17,114 (1,581) 1,503 1,747 (244) 20,592 (1,681)

Programme Spend

Commissioning - Non Acute 947 789 792 (3) 79 120 (41) 958 (11)Better Care Fund 5,745 4,788 4,776 11 479 468 11 5,732 13Health Analytics 208 173 167 6 17 17 1 201 7Safeguarding 189 158 156 2 16 22 (6) 184 6Non Recurrent Programmes 3,066 2,892 2,885 7 1,494 1,452 42 3,056 10Programmes Projects 9,984 6,212 (426) 6,638 (132) (743) 611 4,281 5,703Reablement 708 590 590 0 59 59 0 708 0NHS 111 640 534 533 1 53 53 0 640 1NHS Prop.Co 1,297 1,081 933 147 108 (39) 147 1,120 177

Programme Spend Sub-total 22,786 17,216 10,406 6,810 2,173 1,408 765 16,879 5,907

Services Provided in a Primary Care Setting

Out of Hours 1,494 1,245 1,245 0 125 125 0 1,494 0Everybody Counts 1,412 1,412 1,412 0 171 171 0 1,412 0Commissioning Schemes 402 335 334 1 33 36 (3) 397 4Primary Care Co-Commissioning 30,373 25,310 25,479 (168) 2,531 2,537 (6) 30,373 0Medicines Management 285 238 203 34 24 30 (6) 258 28Primary Care GP IT 956 796 762 34 80 45 34 881 75GP Prescribing 35,645 29,996 30,510 (513) 3,021 2,980 41 36,253 (607)Oxygen 264 220 225 (5) 22 21 1 271 (7)Central Drugs 1,007 840 879 (39) 84 95 (11) 1,047 (39)

Services Provided in a Primary Care Setting subtotal 71,839 60,392 61,049 (657) 6,090 6,040 50 72,385 (546)

Sub-total Healthcare provision 356,135 294,446 297,197 (2,752) 29,900 30,175 (275) 359,437 (3,302)

Running Costs

CCG Running Costs 6,401 5,334 5,334 0 533 533 0 6,401 0

Running Costs Sub-total 6,401 5,334 5,334 0 533 533 0 6,401 0

Gross Expenditure 362,536 299,779 302,531 (2,752) 30,433 30,709 (275) 365,838 (3,302)



163

Appendix 2

£000 £000 £000 £000Mar 2015

January 2016

Mar 2016

Annual Change

Non-current assets

Property, plant and equipment 2,649 2,683 2,605 (44) Intangible 1,089 907 1,070 (19) Other financial assets - - - - Trade and other receivables - - - - Total Non Current Assets 3,738 3,590 3,675 (63)

Current AssetsInventories - - - - Trade and other receivables 10,204 8,238 10,204 - Other financial assets - - - - Cash and cash equivalents 260 1,190 50 (210) Total Current Assets 10,464 9,428 10,254 (210)

Total Assets 14,202 13,018 13,929 (273)

Current LiabiltiesTrade and other payables (31,838) (42,981) (31,838) - Provisions (2,163) (795) (500) 1,663 Borrowings - - - - Total Current Liabilites (34,001) (43,776) (32,338) 1,663

Net Current Assets/(Liabilities) (19,799) (30,758) (18,409) 1,390

Trade and other payables - - - - Provisions - - - - Borrowings - - - - Total Non-Current Liabilites - - - -

Total Assets Employed (19,799) (30,758) (18,409) 1,390

Financed by:

Taxpayers Equity

General Fund (19,799) (30,758) (18,409) 1,390 Revaluation reserves - - - - Total Taxpayers Equity (19,799) (30,758) (18,409) 1,390

Redbridge CCGStatement of Financial PositionPosition as at 31st January 2016

164

Appendix 3 Number Value Number Value Number Value Number Value Number Value Number Value Number Value Number Value Number Value Number Value Number Value

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Non-NHS Creditors

Total Bills paid in the year 1,092 4,657 790 3,653 634 5,284 1,380 8,565 912 5,374 1,621 8,370 1,225 6,290 1,156 6,049 1,028 6,698 1,025 3,945 10,863 58,885

Total Bills paid within target 1,000 3,650 703 2,384 578 3,533 1,232 8,006 728 4,659 1,423 7,488 1,020 5,503 1,035 5,485 933 5,944 883 3,535 9,535 50,187

Percentage of Bills paid within target 91.6% 78.4% 89.0% 65.3% 91.2% 66.9% 89.3% 93.5% 79.8% 86.7% 87.8% 89.5% 83.3% 87.5% 89.5% 90.7% 90.8% 88.7% 86.1% 89.6% 87.8% 85.2%

NHS Creditors

Total Bills paid in the year 125 16,481 115 18,879 249 18,049 201 17,388 463 18,286 249 23,458 294 18,769 266 18,585 245 18,654 308 18,976 2,515 187,525

Total Bills paid within target 111 16,444 73 17,641 231 17,333 168 17,303 417 18,165 224 21,596 273 18,990 237 17,628 205 18,339 271 18,522 2,210 181,961


All Creditors

Total Bills paid in the year 1,217 21,138 905 22,532 883 23,333 1,581 25,953 1,375 23,660 1,870 31,828 1,519 25,059 1,422 24,634 1,273 25,352 1,333 22,921 13,378 246,410

Total Bills paid within target 1,111 20,094 776 20,025 809 20,866 1,400 25,309 1,145 22,824 1,647 29,084 1,293 24,493 1,272 23,113 1,138 24,283 1,154 22,057 11,745 232,148


Redbridge CCGInvoice Payment Performance Measure

Position as at 31st January 2016May-15 CumulativeJun-15 Aug-15 Sep-15Apr-15 Jul-15 Oct-15 Nov-15 Dec-15 Jan-16

165

Appendix 4

£000January

2016

Cashflows from Operating ActivitesNet operating cost before interest operating surplus/deficit (302,531) Interest paid(Increase)/decrease in inventories(Increase)/decrease in trade and other receivables 1,965 Increase/(decrease) in trade and other payables 11,143 Provisions utilised (205) Increase/(decrease) in movement in non cash provisions (1,163) Net cash inflow/(outflow) from operating activities (290,791)

Cash flow from investing activitiesInterest received(Payments) for property, plant and equipment (34) (Payments) for intangible assets 182 (Payments) for other financial assetsProceeds of disposal of assets held for sale (PPE)Proceeds of disposal of assets held for sale (Intangible)Proceeds from disposal of other financial assetsNet cash inflow/(outflow) from investing activities 148

Net cash inflow/(outflow) before financing (290,643)

Capital element of payments in respect of finance leases and On-SoFP PFI and LIFTNet parliamentary funding 291,573 Net cash inflow/(outflow) from financing activities 291,573 Net increase/(decrease) in cash and cash equivalents 930 Cash and cash equivalents (and bank overdraft) at beginning of the period 260

Cash and cash equivalents (and bank overdraft) at YTD 1,190

Reconciliation of Cash Drawings to Parliamentary FundingTotal cash received from DH (Gross) 238,257 (Less)/plus: transfers (to)/from other resource account bodiesPlus: cost of Co-Commissioning (central charge to cash limits) 22,578 Plus: drugs reimbursement (central charge to cash limits) 30,738 Parliamentary funding credited to General Fund 291,573

Redbridge CCGCash to income and expenditure reconciliation

Position as at 31st January 2016

166

Appendix 5

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000April May June July August September October November December January February March Total2015 2015 2015 2015 2015 2015 2015 2015 2015 2016 2016 2016 2016

Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast

Receipts

Balance bfwd 285,774 904,385 2,433,773 548,109 4,189,315 7,927,135 243,160 1,177,032 5,757,851 2,438,813 2,506,680 1,136,267 285,774

NCB Drawdown 21,500,000 22,500,000 20,500,000 25,000,000 25,900,000 24,195,000 26,500,000 27,000,000 21,000,000 22,500,000 24,250,000 39,190,299 300,035,299 Other 5,078,334 5,148,708 6,717,264 13,917,954 2,070,019 8,297,695 5,993,523 7,798,703 8,048,356 5,549,680 1,925,073 3,316,102 73,861,411 PCS Payments Reimbursements 1,700 1,100 10,081 2,101 4,165,185 1,728 - - - - - - 4,181,895 VAT 85,796 155,629 52,162 258,685 26,166 682 64,477 - 163,282 - 20,686 - 827,565

Total 26,951,604 28,709,822 29,713,280 39,726,849 36,350,685 40,422,240 32,801,160 35,975,735 34,969,489 30,488,493 28,702,439 43,642,668 379,191,944

Payments

Creditors NHS 16,495,874 19,151,837 18,055,016 17,390,234 18,306,310 23,461,415 18,859,478 18,609,436 18,654,327 18,975,405 19,280,947 30,430,222 237,670,501 Creditors BACS 4,049,410 3,044,263 4,860,962 8,300,491 3,803,644 7,402,345 5,613,755 4,589,184 6,246,229 3,808,925 7,683,394 12,560,615 71,963,217 Creditors CHAPS 607,035 196,145 62,579 258,822 1,502,500 918,679 544,817 1,329,539 448,893 19,405 - - 5,888,414 Salary CHAPS - - 587 - - 2,545 2,281 - - - - - 5,413 Cleared Payable Orders 724 - 237,425 216,254 68,853 52,637 40,553 109,528 2,500 19,147 - - 747,621 Salaries & Wages 296,710 295,047 303,938 306,514 312,999 310,120 324,442 324,094 328,934 325,149 325,149 325,149 3,778,245 Pensions 97,369 97,964 100,193 101,905 103,679 106,744 104,025 109,317 108,312 110,336 110,336 110,336 1,260,516 Tax & NI 153,154 152,510 153,545 157,318 160,509 164,264 158,645 164,614 165,216 166,346 166,346 166,346 1,928,813 Standing Orders/Direct Debits - - - - - - - - - - - - - Foreign Payments - - - - - - - - - - - - - Other 4,346,943 3,338,283 5,390,926 8,805,996 4,165,056 7,760,331 5,976,132 4,982,172 6,576,265 4,557,100 - - 55,899,204

Total 26,047,219 26,276,049 29,165,171 35,537,534 28,423,550 40,179,080 31,624,128 30,217,884 32,530,676 27,981,813 27,566,172 43,592,668 379,141,944

Balance cfwd 904,385 2,433,773 548,109 4,189,315 7,927,135 243,160 1,177,032 5,757,851 2,438,813 2,506,680 1,136,267 50,000 50,000

Redbridge CCGCash position and Predicted Year End Value

Position as at 31st January 2016

167

To: Meeting of the NHS Redbridge CCG Governing Body From: Jacqui Himbury, Nurse Director Date: 24 March 2016 Subject: Quality in Commissioning Executive summary

The Clinical Commissioning Group (CCG) is committed to improving the quality of care for all services we commission and to driving improvements in the quality and outcomes of all our commissioned services. We do this in a number of ways and across all our activities, as quality underpins all that we do. Within our operating plan we have described our priorities for 2015/16 and confirmed our continued commitment to delivering the recommendations from the Francis, Berwick and Winterbourne View Reports. We have also confirmed that we will deliver the statutory functions that we are required to do as part of the CCG Assurance Framework along with responding to new national policies, for example, the Transforming Care Programme (2015). This paper provides assurance to the governing body on delivery of these functions. In addition this paper provides assurance that we implement recent legislative and policy developments with regard to quality and safety. This paper has been written to advise the governing body on the progress made since the last report.

Recommendations The Governing Body is asked to: • Review progress and improvement actions being taken to date • Suggest any further actions required to provide further assurance.

1.0 Purpose of the Report 1.1 The purpose of the report is to provide assurance to the governing body that the CCG continues

to implement the recommendations and requirements of the Transforming Care Programme (TCP), quality and safeguarding improvement plans, actions to reduce health inequalities, along with new initiatives around compliance with Francis.

2.0 Transforming Care Programme 2.1 In October 2015 a national three year plan called “Building the Right Support”, jointly developed

by NHS England (NHSE), the Local Government Association (LGA) and Association of Directors of Adult Social Services (ADASS) was published. Its publication marked the next important

168

2

milestone for cross-system service transformation and includes the requirement to establish a Transforming Care Partnership to re-shape local services to meet the needs of people with a learning disability and/or autism and behaviour that challenges, including people with mental health needs. This is supported by a new service model for commissioners across health and care that defines what good services should look like. We have now established our Transforming Care Partnership (TCP) to lead the transformation.

2.2 The Barking and Dagenham, Havering and Redbridge (BHR) TCP is a partnership from the three Local Authorities (LAs), the three Clinical Commissioning Groups (CCGs), NELFT NHS Foundation Trust, NHS England (NHSE) Specialist Commissioning and people with a lived experience of using our services.

2.3 The national plan builds on other transforming care work to strengthen individuals’ rights; roll out

care and treatment reviews to reduce unnecessary hospital admissions and lengthy hospital stays; and test a new competency framework for staff, to ensure the workforce have the right skills in the right place. There is a requirement for us to deliver this national plan locally and we are currently working with our partners to develop a local plan that sets out how we will achieve this and deliver:

• a reduction in inpatient bed usage over the next three years; • improved quality of care; and • improved quality of life.

2.4 In order to achieve these outcomes NHSE, LGA and ADASS have set out a number of actions

for each TCP to deliver as part of the CCG operating plan, which is due for submission on 11 April 2016. These actions include: • agreeing a shared vision: BHR TCP must develop a shared vision of how the services will

change across the new TCP geographical area and what we will achieve; • developing a detailed three year plan; BHR TCP must clearly set out how it will deliver the

outcomes listed above and identify the resources required to ensure success; and • mobilising the plan; BHR TCP must have a strong foundation to deliver this challenging

transformation plan with strong leadership, clear governance and a programme of work with clear outcomes.

2.5 The plan must demonstrate that the views of people with a lived experience of using

assessment and treatment inpatient services have been used to inform the design of the new service model.

2.6 Over the past two months representatives from the BHR health and care economy have been working together to produce an initial vision for the TCP. At this stage no resources have been committed by any of the member organisations, although partners are expected to align existing resources to achieve the vision for this group of people.

2.7 Locally across BHR our vision is consistent with the national service model and is currently

“People with a learning disability and/or autism, including people with complex and challenging behaviour, can lead fulfilling and rewarding lives while being part of a community that is able to support them with dignity and respect and ensure that people’s individual wellbeing is at the heart of decisions. Please note that this is subject to further stakeholder engagement, after which we will confirm the exact wording,

169

3

2.8 The partnership has confirmed a commitment to achieving this vision by designing and implementing care and support services that;

• provide support and interventions in the least restrictive manner and for the shortest possible time;

• provide respite for families and carers that enables people living at home to stay there with positive family relationships;

• ensure that people who need inpatient care do not have to travel long distances to access it;

• strengthen multi-disciplinary and multi-agency working to reduce health inequalities; • make better use of community provision across the three boroughs; • ensure people have choice and control over their own health and care services; • ensure that early identification and early support is commissioned and provided; and • enable people with learning disabilities and/or autism and their family and carers to have

access to the right level of information, advice and advocacy. 2.9 Our draft plan was presented to a review panel led by NHSE on 25 February 2016. The review

panel included representatives from ADASS, LGA, advocacy services and people with a lived experience of using assessment and treatment unit services. We received formal feedback that our plan was partially assured and since that feedback we have been working to improve the plan and define and co-produce our future service model for people with learning disabilities and/or autism.

2.10 A more detailed report describing the TCP aspirations, plans, risks and next steps will be

presented to the next governing body meeting.

2.11 The next steps are: • Continue to develop and strengthen the plan working as a partnership; • Submit a detailed operating and financial plan to NHSE on 11 April 2016: and • Work with NHSE to mobilise the plan from 1 April 2016.

3.0 Safeguarding 3.1 At the last governing body meeting it was reported that In December NHSE undertook a deep

dive assurance review of our adherence to the NHSE Safeguarding Assurance and Accountability Framework and compliance with statutory functions. This covered both adults and children’s safeguarding across the three BHR CCGs.

3.2 We have now received formal notification of the review outcome and have received an overall judgement of good using a four point judgement scale of not assured, limited assurance, good and outstanding.

3.3 The deep dive assurance process covered 4 key domains: • governance, systems and process • workforce • capacity levels in the CCG • assurance systems

3.4 We received a good judgement for three of the four domains. For workforce we were given a

judgement of limited assurance. This is predominantly because of safeguarding training, especially for the PREVENT agenda. PREVENT training is now a mandatory requirement for all CCG employed staff and is available as an online module. The national requirement is 85% of the workforce must be trained in PREVENT and as of 29 February 2016 the CCG performance was significantly below this requirement. To address this we have published the training

170

4

requirement in the staff news, the designated nurses are speaking to individual staff members and we are monitoring performance weekly.

4.0 Special Educational Needs and Disability (SEND) 4.1 The strategic SEND group continues to meet and has developed a combined BHR CCGs

response to the forthcoming inspections. From April, there will be an inspection of both the services that support this agenda and the ability of each partner organisation to respond to the needs of the overall system to improve the quality of the children and young people’s lives. The inspection will also focus on the involvement of children, young people and their families and how their views have shaped services.

4.2 As reported previously there is a need to ensure each organisation informs the local community of the services and support they offer to improve quality. This is through the local offer website of each LA. The CCG is working closely with the LA to enhance and improve the current site to describe and detail all that we commission. This will be a useful reference site for general practitioners and universal community services once completed.

4.3 The number of children and young people with complex health, education and social care needs

continues to increase, which is placing increased demand on all services, including community paediatric and therapy services. Therefore there is to be a service demand and capacity review during 2016/17 to ensure that the CCG has commissioned the right level of support to meet the identified need.

5.0 Maternity Commissioning 5.1 The national review of maternity services, led by Baroness Cumberledge has now been

published and the CCG is currently completing a benchmarking process and gap analysis against the recommendations to inform our improvement plan. The outcome of this benchmark review and improvement actions will be presented to the next governing body meeting.

5.2 The North East London Maternity Clinical Network is now meeting as planned and is monitoring

the maternity flow and delivery capacity across the system as there is an emerging risk that the agreed annual delivery capacity numbers for each maternity unit may be exceed, especially as the birth rate is rising. To mitigate this risk monthly delivery numbers are reviewed and monitored at the BHRUT maternity clinical quality review group. BHRUT are currently within their agreed annual cap of 8,000 births, although this is projected to increase to 8,500 during 2016/17. To mitigate this risk BHRUT have commenced a piece of work to increase the utilisation of their birthing centre, recognising that their maternity activity continues to increase in line with our other providers.

6.0 Quality of care in Care Homes (with Nursing) strategy

6.1 This is an update to advise the governing body of the progress with the strategy to improve the

quality of care provided in care homes (with nursing). The purpose of the strategy is to develop a systematic and consistent approach and methodology to drive improvements in the quality of nursing care within our care homes with nursing, and to respond effectively and swiftly when poor care is identified. This work is one of the work streams we have that will implement the national nursing strategy, “The 6 C’s”.

