Board Part I - Wandsworth CCG · 14-12-2016 · Sean Morgan (SM) Director of Corporate Affairs, Performance and Quality Lucie Waters (LW) Chief of Commissioning Operations Andrew

Board Part I

MEETING14 December 2016 10:00

PUBLISHED13 December 2016

W A N D S W O R T H C C G P A G E 1 O F 2

Board Agenda14/12/2016 10:00 East Putney

Meeting of the Wandsworth CCG Board

Held at 73-75 Upper Richmond Road, East Putney SW15 2SR,

on Wednesday, 14th December 2016, at 10:00

P A R T A | M E E T I N G O P E N S T A R T D U R A T I O N

A01 Apologies, Declarations, Quorum 10:00 5 mins

A02 Clinical Chair’s Opening Remarks NJ 10:05 5 mins

A03Minutes – 12th October 2016 Approval &

Status of Actions (p.5)NJ 10:10 10 mins

A04 Items for AOB NJ 10:20 00 mins

P A R T B | D E C I S I O N S & D I S C U S S I O N S

B01 Operational Focus – St George’s Hospital S Mackenzie 10:20 30 mins

B02Clinical Focus – Continuing Health Care

(p.21/30)LW 10:50 30 mins

B03 London Health Devolution (p.60) SI 11:20 15 mins

B04 Board Assurance Framework (p.88) SI 11:35 10 mins

B05

Policies:

Prime Financial Policies (p.128)

Managing Conflicts of Interest (p.132)

NM

SI 11:45 10 mins

P A R T C | M A N A G E M E N T R E P O R T S

C01 Executive Report (p.137) GM/NJ 11:55 5 mins

C02 Performance Report (p.150) SI 12:00 5 mins

C03 Finance Report (p.158) NM 12:05 5 mins

W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [ X ]


P A R T D | B O A R D G O V E R N A N C E

D01

Summary Minutes:

Integrated Governance Committee

(p.197)

Finance Resource Committee (p.200)

Audit Committee (p.202)

Primary Care Committee (p.205)

12:10 5 mins

D02 AOB & Other Matters to Note 12:15 5 mins

D03

Open Space: Public’s Questions

Members of the public present are invited to

ask questions of the Board relating to the

business being conducted. Priority will be

given to written questions that have been

received in advance of the meeting

NJ 12:20 10 mins

P A R T E | M E E T I N G C L O S E

E01 Clinical Chair’s Closing Remarks NJ 12:30 5 mins

Next meeting of the Board: 01/02/2017 10:00-12:30 East Putney

Part A: Meeting Open

Page

1. Part A: Meeting Open 4

1.1. A01 Apologies, Declarations, Quorum

1.2. A02 Clinical Chair's Opening Remarks

1.3. A03 Minutes 12th October : Approval and Status of Actions 5

1.4. A04 Items for AOB

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Minutes of a meeting of the Board held on 12th October 2016

Present: Nicola Jones (NJ) CCG Clinical Lead (Chair)Graham Mackenzie (GM) Chief Officer Neil McDowell (NM) Acting Chief Finance OfficerStephen Hickey (SH) Lay Member GovernanceCarol Varlaam (CV) Lay Member Patient and Public InvolvementAndrew Neil (AN) Secondary Care DoctorDi Caulfeild-Stoker (DCS) Registered NurseZoe Rose (ZR) West Wandsworth Joint Locality LeadMike Lane (ML) Wandle Joint Locality Lead Nicola Williams (NW) Battersea Joint Locality LeadJonathan Chappell (JC) Battersea Joint Locality LeadSandra Iskander (SI) Director of Corporate Affairs, Performance

and QualitySean Morgan (SM) Director of Corporate Affairs, Performance and

QualityLucie Waters (LW) Chief of Commissioning OperationsAndrew McMylor (AM) Director of Primary Care DevelopmentHouda Al-Sharifi (HAS) Wandsworth Director of Public HealthCathy Kerr (CK) Wandsworth Director of Adult and Community

Services

In attendance:Jamie Gillespie (JG) Healthwatch WandsworthSandra Allingham (SA) (Minutes)

16/096 Apologies for AbsenceNone received. The meeting was quorate.

16/097 Declarations of InterestItem B05 Lay Member Board Roles – CV/SH declared an interest as current Lay Members. No action was required.

16/098 Minutes from the previous meeting held on 14th September 2016The Minutes were agreed as being an accurate record.

16/099 Matters ArisingNone.

16/100 Chair’s UpdateNJ welcomed Sandra Iskander back and noted that this would be Sean Morgan’s last Board meeting. NJ thanked SM for all of his work on behalf of the CCG during his time in post.

16/101 Clinical and Operational Focus – St George’s HospitalSt George’s Hospital (SGH) is the major acute, community, and tertiary (specialised) services provider for the CCG.

The paper outlines that through the significant due diligence undertaken as part of the FT process, SGH was identified as a high performing organisation. It was, therefore, a surprise that so quickly after becoming an FT, the Trust experienced financial deficit and service challenges against the core Constitutional standards for

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A&E, Referral to Treatment (RTT), and Cancer. A number of quality concerns were identified and addressed through the Clinical Quality Review Group (CQRG) and the Care Quality Commission (CQC).

The FT Board has the responsibility to deliver financial balance, high quality of care, and core Constitutional standards for all patients. The CCG has the responsibility to also achieve financial balance, and ensure delivery by providers, with a formal collaborative agreement across all SWL CCGs as the lead commissioner for services at SGH. The CCG also has the responsibility to align with NHS Specialised Commissioning, which makes up half of the total spend on services in SGH.

The CCG has a responsibility to support the Trust in taking action and, where actions were not having an effect, to take a formal contractual position. The Trust has been asked to product a Remedial Action Plan, which has been co-developed with the CCG, to deliver improvements.

Where multiple failures are identified, regulatory intervention is then put in place through NHS Improvement (NHSI) and NHS England (NHSE). Because of multiple issues, it is important to make sure that all improvements act in concert. A number of external agencies are available to provide advice and support. There will be an intensive programme of work to ensure the Trust can respond appropriately to the challenges. Currently there were a number of actions plans in place.

The Trust is required to improve in all three areas. Support mechanisms would be used through the CQRG and Clinical Reference Groups (CRGs), but formal notices to enact financial penalties would also be used.

The CCG Board’s input was invited to describe any further actions that can be taken by the CCG to support the Trust.

Comments and questions were invited from members of the Board:

SGH performance in the national context – Although it was acknowledged that there are a number of challenged Trusts, it was considered that the position at SGH was different from the national trend. A significant amount of due diligence had been undertaken through the FT process, but the rapid deterioration against many of the key domains was exceptional. NHSI has done a lot of work with the Trust to identify challenges relating to leadership with a number of changes made.

Single plan and governance going forward – Although there was a series of remedial action plans in place, there was no one single plan. Monthly Trust and Commissioner Assurance Board (TCAB) meetings review the key domains to look at performance in the round. It is the responsibility of the Trust to outline the plan in order to get back on track. The CCG has a role in supporting the Trust and has put in some additional resource. The CCG also has an assurance role, as lead commissioner, regarding the implementation of the plan. Work will be required to bring the multiple plans into one single plan. A six-month view has been provided but this would be dependent on leadership changes. Pressure should be put on the Trust for this to be done with a first draft by the end of the calendar year. It was noted that this paper would be taken to the TCAB meeting with the next step to develop a deliverable timeframe.

The plan would need to designate what the Trust was capable of delivering. The Trust’s prime role is to run a very high standard district hospital, therefore, the plan will need to be different and fundamental.

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Tertiary services duplication – There is some duplication of tertiary services with the DGH (District General Hospital) function, but there was also a very specific component of services, eg the Trauma Unit. There was not sufficient service line costing to identify benefit to the Trust from tertiary services.

Review of tertiary services across London – This review may provide an opportunity to make sure that there were really good pathways for patients, which might lead to some consolidation of services. This is a long term plan and will be looked at on a specialty by specialty basis.

The chronology in the paper sets out the journey to the current position, but was there an understanding of what led to this point, and was there a plan to mitigate that?

Roles and responsibilities of the various players - It was difficult to see tactically the way forward in the wider system and where all players aligned with the dimensions, with clarity regarding their roles in this critical set of relationships.

The CCG needs to consider whether sufficient action has been taken by them, or whether more should be done, with particular reference to the CCG leadership rating. – The CCG needs to continue the diagnostic review of decisions taken at different times. A number of themes have already been identified, including a much larger cultural theme around leadership and development. It was acknowledged that the CCG could have responded faster to re-align and prioritise, but it was not expected that the CCG would have to play a substantive leadership role for the Trust having been achieved FT status. This was now being taken forward by the CCG.

Board-to-Board – The CCG had previously held a Board-to-Board meeting regarding quality of care prior to achieving FT status. It was reasonable for the CCG to expect that Monitor and CQC would look deeper at any issues as part of the assurance role. A further Board-to-Board session would be taken forward once the substantive SGH Board was in place.

SGH leadership issue – This paper had been sent to SGH prior to the meeting. The CCG works closely with SGH on many levels, but it was very important for the CCG to also have an over-arching responsibility for the system – this was a difficult balance. The issue around making substantive appointments has been raised in a number of forums, particularly with the senior leadership team. There could be potential to escalate this to other regulators.

Estate issues – Significant issues had been identified which will require a significant amount of capital to address. These will impact on the services that can be provided. Plans will be developed on improving the quality of the physical state of the site but the full range of services cannot be provided. It was noted that the Trust had applied for a grant to enable remedial repairs to be done quickly.

It is important that the CCG continues to have a strong focus on Out of Hospital (OOH) plans.

Culture of the organisation and staffing – Plans need to address this to ensure that appropriately skilled staff are in place. This would need to be strongly emphasised.

Regulatory report and mechanism around improvement – No evidence of that had yet been received, although this could be requested.

Planning round and two-year contracts – It would be important to negotiate the most reasonable contract for the system – this could provide the opportunity to reset that in a transactional way for the next two-years.

It was important to keep and strengthen clinical connections between the Trust and CCG.

In summary of the discussion, it was noted that:

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a piece of work would be done to understand any learning;

the CG would continue to work closely with SGH;

issues regarding substantive leadership posts would be escalated to NHSI;

an invitation to be extended for the Interim CEO to attend the Integrated Governance Committee, with an invitation for the new substantive Chair/CEO to attend a CCG Board meeting once in post;

through TCAB, plan to put firmer milestones and timelines for plans and to encourage that process;

continued CCG focus on OOH plans.

Further consideration on how to take work forward would be discussed by the Management Team (MT).

16/102 Multi-specialty Community Provider (MCP) procurementAlthough much work has been put in place over the past few years to benefit patients, there was still further work that could be done, including one care/health plan for individual patients across agencies, better use of communities and the voluntary sector to make patients feel more empowered, and support for practices to take provide more complex services. This would be done through the MCP (Multi-specialty Community Provider), with a Lead Provider.

Work had been done over the past eighteen months to develop the MCP model in consultation with patients, stakeholders, and key providers. The Board had previously agreed that a procurement process should be put in place. The CCG had worked with Capsticks and NHS Shared Business Services (SBS) regarding the procurement process, which was signed off the by CCG’s Contract Procurement Management Group.

Members of the Evaluation Panel had been required to complete confidentiality and declaration of interests forms – no conflict of interests had been identified.

The procurement process included three stages, with three bidders initially identified at the Pre-Qualifying stage. Bidders were asked to submit further documentation for the next stage, including financial information. One response was received, with the two other bidders withdrawing from the process. The outcome from the Evaluation Panel was unanimous and scored the bidder above the threshold. The bidder was invited to the interview and presentation stage, which identified them as being well above the minimum criteria for award of contract.

The bidder was a non-profit making organisation across most of the Wandsworth practices. They were able to demonstrate their experience and understanding of the challenges, and their success in delivering a number of existing contracts which would be key enablers going forward. A number of areas had been highlighted for further assurance, which would be explored pending the Board decision, before any move to contract signature and rapid implementation.

The paper recommended award of the contract to Battersea Health Care Community Interest Company (CIC) subject to assurances as outlined in the paper.

NJ noted thanks to the members of the Evaluation Panel, and acknowledged the involvement of some members of the Board in the process.


This had been a rigorous process, with a lot of preparation. The Evaluation

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Panel had been impressed at the presentation stage regarding the quality of thinking behind the proposals and enthusiasm of the bidder.

Healthwatch representation had been included in stage three of the process, and their enthusiasm for the recommendation was noted.

It was acknowledged that the proposed contract was for ten years, with a value of £200m.

Level of assurance regarding overall leadership of the MCP – It was acknowledged that the bidder was still a young organisation. During the Evaluation, a lot of scrutiny had been placed on the organisational structure of the organisation and timelines. Further work was required to provide assurances around general leadership and governance. Further discussions would be required regarding the structuring of the partnership with the CCG and further potential stretch. The outline assurance process would be discussed by MT prior to contracts being signed.

Services will be introduced in a phased approach with gateways for assurance to the CCG around delivery.