6.2 We recognise that currently we have examples of excellent and good practice across the BHR geography, although this is not consistent. Therefore the intention is to develop a strategy that outlines the process for garnering early warning signs from across the economy focused on the

171

5

quality of care, to develop a range of responses when poor care is identified and to establish a central repository for all information so that all CCGs in BHR can have access to all the information related to our nursing home cohorts. The strategy is expected to be finalised in July 2016, and once approved by the Quality and Safety Committee it will be shared with the governing body.

7.0 Frances Report – Duty of Candour 7.1 The CCG has designed and developed a Duty of Candour reporting template which has been

implemented by our two main providers BHRUT and NELFT. This is populated directly from their incident reporting system data and enables the CCG to be assured on the provider’s compliance with the Duty of Candour.

7.2 Both NELFT and BHRUT are now fully compliant with their Duty of Candour regulatory requirements. The CCG is in the process of confirming that Barts Health NHS Trust is compliant. We are working with the lead commissioners to request evidence of compliance.

8.0 Berwick/Winterbourne 8.1 We have robust quality assurance systems and processes in place across all of our providers,

and this includes providers of services to patients with learning difficulties (LDs). We undertake continuous review of our systems and this happens on a quarterly basis through our Quality and Safety Committee.

8.2 Our quality strategy continues to be implemented as planned. Our early warning system using the Key Line of Enquiry (KLoE) tracker is now fully developed and operational. This is a sophisticated quality assessment, assurance and improvement model that enable the CCG to identify key risks, trends and issues as they emerge and to monitor the impact of any improvement actions. We are in the process of sharing this with NHSE London as an example of good practice.

8.4 However, it is recognised that this model can be improved upon and currently we are working to

develop an automated system of reporting and increase the functionality of the KLoE tracker. 9.0 Resources/Investment 9.1 There are no resource investment implications arising from this report.

10.0 Equalities 10.1 There are no equalities implications arising from this report.

11.0 Risk 11.1 The risks arising from this report have been described in the relevant sections of the report

along with the mitigating actions.

12.0 Managing conflicts of interest 12.1 There are not any conflict of interest implications for this report. Authors: Jacqui Himbury and the Quality and Safeguarding Team 29 February 2016

172

To: Meeting of NHS Redbridge Clinical Commissioning Group (CCG) Governing Body From: Marie Price, Director of Corporate Services Date: 24 March 2016 Subject: Revisions to committee terms of reference (TORs) and establishment of an auditor

panel Executive summary: Following a review of the commitments of a number of governing body members and issues with the workings of some committees, a number of amendments are proposed to TORs.

• Audit and Governance Committee: The secondary care consultant was included as a member

of the committee in 2013 initially because there was a concern that the committee may struggle for quoracy. It was acknowledged that this was not the best use of secondary care consultant expertise. The meeting has not been inquorate in the three years that it has been in operation. It is therefore recommended that secondary care consultant be removed as a member.

• Remuneration and Workforce Committee: See above for rationale. There is not an additional co-opted member on this committee, but again there have not been issues with quoracy. It is therefore recommended that secondary care consultant be removed as a member.

• Investment Committee: because the committee deals with matters where there are conflicts of

interest there is a greater risk that this committee could be inquorate on occasion. It is therefore proposed that the quorum be amended to enable members of other CCGs e.g. lay member for PPI, chair or secondary care consultant from another CCG to be included as a substitute member should there be a quoracy issue for one or more of the CCG committees (recognising that this is three committees meeting as one). This is in line with how we have made decisions previously where one or members have not been able to take part in a discussion or decision due to a conflict of interest.

• Primary Care Committee: The terms of reference have been updated in line with the

recommendations to this governing body on 28 January 2016. (See attached appendix A) • Quality and Safety Committee: That the Redbridge secondary care consultant continues to act

as chair of the committee for 2016/17. That the CCG chairs nominate attendees for 2016/17 who can commit to the schedule of meetings as outlined.

173

Establishing an auditor panel

The Local Audit and Accountability Act 2014 requires CCGs to appoint an auditor panel, which will advise on the appointment of external auditors for 2017/18. The governing body must decide how it appoints the panel and it can be an existing committee. Nationally, draft TORs have been prepared that assume the audit committee will perform this function. It is therefore recommended that our existing Audit and Governance Committee act as the auditor panel.

Recommendations

The Governing Body is asked to:

• Endorse the proposed amendments to the committee TORs

• Agree that the Audit and Governance Committee act as the auditor panel.

Author: Marie Price, Director of Corporate Services Date: 29 February 2016

174

Redbridge Clinical Commissioning Group

Primary Care Commissioning Committee-in-Common Terms of Reference February 2016

175

Revision History

Revision date

Summary of Changes Writer / Reviewer

Version

Nov 2014 First draft as part of delegated commissioning application Sarah See 1.0

Jan 2015 Amendments made to reflect feedback from NHS England as part of the application process

Sarah See / Rod McEwen

2.0

8 May 2015 Amendments to reflect changes in Delegation Agreement Sarah See 2.1

11 May 2015 Review and comments Rod McEwen 2.2

2 June 2015 Amendments regarding urgent meetings Sarah See / Rod McEwen

2.3

10 June 2015 Review and final comments by Primary Care Commissioning Committee members

Committee members

3.0

30 June 2015 Amendments around representatives of Local Medical Committees, HealthWatch and Health and Wellbeing Boards

Rod McEwen / Sarah See

4.0

29 Oct 2015 Amendments around proposed changes in GP representation

Sarah Everiss/Sarah See/Rod McEwen

5.0

1 Feb 2016 Suggested amendments from NHSE following changes to membership of the Committee. Further review may be necessary upon publication of a national CoI review currently being undertaken (Project Starlight)

Sarah See / Rod McEwen

6.0

176

3

Introduction 1. Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014

that NHS England was inviting CCGs to expand their role in primary care commissioning and to submit expressions of interest setting out the CCG’s preference for how it would like to exercise expanded primary medical care commissioning functions. One option available was that NHS England would delegate the exercise of certain specified primary care commissioning functions to a CCG.

2. In accordance with its statutory powers under section 13Z of the National Health Service Act 2006 (as amended) (“NHS Act”), NHS England has delegated the exercise of the functions specified in Schedule 2 to these Terms of Reference (“ToR”) to NHS Redbridge CCG (“CCG”). The Delegation Agreement is set out in Schedule 1.

3. The CCG has established the NHS Redbridge Primary Care Commissioning Committee (“the Committee”). The Committee will function as a corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers.

4. NHS Havering CCG and NHS Barking and Dagenham CCG have agreed to establish a committee (“committee-in-common”) with the same membership and the same terms of reference as the committee established by the CCG (although depending on the identity of the committee such members would not necessarily have the right to vote on such committee (further particulars as are set at paragraph 18 in Terms of Reference for each such committee)). The three committees shall be known together as the BHR PCC Committee-in-Common. Notwithstanding that the Committee shall also operate as a committee–in-common, where it does so, it shall always do so in recognition of and cognisant of the CCG’s own duties to the patients and population of Redbridge.

Statutory Framework 5. NHS England has delegated to the CCG authority to exercise the primary care

commissioning functions set out in Schedule 2 in accordance with section 13Z of the NHS Act.

6. Arrangements made under section 13Z may be on such terms and conditions (including terms as to payment) as may be agreed between NHS England and

177

the CCG. These arrangements are set out in the separate delegation agreements entered into by the CCG and NHS England dated 1 April 2015.

7. Arrangements made under section 13Z do not affect the liability of NHS England for the exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and including:

a) Management of conflicts of interest (section 14O);

b) Duty to promote the NHS Constitution (section 14P);

c) Duty to exercise its functions effectively, efficiently and economically (section 14Q);

d) Duty as to improvement in quality of services (section 14R);

e) Duty in relation to quality of primary medical services (section 14S);

f) Duties as to reducing inequalities (section 14T);

g) Duty to promote the involvement of each patient (section 14U);

h) Duty as to patient choice (section 14V);

i) Duty as to promoting integration (section 14Z1);

j) Public involvement and consultation (section 14Z2).

8. The CCG will also need to specifically, in respect of the delegated functions from NHS England, exercise those duties set out below:

• Duty to have regard to impact on services in certain areas (section 13O);

• Duty as respects variation in provision of health services (section 13P).

9. The Committee is established as a committee of the CCG in accordance with Schedule 1A of the NHS Act.

10. The CCG acknowledges that the Committee is subject to any directions made by NHS England or by the Secretary of State.

Role of the Committee 11. The Committee has been established in accordance with the above statutory

provisions to enable the CCG to make decisions in common with NHS Havering CCG and NHS Barking and Dagenham CCG on the review, planning and

178

procurement of primary care services within Barking and Dagenham, Havering and Redbridge, under delegated authority from NHS England.

12. In performing its role the Committee will exercise its management of the functions in accordance with the agreement entered into between NHS England and the CCG, which will sit alongside the delegation and terms of reference.

13. The functions of the Committee are undertaken in the context of a desire to promote increased co-commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers.

14. The role of the Committee shall be to carry out the functions relating to the commissioning of primary medical services under section 83 of the NHS Act delegated to the CCG under the terms of its delegation.

15. This includes the a number of functions that have been specified by the Delegation Agreement (full particulars of which are set out in Schedules 2, 3 and 4), including:

• Planning of the provider landscape in the area, including: decisions on establishing new GP practices in an area and procurement of associated Primary Medical Services contracts; decisions on practice mergers and closures, and on any associated list dispersals; agreement on GP practice boundary changes; and decisions on practice list cleansing.

• Design and commissioning of urgent care for out of area registered patients, including home visits as required.

• Premises Cost Directions Functions, including: making decisions in relation to applications for new payments or revisions to existing payments; and premises and strategic estates planning.

• Design and commissioning of Enhanced Services (“Local Enhanced Services” and “Directed Enhanced Services”).

• Design and offering of Local Incentive Schemes in addition or as an alternative to the national framework (including Quality Outcomes Framework or Directed Enhanced Services) provided they are voluntary and have undergone consultation with the Local Medical Committees;

• Primary Medical Services contract management including: the design of PMS and APMS contracts and periodic contract reviews to ensure value for money; monitoring of contracts with respect to observance of specifications

179

and quality standards; and performance management of poorly performing practices.

• Making decisions on discretionary payments (e.g., returner/retainer schemes) in accordance with the Statement of Financial Directions.

16. In order to successfully deliver its delegated primary care commissioning functions the Committee will need to carry out the following activities:

• Management of the delegated budget for commissioning of primary medical services in Redbridge. The Committee will ensure that the required financial processes are in place for planning, reporting, risk management, contingencies, probity and conflict of interest management. It will also agree any Quality, Innovation, Productivity and Prevention (QIPP) plans and manage their delivery.

• The Committee is accountable for the development of the Primary Care Strategy for Redbridge ("the Strategy"). The responsibility of Strategy development in BHR will rest with the Primary Care Transformation Programme Board (PCTPB), which will carry out key tasks such as supporting the Joint Strategic Needs Assessment , designing the models of care within the NHS England ‘Strategic Commissioning Framework for Primary Care Transformation in London’, and leading consultations and public and patient engagement. However, as the budget holder The Committee will sign off the Strategy and will liaise with the PCTPB to ensure that it is in line with the financial plan.

• The Committee will take all decisions on investment, procurement and contracting with regards to the strategy.

• The Committee will review, investigate and manage unacceptable variations in care by regularly reviewing information on outcomes, patient experience, complaints, incidents and CQC reports. The Committee will also authorise investigations into practices where there are concerns about quality of care, liaising with the CQC and putting in place performance management arrangements when necessary.

• The Committee will also work with NHS England Regional Team to monitor compliance of practices with key contracting processes (such as the completion of annual practice declarations).

180

Geographical Coverage 17. The Committee will take decisions in respect of the population of NHS Redbridge

CCG.

Membership 18. The Committee shall consist of the following voting members:

• Lay Member, Redbridge CCG

• Lay Member, Audit Chair, Redbridge CCG

• Accountable Officer, Redbridge CCG (Executive Member)

• Chief Finance Officer, Redbridge CCG (Executive Member)

• Nurse Director, Redbridge CCG (Executive Member)

• Director of Primary Care Transformation, Redbridge CCG

• Secondary Care Consultant, Redbridge CCG

• GP partner and/or GP Clinical Director and /or a GP employee of a Member of Redbridge Clinical Commissioning Group (x 2)

• An Independent GP

The following shall be in attendance as members of the Committee but shall be non-voting:

• Chair, Redbridge CCG

• NHS England (NHS England representative)

• Redbridge Health and Wellbeing Board (local authority representative)

• Redbridge Local Medical Committee (Redbridge LMC representative)

• Redbridge Healthwatch (Healthwatch representative)

• Lay Member, Barking and Dagenham CCG

• Lay Member, Havering CCG

• Secondary Care Consultant, Barking & Dagenham and Havering CCG

• Chair, Havering CCG and GP partner and/or a GP employee of a Member of Havering Clinical Commissioning Group (x 2)

• Chair, Barking and Dagenham CCG and GP partner and/or a GP employee of a Member of Barking & Dagenham Clinical Commissioning Group (x 2)

181

• Havering Health and Wellbeing Board (local authority representative)

• Barking and Dagenham Health and Wellbeing Board (local authority representative)

• The Barking and Dagenham and Havering Local Medical Committee (BH LMC representative)

• Havering Healthwatch (Healthwatch representative)

• Barking and Dagenham Healthwatch (Healthwatch representative)

A list of the individuals who hold these positions is set out in Schedule 3 to these terms of reference.

19. The Chair of the Committee shall be Lay Member of a BHR CCG.

20. The Vice Chair of the Committee shall be Lay Member of a BHR CCG.

Meetings and Voting 21. The Committee will operate in accordance with the CCG’s Standing Orders. The

secretary to the Committee will be responsible for giving notice of meetings. This will be accompanied by an agenda and supporting papers and sent to each member representative no later than 5 working days before the date of the meeting. Where the Chair of the Committee deems it necessary in light of the urgent circumstances to call a meeting at short notice, the notice period shall be such as s/he shall specify and the papers for the meeting shall be circulated in accordance with his/ her instructions.

22. Each voting member of the Committee shall have one vote. The chair of the Committee will work to establish unanimity as the basis for decisions of the Committee. If, exceptionally, the Committee cannot reach a unanimous decision, the chair will put the matter to a vote, with decisions confirmed by a simple majority of those voting members present, subject to the meeting being quorate.

Quorum 23. The quorum shall be 5 voting members who shall include at least one lay

member and one executive member (as defined at paragraph 18 above) and at least one GP partner or a GP employee of a member of Redbridge Clinical Commissioning Group.

182

24. If the committee cannot be quorate for the purposes of any business because of the declarations of interest that have been made by its members, the committee shall have the power to co-opt one or more lay members from another CCG’s Governing Body onto the committee.

Frequency of meetings 25. The Committee will meet on a monthly basis on the 2nd Wednesday of each

month. After 12 months the frequency will be reviewed.

26. Meetings of the Committee:

a) shall be held in public, subject to the application of paragraph 26 (b) below;

b) (the Committee) may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time;

c) the closed confidential part of the meeting (as provided for at 26 (b) above) shall be referred to as Part 2 of the meeting and shall have a separate agenda and minutes;

d) the Committee may resolve to exclude the representatives of the local authority, Local Medical Committees and Healthwatch from Part 2 of any meeting where it considers it is not appropriate for such representatives to attend all or part of Part 2 of the meeting.

27. Members of the Committee have a collective responsibility for the operation of the Committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view.

28. The Committee may call additional experts to attend meetings on an ad hoc basis to inform discussions.

29. Members of the Committee shall respect confidentiality requirements as set out in the CCG’s Constitution.

183

30. The Committee will present its minutes to the governing body of NHS Redbridge CCG for information.

31. The CCG will also comply with any reporting requirements set out in its constitution.

32. Terms of Reference will be reviewed on an annual basis.

Immediate and urgent decisions 33. There may be instances when the Committee is required to make a decision in

advance the regular full committee meetings in light of unforeseen circumstances. Depending on the urgency of the matter such decisions may need to be immediate (i.e. to be made 24 hours) or urgent (i.e. to be made in timeframes longer than 24 hours but in advance of the next scheduled meeting).

34. The Director of Primary Care Transformation will decide when an immediate or urgent decision is required and will initiate the decision making process.

35. In the instances where an immediate decision is needed the Director of Primary Care Transformation will arrange a meeting with the Chair (or Vice Chair if the Chair is not available) and the CCG Accountable Officer to take the decision. Such decisions will only be taken in exceptional circumstances, such as the need to close a practice due to clinical reasons or contractor death. Any immediate decisions taken under this procedure will be presented at the next Committee meeting.

36. In the instances when the Director of Primary Care deems it necessary to request an urgent decision the Chair will be contacted. The Chair (or Vice Chair if the Chair is not available within the required timeframes) may deem it necessary to call a meeting at short notice outside the regular full committee meetings, as set out in paragraph 21 above.

37. In these instances the meeting may be held by virtual means such as telephone, email or internet conferencing, with papers circulated by email in advance to members.

Accountability of the Committee 38. The CCG has Prime Financial Policies and Detailed Financial Policies and this

Committee shall act in accordance with the same.

184

39. For the avoidance of doubt, in the event of any conflict between these Terms of Reference and the Prime Financial Policies and Detailed Financial Policies of the CCG, the latter will prevail.

40. The Committee will have regard to the CCG’s duties to make arrangements to secure that individuals to whom the services are being or may be provided are involved in the planning of the commissioning arrangements by the group, and in the development and consideration of proposals by the CCG for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them, and in decisions of the CCG affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact.

Procurement of Agreed Services 41. Detailed arrangements regarding procurement will be set out in the delegation

agreement but for the avoidance of doubt, the Committee will consider the CCG’s procurement law duties as set out inter alia in the following:-

• The Public Contracts Regulations 2006 (as amended from time to time);

• Overarching principles enshrined in the treat on the Functioning of the European Union; and

• The National Health Service (Procurement, patient Choice and Competition) No.2 Regulations 1023 ("the S75 Regulations" ) and Monitor’s substantive and enforcement guidance on the S75 Regulations or any such additional/replacement guidance and/or regulations from time to time in force.

Decisions 42. The Committee will make decisions within the bounds of its remit.

43. The Committee will ensure that any conflicts of interest are dealt with in accordance with the CCG’s Constitution and Standards of Business Conduct Policies which for the avoidance of doubt may include members (voting or otherwise) being excluded from a decision and/or the discussions leading thereto.

185

44. All decisions taken in good faith at a meeting of the Committee shall be valid even if there is any vacancy in its membership or it is discovered subsequently that there was a defect in the calling of the meeting, or the appointment of a member attending the meeting.

45. The decisions of the Committee shall be binding on NHS England and NHS Redbridge CCG.

[Signature provisions]

186

Schedule 1 – Delegation Agreement

Redbridge PB signed.pdf

187

Schedule 2 – Delegated Functions

Delegated Functions Delegated CCG responsibilities

Planning and reviews Plan the commissioning of primary medical services, including:

Carrying out regular primary medical health needs assessments (to be developed by the CCG) to help determine the needs of the local population in the Area;

Recommending and implementing changes to meet any unmet primary medical services needs.

Planning the provider landscape

Develop the Primary Medical Services commissioning strategy and take the key planning decisions, including for:

Establishing new GP practices in the area;

Procurement of new contracts;

Closure of practices and branch surgeries;

Approving practice mergers and closures;

Dispersing the lists of GP practices;

Agreeing variations to the boundaries of GP practices;

Co-ordinating and carrying out the process of list cleansing

Urgent care services Manage the design and commissioning of urgent care services (including home visits) for patients registered out of area

Enhanced services commissioning

The CCG will agree on, design and commission enhanced services for the area by:

Assessing the needs of the local population;

Developing the necessary specifications and templates for the Enhanced Services;

Consulting with Local Medical Committees, Health and Wellbeing Boards and other stakeholders in accordance with the duty of public consultation;

Liaising with system providers and representative bodies to ensure that the system in relation to the Enhanced Services will be functional and secure; and

Supporting GPs to enter into data processing agreements and Data Controllers in to provide “fair processing” information.

Design of Local Incentive Schemes

Design and offer Local Incentive Schemes for GP practices in addition to or as an alternative to the national framework (i.e. QOF or DES), provided that such schemes are voluntary and have undergone consultation with the Local Medical Committee;

Procurement and new Contracts

Make procurement decisions in accordance with the NHS England procurement protocol, ensuring that any locally designed contract has undergone LMC consultation and can demonstrate that the scheme will improve care in the area.

188

Delegated Functions Delegated CCG responsibilities

Primary Medical Services Contract management

Manage the Primary Medical Services Contracts and perform NHS England’s obligations under the contracts, including:

Actively managing the performance of the counter-party to secure the needs of the service users, improve service quality and improve efficiency of provision;

Ensuring respect of quality standards, incentives and the QOF, observance of service specifications, and monitoring of activity and finance;

Assessing quality and outcomes (including clinical effectiveness, patient experience and patient safety);

Managing GP practices providing inadequate standards of patient care, conducting practice reviews, agreeing remedial action plans and issuing contract breach notices when necessary;

Managing variations to the relevant Primary Medical Services Contract or services;

Agreeing information and reporting with practices:

Agreeing local prices and ensuring value for money. Keeping records of all contracts

Management of poorly performing practices

Make decisions in relation to the management of poorly performing GP practices, including in liaison with the CQC where there has been a reported non-compliance with standards (but excluding any decisions in relation to the performer’s list). This includes:

Ensuring regular and effective collaboration with the CQC and taking appropriate action to CQC findings;

Ensuring that risks are appropriately identified, managed and escalated;

Responding to CQC assessments of practices where improvements is required;

When a GP practice is placed into special measures lead a quality summit to develop an improvement plan and ensure the monitoring of the said plan;

Discretionary payments Make decisions on discretionary payments, including in relation to QOF, Enhanced Services and Local Incentive Schemes

Premises Cost Directions

Make decisions in relation to the Premises Costs Directions Functions concerning:

Applications for new payments and revisions to existing payments

Working together with other CCGs to manage premises and to carry out strategic estates planning;

Liaising with NHS Property Services Limited and Community Health Partnerships Limited.

189

Schedule 3 - List of Members

Position Individual name Committee role

Voting members GP partner and/or a GP employee of a Member of Redbridge Clinical Commissioning Group x2

Dr Shabana Ali TBC

Clinical Director TBC

Lay Member, Redbridge CCG Khalil Ali Lay Member, Audit Chair, Redbridge CCG Kash Pandya Vice Chair Accountable Officer, Redbridge CCG Conor Burke Executive member Chief Finance Officer, Redbridge CCG Tom Travers Executive member Nurse Director, Redbridge CCG Jacqui Himbury Executive member Director, Primary Care Transformation, Redbridge CCG

Sarah See

Secondary Care Consultant, Redbridge CCG

Ah-Fee Chan

An Independent GP TBC Non-voting members Redbridge Healthwatch Cathy Turland Chief Executive Redbridge Health and Wellbeing Board Vicky Hobart Director, Public

Health NHS England Alison Goodlad Head of Primary

Care Commissioning

Redbridge LMC representative Dr Ambish Shah Chair Redbridge CCG Dr Anil Mehta Chair

190

To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body From: Marie Price, Director of corporate services Date: 24 March 2016 Subject: Use of the Clinical Commissioning Group’s seal Executive summary The Clinical Commissioning Group’s constitution includes guidance the use of the Group’s Seal and authorisation of documents (section 10). In line with this guidance and our requirements, this report includes the details of the use of the Group’s seal during 2015/16. The seal was applied four times during the year for three lease agreements and one framework partnership agreement.

Recommendations The governing body is asked to: • Note the report.

1.0 Purpose of the report 1.1 To advise the governing body on the use of the seal during 2015/16.

2.0 Application of the seal 2.1 The Group’s seal was applied to the following:

• Framework Partnership Agreement (Better Care Fund) which was authorised by

Conor Burke, chief officer and Tom Travers, chief finance officer on 22 May 2015.

• Lease of the fifth floor, Becketts House which was authorised by Conor Burke, chief officer and Tom Travers, chief finance officer on 11 September 2015.

• Lease of part of the sixth floor, Becketts House which was authorised by Conor Burke, chief officer and Tom Travers, chief finance officer on 11 September 2015.

• Lease of Unit 6a Banters Trading Estate, Main Road, Great Leigh which was authorised by Conor Burke, chief officer and Tom Travers, chief finance officer on 26 October 2015.

3.0 Resources/investment 3.1 Resources associated with the cost of the lease were agreed by the chief finance

officer.

191

4.0 Equalities 4.1 There are no equalities issues arising from this report.

5.0 Risk 5.1 There are no risks arising from this report. 6.0 Managing conflicts of interest 6.1 There are not any conflict of interest implications in relation to this report.

Author: Anne-Marie Keliris, Company Secretary Date: 15 March 2016

192

To: Redbridge CCG Governing Body From: Kash Pandya, Vice Chair of the Finance & Delivery Committee and Lay Member,

Governance Date: 24 March 2016 Subject: Feedback report from the February 2016 Finance & Delivery Committee meeting Summary The Redbridge CCG Finance & Delivery Committee provides the minutes of each meeting to the Governing Body. To provide additional assurance to the Governing Body, this brief feedback report provides key highlights from the last meeting. Key challenges discussed and risks addressed:- Finance report

• Barts Health – this contract continues to present the largest financial risk to the CCG. The over performance is across a range of points of delivery.

• BHRUT - the first 8 months of data indicate over performance across a number of points of delivery. The Trust is also highlighting a significant RTT pressure which they have estimated to be in excess of £17m.

• Independent Sector - significant levels of activity are still being reported. The CSU presented an updated analysis report to the Committee on referrals to the Independent Sector.

• CHC – a forecast overspend of £1,648k was reported. Concerns were raised by the Committee about the level of challenge still facing the CCG if it was to achieve the agreed financial targets for 2015/16 and those for 2016/17. It was agreed that a review of the budget will be undertaken as a priority to identify opportunities for savings. Borough risk register: The risks were discussed and Committee members agreed to additional risks being added; issues with the Electronic Referral System (C&B), London Ambulance Service, PELC. QIPP Committee members were briefed on the month 8 QIPP position for 15/16. Exception reports on four schemes were presented to the Committee; Cardiac Diagnostics, Calprotectin, Pathology, Un-planned Care. Contracts/deep dives The contracts report was reviewed and discussed and areas of concern were LAS and the over spend within the independent sector. Recommendation:

• The Governing Body is asked to note this feedback report and the February Committee minutes which provide more detail on all the matters considered.

15 March 2016

193

1

Draft Minutes of the Redbridge CCG Finance & Delivery Committee held on 23 February 2016 at Becketts House

Members: Kash Pandya (KP) Lay member, Governance – Vice Chair Dr Sarah Heyes (SH) Clinical director Dr Jyoti Sood (JS) Clinical director Rob Adcock (RA) Deputy Chief Financial Officer Tracy Welsh (TW) Deputy Chief Operating Officer Attendees: Mark Pearse (MP Interim Assistant Director of Contracts - CSU Kevin Hough (KH) Business Intelligence Analyst - CSU Anna McDonald (AM) Business manager Apologies: Dr Mehul Mathukia Dr Muhammad Tahir Dr Chidi Okorie Tom Travers Louise Mitchell 1.0 Welcome and apologies Action The chair welcomed members to the meeting and apologies were noted.

Before the meeting started, the Chair acknowledged that the meeting was following on directly after the Redbridge CCG Executive Committee and therefore, a number of the reports would have already been discussed at that meeting with some of the same attendees present.

1.1 Declarations of interests No additional declarations of interest were declared.

1.2 Minutes of the last meeting The minutes of the meeting held on 3 December 2015 were agreed as an

accurate record.

1.3 Matters arising/actions log

Summary of main activity spend for drugs – KP said he found the summary provided by Sanjay Patel (SP) QIPP Programme Pharmacist helpful and suggested it would be useful for it to be shared across the CCGs. RA to speak to SP about the possibility of sharing the paper excluding the individual practice information. SH added that in addition to providing the summary, SP had also visited her practice and she now had a better understanding of how the payment is achieved.

RA

194

2

Choose & Book (C&B) System – MP explained that the CSU is still trying to determine the causes of the problems with the system and the team are and are raising the matter at the contracts meetings. A verbal update to be given at the next meeting. SH advised that a member of staff at Barts Health had agreed to visit her practice to see for themselves, the problems GPs are having. KP asked for C&B for both BHRUT and Barts Health to be added to the Risk Register. The actions log was reviewed and updated.

MP LM

2.0 Finance reports / risks

2.1 Financial risks report The month 9 position has remained stable and the CCG has maintained a break even position. At month 9 this represents year to date slippage of £2,201k against the planned 1% year to date surplus and £3,302k slippage against the planned forecast 1% surplus. Barts Health – the contract continues to present the largest financial risk to the CCG. The latest data received from the Trust highlights over performance across a range of points of delivery. The reported forecast outturn at month 9 is a £4.6m overspend, which includes assumptions that a number of challenges are successful, and that worsening activity trends are mitigated. The CSU has undertaken further analysis and discussions with the Trust continue regarding agreeing a year end position. BHRUT - The first 8 months of data indicate over-performance within a number of points of delivery. The CSU is working through the Q1and Q2 reconciliation process which will inform the final position. The current level of activity and charges made by the Trust could lead to a significant cost pressure in 2016/17, which would be unaffordable within current funding levels. The Trust is also highlighting a significant Trust wide RTT pressure which they have estimated in excess of £17m. Associates - a number of large financial pressures are being highlighted across the associate contracts. The largest two over performances are the Homerton contract which reports a forecast overspend of £1,030k and Guys and St Thomas’s which reports a forecast overspend of £607k. The main drivers behind the Homerton overspend are IVF cycles and coding on the maternity pathway. The position on Guys has worsened by £411k since month 8 due to a critical care patient who has been in the Trust since the beginning of the year. Independent Sector - significant levels of activity are being reported across the range of independent providers. This has led to a forecast overspend across the ISTC, Independent Diagnostics, Spire and BMI budgets of £1.68m. Co-Commissioning - a year to date overspend of £162k was reported. Projections from NHSE show a potential year end over spend up to £600k. Further information requests have been made to NHSE in relation to this. A non-recurrent resource adjustment will be made to the CCGs baseline in month 10, when NHSE will transfer the financial benefit of 14/15 accruals to the CCG. This will help to mitigate the year to date overspend reported in month 9. Continuing Care - a forecast overspend of £1,648k was reported. Work is on-going to finalise the operational reporting with the CAPS system. Until reliable activity data is used to drive the financial project, a risk with regard to the estimated position remains. Prescribing - the final outturn position will be heavily impacted by QIPP delivery and Category M prices. The CCG prescribing team have identified a potential additional risk of approximately £600k. The data will continue to be

195

3

carefully monitored. KP expressed his concern about the risks associated with the delivery of the proposed 2016/17 budget and asked for a line by line review of the budget to be undertaken as a priority to identify opportunities for savings and also asked for a report back to the committee. TW to feedback the requests to LM. KP added that the committee needs to see a QIPP plan as soon as possible. TW advised that the QIPP plan is now much more aligned to Transformation Programme. RA said significant QIPPs are needed and they will be more effective if they cover a broader area. SH gave her view on why she feels that the MSK QIPP project is unlikely to succeed and TW responded saying the general feedback is quite positive and it’s not known yet if the underlying assumptions are right. SH and JS raised concerns that clinicians are not yet sighted on what the QIPP is for next year. RA responded saying we have to have clinically led QIPPs and TW added that the CCG is looking at a bigger scale as part of the Transformation Programme. 2.2 Independent Sector Referral Analysis – update report KH presented the updated paper which showed planned care activity trends in the Independent Sector and Independent Sector activity and referral information comparing this year’s data with the same period last year. SH asked if the proposal to develop a pathway along the lines of a “one stop shop” was still being worked on with Holly House, acknowledging that this had not been possible during 2015/16 due to the provider’s IT system. TW confirmed this was the case and that she was also looking at the potential for doing this in other specialties e.g. Gynaecology and also rolling out at Spire. JS asked TW if she could bring some information relating to Pain Management procedures being undertaken at Spire and Holly House, specifically spinal injections along to one of the Locality meetings with information on the IFR process that is applied to treatments that require approval under the Policy of Limited Clinical Value (PoLCV) and TW agreed. JS added that SPIRE and Holly House are not adhering to the policy. MP to raise the issue at the contracts meeting. 2.3 Borough Risk Register The risk register was reviewed. KP said he was concerned at the number of risks on the register and said he would like to meet with LM before the next meeting to go through the register in more detail to see if any of the risks could be condensed. KP also asked for the ‘target risk rating’ column to indicate when the CCG expects it to be achieved and also for C&B and PELC to be added. SH reported that LAS are in special measures and it was agreed this should be added to the risk registers for all 3 CCGs. 2.4 QIPP delivery 15/16 Month eight flex data is reporting achievement of £915K actual savings against a target of £1.08M which represents a year to date saving of £5.55M against a plan of £6.52M. Four schemes have reached escalation level and exception reports on each were escalated to the Committee. 2.4.1 Exception reports Cardiac diagnostics - over performance against activity is largely attributable to the Echo modality, which has grown at both BHRUT and the new community provider. The CCG expects to see improved performance from month 9. Calprotectin - since the last committee meeting the CCG has carried out a

TW TW MP LM LM

196

4

further review of the scheme’s performance and has issued a revised action plan which will focus on working with high performing practices to provide feedback through localities to share learning. In addition the CCG will look to review patient outcomes following the use of the test to understand if the correct cohort of patients is accessing the diagnostic. Pathology – the CCG has developed a plan that will focus on addressing the disparity between Barts Health and BHRUT performance. The CCG has also identified an additional test which may provide a further QIPP opportunity. JS said there have been 10,000 less tests requested and she is not sure what else can be done. Un-planned care - the CCG is continuing to implement the recovery plan agreed in September. Since the last report the CCG has worked with BHRUT to address double counting of activity in relation to Ambulatory Care and will work with both the Trust and the CSU to identify the cause for the increase in admissions related to heart failure. TW confirmed that examples of best practice are being shared at locality meetings. Community Diagnostics – Following the December 2015 Committee meeting, attention was drawn to a request within the QIPP delivery report which was a recommendation to close down the current Community Diagnostic scheme and implement a revised scheme focusing on specific pathways. Committee members were asked to consider this recommendation via a virtual arrangement and the recommendation was supported. 2.4.2 QIPP Plans 16/17 It was acknowledged that what needs to be done had been discussed. KP reiterated the need to undertake a line by line review of the budget as a priority.

3.0 Contracts position and deep dive reports

3.1 Contracts position The content of the report was noted. KP added that LAS is a concern and also the over spend within the independent sector. 3.2 Updated schedule of contracts MP presented the schedule showing all the contracts held by the CCG. KP said he was concerned about the number of contracts that still remain un-signed at this stage of the financial year and said the CCG needs to think how this can be avoided in 16/17. RA reminded members that the CCG is not the lead commissioner for a number of the contracts. It was also noted that the RAG rating within the schedule relates to how the contract is performing. Sarah Heyes left the meeting KP asked MP for a cover report to accompany the schedule at each meeting going forward giving key highlights and also to highlight in the cover report which contracts are coming up for renewal to avoid the need for tender waivers.

MP

4.0 Any other business

197

5

Cancer breaches - JS asked if it would be possible to find out how many cancer breaches there have been this year compared to last year. KH confirmed that the number of breaches in terms of the pathway could be quantified. MP/KH to provide the information to JS by 20 March so that JS can take it to the BHR-wide Cancer Group.

MP/KH

5.0 Date of next meeting

28 April 2016 1.00pm – 3.00pm Becketts House

198

To: Barking & Dagenham, Havering and Redbridge CCGs

From: Kash Pandya, Chair of Audit & Governance Committee

Date: November Governing Body meetings

Subject: Feedback from the 19 January 2016 Audit & Governance Committee meeting

Summary

The BHR Audit & Governance Committee provides the minutes of each meeting to the three BHR Governing Bodies. To provide additional assurance, this Committee Chair’s report provides the key matters arising from the last meeting on 19 January 2016 to be drawn to the attention of the Governing bodies.

• Progress in closing down and preparing the 2015/16 accounts and the annual report is on track

• The Committee remains very concerned about the risks still to be addressed to achieve the 2015/16 year-end financial targets and the outlook for meeting them in 2016/17. Areas of particular concern include continued over-activity at our acute providers, the unquantified Referral to Treatment (RTT) backlogs, the continuing health care (CHC) overspends and difficulties in delivery of QIPP targets.

• The Committee noted the mitigations in place or being developed by officers and requested a further report on progress made in achieving financial balance at the March Audit Committee meeting

• The Committee approved the external audit plan for 2015/16 and noted the progress on the delivery of the internal audit and local counter fraud plans for 2015/16. The Committee were assured that the arrangements for the payment of CHC invoices had been strengthened and that a review on sponsorship had not identified any matters of significant concern. However, the Committee decided that it wanted continued vigilance by auditors and officers over the arrangements for sponsorship and declarations of interests. A standing group of the Audit Committee is continuing to review the effectiveness of these arrangements.

• The Committee considered the arrangements for the delivery of QIPP. The Committee welcomed the deep dives being undertaken on QIPP schemes that were not delivering as expected but expressed concern about the limited progress in delivering QIPP targets that are currently protected by the BHRUT fixed price contract. A further report on QIPP delivery will be considered by the Audit Committee during 2016.