Organisation Development plan – It would be useful to have more assurance around delivery of the OD plan. – Development of the organisation would continue, and there was full awareness within the organisation of their current position, where they would need to be, and what is required to take on this contract.

Leadership – Leadership of the organisation continues to develop. There are a number of strong clinical leads in place. The organisation includes thirty-nine practices in Wandsworth - the three remaining practice contracts are managed on a different basis and not included in the CIC, but the CIC demonstrated that they were able to work with those three practices to deliver the contract. Previous small value contracts have been issue on a short term basis, which means that the CIC has not been able to put in place a critical core mass of staff. This had been raised by the Evaluation Panel, who was assured that, although this was still in development, there was a strong understanding of what was required.

Pace to develop the organisation – This organisation would be looking after the welfare of the CCG’s patients. The CCG has a role to help the organisation develop in a formative way and make sure there is assurance that is to the benefit of patients. – The CIC was keen to establish a collaborative partnership with the CCG and fully acknowledged the level of learning required. The Evaluation process included much time spent on the concept of the Lead Provider, and the Panel agreed that this was a reasonable ask at this stage and was a safe process.

SGH Community Services contract – The contract for Community Adult Health Services (CAHS) with a value of £16m, has been commissioned with SGH for this year. The Board had previously agreed to serve notice on the contract to SGH for 2017/18 – this could present a risk to SGH.

Engagement – The CIC had undertaken engagement with their members. A discussion had been held on how the organisation would respond as commissioners to any issues raised in practices and onward engagement with practices. They had described how the organisation would support their members, while acknowledging that sometimes more input may be required. The organisation’s long term vision was aligned with the CCG’s aspirations, with an aligned end point although the journey to achieve this would need to be worked through.

Local Authority – The LA had been included in the procurement process, which was seen as an exciting development to provide a real basis for people to receive well-coordinated care out of hospital. The LA was keen to continue to be part of that on-going journey. OD learning around partnership working should include the wider form and the LA was keen to be included in the on-

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going development of the CIC.

Patient and Public Involvement (PPI) – Currently, the CIC was an unknown organisation, if agreed as the Lead Provider for the MCP they would have to start to be more outward facing, with more PPI, and meetings in public. This should be included as part of the OD plan.

Recruitment of nurses – The CIC already has an education provider network in place and was confident that they can start to roll out more programmes to attract and retain nurses.

Interaction with SGH – SGH was keen to have the Federation take on more services and will take forward any opportunities for more services to be done in this way, where this was identified as the best way forward.

Following the discussion, the Board was asked whether they approved the recommended award of the contract to Battersea Health Care CIC, subject to the assurances required, OD plan, and due diligence. The Board agreed the recommendation.

16/103 Talking Therapies procurementIn July 2015, the Board had agreed a decision to re-procure the Improving Access to Psychological Therapies (IAPT) service. Work was done over the past year, with engagement from users and carers, to develop a new specification for Talking Therapies, which would be rolled out to provide benefit to more people in Wandsworth, aligning with prevention, and self-help, to address issues earlier in the pathway.

The specification was published on the procurement portal with an invitation to tender. Nineteen expressions of interest were received, of which three bidders went through to the evaluation phase. The scores of the Evaluation Panel identified a clear preferred provider. Two bids went forward to interview stage, from which there was a clear preferred provider. Three pre-conditions to contract signature have been identified around Crisis Planning systems, hard of hearing/sensory impairment, and suicide prevention.

On the basis of the process outlined, the view from the clinical lead, procurement support from NHS SBS, and support from users and carers, the Board was asked to approve award of the contract.


This has been a good process, with the potential to use for other suitable procurements.

Assurance regarding performance issues – The issues around performance had been debated, with the Performance Manager included on the Evaluation Panel. All best practice for procurement had been followed, with a rigorous methodology used to evaluate the very high quality bids. This was a known provider and all of the mitigations and any performance issues would be picked up through the implementation process. Clear contract levers would also be in place.

Domiciliary service for housebound patients – This had been provided for within the specification. It was not known how patient transport would work, but this would only apply to a small number of patients.

Service users had been involved in the process and were happy to support the process and recommendation.

The Board was asked to approve award of the contract to bidder two, subject to delivery of the pre-conditions. The Board approved the recommendation.

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16/104 Battersea Locality Annual ReportEmma Gillgrass (EG), Locality Manager, and Sue Marshall (SM), Patient Representative, attended the meeting.

The following highlights from the report were noted:

The Locality includes twelve practices, with seventy-two GPs, covering a population of 96k patients. The population was diverse and vibrant, with areas of contrast regarding income, access, and cultural influence on health. The opportunities and challenges were similar across Wandsworth.

Significant input had been received from Public Health, providing data to inform work in the Locality.

In comparison with other Localities, Battersea had more complexity regarding providers with more choice of hospitals. However, this complexity provided some challenges regarding access to information. A solution to achieve better access to information at St Thomas’ Hospital was due to be put in place.

At the centre of the work in the Locality is the monthly GP Forum, with good engagement from practices and sharing of ideas for patient care. That level of engagement is continued in Locality meetings. The format of these meetings is split into two section – the first section includes constructive discussion around issues such as collaboration, feedback from patient groups on services, quality issues of commissioned services; the second section includes representation from specific commissioned services, and commissioning ideas generated from members, some of which are rolled-out to benefit all Wandsworth patients.

There was a strong level of patient participation and involvement, providing real meaning. There is a vocal patient group in Battersea, with the opportunity to feedback from other practices. The Members’ Forum includes two patient attendees from the Locality.

Initiatives:o Public Health works with the Locality to identify need and projects that

can be initiated.o Mindfulness courses – The course had initially started in Thurleigh Road

practice, and has since been rolled-out to all practices. Pre and post course surveys are completed by attendees, which indicate an increased level of confidence to deal with stress, improvements in sleep and general mood.

o Parenting Courses – This course was now being rolled-out to all Battersea practices. Seven courses have been held over the past year, with thirty new mothers attending. Pre and post course surveys provided positive feedback for the course.

o Birthday Card Scheme – The scheme has been implemented with Public Health support, to increase uptake of immunisations. Seven hundred cards had been sent out, with the effect that pre-school boosters mainly had increased, with a smaller increase in other immunisations.

o Obesity in Children – The aim of the project is to identify children earlier, with weight/height being measured when children receive their pre-school booster, and onward referral if required to weight management services. Results from the project were currently being analysed.

o Patient Welfare Advice Service – This service provides non-medical advice and support, working with Citizens Advice Bureau (CAS), Family Action, and DASCAS (Disability & Social Care Advice Service). Practices had referred one hundred and seventy patients to CAS. Feedback received indicates that the service has enhanced the quality of life and met users needs.

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As well as continuing the work around Childhood Obesity and Mindfulness, the following three priority areas would be taken forward in the coming year: COPD/Smoking; Cervical Screening; Learning Disability (LD) annual health checks.


Good input received from Public Health. With the recent changes, PH would ensure continuity of input to the Locality.

Nine Elms Vauxhall (NEV) liaison – NW sits on the NEV Project Team on behalf of Battersea, which works with the Programme Board, and also provides clinical representation from the CCG.

Childhood Obesity – Learning from discussions with parents and onward referrals agreed, should be cascaded out to general practice and other services.

It was important to pull processes together across Localities to make sure that those most effective are applied in a common way.

NJ thanked the Battersea Locality team for the report and work done over the past year.

16/105 Lay Member Board RolesPart of the response to the revised statutory guidance for CCGs, was a requirement for each CCG to move from two to three Lay Members. The proposal has previously been reviewed, and supported, by the Integrated Governance Committee.

Consideration has been given around the roles and definitions for each of the Lay Member roles. It was proposed that the description for the Governance role should include the new Conflicts of Interest Champion. The PPI lead description would be retained. The third role would have a specific focus on finance, to help maintain financial control and financial forward look.

It was acknowledged that the current terms of office for both the Governance and PPI Lay Member roles were due to end at different times in 2017. Therefore, it was proposed to recruit to all three roles at the same time in the next few months, with staggered start dates for each role. The priority would be to recruit for the third post as soon as possible. The IGC discussion stated that the aim should be to have this post in place for January.


Time requirement for three days per month was probably under-stated, and the salaries quite high. – It was noted that the salaries and time requirement has been benchmarked with other CCGs. It would be more important to reflect on appropriate use of time. Two Associate Lay Member posts would be retained, therefore, an overall sharing of responsibility would be appropriate to do.

The recommendation for a third Lay Member was agreed.

16/106 Executive ReportThe content of the report was noted.

16/107 Finance ReportThe Month 5 position builds on that previously reported at Month 4. The following

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key points were noted:

Targets still on track to be achieved.

QIPP target is unlikely to be achieved. Current under-performance of £1.6m-£2m, which was currently being offset from reserves, but there was a risk, as previously discussed, that the under-performance will continue.

Finance Recovery Group had now been set up to look in detail at contracts and QIPP.

Continuing Health Care – This remains an area of significant risk. It was expected that work would be done to review packages of care.

Acute – An increase had been reported at both SGH and Chelsea and Westminster.

Prescribing – Some benefit had been seen from some technical adjustments (one-off), and some changes in national prices have been factored in.

Balance position was currently being covered from reserves, but there was a risk if QIPP programmes are not achieved.

Planning Guidance had now been issued, which formalised information previously known. Two-year contracts would be put in place from 2017 – discussions with providers were starting to happen as part of the contract round.

Headlines:

Expectation that CCGs will achieve break even in-year.

No potential to draw down surplus from previous year – to be clarified.

1% non-recurrent reserve will have to be retained – 0.5% uncommitted, and 0.5% to be available for transformation.

CQIN – Previously set at 2.5%, only 1.5% to be available to providers to hit national targets next year.

Business rules generally in line with 16/17, to include 0.5% contingency, and 0.1% tariff uplift. The impact on CCGs this year from the tariff uplift had not taken into account the increase across all providers, which was probably nearer 0.8% rather than 0.1%.

Timetable:

1st November – initial Operating Plan submission

4th November – Contract offers to be issued to providers

24th November – first full draft of Operation Plan to be submitted

Final signed contracts by end of December


Contracting round risk – The potential risk to the CCG will need to be considered.

Transformation funding for providers – STF funding includes two elements around financial targets and performance targets. Work was being done to work that through.

The content of the report was noted.

16/108 Performance ReportThe following key points were noted:

SGH – As noted in the earlier item.

Clinical Priority Area Assessment – This had now been published for Cancer to include four indicators. Wandsworth was rated as Needs Improvement, with

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the worst element around the sixty-two day target.

A&E – Performance at SGH had improved.

RTT data relates to other providers not SGH.

Mental Health – Most of the indicators were being met.

IAPT Recovery rates – Performance was improving.

Board Assurance Framework – A summary had been included in the report. The full report would be presented to the meeting in December.

The content of the report was noted.

16/109 Summary MinutesThe content was noted.

16/110 Any Other BusinessNone.

16/111 Open SpaceNo questions were received from members of the public.

16/112 Clinical Chair’s Closing RemarksThis had been a very full Agenda with a number of important issues discussed.

There being no further business, the meeting closed at 12:20

Date of next meeting: 14th December 2016

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Summary of discussion from Part II of the Board meeting held on 12th October 2016

Feedback was received from the members of the Board on the Part I meeting.

Procurements – Procurement and legal advice had been received, which stated in accordance with best practice guidance, that approval for procurement could be dealt with in Part I, unless there was a commercial in confidence issue, with names of bidders removed from the paper. Following discussion of the points raised, it was agreed that future procurements should be discussed and agreed in Part II, with decisions ratified at the next meeting in public.

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Role Status Name Details of Declaration Committee membership Comments

Wandsworth CCG - Governing Body (Chair); Integrated

Governance Committee (Chair); St George's Hospital Clinical

Commissioning Reference Group (Chair); Management Team

SWL - Chair System Resilience Group; Clinical Lead SWL &

Surrey Downs Health Care Partnership Clinical Board and

Programme Board; Clinical Lead for SWL & Surrey Downs

Health Care Partnership Clinical Board and Programme

Board, and Clinical Lead for SWL Transforming Primary Care

Programme;

Wandsworth - Health and Wellbeing Board

Wandsworth CCG - Governing Body; Management Team;

Integrated Governance Committee; Finance Resource

Committee; Audit Committee; Remuneration Committee;

Primary Care Committee; Workforce Committee

SWL - System Resilience Group


Chief Finance Officer Voting Member Neil McDowell Spouse employed by Guildford and Waverley CCG Wandsworth CCG - Management Team; Audit Committee;

Finance Resouce Committee

Wandsworth CCG - Governing Body (Vice Chair); Finance

Resource Committee (Chair); Audit Committee (Chair);

Remuneration Committee (Chair); Workforce Committee;

Primary Care Committee

Removed interests - Chair, St George's Hospital Charity (term

ended September 2016); Member DLF Advisory Board;

Member Shaw Trust.


Lay Member for Patient and

Public Involvement

Voting Member Carol Varlaam Trustee & Vice Chair, St George's Hospital Charity; Trustee, Wandsworth Care

Alliance; Member St George's University Hospital Foundation Trust

Wandsworth CCG - Governing Body; PPI reference Group

(Chair); Primary Care Commissioning Committee (Chair

elect); Audit Committee; Integrated Governance Committee;

Remuneration Committee; Communications and

Engagement Working Group.