• The Committee approved several information governance policies and were assured that good progress was being made by the CCGs in completing mandatory information governance training by 31st March 2016.

The Audit Committee minutes refer to a variety of other matters which are not recorded within these key messages.

Kash Pandya, Audit Committee Chair

2 March 2016

199

1 Draft Minutes BHR Audit Committee 19 January 2016 v1

Draft Minutes of the Joint Barking & Dagenham, Havering and Redbridge CCGs Audit &Governance Committee held on 19 January 2016 at Becketts House 9.00-12.30pm.

Present –Members

Kash Pandya (KP) BHR Audit Chair, Lay Member for Audit & Governance Khalil Ali (KA) Lay Member PPI Redbridge CCG Charles Beaumont (CB) BHR Co-opted Member for Audit & Governance Richard Coleman (RC) Lay Member PPI Havering Ah-Fee Chan (AFC) Secondary Care Consultant In attendance-Officers

Marie Price (MP) BHR Director of Corporate Services Tom Travers (TT) BHR Chief Financial Officer (CFO) Paul Hunt (PH) NELCSU, Senior Financial Control Manager Anne-Marie Keliris (AMK) BHR Company Secretary Rob Meaker (RM) part Director of Innovation Sarah See (SS) part Director of Primary Care Transformation Pam Dobson (PD) part Asst. Director of Corporate Services In attendance-auditors

Nick Atkinson (NA) Internal Auditor, RSM John Elbake (JE) Internal Auditor, RSM Gemma Higginson (GH) LCFS RSM Charlie Nicholl (CN) LCFS, RSM Stephen Bladen (SB) External Auditors Ernst & Young Kevin Suter (KS) External Auditors Ernst & Young

Action

9.00 Committee Members held a short private meeting and a further brief meeting with the Internal Auditor

9.30 01/16

Welcome and Apologies for absence

Apologies were received from Sahdia Warraich.

02/16 Declaration of Interests (DOI) Members declared no further interests to that on the 3 CCG registers provided.

03/16 Minutes of meeting held on 8 December 2015 The minutes of the previous meeting were agreed subject to the change of “locus

to focus” the minutes would be signed by the Chair as a correct record.

AW

200


04/16 Matters Arising Further to minute 110/15 – JE agreed to report an update to the next committee

on primary care self-certification. Further to minute 112/15 – The next LCFS benchmarking report will be shared with members.

JE RSM

05/16 Primary Care A recently issued Internal Audit report, prepared by exception, that included

findings on Co-commissioning and Contract Management was provided and discussed. The report highlighted the overspend position at M7 for all three CCGs but the forecast remained at break-even by year end. The report also provided good practice benchmarking for consideration. In response to the detailed findings an action plan had been agreed by management with low-medium priority actions. SS reported that the self-certification was not ready for review. She added that steps have been taken to address clinical engagement on the PCC and delivery of the QIPP. There had been suggestions around good practice including a clinical senate which needed to be explored further. RC questioned where the clinical senate would sit within the governance structure. SS responded that this still needs to be explored and would be discussed with WEL colleagues as we would be reluctant to add an unnecessary meeting to an already busy corporate calendar. KA questioned if the responsibilities of the clinical senate would be similar to that of the former professional executive committee adding that this would need to align to our strategies and a strong business case would be required for its creation. CN reported that only contracts over the value of £200k needed to include a fraud profile and would welcome a discussion on this outside of the meeting to clarify this. RC highlighted 2 errors for correction in section 3.5 and 3.8. SS reported that all actions are currently being picked up and she would update on progress at the next meeting. The Chair questioned when the risk awareness training would be taking place for GB members. CN reported that this would take place at executive committees and the Chair confirmed he would also attend. The IA report was noted.

RSM SS

06/16 Internal Audit 06/1 Cover report on BHR and CSU progress- The report highlighted progress

against IA plans and reports. Two final reports had been issued on Primary Care Commissioning (referenced above), Contract Management and an advisory report on Continuing Health Care payments. Work continued on the audits of QIPP, Procurement, IG and IT security. The GP Federation conflicts of interest review will start in February. It was noted that NHSE had requested early notification of any issues relating to the Internal Governance Statement 6/1 BHR Progress Two low priority IA recommendations had been followed up and were now implemented. Early notification of any known governance issues were required on

201


an exception basis as part of the M9 data collection and these were required to be signed off and submitted by 21 January. The draft HOIAOs were due by 22 Feb and it was confirmed these were on track. The report also highlighted a number of briefings issued since the last meeting Referring to the draft HOIAOs, the Chair questioned if there were any negative features in the report that the committee should be aware of. JE reported that the Barking & Dagenham CHC issue would be raised but it will still be a positive report. TT commented that he was not expecting this to be included or feature significantly as this was not on the original work plan. KP agreed that reference to this being an advisory piece of work needed to be clear. 6/2 CSU Progress Final reports had been issued on IT General Controls, Business Continuity/Disaster recovery and Continuing Health Care and these had been considered at the Quality Assurance Group. There were three reports out as drafts on Procurement, Co-Commissioning and Provider Quality Management. There had been a follow-up of 10 recommendations, 7 of which had been implemented and the remaining 3 were not yet due. The Internal Audit reports were noted.

07/16 LCFS 07/1 BHR progress

The report referred to the completed local proactive exercise on Sponsorship discussed below. The report listed a number of activities for completion by the March audit meeting that included raising awareness by inform and involve and protect and deter exercises, completing review of non-creditor matches, early work on 2016/17 LCFS work-plan, and considering a local proactive exercise on Organised Crime Profiles (OCPs). Emerging fraud risks included a bogus invoice email, elsewhere in London, and public wi-fi access for cyber fraud. For reactive work there had been 4 referrals for investigation, 2 since closed and 2 still under investigation. 07/2 Sponsorship review The exercise had identified areas of good practice and 5 medium level management actions suggesting best practice identified from national benchmarking. The recommendations would be monitored and a full and final report issued to a subsequent meeting. CN thanked the CCG for their assistance with the review and was pleased to report that overall good processes are in place at the CCG. He added it was good to see the frequency of submissions by the medicines management team. MP reported that she had discussed the outcome with Belinda Krishek and will be continuing the working group to review if sponsorship should continue. The Chair asked for an update on the previous minute 116.2. TT reported that the staff member in question was no longer employed by the Provider. There had been a local exercise on impact and patient safety with a focus on small contracts to ensure lessons learnt. The Provider was working through the action plan which will need to be agreed by the CCG to give assurance on patient safety and processes. TT confirmed the matter was on the risk register. KA referred to the CCGs checking processes in procurement and questioned how deep can we go in terms of how good their processes are in checking fraud schemes were in place, suggesting that this should be part of the procurement process and PQQs. TT responded that the findings of the investigation would be reviewed to see if the

202


processes in place were risk satisfied.

08/16 External Audit The report that was provided outlined on-going progress of planning procedures

as described in the External Audit Plan agreed in December. This included reviewing the operation of the Better Care Fund (BCF) where the CSU had provided a paper considering accounting implications for the CCG’s financial statements. EA would review the paper and seek agreement with the CCGs on the accounting treatments proposed. Noting a risk assessment of the Value for Money (VFM) conclusion, KA expressed concern that this was based on a pure finance response. The Chair understood the concern raised but risk assessment was based on information available. KA questioned the robustness of the cover report and how this covers inequality and could be strengthened as this could help in preparation for the annual report. MP referred to a recent report around stroke consultation and engagement where significant thought was given to inequalities. She asked if KA could point out particular reports where more detail could be included and she would raise this with individual directors and would also explore other ways to improve this area. The update was noted.

09/16 Information Governance 09/01 Mandatory training update

RM reported that 84% of staff had completed mandatory training and was confident that the target would be achieved. Outstanding members of staff will be spoken to individually and a formal update will be reported to the next meeting. 09/02 Update on IG breaches No formal breaches. 09/03 IG Policy-Data Protection v13 to approve The committee approved the policy. The Chair highlighted section 9 on the role of the audit committee and ensuring that the committee is adhering to the policy. 09/04 Process for managing IG security incidents v13 to approve The committee approved the policy. The Chair drew attention to section 4, the role of the audit committee/Governing Body and ensuring that the committee/GB is adhering to the policy. Communication with staff was also highlighted. TT highlighted that it was a joint policy and needed to refer to “the CCG”. The updates were noted and the two policies approved subject to minor amendment.

RM RM

10/16 Governance 10/1 Mapping of Assurances

MP presented a first draft for comment of the mapping of where the CCG gains assurances. The Chair welcomed the useful starting point and this should be presented to the Governing Body in the future to see if all these meetings are required with the right people attending. KP questioned if there was similar mapping at other organisations and SB responded that there was and he would share similar information. KA welcomed the helpful first draft and would find it useful to include who owns

SB

203


risks and see that each committee/group has a risk register to ensure that risks can’t be missed. KS agreed adding that it is essential to be able to track a risk through the network of committees and the map is a good starting point. Members discussed how we could capture work such as the Healthwatch reports to ensure triangulation but without creating an industry. TT had some additional groups to add to the mapping and would discuss this with MP. The Chair added that there needed to be links to the GBAF and PD would be developing he map further. 10/2 Risk Appetite-next steps MP reported that monthly reviews take place with directors and risk appetite will be discussed at the next meeting. Consideration would be given to a GB session exploring risk appetite and an update would be provided. 10/3 Feedback from Working Group MP presented the minutes of the working group adding that the group are continuing to look at DOI in more detail including LMC membership. It was noted the group would continue to meet on a quarterly basis. KP welcomed this arrangement, adding it was important to ensure that reputational risk is mitigated. The governance reports were noted.

11/16 Finance updates 11/1 Financial Out-turn

TT presented the report and highlighted the projected outturn with a revised position previously reported. Main risk continues to be exposure to acute over- performance at Barts Health and the private sector. For Barts Health there was on-going negotiation and discussion with WEL and there was confidence in reaching an agreed position shortly. The Chair referred to Barts Health as the most serious issue impacting on both Redbridge and Barking & Dagenham and questioned if there are any suggestions to do anything differently to what was being done already. External Audit responded that lines of communication need to be kept open to try to agree the best position for year end. AFC questioned if the Barts Health contract need to be reviewed. TT responded that not all was related to patient activity and this was a complex issue discussed at the Finance and Delivery committee. The Chair raised whether charging for over-performance was appropriate whilst primary care provision is available. He proposed that everything to support BHRUT recovery should be done to enable patients to choose them over Barts Health and the private sector. TT agreed adding the CCG were taking a more robust approach. AFC commented that RTT needs to be reviewed and TT agreed adding that a commissioning clinical reference group had been established to review referral quality and protocols to reduce pressure. The Chair added that Audit Chairs colleagues in Imperial College and Barts Health are similarly concerned and welcomed any good practice to share. 11/2 Update on outstanding debt 2014/15 TT reported that the vast majority relates to walk-in-centre debt, which is a London-wide issue that relates to patient identifiable data (PID) and a next steps meeting has been arranged. KA questioned if there was assurance on the PID issue and TT reported that this was part of work undertaken across a London

TT

204


agreement. The Chair agreed to raise this with London audit chairs. CB would welcome a detailed breakdown of all outstanding debt last year for comparison with this year when available. TT agreed to present a process map for outstanding debt at the next meeting. 11/3 Debt Recovery Write off There were no write-offs required at present. 11/4 Annual Accounts/Annual Reports timetable and update on 9 month interim close-down TT reported that month 9 closedown had been completed within the NHS timetable and BCF was in line with the year- end timetable. The Chair asked the committee to note the proposed timetable for comments on draft accounts by 29 April 2016 and requested that members focus on their own individual CCGs. 11/5 IA final report on CHC payments at B& D and CHC financial position. TT presented an advisory report on CHC payments in Barking & Dagenham which highlighted 3 areas of significant exposure. RSM reported that the audit included a 3 month review of invoices. The same new process applied to all 3 boroughs where there were full records of patients and we were only paying for care we have commissioned. CB questioned how we recover the overpayments. RM responded that payments are recovered from the correct commissioners. The Chair referred to the Internal Audit during summer 2015 and the work undertaken to assure that patients under the care of our CCG are BHR patients and where legacy over-payments have to be recovered. RM referred to the Section 75agreement, with Redbridge having the biggest issue but not a large amount. The Chair asked for outstanding CHC debt to be included in lists of debtors. He was reassured by the report but requested a follow up with a broader CHC audit in due course. 11/7 Robustness of QIPP delivery The report provided outlined new measures this year to enhance the robustness of QIPP delivery. There had been a BHR wide QIPP summit in October, the QIPP programme had ben aligned to the One Team structure, there was greater emphasis on the QIPP plan at CCG level and the PMO were doing review of where QIPP delivered successfully across the country. A 16/17 QIPP pipeline and QIPP development timeline had also been agreed. TT reminded the committee that the three CCGs were separate statutory bodies. The Chair welcomed the work done and alignment to the Vanguard status. TT felt there was a stronger process this year and the QIPP was discussed at each individual finance and delivery committee and deep dives were undertaken. The Chair questioned how our local processes compare, noting the useful QIPP summit and positive working across the CCGs and by year end would we be delivering the QIPP that we wanted. CB questioned how it related to our forecast for next year. TT advised that the QIPP requirement was yet to be landed and whilst QIPP could deliver in financial terms at BHRUT, not so for activity. The primary care elements were raised and TT had to reach agreement with NHSE on the QIPP plan and there was tracking and monitoring at the PCC. The Chair added that the one team approach was vital to ensure CDs remain engaged together on particular QIPP areas. The Committee noted the contents of the progress report.

TT TT

205


12/16 Messages for Governing Body The Chair would liaise with the secretary on the key messages for feedback to the

next Governing Bodies.

13/16 Any Other Business It was noted that the NHSE had requested early notification of any issues relating

to the internal governance statement which need to be agreed by KP and Conor Burke. It was suggested that discussion would be needed to decide if key risks with providers should be highlighted.

KP/ MP/ RSM

14/16 Next Meeting The next meeting was confirmed as 8 March 2016

15/16 Items for Noting 15/1 Assurance Committee Minutes-the minutes of the meeting held on 2

October were noted.

15/2 Information Governance Steering Group Minutes-the minutes of the meetings held on 25 August and 23 September were noted.

15/3 Draft Finance & Delivery Committee Minutes-the minutes of the meetings held on 3, 8, 9 December 2015 were noted.

Signed………………………………………………..Date………………………….

206

To: Barking & Dagenham, Havering and Redbridge CCGs

From: Kash Pandya, Chair of Audit & Governance Committee

Date: March Governing Body meetings

Subject: Feedback from the 8 March 2016 Audit & Governance Committee meeting

Summary

The BHR Audit & Governance Committee provides the minutes of each meeting to the three BHR Governing Bodies. To provide additional assurance, this Committee Chair’s report provides the key matters arising from the last meeting on 8 March to be drawn to the attention of the Governing bodies.

• The Committee remain concerned about the about the level of risk associated with the delivery of the financial objectives for 2015/16 and 2016/17. The Committee were assured by the Chief Financial Officer (CFO) that with the mitigations in place, the 2015/16 financial targets would be met. He said that the budget for 2016/17 was still being worked on and several risks remained that had still to be mitigated, including the outcome of contract negotiations with BHRUT, level of Referral to Treatments (RTT) backlogs that would require to be funded and delivery of QIPP plans. The Committee requested a further update on progress made with the 2016/17 budget at its next meeting and also requested that internal audit review the robustness of the 2016/17 budget and QIPP plans.

• The Committee were advised that the preparation of the annual accounts and the annual report for 2015/16 remain on track for delivery for audit by 19th April 2016. There are no issues of concern to report on the accounts at the present time.

• The Committee approved the delegated functions self-certificated return to the NHSE for Quarter 3 of 2015/16. The Committee noted the actions being taken to mitigate the risks associated with the outcome of the PMS funding reviews for GP practices (currently in progress) and the actions being taken to ensure that conflicts of interests were effectively managed at PCCC meetings. The Committee also urged that greater priority be given to workforce planning to address current and projected shortfalls in GPs and nurses in primary care within the CCG area.

• The Committee was advised by internal audit that on the basis of their work to date, the CCG would most likely receive an unqualified Head of Internal Audit Opinion for 2015/16 with no caveats. The Committee also approved the internal audit and the local counter fraud plans for 2016/17. The plans include reviews of the budget, QIPP, procurement arrangements, contract performance management, PMS, cybersecurity and collaborative working arrangements.

• The Committee approved the updated 2015/16 external audit plan, including their proposals for assessing value for money arrangements. The Committee is also making arrangements to re-procure external audit services for 2017/18 onwards.

• The Committee were advised by officers that, subject to an internal audit review, the CCG was expecting to achieve a Level 3 for information governance for 2015/16. The Committee welcomed the progress made and thanked officers for their efforts.

The Audit Committee minutes refer to a variety of other matters which are not recorded within these key messages.

Kash Pandya, Audit Chair

14 March 2016 207

1 Draft Minutes BHR Audit Committee 8 March 2016 v1

Draft Minutes of the Joint Barking & Dagenham, Havering and Redbridge CCGs Audit &Governance Committee held on 8th March 2016 at Becketts House 9.00-12.00pm.

Present –Members

Kash Pandya (KP) BHR Audit Chair, Lay Member for Audit & Governance Khalil Ali (KA) Lay Member PPI Redbridge CCG Charles Beaumont (CB) BHR Co-opted Member for Audit & Governance Richard Coleman (RC) Lay Member PPI Havering Sahdia Warraich (SW) Lay Member PPI Barking & Dagenham In attendance-Officers

Marie Price (MP) BHR Director of Corporate Services Tom Travers (TT) BHR Chief Financial Officer (CFO) Paul Hunt (PH) NELCSU, Senior Financial Control Manager Angela Ward (AW) BHR Company Secretary Rob Meaker (RM) part Director of Innovation Sarah See (SS) part Director of Primary Care Transformation In attendance-auditors

Nick Atkinson (NA) Internal Auditor, RSM Gemma Higginson (GH) LCFS RSM Stephen Bladen (SB) External Auditors Ernst & Young Kevin Suter (KS) External Auditors Ernst & Young

Action

9.00- 9.30

Committee Members held a short private meeting and a further brief meeting with Internal Audit (IA) and Local Counter Fraud Service (LCFS) leads from RSM.

16/16 Welcome and Apologies for absence

There were no apologies for absence.

17/16 Declaration of Interests (DOI) In addition to the declarations on the registers provided, SW advised that her

earlier interest as a Healthwatch director had ceased on 7 December 2015. The register would be updated.

AW

18/16 Minutes of meeting held on 19 January 2016 The minutes of the previous meeting were agreed and would be signed by the

Chair as a correct record.

208


19/16 Matters Arising

In addition to the actions where reports were on the agenda, the Committee received updates on: 110/15 Primary Care self-certification- the Chair and IA had questioned auditing requirements with NHS London and a response was awaited. IA had agreed a way forward with TT and proposed a quarterly self-assessment review within their 2016/17 plan. 111/15 IA Progress report- TT would bring financial policies to the next meeting within a suite of documents. 112/15 LCFS- Reports on benchmarking were tabled. 11/16 Finance updates- O/S debt and London wide agreement- The Chair had raised this at an Audit Chairs meeting but there was no appetite for debate of the issues. CHC Payments- TT was awaiting a report from LBR. 13/16 AOB- Internal Governance Statement-provider issues. MP confirmed that the provider issues had now been referred to in the CCG returns.

TT

20/16 Primary Care self- certification Qtr.3 Due to the timing of submissions and the Committee, the PCCC had reviewed

and agreed the assessment subject to KP and Conor Burke sign-off. Comments from IA had been incorporated. The advertisement for an independent GP had received some interest and RC and the CCG Chairs would be involved in selection process - the closing date is the end of March. Both B& D and Havering had completed the selection process for voting GPs but an expression of interest was awaited from Redbridge GPs. Members noted the Membership change in the TOR these will be shared with the GBs for agreement - approval would be via NHS England as the statutory commissioner. RC requested that IA make an amendment to both CCG and CSU reports to note the typo referencing recruitment of the secondary care consultant - it should reference the independent GP. The progress of the PMS review and significant financial implications and risks were discussed. In Havering there was minimal financial impact with no practices adversely affected. Current variance between positions in Barking & Dagenham, Havering and Redbridge were noted. B & D and Havering LMC had been informed of the position but Redbridge had not as yet but proactive communication was being planned. Although to date financial focus had prevailed, quality impact was also essential. The Chair requested that the Qtr.4 return be brought to the Audit Committee and an update of the impact of the PMS review at that point. The Chair noted that the self-certification refer to the handling of CoIs, in particular of instances where GPs had been asked to leave the meeting where they had potential CoIs. He

SS

209


also stressed the need to highlight the risks associated with workforce shortfalls within the BHR area for GPs and practice nurses. The Committee supported the sign-off of the respective QTR3 2015/16 self-certificate.

21/16 Internal Audit 21.1 IA BHR progress report

BHR- The final Procurement and Contract Register report had been issued with an amber/green rating. Work was still in progress on Information Governance (IG) Toolkits, Board Assurance/Risk Management, QIPP (Quality, Innovation, Productivity and Prevention) and Continuing Health Care (CHC). All were at the debrief stage. NA also reported on the good progress made by the CCGs in implementing audit recommendations. IA was still awaiting the full range of evidence to be uploaded in support of the IG toolkits to review. The QIPP audit had been held back to accommodate latest changes to process and CHC results were reassuring so far. 21.2 CSU Progress report- Reports had been finalised on Procurement, Co- Commissioning and Provider Quality Management. NA also reported on the good progress made by the Commissioning Support Unit (CSU) in implementing audit recommendations. KA questioned CSU’s effectiveness, In his view, an important policy area of the contracted out service, was in engaging the patient voice in procurement. MP added the CSU work was not part of the CCG’s own communication and engagement work and this was being revisited in the revised engagement strategy. Member’s questioned the high level of purchases through the non- purchase order (PO) route. NA advised that the use of POs needed to be better analysed and good practice sought. PH agreed to speak to Tony Uttley at the CSU to investigate this further. It was agreed the Chair, CFO and NA would discuss provider quality management by the CSU and also in-house. 21.3 Draft Head of Internal Audit Opinion (HOIAO) for Barking & Dagenham, Havering and Redbridge CCGs-The draft reports provided the current opinion on concluded work that were submitted to meet national deadlines in February. At this point controls were found to be generally effective with no concerns raised. 21.4 IA Plan 16/17 and 3 year strategy for B& D, Havering & Redbridge CCGs- Drafts had been discussed with the CFO and awaited the Committee’s view. KA added that the CCGs were now three years in existence and he would expect green ratings for core business matters. NA added that there many complexities even within CCG core business with many systems in use and differing items were reviewed each year as the IA Plan was risk based. The Chair noted opinions were broadly positive by comparison with other CCGs. He questioned the position on the S75 agreement with LB B& D and NA was satisfied with the progress. There were 4 reports not yet due for finalisation and IA acknowledged that work was close to year-end. KA added it was important to align risks with our objectives and there had been mention at GBs over 3 years about Recovery Plans actual improvement. NA added this had been discussed at the CSU Assurance Group where limitations of the CCG in ensuring Trust improvements were discussed. The CCGs had a number of avenues to challenge and issue contract notices but much was the Trust responsibility. However, it was important not to lose focus on the smaller

PH

210


contracts and ensure grip was maintained on contract management. TT advised that issues were registered, audited, challenged and the CCGs needed to The progress reports and draft HOIAOs were noted and the IA Plans and 3 year strategy were approved subject to further discussion between the Chair and CFO.

22/16 LCFS It was confirmed that the planned working days aligned with the tender. A

training session had been planned for Redbridge and the recent presentation to CCG staff had been shared through the staff newsletter. The plan was awaiting NHS Protect standards to finalise mandatory requirements and was to be discussed further with the CFO. It was noted a full risk and bribery review would take place in-year. It was agreed that whistle-blowing would be added to the sources of information diagram. The Plan was agreed subject to discussion between the Chair and CFO and subject to flex between IA and LCFS work days.

23/16 External Audit (EA) EA Progress on Plans

The report summarised activities and provided an overview of the current stage of auditing and KS confirmed that the plan was on track to meet the national submission deadline of 27 May. Updated Plans for BHS CCGs Updated plans were provided that took account of new guidance around the EA’s Value for Money (VFM) conclusion for 2015/16. A risk assessment had since been completed and risks identified in the updated plans. Those risks, deemed significant were in the areas of Financial Planning and Resilience, Primary Care Co-commissioning and Provider Performance. The plans had also been updated following receipt of National Audit Office (NAO) guidance on service auditor reports. For Provider Performance, Members noted the current position with BHRUT, BartsHealth and also the London Ambulance Service (LAS) and the need for assurance to come from other CCGs who were the lead commissioners for some contracts. TT acknowledged the difficulties of being an associate provider and was the lead for the others e.g. Havering CCG for BHRU. The Chair called for further consideration of performance management of the associate contracts. SB said that he would be writing to the Chair to seek assurances about arrangements in place for mitigating fraud and corruption.. The updated Plan was approved.

SB

24/16 Information Governance RM confirmed the matters arising action relating to policies had been completed.

For the action on completing IG mandatory training before year-end, RM confirmed that the target had been met. IA were informed that all evidence in support of the Toolkits had now been uploaded and it was anticipated that BHR CCGs would move from a Level 2 to Level 3 position. It was agreed that subject to IA finding the evidence was satisfactory within the next few days, informing the Chair and the CFO, the CFO would review the completed documentation on behalf of the Audit Committee

211


and inform the Chair, who in turn would inform Members when sign-off was completed. The Chair reported that the Remuneration Committee had discussed mandatory training compliance and it was noted that to improve early response a deadline would be set his year for completion in the first quarter rather than last. The Toolkits were approved in principle subject to IA, CFO and Chair receiving final assurances.

25/16 Governance Update on Annual Reports progress

MP advised that the Annual Report production process for 2015/16 was on track and drafting in progress co-ordinated by Rowan Taylor. As in previous years they followed a national format, with some slight changes this year.. KA asked if there could be some benefits in including within the annual reports the key objectives of the CCG in respect of a particular service, the achievements to date and risks still being managed.. The Chair referred to a recent Havering CCG Members’ meeting presentation by the CCG Chair which had followed this format and might be useful as an aide memoire. Terms of Reference Review MP reported on a review of Committees maintaining a quorum and GB Member’s commitments. Noting a new secondary care consultant had joined B& D and Havering, a portfolio of meetings was required to make best use of their 1 day per week commitment and clinical expertise. Areas such as the developing ACO required input. The following was proposed; Audit Committee- No issues with maintaining a quorum, therefore remove secondary care consultant input with an on-going opportunity for the Committee to co-opt clinical input for any specific advice, if required. Remuneration Committee (Remco)- No issues with quorum, therefore remove secondary care consultant. Investment Committee- Risk of maintaining a quorum is high due to regular matters where conflicts of interest apply. It is proposed that Members of different CCGs (Chair, PPI Lay Member, secondary care consultant) can substitute for each of the three Committees meeting as one. SW commented on her concerns about GPS in attendance at the Investment Panel meetings, given their potential COIs. RC said that this was to gain a local perspective and that arrangements were in place to manage COIs during meetings by excluding them, if considered to be appropriate.. Primary Care Committee- The Terms of Reference had already been updated for the next GB. Quality & Safety Committee-It is recommended that the Redbridge secondary care clinician continues to act as Chair in 2016/17. Noting there are difficulties in maintaining a quorum for each of the 3 CCGs at this meeting in common, it is proposed that the CCG Chairs nominate Clinical Directors who can attend the set schedule of meetings. Establishing an Auditor Panel- The CCGs are required to appoint a Panel to advise on the appointment of External Auditors for 2017/18 and draft national

212


TORs support this function being performed by the Audit Committee. Noting the Committee had already pre-empted this process it was recommended that the Audit Committee form the Panel. Members supported all recommendations to be forwarded to the GBs for ratification.

26/16 Finance Updates 26.1 Financial out-turn and m9 accounts

BHR met the national deadlines for submitting draft accounts at the Month 9 position. A balances exercise has been agreed with Providers, bar Barts Health where there was an ongoing contract dispute. Although the CCGs are on track to meet the required 1% year-end surplus there are significant underlying risks, with Barts Health the largest, relating mainly to over-performance. There are many data challenges ongoing and contract levers have been applied but the position ahead is still unclear. EA were aware of the current position and risks associated with Barts. TT confirmed a prudent approach was taken but there was currently a gap of £3-400k to be resolved. Discussions were in progress with NHSE and Barts over specialist commissioning relating to misattributions and inappropriate billing. CB questioned the impact on next year and TT confirmed it would be financially challenging. The report provided a range of scenarios for each CCG entitled Downside, Reported and Upside, which were discussed by Members. Risks within Havering also included CHC due to density of Care Homes. KA, in considering root cause of yearly ongoing pressures, questioned whether budgets were correct and referral patterns were fully accounted for and would a summit be beneficial. He added that there had been much investment in primary care transformation, community and home care but it was clear it was still demand led. The Chair responded that there was a budget setting process review planned by IA this year. TT confirmed that both finance and delivery details were discussed at the Finance and Delivery Committees and deep dives into underlying issues carried out but there were always unplanned expenditure changes in year such as prescribing costs. 26.2 Update on O/S debt and write-offs TT advised that the CSU were working on resolution of the Walk in Centre recharges to be cleared as part of London agreement. CB questioned why the tranche of debt over 90 days was static and it was explained that billing for this year had been held back to bill for whole year in March. The current position on debts was noted. 26.3 Tender Waivers TT advised of a tender waiver for short term loan wheelchairs as this was a single provider. The tender waiver for a NHS 111 patient relationship manager was due to a single bidder with specialist expertise. The two tender waivers were noted. 26.4 Better Care Fund (BCF) accounting treatment The report provided information on the technical accounting treatment of the BCF Section 75 agreement and presentation of financial values within BHR year-end statements. KS confirmed the arrangements reflected their own

213


understanding. It was confirmed that BHR accounted for their own elements with a creditors/debtors process. In response to risk of non-delivery it was confirmed the risk share agreement would apply. The Chair called for checking whether BCF fund objectives were being met and whether any lessons learnt could be applied going forward. The technical advice was noted.

27/16 Messages for Governing Body The Chair would summarise the key messages and forward to the secretary.

28/16 Any Other Business The Chair would discuss developing a committee work-plan for 2016/17 with TT

and AW for the next meeting The Chair had discussed the ACO development with the BHRUT Audit Chair who was also the CEO of CIPFA.

KP/TT/AW

29/16 Next Meeting The next meeting was confirmed as Tuesday 19 April

30/16 Items for Noting 30.1 Lay Member training on co-commissioning Conflicts of Interest

management-Members received NHSE slides covering statutory requirements.

30.2 Assurance Committee Minutes-the draft minutes of the meeting held 3 February 2016 were noted.

30.3 Information Governance Steering Group Minutes-the minutes of the meeting held on 19 January 2016 were noted.

30.4 Draft Quality & Safety Committee minutes- the draft minutes of meeting held on 9 February 2016 were noted.

Signed………………………………………………..Date………………………….

214

Redbridge Executive Committee 23rd February 2016

13:00 – 15:00 Boardroom B, Becketts House

Present: Dr Anil Mehta (AM) Chair NHS Redbridge CCG Dr Shabana Ali (SA) Clinical Director of Wanstead & Woodford Locality Dr Samia Azeem (SAz) Clinical Director of Seven Kings Locality Conor Burke (CB) Chief Officer NHS Redbridge CCG Dr Sarah Heyes (SH) Clinical Director of Wanstead & Woodford Locality Dr Mehul Mathukia (MM) Clinical Director of Cranbrook & Loxford Dr Syed Raza (SR) Clinical Director of Seven Kings Locality Dr Jyoti Sood (JS) Clinical Director of Seven Kings Locality Dr Heath Springer (HS) Clinical Director of Fairlop Locality Dr Muhammad Tahir (MT) Clinical Director of Fairlop Locality Tom Travers (TT) Chief Finance Officer NHS Redbridge CCG In attendance Sue Elliott (SE) Deputy Director, Safeguarding Jenny King (JK) Redbridge Locality Support (minutes) Peter McDonnell (PT) Senior Contract Manager, NEL Commissioning Support Unit Sarah See (SS) Director, Primary Care Transformation Tracy Welsh (TW) Deputy Chief Operating Officer Apologies Jacqui Himbury Nurse Director, BHRCCGs Louise Mitchell Chief Operating Officer NHS Redbridge CCG Tracey Murphy Executive Assistant Dr Chidi Okorie Clinical Director of Cranbrook & Loxford

Item Action 1.0 Welcome and Apologies AM welcomed all to the meeting and apologies were received as shown above. 1.1 Declaration of Conflict of Interest No new declarations were reported. 1.2 Notes/Actions of previous meeting

215

Page 2 of 8

The content of the previous minutes were agreed as accurate; SA requested that a note be made to show that she was in attendance. Amend previous minutes to show SA was in attendance.

TM

1.3 Matters arising Update of Risk Register

SE reported that the issues previously identified were being addressed and an update would be available at the next meeting. Quality and Safety GP alerts TW confirmed that the report had been shared at the Locality Meetings. Risk register TW stated that the format/wording of the risk register has been updated to address the issues previously identified. This should take effect from next month. Co-Commissioning SS reported that further to the positive news of NHS England agreeing that the CCG can have two voting GP members on its Primary Care Commissioning (PCC) Committee, an email has now been sent to all GPs outlining the process for the selection. It was agreed that Dr Shabana Ali, Clinical Director with a portfolio for primary care, would be ideal for the role. SS would update at next meeting Motor Neurone Disease TW confirmed that no other neurological conditions were included. Diabetes Strategy – Concordat TT stated that he had liaised with the CSU regarding the stratification of the contract in relation to the quality concerns previously mentioned. They have responded with a proposal on how they will performance manage the smaller contracts to address the quality concerns.

SE/JH SS

2.0 Primary Care Transformation 2.1 Primary Care Update SS reiterated that as agreed at a previous meeting the next PLE would focus on

Primary Care Transformation. She circulated a draft version of the suggested presentation and requested members’ opinion on how they would like this be presented. To comply with an action from JET, the Urgent and Emergency Care Vanguard would also be included in the programme. AM stressed that this would be one of the most important PLE events delivered. Based on prior conversations with Dr Joe Cohen, Dr Sally Smith and TW it is clear that this is an important issue and GPs need to be clear on the ramifications for them. After an in-depth discussion, the following was noted. • Start the session by reminding attendees that they have already agreed to locality

working

• Slide 2 - SS confirmed that feedback quoted was based on actual feedback received from GPs via locality meetings. Action:

AM

216

Page 3 of 8

Amend slide to read “as evidence from locality meetings” • Slide 3 – SH requested that Barts Health information be included; this was agreed.

Action: Include Barts Health information

• Slide 4 – All agreed that the jargon buster was useful. SH: suggested that a

compare and contrast section be added to highlight the differences. Ie., how is Accountable Care different from what we already have? This was agreed Action: Add ‘compare and contract’ section

Ensure the following were included in presentation: • Add examples of how GPs will benefit: ‘Why can’t I see a dermatologist at my

surgery? Why do I need to be referred?’ • Ensure presentation highlights the effect on practices on a day to day basis. • Be realistic as to what can deliver be delivered. • Manage expectation

• Slide 5 – Devolution - There was an emotive discussion on this topic and as the

eventual outcome was unclear it was decided to leave this slide until the end of the presentation to avoid distracting from the other issues.

Have pre-empting responses ready: • We had dermatology service in the past which was pulled as it was deemed

unviable; how is this different? • If a whole team was in charge of finance in the past and failed what will be different

now? • Will the contract be for in hours or out of hours? • Is the primary care strategy working? • How do we tackle workforce issues: people leaving the profession? Concerns noted included: • Different localities are at different stages; there are trust issues; • Fear of loss of autonomy; practices are used to a certain way of working • Will GPs lose ownership? • IT issues • Estates • Community services – will they be more accountable to practices

CB appreciated these sentiments and suggested that a non-interested party be brought in to mediate any issues/concerns. In response of issues relating to estates, SS reassured that an Estates Strategy is being developed and any capital funding going forward will need to be in line with state strategy.