Secondary Care Doctor Voting Member Andrew Neil None Wandsworth CCG - Governing Body; Integrated Governance

Committee; Information Governance Committee (Chair)

Registered Nurse Voting Member Diana Caulfield-Stoker Trustee Cavell Nurses Trust; Member Moorfields NHS Trust Wandsworth CCG - Governing Body; Integrated Governance

Committee (Vice Chair); Quality Group (Chair); Safeguarding

Sub-Committee (Chair)

West Wandsworth Joint

Locality Lead

Dr Zoe Rose GP Partner Putneymead Group Medical Practice (Holds PMS contract). Practice

is a member of the Wandsworth GP Federation(Battersea Healthcare CIC). No

roles or responsibilities held in GP Federation


West Wandsworth Locality Forum and Management Team;

Primary Care Committee; Primary Care CQRG (Chair)

Practice is a member of Battersea Healthcare CIC but Dr Rose

holds no director post and has no specific responsibilities

within that organisation other than those of other Member

GPs.

West Wandsworth Joint

Locality Lead

Dr Rumant Grewal GP Principal, Lead for Mental Health, Substance Misuse, Primary Care

Research, Referrals Management; on-going work as named author for a

Cochrane Review

Wandsworth CCG - Governing Body; Management Team Practice is a member of Battersea Healthcare CIC but Dr

Grewal holds no director post and has no specific

responsibilities within that organisation other than those of

other Member GPs.



Committee; Communications and Engagement Group;

Quality Group; St George's Clinical Quality Review Group;

Community Services Wandsworth Clinical Quality Review

Group (co-Chair); Clinical Scrutiny Group; Primary Care

Transformation Group; Wandle Locality Forum (co-Chair)

South West London - Clinical Advisory Group member;

Clinical Lead for Maternity Clinical Design Group

Voting Member Stephen Hickey Chair Community Transport Association;

Voting MemberWandle Joint Locality Lead

Declarations of Interest - Board Members 2016

Voting Member

Chair Voting Member Dr Nicola Jones Managing Partner Brocklebank Group Practice and St Paul's Cottage Surgery.

Both practices hold PMS contracts. Clinical Lead for Cardio Vascular Disease,

WCCG.

Practice is a member of Wandsworth Integrated Healthcare

Ltd but Dr Nicola Jones holds no director post and has no

specific responsibilities within that organisation other than

those of other member GPs.

Chief Officer Voting Member

GP Partner, Grafton Medical Partner; GP Partner, Lambton Road Medical

Partnership; Director, Raynes Park Health Ltd (building management company;

London Maternity Lead, Royal College of General Practitioners; Volunteer

Doctor, Crisis homeless charity; Member Agenda advisory panel, UK Health

Informatics Forum; Member London Clinical Senate Forum; Non-voting

Member of the Clinical Expert Panel for Maternity of the CCG Improvement and

Assessment Framework (IAF)

Dr Michael Lane Practice is a member of Battersea Healthcare CIC but Dr Lane

holds no director post and has no specific responsibilities

within that organisation other than those of other Member

GPs.

Graham Mackenzie Spouse is employed by Imperial College NHS Trust.

Lay Member for Governance,

Vice Chair

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Battersea Joint Locality Lead Dr Nicola Williams Partner Battersea Rise Practice Wandsworth CCG - Governing Body; Delivery Group;

Management Team; Primary Care Transformation Group;

Primary Care Quality Group

Practice is a member of Battersea Healthcare CIC but Dr

Williams holds no director post and has no specific


other Member GPs.

Battersea Joint Locality Lead Dr Jonathan Chappell GP Partner Battersea Fields Practice Wandsworth CCG - Governing Body; Management Team;


Committee;


Chappell holds no director post and has no specific


other Member GPs.



Committee; Audit Committee; Remuneration Committee;

Primary Care Committee; Workforce Committee

South West London - System Resilience Group

Director of Corporate Affairs,

Performance and Quality

(Maternity Leave)

Non Voting Member Sandra Iskander None Wandsworth CCG - Governing Body; Management Team;

Integrated Governance Committee; Workforce Committee;

Information Governance Group

Wandsworth CCG: Board; Management Team; Integrated

Governance Committee; Delivery Group; GP Resources

Committee; Primary Care Implementation Group; Primary

Care Transformation Group (co-Chair); Estates Steering

Group; Business Intelligence Group

SWL: SRO SWL Out of Hospital Clinical Delivery Group

Director, Commissioning and

Planning

Non Voting Member Rebecca Wellburn None Wandsworth CCG - Management Team; Integrated

Governance Committee

Local Authority Director of

Public Health

Non Voting Member Houda Al Sharifi None Wandsworth CCG - Governing Body

Local Authority Director of

Children's Services

Non Voting Member Dawn Warwick None Wandsworth CCG - Governing Body

Healthwatch Wandsworth Non Voting Member Jamie Gillespie Executive member Healthwatch Wandsworth; Family member employed by

SLAM; Affiliations - 38 Degrees member, SNP member

Wandsworth CCG - Governing Body

Associate Lay Member Chris Savory Advisor Interserve PLC Ltd; Advisor to Liberata and Capacity Grid; Member of

the Dorset NHS Trust

Wandsworth CCG - Integrated Governance Committee;

Finance Resource Committee; Audit Committee;

Remuneration Committee

Associate Lay Member Kimball Bailey Director of Alastor - an independent management consultancy practice that

has, over the past five years, carried out work directly or indirectly for the

Department of Health and various NHS Trusts and other organisations

(including Springfield Hospital). None of this has had a direct impact on

commissioning nor is material to my role as Associate Lay Member for

Governance; member of Essentia advisory board

Wandsworth CCG - Integrated Governance Committee; Audit

Committee; Remuneration Committee; Estates Committee

SGH CQRG Clinical Lead Tom Coffey Partner, Brocklebank Group Practice; MICAS Advisor/OD Lead Battersea

Healthcare CIC; Clinical Assistant A&E Charing Cross Hospital; Advisor EY

(Ireland); Informal advice to London Mayoral candidate Sadiq Khan

Wandsworth CCG - Management Team; SGH CQRG (Chair)

Wandle Joint Locality Lead Voting Member Dr Seth Rankin Partner - Wandsworth Medical Centre; Director - London Travel Clinic Ltd

providing private travel vaccinations; Director - London Doctors Clinic Ltd

providing private GP services; Director - Medilaser Ltd (trading as Wandsworth

Village Skincare) providing cosmetic and medical laser therapy not available on

the NHS; Director - Rankin Press Ltd (dormant) intending to publish books;

Director - Healthy Lifestyle Enterprises (dormant) intended to provide and

deliver weight management programmes; Director - Ezimed Ltd intended to sell

networked panic alarm buttons to GP surgeries; Trustee - Sustainable Medical

Charities International (CIO) providing the resources to deliver healthcare to

the people of Darsilameh Village in the Upper River Region of The Gambia;

Consulted by Circle Partnership in Community Services Redesign;

Advisor/consultant to the Nuffield Trust about Virtual Wards in Community

Services; Consulted by The Sollis Partnership about risk prediction modelling of

patients in primary care


CAHS Project


Rankin holds no director post and has no specific


other Member GPs. Resigned wef 01/10/2016

Director of Corporate Affairs,

Performance and Quality

Non Voting Member Sean Morgan Substantive employer is South East CSU Wandsworth CCG - Governing Body; Management Team;

Integrated Governance Committee; Workforce Committee;

Information Governance Group; Primary Care Committee

Stepped down from Board role wef 11/10/2016

Director of Primary Care

Development

Non Voting Member Andrew McMylor None

Chief of Commissioning

Operations

Non Voting Member Lucie Waters None

Voting Member

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Last updated 17/08/2016

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Meeting

date

Minute

No.Item Lead Decision Action Target Date Progress

Date

CompletedConflicts of Interest

Action to manage

Conflicts

Request for Chair's

ActionApologies Quorate

16/101 Clinical and Operational Focus - St

George's Hospital

LW Further consideration on how to take work

forward would be discussed by MT

ASAP

16/102 Multi-specialty Community

Provider (MCP) procurement

AM Board agreed the recommendation to award

the contract to Battersea Health Care CIC

16/103 Talking Therapies Procurement LW Board approved award of the contract to

bidder two, subject to delivery of the pre-

conditions.16/104 Battersea Locality Annual Report NW/JC

16/105 Lay Member Board Roles GM Recommendation to proceed with

recruitment of a Lay Member was agreed

S Hickey and C Varlaam -

current Lay Members

No action required

16/106 Executive Report GM

16/107 Finance Report NM

16/108 Performance Report SM

None None Yes

LOG OF DECISIONS AND ACTIONS - Board

12/10/2016

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Part B: Decisions and Discussions

Page

2. Part B: Decisions and Discussions 20

2.1. B01 Operational Focus - St George's Hospital

2.2. B02 Clinical Focus - Continuing Health Care 21

2.2.1. Equity and Choice Policy 30

2.3. B03 London Health Devolution 60

2.4. B04 Board Assurance Framework 88

2.5. B05 Policies 128

2.5.1. Prime Financial Policies 128

2.5.2. Managing Conflicts of Interest 132

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Continuing Healthcare Clinical FocusAuthor: Debbie Baronti Sponsor: Rebecca Wellburn Clinical Sponsor: Andy Neal Date: December 2016

Executive Summary

Context

NHS Continuing Healthcare is a needs led service; the CCG has responsibility for commissioning care that meets the needs of eligible patients. Eligibility to CHC is based on assessed need and not on the patient’s ability to pay, therefore if an individual's health needs change, responsibility for funding their care and support may also change. This is a complex and highly sensitive area which can affect individuals at a difficult stage of their lives and can be a very challenging time for them and their families who are often called on to make difficult decisions. It is therefore important that the process and decision making is robust and transparent for all parties.

This paper provides an overview of the WCCG Continuing Healthcare Service and outlines

the process of assessment to establish eligibility for NHS Continuing Healthcare. The paper

also summaries the legacy issues arising from the service delivered by the previous provider

and summaries the actions taken to address these by the CCG and CHS Healthcare since

the service transitioned to the new provider in April 2016.

Question(s) this paper addresses

1. What is CHC and how is eligibility decided?

2. CHC in Wandsworth; what are the current issues?

3. What is the role of the CCG (market management, quality assurance, funding)

Conclusion

1. NHS CHC is a package of care arranged and funded solely by the NHS for patients

aged 18 or over; eligibility is assessed through a legally prescribed decision-making

process based on assessed need.

2. The previous service provider was decommissioned due to poor performance and the

service transitioned to the new provider from 1 April 2016; a range of legacy issues

were identified following transition.

3. The CCG has a duty to provide care to a person assessed as eligible for continuing

healthcare in order to meet their assessed needs.

Input Sought

We would welcome the board’s input regarding the issues raised in this report and for the

Board to note its contents

W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [

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1. What is CHC and how is eligibility decided?

What is CHC?NHS continuing healthcare (NHS CHC) is a package of care arranged and funded solely by the NHS for patients aged 18 or over to meet physical or mental health needs arising because of a disability, accident or illness. NHS Continuing Healthcare provision can take the form of a care home placement or a package of care in the individual's own home or elsewhere.

How is NHS CHC eligibility decided?

In order for someone to receive NHS Continuing Healthcare funding they have to be assessed according to a legally prescribed decision-making process to determine whether they have a 'primary health need'. NHS CHC eligibility decisions are based on whether the patient’s needs for long term care are primarily health related because of complicated, intense or unpredictable healthcare needs. Therefore eligibility is not based on a specific condition or diagnosis and people with the same health condition can have very different needs. The CCGs responsibility to commission, procure or provide care, including NHS Continuing Healthcare, is not indefinite, as needs can change. If the CCG is commissioning, funding or providing any part of the care, a case review should be undertaken three months after the initial eligibility decision (or sooner if needs are thought to have changed), in order to reassess care needs and eligibility for NHS CHC and to ensure that those needs are being met. Following this reviews should then be undertaken annually, as a minimum.

The process to assess eligibility is described in the National Framework for NHS continuing healthcare and NHS-funded nursing care and once consent has been obtained and capacity established one or more of the following tools will be used in the process:

Fast Track Tool.

The Checklist

Decision Support Tool

Fast Track Tool - if a patient has a rapidly deteriorating condition and appears to be reaching the end of their life, the Fast Track Tool can be used to recommend they move quickly onto NHS CHC.Fast tracking is not the usual way and in most cases the type and level of needs should prompt staff to apply the Checklist.

Checklist – The first step in the process for most patients will be a screening process using the NHS Continuing Healthcare checklist; a positive Checklist triggers a full assessment of need. If a patient is about to be discharged from an acute hospital and has significant health and care needs, consideration should be given as to whether they have the potential to improve if offered services such as rehabilitation or intermediate care in a community hospital or other setting before applying the Checklist. If additional services are provided the Checklist should be applied at the end of this period, when the patients’ needs are clearer.