SS SS SS SS SS SS SS/CDs

Actions:

217

Page 4 of 8

Forward any further comments to SS Defer ACO until more firm information is available Share PLE agenda once agreed SS will have dialogue with all CDs before PLE so everyone on same page; pre-meets to be arranged Have a follow up PLE in April AM thanked SS for attending

ALL SS SS SS SS/TW

3.0 Risk Assurance 3.1 Risk Register TW presented a paper prepared by Pam Dobson. The Clinical Commissioning Group

has 53 risks on its January risk register. There are 19 risks with a red (severe) rating, an increase of two since the last meeting in November 2015. Five new risks were added to the risk register since the last meeting. The first two listed below being red rated and the remainder rated as amber. 1. Concordia community diagnostic service 2. New born hearing service at Queens hospital 3. Co-commissioning: Spearpoint practice dispersal 4. BHRUT and the revised latent TB pathway – this has been de-escalated and is 5. moving forward 6. Utilisation of the CAMHS transformation plan funds SH expressed her concern regarding practices connected with Barts Health receiving a large number of letters relating to RTT and IT issues, requesting GPs to check with patients as to whether or not they have been referred. She reported that at a separate meeting RTT issues were discussed and it was agreed that GPs would assist where possible, with the following conditions • There would be approximately 10 patients per practice • GPs would be notified prior to any letter being sent so this could be discussed at

locality meetings • Barts Health would attempt to contact the patient 2/3 times before contacting GP • Any actions would not coincide with QOF or CQC • Appropriate governance would be in place

SH reported that there is a 21 day deadline and it is impossible for practices to comply. TW responded that she is aware of this issue and action is being taken to address this. She was not however aware of the 21 day deadline. CB agreed that this this was a serious issue as it related to patient safety and needed to be addressed. He will draft a letter to the Chief Executive at Barts expressing the Committee’s concern. Action Draft letter to Chief Executive; governance issues, patient safety, unacceptable time scale, Clarify process with WELC

CB TW

4.0 Strategy and Planning

218

Page 5 of 8

This had been covered as part of the primary care discussion. 4.1 Procurement Pipeline and Contracts update PM presented a report relating to current contractual arrangements for a number of

small community based service contracts ending on 31st March 2016 and sought agreement from the Executive Committee to implement the recommendations from the 1st April 2016 or make a recommendation for endorsement to the Governing Body if the contract was worth over £250,000. The Committee were asked to: • Support the procurement and contractual recommendations • Agree the approach in relation to those contracts under £250,000 • Recommend agreement to the Governing Body where the contract costs exceed

£250,000 for the proposal, which includes PROVIDE Essex, St Francis, Haven House and the TOPs (Termination of Pregnancy) arrangements.

The Committee Agreed.

5.0 Quality and Performance TT presented a report summarising the financial position as at the end of December

2015 (Month 9). The following points were highlighted.

• As at the end of Month 9 the CCG achieved breakeven against a year to date planned surplus of £2,476k. It is forecast the CCG will achieve a year end outturn of breakeven.

• The CCG has a resource limit of £362,459k; there have been three changes to the resource limit at Month 9 to Liaison Psychiatry, UEC Vanguard Sites, and Mental Health CAMHs – Transformational Allocation.

• Barts Health risk assessment has resulted in a predicted year-end over performance of £4,578k for Redbridge.

• Barts Health – the Lead Commissioners are nearing agreement of the year end position with Barts and NHSE that encompasses the CCG position and specialist commissioning position.

• BHRUT – financial position is largely protected by the fixed priced deal; discussions are ongoing with the Trust around performance particularly over 52 week wait on RTT and cancer performance.

• Significant event: long stay care patient at Guys which has been billed to Redbridge dating back to 2014. This is being challenged to ensure it isn’t specialist commissioning and that the entire stay was at level 3 organ support.

• Over prescribing and Continuing Health Care continue to represent a pressure to the CCG.

A number of risks have been identified within the reported position. These are being managed and it is expected that the mitigating actions identified will allow the CCG to deliver the break even position. The committee were asked to:

219

Page 6 of 8

Agree the financial position noting the action taken to achieve it. The Committee Agreed

5.1 Finance and Contract Report TT presented a report in relation to the main providers; Barking, Havering and

Redbridge University Hospitals NHS Trust (BHRUT), Barts Health NHS Trust (Barts), North East London Foundation Trust (NELFT), Partnership of East London Cooperatives (PELC) and the London Ambulance Service (LAS). Particular points to note:

• BHRUT A&E performance year to date 91.5% through December continues to be a challenge.

• RTT BHRUT – ongoing work continuing • BHRUT Diagnostics • Cancer standards • Risks identified by NELFT in relation to service continuity. • PELC contract discussions • LAS difficulties

The Committee were asked to:

• Agree the reported M8 position for the two main acute and two main non-acute contracts.

• Review the performance against standards and requirements and agree remedial actions being taken. • Agree any further risks that are to be added to the Assurance Framework.

The Committee agreed

5.2 2016/17 Budget allocation update TT presented a report updating the current status of the 2016/17 Financial Planning

process. The first draft of the operating plan has been produced and submitted to NHS England. The plan sets out a planned surplus for the CCG of £3.4m, and achieves business rules as required by NHSE with the exception of an uncommitted 1% non- recurrent reserve. At this stage the plan includes a high level of risk and has a QIPP requirement of £9.8m. The paper identifies key assumptions and risks to achievement of the CCG’s financial targets in 2016/17. Particular points to note:

• The CCG has received Programme allocation growth of £16,164K (5.1%) in 2016/17.

• We are required to hold a 0.5% Contingency as a business rule • We are required to hold a 1% non-recurrent reserve (Transformation Fund)

which is not included in the operating plan. Given then RTT issues we have informed NHSE that we cannot hold that 1% uncommitted, it needs to be the first source of funding. NHSE are challenging this.

• Pressure in budget: as shown in the report there is a tariff inflator cost pressure this year; in recent years there has been a deflator; a net pressure on providers in term of efficiently assumption within the tariff. A level of growth uplift in budgets for next year is included

220

Page 7 of 8

• GP IT is now funded in the baseline • QIPP target for next year is £9.8million • In terms of change of Governance; QIPP transformation programmes, new ways

of working, aligning capacity, planned care and mental health etc - all of these work streams have a benefit tracker which will be driven through PMO and fed back to borough level plans, which will help support the CCG in building up £9.8m.

• Most important message is despite 5.1% uplift, the financial planning for next year is going to be a significant financial challenge. To reach the business rules compliance position represented in the report we have not been able to include an acute activity reserve for budgets. Therefore, if any of the contracts over perform the levels allowed for in the budgets, there will need to be an increase in QIPP and consider investment/disinvestment de-commissioning which the CCG has not considered before.

TT clarified that RTT, Cancer, A&E attendance and non-elective admissions at BHRUT sit within the fixed price agreement for this year but there will be ramifications next year. BHRUT have employed a number of people to follow through on clinical issues/recode. The cost of that in terms of the 2016/17 contract is approximately an extra £30m cost to Redbridge for the same activity. In terms of the process of challenging, this is on-going dialogue and promotes the clinical audit. The Executive Committee noted the current status of the financial planning process for 2016/17.

5.3 QIPP Report TW presented a report prepared by LM outlining the proposed reporting and assurance

framework for the delivery of the 2015/16 QIPP plan. Redbridge CCG has a QIPP plan of £11.1m for 2015/16, which includes £4.5M currently unidentified (40.5% of target).

Underperformance has been reported to the Finance and Delivery Committee for the following projects:

• Calprotectin (activity and delivery milestones off plan) • Cardiac Diagnostics (finance off plan) • Pathology (finance off plan) • Unplanned Care (finance and activity off plan)

TW confirmed that QIPP next year will focus on transactional schemes and transformation will focus on Vanguard, planned care, mental health etc. The borough team will continue to progress the pipleline projects. SA had a concern regarding the over performing of cardiac diagnostics in the community. Currently data is better from BHRUT as Barts lag in returning data. From initial activity it appears that planned cardiology referrals are 24% down compared to last year, however, on further investigation it transpires that Redbridge has over performed. SA has identified that Wanstead and Woodford GPs using Barts Health show a very high use in echo activity. This appears to be due to the way Barts’ pathology data reports abnormal results and the GP therefore requesting an echo. This has been highlighted and corrected but this needs data to be captured. TT stated that this would be captured in terms of activity delivery.

221

Page 8 of 8

Recommendations The committee was asked to: • Note the month eight (flex) position at CCG and project level • Review the actions that are being taken to deliver projects within each

workstream • Recommend any further actions that should be taken by the executive

committee to manage the risks to delivery of the QIPP • Escalate significant risks to delivery to the Finance and Delivery

Committee

Agreed

5.4 Quality and Safety Report SE presented a paper which gave an overview of the 5 significant Serious Incidents.

The report contained details of the incident, risks, mitigating action taken and assurance levels. SH raised the issue of Barts Health misplaced NG tubes and would like a progress update. SE will take this back. Action: Feedback progress on misplace NG tubes at Barts Health

SE

6.0 Item for Information • Locality Committee Meetings • JET • System Resilience Group • Area Prescribing Committee

7.0 Any Other Business 8.0 Date of Next Meeting

19th April 2016

222

Redbridge CCG PEF, 19 January 2015 Page 1 of 3

Redbridge Clinical Commissioning Group Patient Engagement Forum (PEF)

Tuesday, 19 January 2016

Becketts House, Ilford

Minutes of the meeting

Present: Lorraine Silver Howard Clarke-Melville

PEF Chair, Fairlop PEF Vice-Chair, Seven Kings

David Lyon Dee Data Khalil Ali Shushila Patel Vivien Nathan Anne Bertrand

PEF member, Fairlop PEF member, Cranbrook and Loxford Lay member, Redbridge CCG PEF member, Cranbrook and Loxford PEF member, Cranbrook and Loxford Redbridge Healthwatch and WW PEF rep PEF

Swati Vyas Health Partnership manager, Redbridge CVS John Elliff The Redbridge Forum Samina Dyer Support worker for Mr Elliff Michelle Greene PEF member, Wanstead and Woodford Dr Jyoti Sood Clinical Director, Redbridge CCG Raina Gee The Redbridge Youth Council Co-ordinator James Edwards Redbridge Youth Council Bridget Okhioigbe Redbridge Youth Council Tahir Mahmud PEF member, Seven Kings Louise Mitchell Redbridge CCG COO Jean Goody PEF member, Fairlop Jon Abraham Redbridge Concern In attendance: Abbie Malambo London Borough of Redbridge, Public Health Ola Kanu TB Awareness Project Coordinator & Community Fundraiser, Redbridge CVS Apologies: Jay Solanki PEF member, Cranbrook and Loxford Christine Lewis PEF member, Wanstead and Woodford Boba Rangelov PPE Advisor BHR CCGs Elaine Freedman PEF member, Seven Kings

Item Action

1 Welcome and apologies

Chair welcomed everyone, introductions were made and apologies accepted.

2 Minutes and matters arising (including PEF log)

2.1

2.2 2.2.1

Minutes were noted as a correct record of the meeting. All actions have been completed. PEF log The care.data: DL stated that there was no change to the position reported

223


2.2.2

2.2.3

2.2.4

from NHSE. Phlebotomy update: Working group met today, 19th January. Progress has been made regarding current service offer. Centres “proposed” are going back to BHRUT leads after today’s meeting to discuss proposals. Aim is to have “2” sites in every locality. Referral to the treatment (RTT): Action: DD to send link to the website to BR for further distribution to the group. Cervical smear tests: Action continues to be progressed with labs.

DD and BR

3.0 Redbridge CCG Lay member’s report-Khalil Ali, lay member

3.1 Main actions are: To clarify waiting time for children for IAPT and send to the group for info. To send info to PEF on sites where IAPT is delivered within Redbridge practices. Feedback on leaflets-image on leaflet has cross earrings, so this could preclude “faith” groups. ACTION: To feedback this to Simon James and Dr Chidi and also mental health groups.

LM and BR

4.0 The Redbridge Youth Council report-James Edwards, Bridget Okhioigbe with Raina Gee, YC Co-ordinator

4.1 Upcoming meeting is planned with Ian Duncan Smith. The young people will feedback at future meeting.

YC

5.0 The Redbridge Healthwatch report

5.1 AB provided an update from Redbridge Healthwatch. ACTION: Healthwatch to review wording of letter sent to PPGs that states they will conduct two visits a year to each PPG.

AB and CT

6.0 Feedback from the PPG localities

6.1 6.2 6.3 6.4 6.5 6.6

W/W issues received from Asya Patel need to be updated by Barts Health PEF requested to have info regarding which Patient expert groups currently exist Using syringes instead of white pots for urine sample: PEF is not happy with the BHRUT response and they would like to address this by writing the letter to BHRUT. ACTION: BR to draft a letter on behalf of PEF and LS to sign it off. ACTION: BR to update template to insert “date received” for each issue raised ACTION: Dr JS to update on diabetes strategy at future meeting ACTION: To take forward regarding patient transport at Barts Health

BR BR

BR BR

Dr JS

BR, TW and LM

7.0 Redbridge CCG Commissioning intentions 2016/17

7.1 LM gave a presentation about CCG’s commissioning intentions for the next year.

8.0 TB in Redbridge-Abbie Malambo, Public Health Redbridge and Ola Kanu, TB Awareness project, Redbridge CVS

8.1 Offer to PPGs from RCVS to go out to each PPG to discuss and raise awareness about TB ACTION: to send info to all PPG Chairs

BR

9.0

9.1

AOB including briefing from Sarah See, Director of Primary Care Transformation programme PEF suggested that patients are phoned not just written to in terms of significant changes within practice.

SS and BR

9.1

10.0 Close and date of the next meeting

10.1 LS closed the meeting and thanked everyone. The next meeting is on Tuesday, 15th March 2016, Becketts House, Ilford, IG1 2QX, 2nd floor, boardroom A.

224


Dates of the PEF meetings in 2016 are: Tuesday, 17 May 2016 Tuesday, 19 July 2016 Tuesday, 20 September 2016 Tuesday, 15 November 2016 All meetings are held 5-7pm in Becketts House, 2nd floor, boardroom A. Glossary: PEF Patient Engagement Forum CCG Clinical Commissioning Group YC Youth Council CVS Council for Voluntary Service PPE Patient and Public Engagement PPG Patient Participation Group BHR CCGs Barking and Dagenham, Havering and Redbridge Clinical

Commissioning Groups IAPT Improving Access to Psychological Therapies BHRUT Barking Havering and Redbridge NHS Trust

225

1

Joint Executive Team Meeting 14 January 2016

MINUTES

Attendees Title Dr Waseem Mohi Chair – Barking and Dagenham CCG Dr Rami Hara Clinical Director – Barking and Dagenham CCG Dr Gurkirit Kalkat Clinical Director – Barking and Dagenham CCG Dr Chandra Mohan Clinical Director – Barking and Dagenham CCG Dr Anju Gupta Clinical Director – Barking and Dagenham CCG Dr Jagan John Clinical Director – Barking and Dagenham CCG Sharon Morrow Chief Operating Officer – Barking and Dagenham CCG Dr Atul Aggarwal Chair – Havering CCG Alan Steward Chief Operating Officer – Havering CCG Dr Anil Mehta Chair – Redbridge CCG (meeting Chair) Dr Sarah Heyes Clinical Director – Redbridge CCG Dr Mehul Mathukia Clinical Director – Redbridge CCG Dr Shabana Ali Clinical Director – Redbridge CCG Dr Samia Azeem Clinical Director – Redbridge CCG Dr Syed Raza Clinical Director – Redbridge CCG Dr Muhammad Tahir (arrived 2.05pm) Clinical Director – Redbridge CCG Dr Heath Springer Clinical Director – Redbridge CCG Dr Chidi Okorie Clinical Director – Redbridge CCG Dr Jyoti Sood Clinical Director – Redbridge CCG Louise Mitchell Chief Operating Officer – Redbridge CCG Conor Burke Chief Officer – BHR CCGs Tom Travers Chief Financial Officer - BHR CCGs Jacqui Himbury Nurse Director – BHR CCGs Marie Price Director of Corporate Services – BHR CCGs Sarah See Director of Primary Care Transformation – BHR CCGs Rob Meaker (item 5.0) Director of Innovation - BHR CCGs Ian Winning North East London Commissioning Support Unit John Higton (item 4.0) Pederi Harriet North (item 4.0) Pederi 1.0 Welcome, Introduction and apologies

The following apologies were noted; Barking & Dagenham CCG: Dr Ravi Goriparthi Havering CCG: Dr Ashok Deshpande, Dr Gurdev Saini, Dr Alex Tran, Dr Ann Baldwin, Dr Maurice Sanomi, Dr Ranjan Adur BHR CCGs: Jane Gateley NEL CSU: Sue Anderson

226

2

2.0 Declarations of interest There were no new declarations of interest.

Note

3.0 Minutes from previous meeting/Matters arising Minutes of the meeting held on 10 December were agreed. There were no matters arising.

Note

4.0

Primary Care Transformation update Dr Ali gave an overview of the slide pack outlining the case for change, confirming that each CCG will have their individual strategy. There were a number of themes that had come out of the engagement process with GPs, which has helped to develop an emerging vision for primary care. A discussion was held on views of what GPs want for general practice, what they should or should not be offering and what can enable that to happen. It was acknowledged that there are differing views from GPs even at the same practice, depending on their experience, size of practice and their personal circumstances which makes this a challenging piece of work. It was agreed that changes need to be made at a locality level to try to get GPs to come to a consensus and make small changes to start to progress this and that if a small group are ready to move quickly they should be supported to do so. Dr Mohi suggested it be made clear to practices what the current issues are and the long term implications should no changes be made e.g financial, quality impact etc and benefits, which may improve engagement with GPs. It was suggested that this be taken forward via informal CDs meeting within each CCG to agree the framework for the networks and a work programme to deliver on the way forward; this can then be tested at the respective locality/cluster meetings.

Note SS

5.0

Urgent and Emergency Care Vanguard update Dr Mathukia provided an overview of the slides outlining what work had been undertaken since the last update. Rob Meaker briefed members on the technology requirements to support the programme. It was acknowledged by Dr John that the ability of Out of Hours providers to see shared care plans through Health Analytics has improved the service provided to patients. Dr Tahir asked that it be clarified that when the vanguard support finishes where the resource will come from for the service to continue. He was advised that the programme was designed and had to deliver a more affordable Urgent and Emergency Care system that would provide the resources across the pathway as a whole (including local councils).

6.0 6.1

Briefing items Accountable Care Organisation (ACO) Conor Burke confirmed that it had been formally announced that BHR had been selected as a pilot site for ACO development. A business case will now be produced for a recommendation to go to Governing Bodies in June to decide if this is to be progressed. Conor advised that the Executive Group made up of Chief Executives had met twice and would be meeting again to help plan the process for development of the business case. The first meeting of Democratic and Oversight Group (DCOG) will be held within the next two weeks. A Clinical Leadership and Strategic Planning Group will also be set up which will advise the DCOG. Dr Springer asked if there were risks to the CCGs in respect of BHRUT’s financial position. Conor advised there are risks and opportunities but these would be fully outlined in the business case to allow the Governing Bodies to reach a decision.

Note

227

3

6.2

Everyone Counts update Louise Mitchell confirmed that the first evaluation will take place next week and that all practices will be individually notified of their year-end trajectory by mid-February.

Note

7.0 7.1 7.2

Items for information Collaborative risk log Members noted the update included with the papers. Contract, quality and performance update Members noted the update included with the papers.

Note Note

8.0 8.1

Any other business Diabetes update It was agreed this item would be deferred to the next meeting and will be the first item on the agenda.