Decision Support Tool (DST) -. Where completion of the checklist triggers a full assessment the

DST is applied; the DST features 12 ‘domains’ or areas of need which are considered to decide if the quantity and/or quality of care needed fulfils criteria for a ‘primary health need’. The 12 domains are:

Behaviour

Cognition

Psychological & emotional needs

Communication

Mobility

Nutrition, food and drink

Continence

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Skin & tissue viability

Breathing

Drug therapies and medication

Altered states of consciousness

Other significant care needs to be taken into consideration

Each domain has descriptions of between four and six levels of need ranging from no need through

to severe and priority. Consideration is given to the nature, intensity, complexity and unpredictability of the needs. The DST is completed by a multi-disciplinary team (MDT), which in turn informs the eligibility recommendation to the CCG. The multidisciplinary team (MDT) is defined in the framework as:

two professionals from different health professions or

one professional from a healthcare profession and one who is responsible for assessing individuals for community care services.

Whilst as a minimum an MDT can comprise two professionals from different healthcare professions, the CCG endeavour to follow best practice by including both health and social care professionals who are knowledgeable about the individual’s health and social care needs in the MDT.

Involving the patient and their family is a core component of the MDT process.

The MDT recommendation is required to be ratified by the CCG within 28 days of the receipt of a positive checklist; this is a quality target for the CCG. The allocation of Social Workers to attend the MDT is a potential risk factor to achieving the 28 day deadline for decision. Therefore whilst every effort is made to include a Social Worker in the MDT, in line with the guidance, the MDT can progress without a social worker if necessary.

A flow diagram of the decision making process is attached at appendix 1. A copy of the Decision

Support Tool can be found at www.gov.uk/government/uploads/Decision_Support_Tool

Case study

Mrs W lived in the community and was known to Social Services Her social worker noticed a decline in her general health – a checklist was completed by

the Social worker which triggered a full CHC assessment. The checklist was received by the CHC team and the case was assigned to a nurse

assessor. The nurse assessor completed the LHNA and gathered all relevant data from other

professionals. The nurse assessor arranged to complete DST for Mrs W The Primary Health Needs test was applied by the MDT – Mrs W was CHC eligible The DST was sent to the CHC team leader who ratified the MDT recommendation for CHC The CHC brokerage team worked with the nurse assessor to source the appropriate care

provider or care home.

2.CHC in Wandsworth; what are the current issues?

Following concerns about the service delivered by the previous provider the CHC service was recommissioned and transitioned to the new provider CHS Healthcare (CHS) on a phased basis, with CHS taking responsibility for the full caseload from 1 April 2016.

Although concerns had been identified previously the full range and extent of these became evident following transition; these are described below together with the steps taken to date.

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Growth and forecast spend - A full reconciliation of the database has been undertaken since

transition to cross reference the current caseload in terms of the number of eligible clients, care

commissioned and costs to ensure that all elements are being fully captured and reported. The table

below tracks the month by month impact of this work as the true caseload numbers and the

associated costs have fully emerged. The forecast outturn at month 7 includes these additional

costs which, although already committed at month 1, were not visible. As a result there is a

significant cost pressure against the budget position for the service because the month 1 position

was understated.

YTD

num

ber

Variances 16/17 Budgets

Full Year Outturn

including one

time cost for

CHC FNC Total CHC FNC CHC FNC CHC FNC

M1 313 226 539 - - £23,494,694 £2,061,020 £21,237,887 £684,250

M2 311 231 542 -2 5 £23,494,694 £2,061,020 £22,881,160 £1,378,202

M3 340 215 555 29 -16 £23,494,694 £2,061,020 £26,412,362 £1,268,584

M4 352 213 565 12 -2 £24,041,471 £1,514,243 £26,868,687 £1,589,920

M5 352 221 573 0 8 £24,041,471 £1,514,243 £27,442,411 £1,657,078

M6 363 229 592 11 8 £24,041,471 £1,514,243 £27,630,976 £1,963,379

M7 361 242 603 -2 13 £24,041,471 £1,514,243 £28,114,269 £2,064,698

Strengthening Commissioning & contracting processes – On transfer of the service in April our new provider, CHS Healthcare, implemented a range of measures to strengthen the commissioning and contracting arrangements with providers. One of these is a regular audit of care delivered against care commissioned from domiciliary providers. Since April this process has evidenced efficiencies that are expected to equate to 250k fye without any change to the care delivered to the patient.

Application of the checklist and use of the Fast Track tool A high proportion of new CHC referrals currently come via the Fast Track process and some disparity has been noted in the application of the Fast Track Tool. We have worked with St Georges, our main provider, to agree that the route for all Fast Track referrals will be via the Integrated Discharge Team, thereby ensuring consistent and appropriate application of the Fast Track Tool. In addition an audit of the use of the Fast Track tool has been completed to identify areas where additional training in compliance with the tool may be necessary. This will improve access and ensure eligible patients in this cohort are able to access care quickly.

Backlog of assessments – A case review should be undertaken three months after the initial eligibility decision and then, as a minimum, on an annual basis. Regular reviews are built into the process to ensure that where eligibility is maintained the care package continues to meet the person's needs. On transition of the service it was noted that routine reviews had not taken place since August 2015. These routine reviews of care needs can result in changes in eligibility/care packages where the patients’ needs have changed. Given that these reviews have not taken place the CCG has no assurance that the care commissioned continues to be appropriate to meet the level of assessed need. The CCG has therefore commissioned a fixed term project to undertake this work, which commenced with a clinical triage/desk top review of individual patients and relevant assessments to identify high risk cases. This project is due for completion by March 2017.

24hr domiciliary care - There has been a tendency to allocate 24 hour packages of care for domiciliary patients referred via the Fast Track process. Care packages at home will, on the whole, be more expensive than a Nursing Home placement in cases where the patient requires 24 hour

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care with two 12 hour shifts. Analysis of September data identified 28 patients with 24 hour care packages commissioned by the previous provider at a full year cost of £4.8m.

The CCG aims to commission the provision of NHS funded Continuing Healthcare in a manner which reflects the choice and preferences of individual patients and their families whilst ensuring we meet our statutory responsibilities for patient safety, quality of care and making best use of resources. Whilst the CCG will take into account the views of the individual so far as is possible, the CCG must consider a range of factors and must comply with its statutory financial obligations. The final decision as to the care package is one for the CCG; however it will act on all reasonable requests to the best of its ability.

As a result of the lack of routine review by the previous provider the CCG needs to seek assurance, through the backlog review project, that the packages of care commissioned are safe, appropriate to meet the assessed needs and represent value for money. The review process offers an opportunity to consider efficiencies within the care commissioned. As an example the current average weekly cost of 12 hour shifts is £3100 compared to the AQP rate for live in care at tier 3 of £1300 per week.

High Cost Packages - Continuing Healthcare is based on delivering care to meet the patients assessed need. There are currently 115 clients within Wandsworth who are classified as high cost, in that the care they are receiving exceeds the threshold of £1500 per week. It is recognised that there are some clients whose clinical condition means that they will require an on-going and sometimes increasingly high cost package of care. However as follow up reviews have not been undertaken the CCG needs assurance that the packages of care commissioned are safe, appropriate to meet the assessed needs and represent value for money

Social care

Health and social care systems are underpinned by a number of different legal frameworks and funding systems. Social care, unlike NHS services, is subject to means tested charges.

The increasing pressures on social care arising from an ageing population and the impact of budget restraints are placing a greater emphasis on the accessibility of continuing healthcare and it is important that we ensure that eligibility criteria are consistently and robustly applied in line with the CHC Framework so that patients are treated in a fair and equitable way. The funding arrangements for ongoing care are complex and it is recognised that this is a highly sensitive area which can affect individuals at a difficult stage of their lives and can be a very challenging time for families who are often called on to make difficult decisions.

Eligibility to CHC is based on assessed need and not on the patient’s ability to pay. If an individual's health needs change, responsibility for funding their care and support may also change and it is important that the process and decision making is transparent for all parties.

Our CHC Commissioning and Choice and Equity Policies will set out the process to determine eligibility and our approach to the commissioning of care packages for eligible patients.

Delay in hospital discharge

The constraints within the system described above can impact on the ability to source appropriate care packages for eligible patients in a timely manner which can result in delay in hospital discharge, placing additional pressure on hospital beds.

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3.What is the role of the CCG?

Care home market

The CCG has a duty to provide care to a person assessed as eligible for continuing healthcare in order to meet their assessed needs. An individual or their family/representative cannot make a financial contribution to the cost of the care identified by the CHC team as required to meet the individual’s needs. An individual however, has the right to decline NHS services and make their own private arrangements

Many patients who require Continuing Healthcare will receive it in a specialised environment. The treatments, care and equipment required to meet complex, intense and unpredictable health needs often depend on such environments for safe delivery, management and clinical supervision. Specialised care, particularly for people with complex disabilities may only be provided in a specialist Care Home, which may sometimes be distant from the patient’s ordinary place of residence. These factors mean that there is often a limited choice of safe and affordable packages of care.

Market Management

The CCG has a responsibility to work with providers to ensure suitable, high quality and affordable care for our patients. The CCG has participated in the pan London AQP Domiciliary Care procurement through which a number of new providers were identified. These providers are now

being rolled out for newly commissioned packages of care.

The CCG also previously participated in the pan London AQP Care Homes procurement. This framework ensures consistent standards of care are applied across a range of providers. However as there is a large contingency of self-funding clients within Wandsworth this results in lower interest from Care Homes in participating in the AQP Framework and therefore placements sometimes have to be made outside of the AQP Framework.

FundingThe CCG holds the responsibility to promote a comprehensive health service on behalf of the Secretary of State and we must not exceed our financial allocation. |The CCG is expected to take

account of patient choice but must do so in the context of these two responsibilities. The CCG is therefore required to balance the patient’s preference alongside safety, quality and value for money.

Quality assurance

Quality Assurance within the NHS is made up of the three components - Patient Safety, Patient Experience and Clinical Effectiveness. We have a system of quality assurance which provides

information relating to safety, effectiveness and patient experience to support us to secure positive health outcomes from the care commissioned and improve the quality of the services delivered to our patients.

The CCG also needs to provide NHS England with assurance that arrangements are in place to

meet the overall strategic challenges for NHS Continuing Healthcare in terms of:

the delivery of the National Framework

assessment processes that achieve a consistent approach to eligibility

decision making that is sound and legally complaint

high quality care being delivered to those found eligible for NHS Continuing Healthcare

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C O N C L U S I O N

This report has set out the process for establishing eligibility for NHS Continuing Healthcare and the actions undertaken to improve the management and delivery of the service since April 2016.

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For ReferenceEdit as appropriate:

1. The following were considered when preparing this report:

The long-term implications [Yes]

The risks [Yes]

Impact on our reputation [Yes]

Impact on our patients [Yes]

Impact on our providers [Yes]

Impact on our finances [Yes]

Equality impact assessment [Yes]

Patient and public involvement [Yes]

1. This paper relates to the following corporate objectives:

Commission high quality services which improve outcomes and reduce

inequalities [Yes]

Make the best use of resources, continually improve performance and deliver

statutory responsibilities [Yes]

Continually improve delivery by listening to and collaborating with our patients,

members, stakeholders and communities [Yes]

Transform models of care to improve access, ensuring that the right model of care

is delivered in the right setting [Yes]

Develop the CCG as a continuously improving and effective commissioning

organisation [Yes]

2. Executive Summaries should not exceed 1 page. [My paper does comply]

3. Papers should not ordinarily exceed 10 pages including appendices.

[My paper does comply]

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Appendix 1 -Stages in the process to determine eligibility for NHS CHC

Ye

s

Individual possibly eligible for NHS CHC

Has rapidly

deteriorating

condition

FAST TRACK

Recommendation

by appropriate

clinician

CCG actions

request and care

arranged, ideally

within 48 hours

Could individual benefit

from further NHS

services?

Explain process and sources of

support; provide written

information and seek consent to

start process

Arrange services then review

progress.

Complete CHECKLIST involving

individual/their representative

Write to individual explaining

checklist outcome.

Eligible for next stage: Full needs

assessment + DECISION SUPPORT

TOOL (DST)

NHS appoint Nurse Assesor Identify

assessment information required for

consideration at multidisciplinary team

(MDT) meeting. Invite individual/their

representative to participate

MDT discusses needs, completes DST

and makes recommendation.

CCG verifies MDT

recommendation

Individual/representative sent

written explanation of decision and

completed DST. Where necessary

information

Eligible: care planning

discussions to agree care

package to be fully funded by

CCG.

Not eligible: care planning

discussions to agree how to

meet needs. Means test.

Review needs after 3

months then at least

every 12 months. May

need to reconsider

eligibility.

Not eligible for next stage.

Full health and social

care assessment to

identify eligible needs

then care

planning/means test

Appeal:

Local process then

Independent Review

Panel then

Ombudsman

If still unhappy

can use NHS

complaints

process

Ask CCG to

reconsider

CHECKLIST

outcome.

No

Yes No

Yes No

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Equality and Choices PolicyAuthor: Debbie Baronti Sponsor: Rebecca Wellburn Clinical lead: Andy Neal Date: December 2016

Executive Summary

Context

Continuing Healthcare is a significant area of care for a vulnerable group of individuals. The CCG

needs to ensure that our processes for delivering CHC meet the requirements set out in the National

Framework; that they are clear and transparent and that our allocation of resources is applied

equitably with robust decision making that is legally compliant.

This paper provides an overview of the Continuing Healthcare Commissioning and Equity and

Choice Policies. These policies have been developed to strengthen our governance arrangements

for the service and provide assurance that the CCG is fully meeting its commissioning

responsibilities.

Questions addressed in this paper

1. Why do we need the CHC Commissioning and Equity and Choice Policies?

2. What are the risks and opportunities associated with implementation?

3. What are the risks of delaying approval?

Conclusion1. The CCG needs to ensure that our processes for delivering CHC meet the requirements

set out in the National Framework and are clear and transparent, applied equitably and that

our decision making processes are robust and legally compliant.

2. Care may not be aligned to meet assessed needs and our commissioning decisions may

be viewed as inequitable and open to challenge. The policies will support transparent, fair

and equitable decision making.

3. There will be no clear and transparent framework for decision making and allocation of

resource.

Input Sought

To note the contents of the report and approve

the CHC Commissioning and Equity and Choice

Policies

Input Received

The draft policies have previously been shared

with Management Team and Capsticks

Context

W A N D S W O R T H C C G P A G E 1 O F [ X ]

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NHS continuing healthcare is a package of care arranged and funded solely by the NHS for patients

aged 18 or over to meet physical or mental health needs arising because of a disability, accident or

illness. In order for someone to receive NHS Continuing Healthcare funding they have to be

assessed according to a legally prescribed decision-making process to determine whether they have

a primary health need. WCCG is responsible for commissioning and procuring services for

Wandsworth patients who qualify for NHS Continuing Healthcare and in meeting our commissioning

responsibilities the CCG must balance a number of issues. The fundamental challenge is how we

allocate our limited resources to best serve the local population as a whole, whilst also having due

regard to individual rights and choices.

We need to ensure that our processes for delivering CHC meet the requirements set out in the

National Framework and that we can demonstrate clear transparent processes that are applied in

an equitable way, underpinned by robust, legally compliant decisions. We have developed the

Wandsworth CCG CHC Commissioning Policy (appendix 1) and Wandsworth CCG Choice and

Equity Policy (appendix 2) to support this.

1.Why do we need the CHC Commissioning and Equity & Choice Policies?

These two policies set out our approach and how we will make provision of care once eligibility to

CHC has been established. Neither policy relates to eligibility to NHS Continuing Healthcare funding;

this is a legally defined process as described in the NHS Continuing Healthcare and Funded Nursing

Care Framework (revised 2012).

CHC Commissioning Policy

This policy relates to patients eligible for NHS Continuing Healthcare, NHS funded nursing care, or

a joint package of health and social care who are registered with a GP in Wandsworth or where the

CCG is responsible under the responsible commissioner guidance, Who Pays - NHS England 2013.

The purpose of this policy is to support the CCG to meet our statutory and other legal obligations

and ensure that the reasonable requirements of eligible individuals are met. Elements covered by

the policy include:

The range of factors the CCG will consider when commissioning a package of care

The approach to sourcing care providers

The elements the CCG will cover through NHS Continuing Healthcare funding

The process of review

CHC Equity and Choice Policy

This policy describes the way in which Wandsworth CCG will ensure equity and choice in the

provision for the care of people who have been assessed as eligible for fully funded NHS Continuing

Healthcare. It describes the process of decision making for provision subsequent to an assessment

of eligibility under the National Framework.

Elements of the policy include:

How the CCG will make provision of NHS funded Continuing Healthcare in a manner which

reflects the choice and preferences of individuals as far as is reasonably possible.

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How we will source care home placements using the preferred provider framework and our

approach where an assessed individual wishes to move into a home outside of the preferred

provider list.

The elements that need to be considered prior to commissioning a care package at home.

Out of Area Care at Home and the Responsible Commissioner

Choice and the Mental Capacity Act 2005

Approach to development

The issues addressed in these policies are not unique to Wandsworth and in developing our

approach we have been guided by national and local policy and relevant case law. Similar

arrangements are already in place in a number of CCGs nationally and are in development with

other CCGs in South West London. Local stakeholders have contributed to the development of these

policies the approach described takes into account relevant case law.

What are the implications for the board and the business?

The policies will guide decision making on the provision of Continuing Healthcare and that our

approach will:

Ensure the process is robust, fair, consistent and transparent

Ensure that there is consistency in the services that individuals are offered

Inform robust, consistent and transparent commissioning decisions for the CCG

Promote individual choice as far as reasonably possible

Facilitate effective partnership working between health care providers, NHS bodies and the

Local Authority

Ensure the CCG achieve best value in their purchasing of services for individuals eligible

for NHS Continuing Healthcare and joint packages of care

Ensure compliance with and adherence to the CCG’s Standing Financial Instructions and take into account the need for the CCG to allocate its financial resources in the most cost effective way.

Offer choice where available in the light of the above factors

The National Framework sets out the key considerations to take into account when a service user has requested a package of care that is outside of the agreed thresholds. The CCG must be able to demonstrate that it has taken all relevant factors into consideration in our decision making whilst at the same time ensuring that we equitably distribute public resources. There must therefore be a process to ensure that an individual could be enabled to have a package of care outside of the agreed process, on the grounds of exceptionality. The policies include the provision for a review for care packages commissioned outside of policy on grounds of exceptionality; this would be by panel, the draft terms of reference are attached at appendix 3.

2. Risks and opportunities

Risks

Whilst the policies provide a framework for decision making and a transparent process it is

recognised that provision of NHS Continuing Healthcare funding is a complex and emotive

issue for individuals and their families. Therefore implementation of the policies in

consideration of patients currently in receipt of NHS CHC will need to dealt with sensitively

on a case by case basis.

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Opportunities

Implementation of these policies will have a beneficial impact in ensuring equitable

distribution of resources and offer of choice to eligible patients.

Sourcing and commissioning packages of care through agreed frameworks is likely to lead to

financial efficiencies.

Equality Impact AssessmentAn understanding of cultural differences and attitudes is needed for effective healthcare to be

delivered appropriately. E.g. different attitudes to clinical examination and what is acceptable to the

patient and patient’s preferences for doctors or nurses of particular gender. Providers will be

required to provide detailed training on equality and diversity, to all staff both clinical and non-clinical,

nurturing their workforce and leadership and commitment to E&D.

Ethnicity may impact on healthcare and access to it at many levels, acting through factors such as:

• differences in service uptake

• communication issues

• culture and attitudes

• socio-economic factors

• differences in disease prevalence

These differences affect access to services and act as barriers to good healthcare.

Effective advertising by providers will help to address issues such as hard to reach groups,

encouraging inclusion with those who may feel that they are unable to access services.

Following the qualities Act of 2010, providers of health and social care services will also be required

to ensure that information is available in a variety of formats, with the provision of language

interpreters where necessary.

All providers that provide NHS care or adult social care are legally required to follow the Accessible

Information Standard. The standard aims to make sure that people who have a disability, impairment

or sensory loss are provided with information that they can easily read or understand with support

so they can communicate effectively with health and social care services. Successful

implementation will lead to improved outcomes and experiences, and the provision of safer and more

personalised care and services to those individuals who come within the Standard’s scope.

3. What would the impact be of delaying approval?

Care may not be aligned to meet assessed needs and our commissioning decisions may be

viewed as inequitable and open to challenge.

Without a clearly defined process care packages may be procured outside the framework and this is likely to lead to increased costs.

The CCG Board are asked to note the contents of this report and approve the CHC Commissioning and Equity and Choice Policies

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The long-term implications [Yes ]

The risks [Yes]





Equality impact assessment [Yes]




inequalities [Yes]








organisation [Yes]




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Wandsworth CCG

Continuing Healthcare Commissioning Policy

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Document Control

Title Wandsworth CCG Continuing Healthcare

Commissioning Policy

Originator/author: Alison Kirby / Munya Nhamo

Approval Body Wandsworth CCG Governing Body

Approval Date

Document Status Final

Approved by: Wandsworth Clinical Commissioning Group Board

Review Date December 2018

Stakeholders engaged in development or review London Borough of WandsworthWandsworth EOLC Centre

Target audience: WCCG employees and members

London Borough of Wandsworth (Social Services)

All Commissioned Services

Patients and, where indicated, their

representative(s) who are subject to NHS

Continuing Healthcare Funding.

Implementation of the Public Sector Equality Duty 2011 (PSED) forms the foundation of equality and

diversity activities in Wandsworth CCG. The PSED applies to the CCG as a public authority and

therefore requires that the CCG, in the exercise of its functions, have due regard to the need to:

(a) eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by

or under this Act;

(b) advance equality of opportunity between persons who share a relevant protected

characteristic and persons who do not share it;

(c) foster good relations between persons who share a relevant protected characteristic and

persons who do not share it

These are known as the three sections of the “general duty”

The CCG intends to utilise the NHS equality delivery system (EDS) as the principle means of fulfilling

our commitments under the PSED.

Public Sector Equality Duty - Equality Statement:“This document demonstrates the organisation’s

commitment to create a positive culture of respect for all individuals, including staff, patients, their families

and carers as well as community partners. The intention is, as required by the Equality Act 2010, to

identify, remove or minimise discriminatory practice in the nine named protected characteristics of age,

disability, sex, gender reassignment, pregnancy and maternity, race, sexual orientation, religion or belief,

and marriage and civil partnership. It is also intended to use the Human Rights Act 1998 and to promote

positive practice and value the diversity of all individuals and communities”.

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1.0 Introduction

1.1 ‘NHS Continuing Healthcare’ (NHS CHC) means a package of continuing care that is arranged and

funded solely by the NHS. ‘Continuing care’ means care provided over an extended period of time, to

a person aged 18 or over, to meet physical or mental health needs that have arisen as a result of

disability, accident or illness.

1.2 This is the Wandsworth Clinical Commissioning Group (WCCG) policy on the commissioning of

care packages for patients who are eligible (see section 4.1) for an episode of Continuing Healthcare

(CHC). WCCG is responsible for commissioning and procuring services for all individuals who qualify

for NHS Continuing Healthcare.

2.0 Purpose

2.1 The purpose of this policy is to assist WCCG to ensure that the reasonable requirements of eligible

individuals are met, while meeting the CCG’s statutory and other legal obligations.

2.2 This policy applies once an individual has received a comprehensive, multidisciplinary assessment

of their health and social care needs and the outcome shows that they have a Primary Health Need

and are therefore eligible for an episode of NHS Continuing Healthcare funding

2.3 This policy has been developed to help provide a common and shared understanding of CCG

commitments in relation to individual choice and resource allocation (please refer to WCCG Choice and

Equity Policy)

2.4 The benefits of this policy are to:

Improve the quality and consistency of care

Ensure that there is consistency in the local area over the services that individuals are offered

Inform robust, consistent and transparent commissioning decisions for the CCG

Ensure objective assessment of the patient’s clinical need, safety and best interests

Promote individual choice as far as reasonably possible

Facilitate effective partnership working between health care providers, NHS bodies and the

Local Authority in the area

Ensure the CCG achieve best value in their purchasing of services for individuals eligible for

NHS Continuing Healthcare and joint packages of care

Ensure compliance with and adherence to the CCG’s Standing Financial Instructions

3.0 Aligned Policy

3.1 WCCG CHC Operational Policy

3.2 WCCG Choice and Equity Policy

3.3 WCCG Personal Health Budgets Policy

3.4 Mental Capacity Act

3.5 WCCG Safeguarding Policy

4.0 Scope of the Policy

4.1 This policy relates to patients eligible for NHS Continuing Healthcare, NHS funded nursing care, or

a joint package of health and social care who are registered with a GP in Wandsworth or where the

CCG is responsible under the responsible commissioner guidance, Who Pays - NHS England 2013.

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4.2 The NHS Continuing Healthcare and Funded Nursing Care Framework (revised 2012) is a legal

framework that is used to identify whether patients are eligible for NHS Continuing Healthcare or funded

nursing care. See link below:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213137/National-

Framework-for-NHS-CHC-NHS-FNC-Nov-2012.pdf

5.0 Duties / Accountabilities and Responsibilities

5.1 This policy is issued to support WCCG to meet its commitments under The National Health Service

and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012 (“the

Standing Rules”) for Continuing Healthcare, in accordance with the National Framework. See link

above.

5.2 This policy will ensure that the CCG adheres to national and local requirements to safeguard adults

and adhere to the principles identified within the Mental Capacity Act and its associated Code of

Practice, including the Deprivation of Liberty Safeguards (2009).

6.0 Policy Document Requirements Details

6.1(a) where an individual qualifies for NHS Continuing Healthcare, the package to be provided is that

which the CCG assesses is appropriate to meet all of the individual’s assessed health and associated

social care needs

6.1(b) The CCG will seek to promote the individual’s independence subject to the factors set out in

paragraph 6.1(d).