Note

9.0 Date of next meeting Thursday 11 February 2.15-4pm at Urswick Medical Centre, Dagenham.

Note

228

1 Draft PCC Minutes 9 December 2015 v1

Draft Minutes of the Primary Care Commissioning Committee (Committee in Common) held on 9

December 2015 at Becketts House 1.00pm

Present –Members

Richard Coleman (RC) Chair Lay Member, Havering CCG Khalil Ali (KA) Lay Member, Redbridge CCG Conor Burke (CB) Chief Officer, BHR CCGs Sarah See (SS) Director of Primary Care Transformation, BHR CCGs Jacqui Himbury (JH) Nurse Director, BHR CCGs Tom Travers (TT) Chief Finance Officer, BHR CCGs In attendance Lorna Hutchinson (LH) Assistant Head of Primary Care Commissioning, NHSE Alison Goodlad (AG) Head of Primary Care, NHSE Anne-Marie Keliris (AMK) Company Secretary, BHR Dr Anil Mehta (AM) Chair, Redbridge CCG Dr Waseem Mohi (WM) Chair, Barking & Dagenham CCG Natalie Keefe (NK) Head of Primary Care Transformation, BHR CCGs Liz Wise (LW) Programme Director, Primary Care Transformation Healthy London

Partnership Terilla Bernard (TB) Barking, Dagenham and Havering LMC Vicky Hobart (VH) Director of Public Health Redbridge Sarah D’Souza (SDS) Deputy Chief Operating Officer, Barking & Dagenham CCG (for

item 4) Apologies Anne-Marie Dean Chair, Healthwatch Havering Cllr Kelly LB Havering Kash Pandya Lay Member, BHR Audit & Governance Dr Atul Aggarwal Chair, Havering CCG Ian Buckmaster Director Healthwatch Havering Frances Carroll Chair, Healthwatch Barking & Dagenham Matthew Cole (MC) Director of Public Health, LBBD Cathy Turland (CT) Chief Executive Healthwatch Redbridge Gladys Xavier (GX) Deputy director of public health, LBR Dr Ambrish Shah (AS) Redbridge LMC Sahdia Warraich (SW) Lay Member, Barking & Dagenham CCG

Action 1.


The Chair welcomed those present and apologies were noted.

2. Declaration of Interests Members noted the Committee’s Declaration of Interest Register and no further

interests were declared relating to agenda items.

229


3. 3.1 Minutes of meeting held on 13 November 2015 The minutes of the previous meeting were agreed and would be signed by the

Chair as a correct record. 3.2 Actions log/matters arising Committee members noted the actions that had been taken and the following updates were noted: ACT27 NHS London Operating Model – an appropriate training programme at venues in North East London will be organised with an update presented at the next meeting. JH reported that there had been further discussion on adult safeguarding responsibilities with NHSE where it was reported that responsibility would sit with the CCG but JH had not accepted this position until clarity was gained on resourcing this at the CCG. LW agreed to feed this back the NHSE. ACT30 Pathology costs – It was agreed that the action on pathology costs would be followed up at the next meeting.

AG LW JH

4. Barking & Dagenham PCC

4.1 Nursing Home LIS SDS presented a report which provided an overview of the current service and the outcomes of the enhanced primary care support to nursing home scheme review. It was noted that there had been fewer emergency admission and a reduction in LAS call outs since the scheme was implemented. SDS reported on the issues sustaining a GP service for the Chase View nursing home. Discussion ensued on different approaches to models of care for nursing homes. CB agreed that constant review and looking at best practice will help learning and referenced Health 1000 as a possible solution. SDS confirmed that she has been in discussion with Dr John to explore options. KA welcomed the report and the relationships between ITT and IRS being enhanced. SDS reported that once the scheme had been agreed in principle further engagement with ITT and IRS will take place to work through the patchwork of responsibilities of nursing home resident’s care. JH reported that a nursing home strategy is being produced and AM agreed it was a good time to start this strategy and would welcome a uniform approach to this across BHR. CB suggested that Care City could support this process. The committee noted the service review and recommended that the ‘virtual’ Investment Committee agree to commission the service from practices for a further 2 years with improvements made to the specification and monitoring arrangements to address areas identified in the review. The committee also noted the specific issues surrounding the Chase View nursing home and recommended that the ‘virtual’ Investment Committee agree to the proposed approach to resolve these.

AMK AMK

5. Budget update TT presented the month 7 primary care commissioning budget update.

230


The current overspend position at month 7 for each CCG’s primary care commissioning budget is as follows: Barking & Dagenham CCG £170k Havering CCG £308k Redbridge CCG £217k It was noted that the budget transfer of the Lawns practice had not been included in the report. TT reported that analysis on demographic growth is now included in the report as this information is available monthly. KA questioned if there is an equivalent QIPP programme for primary care. TT responded that there is a unified budget approach to the report with presentational issues that needs to be worked through with more information on specific primary care QIPP at the January meeting. The committee noted the report.

TT

6. Redbridge PCC 6.1 End of Life Scheme

AM presented a report which provided a summary of the current position on the end of life scheme implementation in Redbridge CCG. It was noted that 48 of 60 practices had signed up to the scheme which will be launched in December. KA welcomed the report and questioned if there is a benchmark that could be used on the outcomes of the scheme in terms of the percentages of patients that die in hospital and the community. CB responded that the target does not exist and reported that BHRUT had been commended on their end of life care. WM agreed it was important to see metrics for improvements in care. KA questioned how far St Francis hospice reaches into Redbridge. AM responded that this is one of the areas the scheme will cover, with the aim to establish a ‘hospice at home’ service. The committee noted the progress made in the utilisation of the innovation fund in implementing the end of life gold standard framework training and agreed the schemes’ approach.

6. APMS procurements – update • Loxford

• Kings Park • Orchard village

AG reported on the three APMS procurements currently underway in BHR. It was noted that PQQ were due on 10 December which will be evaluated shortly and invitation to tender will be issued on 1 February 2016. Service specifications are standard across London but CCGs can localise and these will signed off in January 2016. CCGs can also be involved in the evaluation and interview process. SS reported that Havering had aligned the extension of the current King’s Park Surgery APMS contract with that of the procurement schedule (namely the current

231


contract expires on 31 July 2016 with the new contract holder assuming service on 1 August 2016). A similar extension needs to be agreed for the Loxford APMS contract in Redbridge. SS to liaise with Louise Mitchell. TT referred to Orchard Village advising that NHSE have confirmed that there will be an uplift to 2016/17 budgets to ensure all contractual commitments are met. The committee noted the report and a further update would be received at the next meeting.

SS

7. Risk register SS presented the risk register.

The committee noted and agreed the report.

8. For information 8.1 Discretionary payments and contract variations

AG presented a report which summarised discretionary payments and contract variations. The Committee noted the report.

9. Questions from Public There were no questions from the public.

10. Any Other Business SS reported that following proposal to NHSE on changes to the membership of the

PCC, positive feedback had been received. NHSE agree to the inclusion of 2 local voting GPs per Committee, subject to some conditions such as recruiting an independent GP. SS to discuss with Audit Chair and Chairs outside of the meeting – and confirm back with NHSE,

SS

11. Date of Next Meeting The next meeting was confirmed as 13 January 2016.

Signed………………………………………………..Date………………………….

232

1 Draft PCC Minutes 13 January 2016 v1

Draft Minutes of the Primary Care Commissioning Committee (Committee in Common) held on 13

January 2016 at Barking Learning Centre 1.00pm

Present –Members

Richard Coleman (RC) Chair Lay Member, Havering CCG Khalil Ali (KA) Lay Member, Redbridge CCG Kash Pandya (KP) Lay Member, BHR Audit & Governance Sarah See (SS) Director of Primary Care Transformation, BHR CCGs Jacqui Himbury (JH) Nurse Director, BHR CCGs Tom Travers (TT) Chief Finance Officer, BHR CCGs In attendance Lorna Hutchinson (LH) Assistant Head of Primary Care Commissioning, NHSE Alison Goodlad (AG) Head of Primary Care, NHSE Anne-Marie Keliris (AMK) Company Secretary, BHR Dr Anil Mehta (AM) Chair, Redbridge CCG Dr Waseem Mohi (WM) Chair, Barking & Dagenham CCG Dr Atul Aggarwal Chair, Havering CCG Natalie Keefe (NK) Head of Primary Care Transformation, BHR CCGs Cathy Turland (CT) Chief Executive Healthwatch Redbridge Terilla Bernard (TB) Barking, Dagenham and Havering LMC Anne Marie Dean (AMD) Chief Executive Healthwatch Havering Dr Ambrish Shah (AS) Redbridge LMC Frances Carroll Chair, Healthwatch Barking & Dagenham Apologies Anne-Marie Dean Chair, Healthwatch Havering Cllr Kelly LB Havering Matthew Cole (MC) Director of Public Health, LBBD Gladys Xavier (GX) Deputy director of public health, LBR Sahdia Warraich (SW) Lay Member, Barking & Dagenham CCG Conor Burke (CB) Chief Officer, BHR CCGs Vicky Hobart (VH) Director of Public Health Redbridge

Action 1.


The Chair welcomed those present and apologies were noted.


interests were declared relating to agenda items.

3. 3.1 Minutes of meeting held on 9 December 2015 The minutes of the previous meeting were agreed and would be signed by the

Chair as a correct record.

233


3.2 Actions log/matters arising Committee members noted the actions that had been taken and the following updates were noted: ACT27 NHS London Operating Model – SS reported that a meeting is planned with NHSE next week where a review on capacity of the primary care team will take place. ACT46 – SS reported that the recruitment of voting GPs and independent GP will commence shortly.


The current overspend position at month 8 for each CCG’s primary care commissioning budget is as follows: Barking & Dagenham CCG £164k Havering CCG £263k Redbridge CCG £137k It was noted that each CCG were continuing to forecast a break even position and the budget transfer of the Lawns practice had not been included in the report. TT reported that a number of QIPP schemes are progressing and due to the reporting timeline a stronger QIPP and budget report is expected at the next meeting. KP questioned what will change if a breakeven position is being forecast. TT responded that there will be a number of credits from QIPP schemes which have not come through the system yet. The committee noted the report.

5. PMS update SS updated the committee on the latest position of the PMS review.

It was noted that since the last meeting there had been ongoing negotiations taking place between LMCs from across London and NHSE; the wording of the core contract was now finalised, negotiations will now focus on the KPIs and ‘offer’ specifications. Locally there had been a focus on the financial analysis of the contract as currently proposed; an impact analysis and Equality Impact Assessment will also be undertaken in the next few weeks. KA questioned if there had been a response to the request for the extension to the final deadline. SS confirmed that the three month extension had been approved but the timeline was still tight and the additional 3 months was to accommodate face to face practice negotiations. KA questioned what support will be available for practices who do not want to sign the new contract; SS responded that we need to understand the position of each practice, develop a fair and transparent transition plan, and if all else fails, under the regulations PMS contract holders have a right to revert back to the national general medical services (GMS) contract. AA commented that the current Havering PMS contract commissions 100 appointments per 1000 patients, and the system is likely to lose this additional capacity or pay more for it, based upon the proposals in the London offer. SS

234


confirmed this, agreeing that in December the benchmark for the core service of the new contract was 72 appointments per 1000 patients, therefore she acknowledged there is a gap which will be captured as part of the impact analysis. She added that there is still a significant amount of practice information missing which is currently being followed up by colleagues at NHSE. KA commented that given the tightness of the timeframe for commissioning intentions given at a London level and local level we are still some way off from agreeing the contract. AM questioned if each CCG are aware of PMS position. SS responded that the CCG does not hold all the detail of what each contract provides. NHSE wrote to individual practices but some responses are still outstanding. AMD questioned if the worse case scenario is being planned for and highlighted that patient care could be missed if this information is not gathered in time. SS responded that this is a complex situation and will produce a report for the next meeting setting out the whole position. Dr Shah suggested the involvement of the LMC to support practices in responding by the deadline, which was welcomed by NHSE. The committee noted the update.

SS DrSh /LH

6. APMS procurements – update • Loxford

• Kings Park • Orchard village

AG presented a report which updated on the three APMS procurements currently underway in BHR. It was noted that all PQQ submissions had been received and were currently being moderated and evaluated before moving into the ITT stage. AG reported that the CCG have been asked to put forward a designated officer to be part of the procurements project group and whether the CCGs wanted to commission any additional services on top of the core offer. SS reported that the CCGs holding position would be to reserve the right until the PMS review is complete, and if applicable, would commission as part of the approach to ensure equity of GMS contracts with PMS contracts. AA commented that it is important that the CCG are involved at the evaluation stage. KA highlighted concern at the lack of a PPI element in the PQQ stage. LH confirmed this is included in the ITT documentation as bidders need to detail how they will address patient experience. LH agreed to circulate the PQQ questions on patient experience. It was noted that no clinical lead would be able to evaluate the bids for any local contracts due to potential or perceived conflicts of interest. The committee noted the report and a further update would be received at the next meeting. The committee noted the report; SS to formally respond to NHSE regarding a holding position on additional services and confirming participation in the evaluation process.

LH

235


7. Havering PCC Committee Kings Park Surgery

AG presented a report which set out the case for the contract provider of the King Park Surgery to receive an uplift to their rent reimbursement as an outcome of an additional room required by the practice to meet demand for appointments. KA questioned that given the increase in patients will additional staffing also be needed at the practice. LH confirmed that an additional clinician has been recruited. TT questioned if the CCG are currently paying void costs. LH confirmed no void costs are being paid as the space was allocated to another service. SS requested that decisions relating to estate should be reviewed by the finance and estates group before being presented to the PCC. NK suggested the CCG should have a policy on the process to be followed for similar requests as there was potential for these types of requests to increase. TT agreed, adding that a primary care estates strategy plan will be available shortly. AA questioned how assessments will be made on less clinical space if list sizes reduce. SS responded that this would be part of the 3 year cycle to review rent reimbursement and should also form part of the primary care estates strategy. Havering PCC Committee approved the request.

TT

8. Primary Care Transformation Funds 2016/17 NK presented a report which provided a brief of NHSE’s approach to the second

year of the Primary Care Transformation Funding; she noted that the criteria and principles listed was subject to agreement the LMCs. Dr Shah commented the criteria could be discriminatory against smaller practices. WM agreed with this, adding that small practices also needed to be given opportunities to expand and did not want to limit single handed practices. SS welcomed the comments made and would reword these criteria as want to support training practices as well as single handed practices. WM suggested a clinician could input into this, SS agreed and reported that this would be via LMCs. JH requested clarity on risks. SS responded that the associated risk was no capital investment and wanted to have a transparent process for practices. The committee noted and agreed the aims, conditions, principles and next steps with rewording to criteria. An updated paper would be reviewed by the Committee once agreement had been reached with the LMCs.

NK

9. Risk Register SS presented the risk register.

CT referred to Spearpoint practice and was concerned that some patients did not know the practice was closing and suggested Healthwatch could work with the CCG to engage with these patients. SS responded that engagement with patients was ongoing with two further events planned and poster and leaflets available at practice reception but welcomed any additional support from Healthwatch. She added that the CCG were actively supporting staff in the practice to find

236


alternative employment including sending CCG vacancies to those staff affected. KA welcomed the update and suggested there could be learning from previous less successful closures. The committee approved the risk register.


11. Any Other Business There was no other business.

12. Date of Next Meeting The next meeting was confirmed as 10 February 2016.

Signed………………………………………………..Date………………………….

237

1 Draft PCC Minutes 10 February 2016 v1

Draft Minutes of the Primary Care Commissioning Committee (Committee in Common) held on

10 February 2016 at Becketts House 1.00pm

Present –Members

Richard Coleman (RC) Chair Lay Member, Havering CCG Khalil Ali (KA) Lay Member, Redbridge CCG Kash Pandya (KP) Lay Member, BHR Audit & Governance Sarah See (SS) Director of Primary Care Transformation, BHR CCGs Tom Travers (TT) Chief Finance Officer, BHR CCGs Dr Adedayo Adedeji (AAde) GP, Barking & Dagenham CCG Sahdia Warraich (SW) Lay Member, Barking & Dagenham CCG Conor Burke (CB) Chief Officer, BHR CCGs Lorna Hutchinson (LH) Assistant Head of Primary Care Commissioning, NHSE Liz Wise (LW) Head of Primary Care, NHSE Anne-Marie Keliris (AMK) Company Secretary, BHR Dr Anil Mehta (AM) Chair, Redbridge CCG Dr Waseem Mohi (WM) Chair, Barking & Dagenham CCG Dr Atul Aggarwal (AA) Chair, Havering CCG Cathy Turland (CT) Chief Executive Healthwatch Redbridge Terilla Bernard (TB) Barking & Dagenham and Havering LMC Ian Buckmaster (IB) Executive Director & Company Secretary, Healthwatch Havering Maria Rodrigues (MR) Primary Care Manager, BHR CCGs Gladys Xavier (GX) Deputy Director, Public Health, LBR Terilla Bernard (TB) Barking, Dagenham & Havering LMC Sarah Pinto-Duschinsky Ernst & Young Susan Lloyd Consultant in Public Health, Public Health, LBB&D Cllr Wendy Brice Thompson Cllr LB Havering Apologies Anne-Marie Dean Chairman, Healthwatch Havering Matthew Cole (MC) Director of Public Health, LBBD Jacqui Himbury (JH) Nurse Director, BHR CCGs Steve Ryan (SR) Secondary care consultant Dr Kalkat (GK) Clinical Director, Barking & Dagenham CCG Vicky Hobart (VH) Director of Public Health Redbridge

Action 1.


The Chair welcomed those present and apologies were noted. The Chair welcomed Dr Adedeji to his first meeting of the PCC. Need to note the change from Cllr Kelly to Cllr Wendy Brice – the new chair of Havering Health and Wellbeing Board. Sarah Pinto-Duschinsky was observing today’s Committee; she is supporting NHS

238


England and London CCGs with a review of the primary care commissioning operating model and resource in London. A summary report will be presented a forthcoming Committee meeting.


interests were declared relating to agenda items. Dr Adedeji has recently submitted his declaration of interest form but had not been in time to be included within the committee papers, it was noted that he held interests in PELC and Together First Limited as well as being local GP provider.

3. 3.1 Minutes of meeting held on 13 January 2015 The minutes of the previous meeting were agreed subject to the addition of the

attendance of Ian Buckmaster and Anne Marie Dean and would be signed by the Chair as a correct record. 3.2 Actions log/matters arising Committee members noted the actions that had been taken and the following updates were noted: ACT33 pathology costs – this action had been closed at the January meeting. ACT35 operating model – it was noted that the review was still ongoing and would be reviewed as part of the NHS England primary care commissioning review of resources / co-commissioning. ACT48 AMPS procurement – LH reported that she had not circulated PQQ questions as ITT had not yet been published so not at liberty to divulge this information yet. The committees noted the revised threshold in the PQQ stage, KP suggested the reasons for this were set out for information.

LH


The current overspend position at month 9 for each CCG’s primary care commissioning budget is as follows: Barking & Dagenham CCG £228k Havering CCG £300k Redbridge CCG £162k TT reported that there were further positive movements in month 10 with the Lawns Medical Care Practice/North Street Medical Care Practice merge budget transfer of £240k to be actioned for Month 10. The committee approved the report.