6.1(c) The CCG’s responsibility to commission, procure or provide NHS Continuing Healthcare is not

indefinite, as needs could change. As defined in the national framework, regular reviews are built into

the process to ensure that the care provision continues to meet the individual’s needs and is funded

appropriately.

6.1(d) When commissioning services for individuals based on their assessed needs, the CCG will

consider a range of factors including:

Safety, Governance & Assurance

Clinical need;

Individual safety;

Public safety;

Individual choice and preference;

Individual’s rights to family life;

Value for money; and

The best use of resources for the population of Wandsworth.

Personalisation, choice & Diversity

Ensuring services meet the required quality standards;

Ensuring services are culturally sensitive; and

Ensuring services are personalised to meet individual need.

These lists are not exhaustive.

6.2 Identification of care provision

6.2(a) Where an individual is eligible for an episode of NHS Continuing Healthcare funding, WCCG will

commission care which meets the individual’s assessed needs. The CCG will only fund services to

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https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213137/National-Framework-for-NHS-CHC-NHS-FNC-Nov-2012.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213137/National-Framework-for-NHS-CHC-NHS-FNC-Nov-2012.pdf

meet the needs that are identified in the care plan, for which it has a statutory responsibility and that

are needed to meet the individual’s reasonable requirements based on all relevant factors, including

those in 6.1(d).

6.2(b) The CHC Nurse Assessor/ individual’s care coordinator will discuss the proposed care provision

with the individual and their representative(s) where the individual gives consent for such a discussion

or where the individual lacks capacity. The care coordinator should identify different options for

providing the care, indicating which of these the individual prefers. The Care Plan will identify the

outcomes the individual wishes to achieve

6.2(c) The care coordinator will use the CCG’s ‘Funding Request Brokerage Form’ to set out the

requested care package and associated information. The brokerage form must be completed in full for

every proposed care package.

6.2(d) The CCG will seek to take into account any reasonable request from the individual and their

representative(s) in making the decision about the care provision, subject to the all relevant factors,

including those set out in paragraph 6.1(d).

6.2(e) The CCG will endeavour to offer a reasonable choice of available, preferred providers to the

individual. Where the individual wishes to receive their care from an alternative provider the CCG will

consider this subject to the following criteria:

Provider’s acceptance to sign up to the NHS Standard Contract;

The individual’s preferred care setting is considered by the CCG to be suitable in relation to the

individual’s needs as assessed by the CCG;

The cost of making arrangements for the individual at their preferred care setting would not

require the CCG to pay more than they would usually expect to pay having regard to the

individual’s assessed needs;

The individual’s preferred care setting is available;

The people in charge of the preferred care setting are able to provide the required care to the

individual subject to the CCG usual terms and conditions.

6.3 Registered care settings

6.3(a) Where care is to be provided in a registered care home setting the CCG will only place individuals

with providers which are:

I. Registered with the Care Quality Commission (CQC), or any successor as providing the

appropriate form of care to meet the individual’s needs; and

II. Not subject to an embargo by the CCG or Local Authority, including the lead CCG or Local

Authority if the provider is not located in WCCG boundaries; and (subject to paragraph 6.3(b)

below), and

III. Contracted as an approved provider under the Pan London AQP (Continuing Healthcare)

agreement OR

IV. Can demonstrate compliance with the non AQP Care Home (CHC) Service specification.

6.4 Care At Home

6.4(a) Where home care is to be provided, the CCG will use domiciliary care agencies it has

commissioned through AQP to provide such care, including agencies commissioned by the Local

Authority on its behalf. Home care will be provided by agencies suitably qualified to deliver the care that

meets an individual’s assessed needs, see paragraph 6.3(a), (i) and (ii).

6.4(b) The cost of home care provision should not exceed the equivalent cost of care in a registered

care setting capable of meeting the needs of the individual.

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6.4(c) If an individual with a domiciliary care package is admitted into an acute setting, the CCG will

only pay for the carer to accompany the service user for the journey and to ensure the service user is

settled on arrival. The CCG will pay to the end of that particular shift or a maximum of 3 hours after the

shift has ended.

6.4(d) In exceptional circumstances, the CCG will fund a care retainer for services where the continuity

of service delivery (most specifically with particular carers skills) is of paramount importance. In such

instances, we would expect the carer to maintain service delivery throughout an acute in-patient

experience, and that the provider liaises directly with the Acute Trust to ensure compliance with local

policy.

6.5 CCG Preferred Providers

6.5(a) To assist the CCG in achieving consistent, equitable care, the CCG will endeavour to offer and

place individuals with preferred providers that are on the CCG’s Approved List of Preferred Providers

and / or part of the Pan London AQP Protocol.

6.5(b) Where a Preferred Provider is not available to meet the individual’s reasonable requirements,

the CCG may make a specific purchase and place the individual with another care provider who meets

the individual’s needs. Where such an arrangement has been agreed the CCG reserves the right to

move the individual to a suitable Preferred Provider when available, where this will provide a clinical

benefit to the patient or better value for money to the CCG.

6.5(c) Though all reasonable requests from individuals and their families will be considered, the CCG

is not obliged to accept requests from individuals for specific care providers which have not been

classified as Preferred Providers.

6.6 Location – Care at Home

6.6(a) The CCG will take account of the wishes expressed by individuals and their families when making

decisions as to the location or locations of care to be offered to individuals to satisfy the obligations of

the CCG to provide NHS Continuing Healthcare.

6.6(b) The CCG acknowledges that many individuals with complex healthcare needs wish to remain in

their own homes, with support provided to the individual in their own homes. Where an individual or

their representative(s) express such a desire, the CCG will investigate to determine whether it is

clinically feasible and within the duties of the CCG to provide a sustainable package of NHS Continuing

Healthcare for an individual in their own home.

6.6(c) Any Care At Home requests will be accompanied by an offer of a Personal Health Budget

(please refer to PHB Policy)

6.6(d) where an individual expresses the preference to receive care at home, the CCG will benchmark

the cost of such a package against the cost of a suitable package of care in a registered care setting

(per Choice and Equity Policy)

6.7 Location – Registered Care Settings

6.7(a) Through discussions with the individual, and/or their representative(s), location requests will be

accommodated as much as reasonably possible, and in accordance with this policy, taking into account

all the relevant factors, including, for example, proximity to relatives. Location requests will be subject

to the criteria described in paragraph 6.3 of this policy.

6.7(b) If the individual requests a care home that was not originally offered, the CCG will accept the

individual’s selection providing it complies with the criteria set out in paragraph 6.3 of this policy.

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6.7(c) The CCG understands that individuals may want to be located near specific places to stay in the

local community and enable family and friends to visit easily. To accommodate this, where the CCG’s

preferred available care homes are not within a reasonable travelling distance, the CCG may choose

to make a specific purchase for that individual to enable them to be accommodated in their preferred

area where the anticipated cost to the CCG may be more than the available CCG preferred

accommodation (based on CCG agreed standard rates for equivalent levels of need).

6.7(d) The CCG will consider such requests on a case by case basis, guided by all the relevant factors

including those set out in paragraph 6.1(d) and using the two stage process for determining exceptional

circumstances set out below in paragraph 6.16(b).

6.7(e) Reasonable travelling distance will be based on a case by case assessment of an individual’s

circumstances, and will take into account factors such as ability of family and friends to visit, which may

include public transport links and mobility of the family and friends.

6.8 Additional services

6.8(a) The individual or their representative(s) has the right to enter into discussions with any provider

to supplement the care provision, over and above that required to meet assessed needs. Any such

costs arising out of any such agreement must be funded by the individual or through third party funding

6.8(b) The decision to purchase additional services to supplement a CHC package must be entirely

voluntary for the individual. The provision of the CHC package must not be contingent on or

dependent on the individual or their representative(s) agreeing to fund any additional services. This

means that the care home must be willing and able to deliver the assessed CHC needs to the

individual, without the package being supplemented by other services as described in this policy.

6.9(a) Any funding provided by the individual for additional services should not contribute towards costs

of the assessed need that the CCG has agreed to fund. Similarly, CHC funding should not in any way

subsidise any additional service that an individual chooses outside of the identified care plan.

6.9(b) Where an individual is funding additional services, the associated costs to the individual must be

explicitly stated and set out in a separate agreement with the provider. If the individual chooses to hold

a contract for the provision of these services, it should be clear that the additional payments are not to

cover any assessed needs funded by the CCG.

6.9(c) If the individual or their representative(s), for any reason, decides that they no longer wish to fund

any such additional services, the CCG will not assume responsibility for funding those additional

services.

6.9(f) Where the CCG is aware of additional services being provided to the individual privately, the CCG

will satisfy itself that they do not constitute any part of the provision to meet assessed needs.

6.10 Availability

6.10(a) To enable individuals to receive the correct care promptly, individuals will be offered available

care as soon as possible. If an individual’s first choice from the CCG’s Preferred Providers is not

available, they will be offered another CCG Preferred Provider to ensure provision as soon as possible.

The CCG will offer care from Preferred Providers before any other unless exceptional circumstances

apply.

6.10(b) If the individual requests care which is currently unavailable, and is unwilling to accept the

CCG’s offer of care, there are several options available to the CCG:

I. Temporary placement of the individual with alternative care provision until the care from the

CCG’s preferred care is available.

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II. The individual may choose to go to their own or a relative’s home without the assessed care

provision until the preferred care is available. The terms set out in paragraph 6.11 of this policy

will apply. The individual will, however, retain the right subsequently to change their mind and

elect to accept the care provision offered by the CCG. If the individual does not have mental

capacity to make this decision, a best interest’s decision will be made in accordance with the

Mental Capacity Act 2005;

III. If it has been agreed with the individual that the assessed needs can best be met through a

care home placement, the CCG may choose to provide home care until the preferred care

home is available, but cost implications to the CCG must be considered. This will be in

accordance with paragraph 6.2 of this policy.

IV. If the individual’s representative(s) are delaying placement in a care home due to non-

availability of a preferred home, and the individual does not have the mental capacity to make

this decision themselves, the CCG will have recourse to the Wandsworth (and Pan London)

Multi Agency Safeguarding Adults Policy, local safeguarding procedures and the Mental

Capacity Act 2005, as appropriate.

V. If the individual is in an acute healthcare setting, they must move to the most appropriate care

setting as soon as they are medically fit for discharge, even if their first choice of care provision

is not available.

6.11 Acceptance

An individual is not obliged to accept a Continuing Healthcare package. Once an individual is eligible

and offered NHS Continuing Healthcare, and they choose not to accept the Continuing Healthcare

package, the CCG may, in appropriate cases, take reasonable steps to make the individual aware that

the Local Authority does not assume responsibility to provide care to the individual. The CCG will work

with the individual to help them understand their available options and facilitate access to appropriate

advocacy support. As appropriate, the CCG will have recourse to Wandsworth (and Pan London) Multi

Agency Safeguarding Adults Policy, local safeguarding procedures and the Mental Capacity Act 2005.

6.12 Withdrawal

The NHS discharges its duty to individuals by making an offer of a suitable care package to individuals,

whether or not they choose to accept the offer.

6.12(a) Where an individual exercises their right to refuse, the CCG will ask the individual or their

representative(s) to sign a written statement confirming that they are choosing not to accept the offer

of care provision.

6.12(b) It may be appropriate for the CCG to remove Continuing Healthcare services where the situation

presents a risk of danger, violence to or harassment of care staff that are delivering the package.

6.12(c) The CCG may also withdraw Continuing Healthcare funded support where the clinical risks

become too high. This can be identified through, or independently of, the review process. Where the

clinical risk has become too high in a home care setting, the CCG may choose to offer Continuing

Healthcare in a care home setting.

6.12 (d) In all such instances, the decision of the CCG will be made by a senior panel of members. No

decision will be made or undertaken unilaterally or without consultation with our Local Authority

This list is not exhaustive.

6.13 Appeals

An individual may appeal against a decision by the CCG as to the nature, extent or location of a care

package being offered. Appeals will be dealt with through the CCG’s Appeals procedure. If the appeal

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cannot be resolved locally the individual or their representative can be referred directly to the Health

Service Ombudsman.

6.14 Continuing Healthcare review

6.14(a) A case review should be undertaken by a Continuing Healthcare nurse no later than three

months after the initial eligibility decision, in order to reassess the individual’s care needs and eligibility

for NHS Continuing Healthcare and to ensure that the individual’s assessed needs are being met.

Clinical reviews undertaken by a Continuing Healthcare nurse should thereafter take place annually as

a minimum.

6.14(b) If the review demonstrates that the individual’s condition has improved to an extent that they no

longer meet the eligibility criteria for Continuing Healthcare provision, the individual, family carers where

appropriate and the CCG will work collaboratively with the Local Authority to ensure the individuals

needs will be met.

6.14(c) At this point the Local Authority has 28 days to review the individual’s requirements and the

individual will be notified they may no longer be eligible for Continuing Healthcare. CCG funding for an

individual’s care may be continued for 28 days where a Local Authority is undertaking such a review or

such longer period as seems reasonable in the circumstances.

6.14(d) The Continuing Healthcare review may identify an adjusted, decreased or increased care need.