5. Revised Terms of reference SS presented the revised terms of reference for each CCG which included the

addition of two additional voting GP onto the membership. SW questioned when the other independent GP will be recruited. SS reported that in addition to Dr Adedeji, Dr Kalkat from Barking & Dagenham CCG will also be a voting member. The independent GP is currently being recruited with the advert on NHS jobs going live later in the week.

239


Barking & Dagenham PCC agreed the revised terms of reference. Havering PCC agreed the revised terms of reference. Redbridge PCC agreed the revised terms of reference. SS to submit the revised terms of reference to NHS England for formal approval.

SS

6. PMS update SS presented a report which updated on the latest position of the PMS review

including: • An update on the ‘London offer’ following on from NHS England and London

LMCs discussions • A draft London rationale presentation that CCGs can adapt for use in their

meetings with GP practices, and also a PMS FAQ • A summary of engagement requirements

KA noted the local engagement with LMCs and the useful discussions and challenges this has brought about and hoped this will bring greater ownership from general practice. Dr A commented that in the past some GMS practices had been disadvantaged and also questioned if GMS contracts will be offered to those who do not want the new PMS contract. SS confirmed that this was part of the review included equity for GMS practices but added that it needs to be affordable to commissioners, and may take a few years to achieve. SS also confirmed under PMS regulations that PMS providers have a right to revert to a GMS contract (which would be funded as per the national contract.) WM requested clarity on the timeline as the June deadline would prove challenging. SS shared the concern around the challenging timeline. She confirmed that commissioning intentions are to be submitted on 19 February and following feedback on these, a governance process to sign off via the Committee and a non-conflicted group of the governing body would need to be arranged. LW recognised the challenges of the timeline and the work required of the complicated process. She added that the balance of not destabilising practices was important and would like to support practices. TB questioned when the information on the effect at practice level will be available. SS confirmed this would be within the next 4 weeks. CB referred to how the PMS review aligns to the BHR systems’ strategic transformation programme, Accountable Care Organisation (ACO) business case and Sustainability & Transformation Plan (STP) and suggested it would be helpful for the committee to understand how these all align. CB agreed to review how and when to do this. The Committee noted the report.

SS CB

7. Internal audit – co-commissioning SS presented the internal audit report on co-commissioning and contract

management which was reviewed at the recent Audit and Governance Committee. It was noted that all the action were amber/green and were medium to low level. The audit and governance committee recommended a review of the governance arrangements. KP welcomed the report at the audit and governance committee with one caveat, as

240


it was felt that the NHSE requirement of quarterly reviews did not add any value and have asked NHSE if it would reconsider the frequency of the reviews. KA commented that it would helpful for the committee to receive an update on the recommendations from the audit in the future. The committee noted the report.

LW SS

8. Quarter 3 delegated self-certificate MR presented the CCG Assurance Framework 2015/16 delegated functions self-

certification. KP noted that he has received the revised version with comments from internal audit and will review with Conor Burke and feedback by deadline of 29 February 2016. It was also noted that this cycle needs to align with the audit & governance committee cycle. TT highlighted the link between internal audit report and self certification flow of information and timeliness. The Barking & Dagenham PCC approved the quarter 3 delegated self-certificate subject to further review and approval by KP/CB review. The Havering PCC approved the quarter 3 delegated self-certificate subject to further review and approval by KP/CB. The Redbridge PCC approved the quarter 3 delegated self-certificate subject to further review and approval by KP/CB.

KP/CB KP/AMK

9. Quality report LH presented the quality and performance report which was a work in progress and

welcomed any feedback from members on the format and information they would like to see in future reports. CB welcomed the report but noted that further work is needed to improve this particularly around content and formatting, as this is one of the most important reports on the agenda and needs to add value. Discussion ensued and it was agreed that further review of the information required and the key lines of enquiry could be agreed by a small group from the committee. LH agreed to circulate key headlines from the CQC to members. The committee noted the report.

SS/LW LH

10. Contract variation and discretionary payments SS presented the recent contract variations and locum reimbursements processed

in January 2015. TT requested that locum rates are included for comparative purposes. LH responded that these are standard rates and would include this information in the next report. The committee noted the report.

LH

11. Havering & Barking and Dagenham PCC Committees

241


8.1 Dr Pervez – change of CCGs SS presented a paper to seek formal approval to the signing of the Health & Social Care Information Centre form so as to allow the data and financial flows to reflect the migration of Dr Pervez from Barking and Dagenham CCG to Havering CCG. The Havering and Barking & Dagenham PCC Committees both approved the signing of the HSCIC GP Practice migration/CCG boundary changes.

12. Risk Register SS presented the risk register.

The committee approved the risk register.


14. Any Other Business There was no other business.

15. Date of Next Meeting The next meeting was confirmed as 9 March 2016.

Signed………………………………………………..Date………………………….

242

1

Agreed Minutes – BHR CCG s Investment Panel

Thursday 29 October 2015

Members: Richard Coleman (RC) Lay member, PPI Havering CCG - Chair Kash Pandya (KP Lay member, Governance, BHR CCGs Sahdia Warraich (SW) Lay member, PPI B&D CCG Khalil Ali (KA) Lay member, PPI Redbridge CCG Dr Atul Aggarwal (AA) Chair, Havering CCG Dr Anil Mehta (AM) Chair, Redbridge CCG Tom Travers (TT) Chief finance officer, BHR CCGs Attendees: Sharon Morrow (SM) Chief operating officer, B&D CCG Clare Burns (CBurns) Deputy Chief operating officer, Havering CCG Anna McDonald (AMc) Business manager, BHR CCGs Apologies: Dr Waseem Mohi Louise Mitchell Alan Steward

1.0 Welcome and apologies The Chair welcomed members to the meeting. Apologies were noted from

Dr Mohi, Louise Mitchell and Alan Steward. It was also noted that some attendees would arrive late due to un-avoidable traffic problems.

1.1 Declaration of interests There were no additional declarations of interests declared.

2.0 BHR CCGs Investment Committee Terms of Reference (ToR) At the September Governing Body (GB) meetings, the three CCGs agreed to

establish an Investment Committee to act as a ‘committee in common’ across the three CCGs. The Chair explained that the draft ToR will be taken to the November GB meetings for approval but in the meantime, due to a number of urgent requests for investment decisions, an Investment Panel had been set up for today. Going forward, the new Investment Committee will stop the need to arrange ad-hoc investment decision making meetings. KP advised that it will be a ‘approval’ committee reporting to the GBs. A number of meeting dates, (approximately 5-6) will be set up in advance for the year but they will only go ahead if there are decisions to be made. KP added that he would like the ToR to include a sentence under the heading ‘in attendance’ to say that clinical directors / lead officers will be invited to attend when required. Members agreed to the ToR being developed via a virtual group in advance of being considered by GB members at the November meetings.

MP

243

2

3.0 BHR CCGs – Model of allocation of £1.25pc QIPP delivery 15/16 – Everyone counts schemes

The paper informed members that the ‘Everyone Counts Schemes’ are now operating across the three CCGs. Part of the financial arrangement for the schemes includes an allocation of £1.25 of the total scheme, upon successful delivery of QIPP. The payment will be allocated on a sliding scale aligned to successful delivery of the practice’s scheme. KP said the panel needs to agree how the money will be distributed and also stressed that the communication that goes out to practices needs to be clear. AA advised members that the metrics feedback has not yet been agreed. SM joined the meeting. KP asked what happens if there is an under spend on the £1.25. AA responded saying if the schemes are not delivered, the money goes into the QIPP saving. Members agreed that this message needs to be communicated in a clear message to practices. AA and AM queried the average unit price of £143 for A&E attendance and agreed that it is in-correct. AM added that all the schemes say that A&E attendance will be reduced and gave his view that the weighting of 5.5% for A&E needs to be changed. AA agreed that it was wrong and needs to change and said that a weighting for patient surveys and ‘friends & family’ needs to be added. KA joined the meeting It was agreed that a higher weighting for A&E is needed and that the weightings should be re-formulated to:- 50% - A&E 40% - non-elective admission 10% - patient satisfaction surveys / friends & family The panel approved the paper subject to a further review of weightings in consultation with the CCG chairs and the Committee chair.

LM

4.0 B&D CCG

4.1 Review of wound care services SM explained to the panel that a proposal submitted by North East London Foundation Trust (NELFT) to provide an interim wound care service to cover the gaps highlighted in an initial service review (out of hours, weekends and bank holidays) was rejected by the CCG’s Executive Committee in May 2015. The Executive Committee proposed that Together First (TF) should be approached to submit a proposal for a service that mirrored what is currently commissioned from GP practices. The recommendation to the Investment Panel was to not accept the proposal from TF as it would be a cost pressure to the CCG and to recommend instead that the CCG focuses on the longer term commissioning plan. SM added that as the CDs are shareholders in Together First, she was advised that she could not take the paper to the Executive Committee as it was considered to be a conflict of interest. AM said that most wound care takes place within working hours and queried why this was needed as an additional payment to practices. AA said that the paper should not have been brought to the Investment Committee, in his view,

244

3

the Executive Committee could have dealt with it as there were no conflicts of interest involved in accepting a recommendation not to award a contract to TF. The majority of Committee members did not agree with this view and were satisfied that the Investment Panel was appropriate for making this decision. The Committee agreed to the recommendation that TF should not be awarded the wounds care contract and arrangements to procure this service should be put in place. KP added that, while new procurement arrangements were being developed, the CCG must ensure that patients continue to receive the required service.

5.0 Havering CCG

5.1 Housebound flu scheme AA was allowed to be present during the discussions about the Havering schemes but it was stressed that he could not take part in any of the decision making. AA presented the paper as CBurns had not yet arrived. Havering CCG has implemented a housebound flu incentive for the last 3 years with increasing numbers of patients vaccinated each year. The paper outlined the scheme and the number of patients vaccinated in the past 3 years and asked members to agree the funding for the scheme to run from November 2015 to January 2016. KA noted a typing error in Appendix 1 - Item 4 in regard to the date, which should read January 2016. AM advised the Panel that GPs in Redbridge and B&D provide this service as part of their day to day work without an incentive payment. AA responded advising that the home visits aren’t just for flu vaccinations, a number of other checks are carried out during the visit in addition to the vaccination such as blood pressure checks, dementia screening, diabetes screening etc. AM suggested that the name of the scheme is changed to something like ‘health checks for the housebound’ instead of ‘housebound flu scheme’, which would save any confusion about the payment incentive across the other two CCGs. AA also confirmed that there was no overlap between this scheme and other incentives to practices e.g. Everybody Counts. The Panel approved the funding for the Havering scheme for 2015/16. 5.2 GP alignment to care home scheme The report provided panel members with details of the pilot scheme, how it was developed and originally procured to address the high reliance on emergency services from care homes and the reactive management of long term conditions. The pilot commenced in March 2013 and was due to end 31 March 2015, however contracts have been extended until a procurement decision has been made. The panel was asked to agree to contract only with the providers within Havering CCG who have a registered list of patients. AA advised members that the pilot scheme has been running for 2 years and involves 17 practices who are paid a fixed amount for the number of patients they have in the care home. The detailed evaluation that was carried out at the end of the pilot period demonstrated that of the homes involved in the scheme, there had been a 26.6% reduction in emergency admissions compared to the previous financial year. Emergency admissions for COPD and UTIs also reduced as well as the number of call outs to the London Ambulance Service.

CBurns

245

4

CBurns joined the meeting KP noted that clear evidence of success had been provided in the appendix to the report. The panel agreed to the recommendation to contract only with those providers within Havering CCG who have a registered list of patients.

5.3 Shared care clinical management and prescribing scheme Havering CCG set up a shared care clinical management and prescribing scheme for the final quarter of 2014/15 commissioned from Primary Care to manage patients in 4 disease areas. Practices had to sign up for all 4 shared care disease areas as part of the scheme. Current data demonstrates that there was a reduction in outpatient follow-up activity for Q4 2014/15 during the pilot period. The pricing structure of this service is 34p per patient per year regardless of how many patients a GP has. Panel members were asked to agree to the continued investment for the scheme for the remaining period of 2015/16. AM said that this is fundamentally an important part of general practice and that there was no overlap with other incentives to practices. KP noted that data on mental health activity was missing from the report. The panel agreed to the continued investment for the remaining period of 2015/16 on the proviso that we look at doing this across the 3 CCGs and that mental health is included. KP added that the schemes and discussions at the meeting today had highlighted the level of inconsistencies across the 3 CCGs.

6.0 Any other business None.

6.0 Date of the next meeting 1 December 2015 – to be confirmed

Becketts House

246

1

Agreed Minutes – BHR CCG s Investment Panel

Wednesday 10 February 2016

Members: Richard Coleman (RC) Lay member, PPI Havering CCG - Chair Kash Pandya (KP Lay member, Governance, BHR CCGs Sahdia Warraich (SW) Lay member, PPI B&D CCG Khalil Ali (KA) Lay member, PPI Redbridge CCG Dr Atul Aggarwal (AA) Chair, Havering CCG Dr Anil Mehta (AM) Chair, Redbridge CCG Tom Travers (TT) Chief finance officer, BHR CCGs

Attendees: Louise Mitchell (LM) Chief Operating Officer, Redbridge CCG Anna McDonald (AMc) Business manager, BHR CCGs 1.0 Welcome and apologies The Chair welcomed members to the meeting. No apologies were received.

1.1 Declaration of interests There were no additional declarations of interests declared.

1.2 Minutes of the last meeting Minutes of the meeting held on 29 October 2015 and the virtual group minutes

for November and December 2015 were agreed as accurate records. It was noted that the meeting would not be quorate for B&D CCG until SW arrived. The Chair explained that two papers from Havering CCG had been deferred to the next meeting due to the lateness of their submission. He reminded everyone of the need for forward planning to ensure that papers are submitted in a timely manner to give members adequate time to review them in advance of the meetings.

1.3 Matters arising Terms of Reference (ToR)

The Chair explained that he did not attend the November meeting of Havering CCG’s Governing Body meeting where the ToR for this Committee were presented. He has since reviewed them and feels that they need to be reviewed in regard to the quorum and added that he felt the section about the CCG Chairs being voting members was ambiguous. AA said it was his understanding that the Chairs are voting members unless there is a conflict and KP said that was also his understanding. AA went on to ask if acute and community stakeholder investment papers should come to this Committee and if not, where should they go. KP

247

2

responded saying that it had been agreed that clarification on what papers come to the Investment Committee would be drawn up. TT confirmed that he has been working with CB and MP on a decision map. The Chair, KP and TT all agreed that the Investment Committee is a decision making body set up to only consider papers where there are conflicts of interest. The Chair asked TT to include AA’s question as to where stakeholder investment papers should go, in the mapping discussions he is having with CB and MP. Sahdia Warraich joined the meeting KA commented that lay members are excluded from Executive decisions and only see the papers when they reach the Governing Body. LM and TT said this would need to be picked up as part of the transformation alignment work.

TT

2.0 BHR CCGs 2.1 Delivery analysis for BHR CCGs GP practice 15/16 Everyone Counts

Schemes Investment in the Everyone Counts Schemes for 15/16 was made available to all practices within BHR CCGs at a per capita rate of £7.50 in total for this financial year. The decision making panel, set up prior to the Investment Committee being in place determined that up to £6.25 of the total sum available would be made available for scheme delivery with the remaining £1.25 being payable upon successful delivery of QIPP metrics that were approved by each CCG Chair. LM talked through the paper and explained that it provided a high level analysis at CCG level of the return on investment (ROI) schemes delivered during 15/16 and that the appendix provided individual practice level detail. KP queried the calculations in columns 3 & 4 of table 1. LM to make the minor changes as discussed. AA said we need to look at which of the schemes can show absolute sustainability and QIPP savings. KA referred to the positive returns from some of the smaller/single handed practices and AA agreed, adding that some practices had done incredibly well in terms of returns for some of their schemes. LM explained that the next step is to set up a Task & Finish (T&F) group to determine which schemes demonstrate maximum benefit and should be considered for future investment. A report would then be brought to the next meeting. SW said she was concerned about the timeframe of the T&F group. LM responded by saying that the expectation is the T&F group would complete the work by 1 March 2016. KP said he felt the T&F group was the best way forward but added that there is a risk that decisions could be made on schemes that could either show an improvement or a decline in the next few weeks as the data being considered was only up to January. Dr Mehta joined the meeting AA referred to a meeting that Clare Burns had had recently with BHRUT about the coding for zero stay and one stay payments and said that may affect the data in regard to some of the schemes. KA said it would be helpful if the next report could include a sentence explaining what each scheme is e.g if it’s nurse-led. AA suggested sending the original dashboard back to the practices asking them to indicate where they have achieved what they said they would and where they haven’t, which could provide additional helpful information that

LM LM

248

3

isn’t already available. It was agreed that this was a good idea but some members felt it would delay the work of the T&F group. LM explained that a communication about the £1.25 payment would be sent to practices by the end of the week and suggested that a sentence could be added to the letter asking them to complete a one page yes/no/other table about whether they have achieved what they said they would in regard to their schemes. This would be separate to the letter itself and sent out the following week, which would not delay the work of the T&F group. The Committee agreed. AM said that some practices have asked if particular reasons for not achieving some of the schemes could be taken into account e.g sickness due to injury. LM responded saying none of the practices have advised that any schemes have been suspended and payments have continued to be made so that would not be possible. AA asked why there is a variation in the investments and it was confirmed that it was based on what the particular practice had asked for. KP said the Committee needs to be mindful that the schemes that are decided on for 16/17 must be practical, sustainable and not resource intensive. A discussion followed about what would be most helpful for the Committee to consider at the next meeting; either one scheme per CCG; the top 5 schemes across the 3 CCGs or the top 3 schemes per CCG.. SW said she would expect to see the top 3 per CCG and the rest of the Committee agreed. The Chair asked members if the expectation is that the future of the schemes would be decided on at this Committee. TT responded saying the Committee has been charged with making the decisions around these schemes but the Governing Bodies have the final decision on all budgets and financial plans and added that in terms of primary care, some thought needs to be given as to how this process links in to future financial plans for each CCG. The committee:

• Reviewed the return on investment analysis provided against per capita investment.

• Took account of the findings of the analysis in the context of primary

care investment opportunities for the 16/17 financial year noting that the allocation per capita for the upcoming year is £5 per head of population.

• Agreed the establishment of a task and finish group to determine which

scheme/s demonstrate maximum benefit and should be considered for future primary care investment in 2016.

LM LM

3.0 Any other business None. 4.0 Date of the next meeting 8 March 2016 at 3.30pm – 5.00pm, Becketts House

249

Documents

1.30 Chair 2.0 1 - Clinical commissioning group...Draft Redbridge Clinical Commissioning Group Governing Body Meeting 28 January 2016 1.30pm. Boardrooms, Becketts House Present: Dr