6.14(e) where an individual is receiving home care, the CCG will consider the ability of the package to

be delivered in the home environment and also the cost effectiveness of this package.

6.15 Fast Track

The eligibility criteria for a Fast Track application are defined within the National Framework for NHS

Continuing Healthcare and NHS-funded Nursing Care (DH, revised 2012),

Care provision for individuals assessed on the Fast Track will be subject to the same principles as set

out in this policy.

WCCG commissions the EOLC Coordination Service (EOLCCS) Provider as the single point of access

for all fast tracks (except for care required within Care Homes with Nursing) and to take the lead in

sourcing the required care packages at home which will be approved after referral ratified by the CCG.

The EOLCCS Provider will brokerage care packages in accordance with the WCCG Commissioning

and Choice and Equity Policies.

7. Public Sector Equality Duty

7.1 Public Sector Equality Duty - Wandsworth CCG aims to design and implement services, policies

and measures that meet the diverse needs of our service, population and workforce, ensuring that none

are placed at a disadvantage.

7.2 The general equality duty requires public sector bodies, in the exercise of their functions, to have

due regard to the need to the need to:

Eliminate discrimination, harassment and victimisation and any other conduct that is prohibited

under the equality Act 2010

Advance equality of opportunity between people who share a relevant protected characteristic

and people who do not share it

Foster good relations between people who share a relevant protected characteristic and those

who do not share it

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7.3 Staff should be alerted to the increased likelihood of harm being suffered by disabled children,

young people and Adults at Risk, along with those living in special circumstances, whose needs may

not be recognised by staff employed in providing services.

Any individual’s communication needs will be considered at all times.

Equality Act 2010 - The Equality Act provides protection from direct or indirect discrimination;

harassment and victimisation for people with a ‘protected characteristic’ that relate to: disability, gender

reassignment, pregnancy and maternity, race, religion belief or non-belief, sex, sexual orientation and

age.

8.0 Documents Relied Upon

Department of Health Policy guidance relating to this document includes the following:

The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care,

Department of Health 2012 (revised)

Continuing Healthcare - Single Operating Model (2015)

DH published guidance - additional Private Care guidance March 2009

Standards for Better Health, Department of Health,

High Quality Care for All, Department of Health, 2008

The Human Rights Act 1998

The Equality Act 2010

Personal Health Budgets, Department of Health 2009

Mental Capacity Act 2005

Deprivation of Liberty Safeguards 2009

Who Pays, NHS England 2013

Care Act 2014

Appendices

Appendix A EQUALITY IMPACT ASSESSMENT (EQIA)

This EQIA aims to embed within the Commissioning intentions and the potential impact and

implications of Continuing Health Care for groups of people who are protected under the Equality Act

(2010) in relation to: • Age • Disability – vision, hearing, LD, autism, carers by association & Physical

impairment and Mental Health • Gender reassignment • Marriage & Civil partnership • Pregnancy &

Maternity • Race, Nationality, Ethnicity • Religious Belief • Gender/Sex - Men & Women • Sexual

Orientation

UNDERSTANDING IMPACT: This policy is likely to have a positive impact on patients and carers.

Any future procurement of provision may result in a service from a non-NHS provider and the

potential impact of this will need to be factored in terms of impact on all equality groups, and fully

considered; as articulated within the recommendations in this EQIA.

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Name of Policy / Strategy / Service redesign etc.

1 Continuing Healthcare Commissioning Policy

2 Briefly describe the aim of the policy, strategy or project. What needs or duty is it

designed to meet? Clinical Commissioning Groups (CCGs) are under a duty to make

arrangements to ensure that, in discharging their functions, they have regard to the need to

procure sound and safe packages of care for those adults in receipt of NHS Continuing

Healthcare

The purpose of the policy is to ensure all CCG staff and patients are aware of their roles and

statutory responsibilities.

This Policy provides support to Wandsworth CCG and their Commissioning Support Services

and strengthens local assurance arrangements for services commissioned for our patients.

3 Is there any evidence or reason to believe that the policy, strategy

or project could have an adverse or negative impact on any

group/s?

Yes No

X

4 Is there any evidence or other reason to believe that different

groups have different needs and experiences that this policy is

likely to assist i.e. there might be a relative adverse effect on

other groups?

Yes No

X

5 Has prior consultation taken place with organisations or groups

which has indicated a pre-existing problem which this policy,

strategy, service redesign or project is likely to address?

Yes No

X

Signed by the manager undertaking the assessment:

Date Completed:

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WANDSWORTH CLINICAL COMMISSIONING GROUP

Continuing Health Care (CHC) and Funded Nursing Care (FNC) Choice and Equity Policy

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Document Control

Title:WCCG Continuing Health Care (CHC) and Funded

Nursing Care (FNC) Choice and Equity Policy

Original Author(s): Alison Kirby/Munya Nhamo

Approval Body: Wandsworth CCG Governing Body

Approval Date:

Title /Version Number/(Date) WANDSWORTH CLINICAL COMMISSIONING GROUP Continuing Health Care (CHC) and Funded Nursing Care (FNC) Choice and Equity Policy

Document Status Final

Approved By WCCG Governing Body

Review Date December 2018

Stakeholders engaged in development or review

London Borough of WandsworthWandsworth EOLC Centre

Equality Analysis Equality AnalysisThis Policy is applicable to all staff employed by the CCG and those staff who work on behalf of the CCG. This document has been assessed for equality impact on the protected groups, as set out in the Equality Act 2010. This document demonstrates Wandsworth’s CCG’s commitment to create a positive culture of respect for all individuals, including staff, patients, their families and carers as well as community partners.

The intention is, as required by the Equality Act 2010, to identify, remove or minimise discriminatory practice in the nine named protected characteristics of age, disability, sex, gender reassignment, pregnancy and maternity, race, sexual orientation, religion or belief, and marriage and civil partnership. It is also intended to use the Human Rights Act 1998 and to promote positive practice and value the diversity of all individuals and communities.

Document Review Control Information

Version Date Reviewer Name(s) Comments

V 1 April 2016 AK

V1.1 April 2016 MN

V1.2 July 2016 AK Updated following comments from WBC

V1.3 Nov 2016 MN Updated following comments from WELCC

V1.4 Dec 2016 DB Update by Capsticks

This policy progresses the following Authorisation Domains and Equality Delivery System (tick all relevant boxes).

Clear and Credible Plan Commissioning processes

Collaborative Arrangements Leadership Capacity and Capability

Clinical Focus and Added Value Equality Delivery System

Engagement with Patients/Communities

NHS Constitution Ref: 4A

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1. Introduction

1.1 This policy describes the way in which Wandsworth CCG will make provision for the care of

people who have been assessed as eligible for fully funded NHS Continuing Healthcare. It describes

the process of decision making for provision subsequent to an assessment of eligibility under the

National Framework.

1.2 It should be read in conjunction with:

The National Framework for NHS Continuing Healthcare revised (2012)

Wandsworth Clinical Commissioning Group’s Continuing Healthcare Pathways and Protocols

WCCG Continuing Healthcare Commissioning policy

Wandsworth CCG Personal Health Budgets Policy. Further information can be found at

Guidance on Direct Payments for Healthcare; Understanding the Regulations. (DH 2014)

The National Health Service Commissioning Board and Clinical Commissioning Groups

(Responsibilities and Standing Rules) Regulations 2012 (“the Regulations”)

2. Context

2.1 Continuing Care is a general term defined as:

Care provided over an extended period of time to a person aged 18 or over, to meet physical or

mental health needs which have arisen as a result of disability, accident or illness. It may require

services from the NHS and/or social care and can be provided in a range of settings. Access to these

services is based on assessed need.

2.2 Fully funded NHS Continuing Healthcare describes a package of on-going care arranged and

funded solely by the NHS.

2.3 The term ‘Continuing Healthcare’ is used in this policy as an abbreviation of ‘fully funded NHS

Continuing Healthcare’.

3.0 Choice and Person Centred Care

3.1 The National Framework for NHS Continuing Healthcare & NHS funded-nursing care (2012,

Department of Health) states:-

“Where a person qualifies for NHS continuing healthcare, the package to be provided is that which the

CCG assesses is appropriate to meet all of the individual’s assessed health and associated social

care needs.”

Whilst the CCG will take into account the views of the individual so far as is possible, the CCG must

consider a range of factors and must comply with its statutory financial obligations. The final decision

as to the care package is one for the CCG; however it will act on all reasonable requests to the best

of its ability.

3.2 Wandsworth Clinical Commissioning Group will commission the provision of NHS funded

Continuing Healthcare in a manner which reflects the choice and preferences of individuals as far as

is reasonably possible, ensuring patient safety, quality of care and making best use of resources.

Cost has to be balanced against other factors in each case, such as a patient’s desire to live at home.

3.3 Patient safety will always be paramount in planning a care package and will not be compromised.

3.4 Wandsworth Clinical Commissioning Group is required to balance the patient’s preference

alongside safety and value for money. Patients will have a choice, whenever possible, from providers

who have a contract with Wandsworth Clinical Commissioning Group (or vicariously through our

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agreed Pan London Procurement Frameworks) and has agreed to Wandsworth Clinical

Commissioning Group quality and pricing structure. This applies equally to Home Care packages as

well as placements.

3.5 The CCG has a duty to provide care to a person with continuing healthcare needs in order to meet

those assessed needs1. An individual or their family/representative cannot make a financial

contribution to the cost of the care identified by the CHC team as required to meet the individual’s

core needs (see paragraphs 3.6 and 3.7). An individual however, has the right to decline NHS

services and make their own private arrangements.

3.6 Wandsworth CCG is not able to allow personal top up payments into the package of healthcare

services under NHS CHC, where the additional payment relates to core services assessed as

meeting the needs of the individual and covered by the fee negotiated with the service provider (e.g.

the care home) as part of the contract.

3.7 However, where service providers offer additional services which are unrelated to the person’s

needs as assessed under the NHS CHC framework, the person may choose to use personal funds to

take advantage of these services (e.g. hairdressing, a bigger room or a nicer view), but only so far as

these costs can be clearly separated and invoiced. Any additional services which are unrelated to the

person's primary healthcare needs will not be funded by the CCG as these are services over and

above those which the service user has been assessed as requiring, and the NHS could not therefore

reasonably be expected to fund those elements.

4. The provision of Continuing Healthcare

4.1 Many patients who require Continuing Healthcare will receive it in a specialised environment. The

treatments, care and equipment required to meet complex, intense and unpredictable health needs

often depend on such environments for safe delivery, management and clinical supervision.

Specialised care, particularly for people with complex disabilities may only be provided in specialist

Care Home (with or without nursing), which may sometimes be distant from the patient’s ordinary

place of residence.

4.2 These factors mean that there is often a limited choice of a safe and affordable packages of care.

4.3 In accordance with the NHS Constitution and the duties at s. 14U (duty to promote patient

involvement) and 14V (duty to promote patient choice) of the National Health Service Act 2006 (“the

NHS Act”). The CCG fully recognises these obligations, but must balance them against its other

duties.

4.4 In commissioning CHC care, the CCG must have constant regard to its financial duties. In brief,

section 223G of the NHS Act provides for payment to the CCG from the NHS Commissioning Board

(“NHS England”) in respect of each financial year, to allow the CCG to perform its functions. Section

223I provides that, in summary, that each CCG must break even financially each financial year. In the

case of Condliff v North Staffordshire Primary Care Trust [2011] EWHC 872 (Admin), the Court

stressed the fundamental challenge for commissioners in allocating scarce resources so as to best

serve the local population as a whole, whilst also having due regard to individual rights and choices.

4.5 The CCG acknowledges that it must also have due regard to the rights of individuals under Article

8 of the European Convention on Human Rights to private and family life, and any interference with

this right must be clearly justified as proportionate, in accordance with Gunter v South Western

Staffordshire Primary Care Trust [2005].

1 See the Regulations, paragraph 21.

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4.6 The CCG must also have due regard to its equalities duties, both under s.14T of the NHS Act

(duty to reduce inequalities) and the Public Sector Equality Duty under s.149 of the Equality Act 2010

(duty to eliminate discrimination and advance equality of opportunity between persons with and

without protected characteristics). The CCG is again guided in balancing its obligations by the case of

Condliff, in which the Court held that a policy of allocating scarce resources on the strict basis of a

comparative assessment of clinical need was intentionally non-discriminatory, and did no more than

apply the resources for the purpose for which they are provided without giving preferential treatment

to one patient over another on non-medical grounds (para. 36).

4.4 In the light of these constraints, Wandsworth CCG has agreed this policy to guide decision making

on the provision of Continuing Healthcare. The policy sets out to ensure that decisions will:

be robust, fair, consistent and transparent,

be based on the objective MDT assessment of the patient’s clinical need

be “person-centred”, which means that the decision will involve the individual and their family

or advocate to the fullest extent possible and appropriate,

take into account the need for the CCG to allocate its financial resources in the most cost

effective way,

offer choice where available in the light of the above factors.

4.5 Once a decision on eligibility is agreed, an offer of a Personal Health Budget will be made to the

patient (or their representative). Where such an offer is accepted, please refer to the Wandsworth

CCG Personal Health Budgets Policy) A personal Health Budget will enable more a flexible approach

to meeting the individual assessed needs outlined on the Support Plan.

4.6 Collaborative commissioning arrangements

4.7 Wandsworth CCG is part of a collaborative commissioning arrangement - the Pan London

Continuing Healthcare ‘Any Qualified Provider’, managed by the London Purchased Healthcare

Team.

5.0 Continuing Healthcare funded care within a placement

5.1 Where a care Home (with or without Nursing) is the most appropriate option, the allocated CHC

Nurse Assessor will work together with the patient and their representatives (where indicated) to

identify establishments which are capable of meeting the assessed needs and which are in a position

to provide a place within a reasonable space of time in line with the Brokerage criteria set out in bullet

point below

the CHC team operates a preferred provider list and the expectation is that individuals

requiring placement will have their needs met in one of the Care homes on the AQP

framework subject to bed availability and capacity to meet the needs of the assessed

individual.

The CHC Team will source a Care Home (with or without nursing) which is an accredited

member of the Pan London AQP (Continuing Healthcare) Framework

The CHC Brokerage Team will source a Care Home (with or without nursing) which accepts

the standard terms of the AQP Framework. In the exceptional circumstances were the costs

of care are above the threshold for AQP tier 2 rate (by more than 6% ) funding approval will

be sought from Wandsworth CCG CHC Lead Commissioner .( High cost and cases outside

AQP threshold will be referred to the Exceptions Panel)

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The CCG approval process will utilise the existing Needs Assessment Resource Allocation

model to determine patient needs and the resources deemed adequate to meet the individual

assessed as eligible for CHC

In the event that the assessed individual wishes to move into a home outside of the preferred

provider list, the CHC team will be required to liaise with the receiving CCG and confirm local

contracting arrangements (to include any potential contract suspensions). As long as the fee

for the bed is comparable to the fee agreed with the preferred AQP provider and the home

can meet the patients care needs the CHC team will consider this option, accepting our

partner agencies local contractual arrangements in relation to good governance. Where there

is a conflict between cost of care and personal choice, Wandsworth CCG will ask its own

internal Expert Case Panel to take a determination.

In the event that the assessed individual is already in a Care Home which is not under the

AQP contract, the CHC Brokerage Team will undertake the due diligence process described

above. A standard NHS contract will be put in place and efforts made to align the CHC

contract weekly costs with the AQP Framework rates.

6.0 Continuing Healthcare Funded Packages of Care At Home

6.1 Many people wish to be cared for in their own homes rather than in residential care, especially

people who are in the terminal stages of illness. A person’s choice of care setting should be taken into

account but there is no automatic right to a package of care at home. The option of a package of care

at home should be considered, even if it is later discounted, with documented reasons.

6.2 In situations where the model of support preferred by the individual will be more expensive than

other options offered by the CHC Team, Wandsworth CCG will take comparative costs and value for

money into account when determining the model of support that will be provided. It may be necessary

to pay more to meet an individuals assessed needs in a way that does not discriminate against them

but the NHS does not have to provide a home care package if it is disproportionately more expensive

than providing care in a Care Home setting.

The CHC team operates a preferred provider list and the expectation is that individuals requiring care

at home will have their needs met by a provider on the AQP framework subject to availability and

capacity to meet the needs of the assessed individual. It is important to note that there may be

exceptions were it would be appropriate to commission outside of the AQP framework. For instance, if

a patient already had a care package with a Provider that is off the AQP framework before becoming

CHC eligible which effectively meeting all their needs.

6.3 The CHC team and WEOLCC will take account of the following issues before agreeing to

commission a care package at home:

Care can be delivered safely and without undue risk to the person, the staff or other

members of the household (including children).

Safety will be determined by a written assessment of risk undertaken by an appropriate

referring clinician, and ratified by the CHC Lead, in consultation with the person or their

family for patients having a full CHC assessment. The proposed plan of can will then be

checked by the relevant CHC clinical lead to ensure it is appropriate to meet the identified

needs. For fast track assessment, the initial risk assessment is completed by the Clinician

making the referral which will then be checked by WEoLCCC before ratification and

proposed care plan by selected Domiciliary Care Provider checked to ensure it safely

meets the needs identified.

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The commissioned Care Home or Domiciliary Care Provider will be expected to conduct

their own risk assessment which will include the availability of equipment, the

appropriateness of the physical environment and the availability of appropriately trained

care staff and/or other staff to deliver the care at the intensity and frequency required.

The acceptance by the CHC team and/or WEOLCC and each person involved in the

person’s care of any identified risks in providing care and the person’s acceptance of the

risks and potential consequences of receiving care at home.

Where an identified risk to the care providers or the person can be minimised through

actions by the person or their family and carers, those individuals agree to comply and

confirmed in writing with the steps required to minimise such identified risk.

The person’s GP agrees to provide primary care medical support;

Care packages or Care Home placements that exceed the set out funding threshold will

be considered on assessed needs through the Resource Allocation function on a case by

case basis to ensure adequate care commissioned for the individual deemed eligible for

CHC.

The cost of the care package will be considered in line with paragraph 6.4 below.

6.4 The CCG will take into account the following factors when considering the cost of a home

placement:

The cost comparison will consider the genuine, rather than assumed costs of alternative

models, so far as this is possible.

Where a person prefers to be supported in a certain location which is not the most cost

effective model, the CCG will work with that person to identify if care can be delivered in

their preferred location in a more effective way.

The cost will be balanced against other factors in the individual case, such as the

individual’s preference as to location.

Where the total cost of providing care is within 10% of the equivalent cost of an AQP

Care Home (with or without nursing) placement (i.e. The cost of the Care Home (with or

without nursing) placement + 10%) the CCG will not fund the placement, save as where

the circumstances have been assessed by the Expert Case Panel as being so

exceptional that the costs are justified in the public interest.

6.5 Wandsworth CCG must consider risks that could potentially cause harm to the individual, any

family and the staff. Where an identified risk to the care providers or the individual can be minimised

through actions by the individual or his/her family and/or carers, those individuals must agree to

comply with the steps required to minimise such identified risk. Where the individual requires any

particular equipment then this must be able to be suitably accommodated within the home.

6.6 Wandsworth CCG is not responsible for any alterations required to a property to enable a home

care package to be provided, save for where these are agreed in accordance with the criteria above.

For the avoidance of doubt, where an individual or representative has made alterations to the home

but Wandsworth CCG has declined to fund the package, Wandsworth CCG will not provide any

compensation for those alterations.

6.7 The suitability and availability of alternative care options:

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The CCG can only provide services in accordance with assessed need following a decision on the

appropriate allocation of the finite resources available to the CCG for all patients it has responsibility

for.

Where there is a conflict between cost of care and personal choice, Wandsworth CCG will ask its own

internal Exceptions Panel to consider the factors set out above, in addition to -

• The cost of providing the care at home in the context of cost effectiveness;

• The relative costs of providing the package of choice considered against the relative benefit to the

person. Examples of particular situations requiring careful consideration are as follows:

Home care packages in excess of eight hours per day would indicate a high level of need

which may be more appropriately met within a Care Home placement. These cases would be

carefully considered and a full risk assessment undertaken.

Persons who need waking night care would generally be more appropriately cared for in a

Care Home placement. The need for waking night care indicates a high level of supervision

day and night and usually Care Home placements are deemed more appropriate for persons

who have complex and high levels of need. Residential placements benefit from direct

oversight by registered professionals and the 24 hour monitoring of persons.

If the clinical need is for registered nurse direct supervision or intervention throughout the 24

hours the care would normally be expected to be provided within a nursing home placement.

6.7 Out Of Area Care At Home and the Responsible Commissioner

If a person is deemed eligible and the choice is to move to a family home in another area, the

responsible commissioner will be the receiving CCG (GP registration applies) but the two CCGs need

to positively discuss the transfer to allow the receiving CCG to assess the care package.

7.0 Choice and the Mental Capacity Act 2005

7.1 Wandsworth CCG will always consult directly with the patient over Choice of Care. In accordance

with the Mental Capacity Act, we will assume that the individual retains the Capacity to make

decisions over every aspect of their life, unless demonstrated otherwise through formal processes.

7.2 The Patient may consciously delegate their decision making function to another nominated

deputy. Wandsworth CCG will be under duty to consult with this person direct.

7.3 Where an individual lacks the capacity to make such a decision then the registered Deputy with

the Lasting Power of Attorney for Health and Welfare will be nominated as The Decision Maker.

N.B While the Decision Maker will speak with the authority of the Patient, the NHS via the CCG

retains responsibility for the final offer of care delivery.

7.4 Where no Deputy has been appointed then all decisions will be made in the Best Interest of the

Patient in accordance with the Mental Capacity Act.

7.5 All decisions will be recorded on the appropriate documentation

8.0 Review of NHS Continuing Healthcare support

8.1 All service users will have their care reviewed at 3 months and thereafter on an annual basis or

sooner if their care needs indicate that this is necessary.

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8.2 The review may result in either an increase or a decrease in support offered and will be based on

the assessed need of the individual at that time. Reviews will involve the individual, their family or

advocate as possible and appropriate.

8.3 Where the individual is in receipt of a home support package and the assessment determines the

need for a higher level of support ,this may result in care being offered from a Care Home (with or

without nursing), whichever best meets the patients overall needs and in line with the Choice and

Equity thresholds of Wandsworth CCG.

8.4 The individual’s condition may have improved or stabilised to such an extent that they no longer

meet the criteria for NHS fully funded Continuing Healthcare. Consequently, the individual will

become either self-funding or the responsibility of the Local Authority who will assess their needs

against the Fair Access to Care criteria. This may mean that the individual will be charged for all or

part of their on-going care.

8.5 Where the review of need results in the Patient no longer meeting the CHC eligibility criteria,

Wandsworth CCG will issue a 28 day notice of transfer of care to both the Patient (or their nominated

representative) and our partners in Wandsworth Local Authority.

8.6 In line with the National Framework for CHC, Wandsworth CCG will ensure that no gap in service

exists and that any transfer of responsibilities maintains the Patients safety as paramount. Neither

Wandsworth CCG nor Local Authority should unilaterally withdraw from an existing funding

arrangements without a joint re assessment of the individuals needs or without first consulting one

another and the individual about the proposed change of arrangement.

8.7 All decisions will be transparent and shared with the Patient and their nominated representatives

where indicated.

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References

a) Department of Health, November 2012 (revised), The National Framework for NHS

Continuing Healthcare and NHS-funded Nursing Care

b) Wandsworth Clinical Commissioning Group , Safeguarding Adults Policy

c) Who Pays? Determining responsibility for payments to providers August 2013 DH

d) Guidance on Direct payments for Healthcare; Understanding the regulations (DH March

2014)

e) DH Practice Guidance for NHS Continuing Healthcare and NHS Funded Nursing Care 2013

f) NHS England Operating Model for Continuing Healthcare 2015

g) NHS England Compassion in Care Assurance Framework 2014

Public Information and Choice.

My NHS care: what choices do I have?

The NHS now gives you more choices about your health care.

This is a guide to your choices about your NHS care and treatment. It explains:

• when you have choices about your health care

• where to get more information to help you choose

• how to complain if you are not offered a choice

For some health care services, you have the legal right to choose and must be provided with choices

by law.

For other health care services, you do not have a legal right to choose, but you should be offered

choices, depending on what is available locally.

This guide covers:

• Choosing:

- your GP and GP practice

- which organisation you can go to for your first appointment as an outpatient for

physical or mental health conditions

- to change hospital if you have to wait longer than the maximum waiting times (18

weeks, or two weeks to see a cancer specialist)

- who carries out a specialist test if you need one

- maternity services

- services provided in the community

- to take part in health research

- to have a personal health budget

- to travel to another European country for treatment

• Where you can obtain more information to help you choose

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• What you can do if you are not offered choice

Where can I get more information to help me choose?

You can find advice on how to get information for particular health services in each section of this

guide.

There are also lots of ways to get general information to help you make the right choice.

• NHS Choices: www.nhs.uk. This website can help you make important health decisions, including

which GP surgery you register with and which hospital you attend for treatment. It provides tools and

resources that help you look at your options and make the right decision.

• Care Quality Commission checks many care organisations in England to ensure they are meeting

national standards. They share their findings with the public, which can be found at: www.cqc.org.uk

or call their National Customer Service Centre: Tel: 03000 616161 (Mon to Fri, 8.30am - 5:30pm).

• The NHS Constitution tells you what you can and should expect when using the NHS. Visit

www.nhs.uk and search for ‘NHS Constitution’. The Handbook to the NHS Constitution provides

additional explanation about the rights and pledges set out in the NHS Constitution. s

• Healthwatch is an independent consumer champion for health and social care in England. It

operates as Healthwatch England at national level and local Healthwatch at local level. Visit

www.healthwatch.co.uk for more information.

What can I do if I am not offered these choices?

First, you can speak to your GP or the health care professional who is referring you, as set out in

the boxes above. In the case of maternity services, speak to your GP, midwife or Head of Midwifery.

If you are still unhappy that you have not been offered these choices, you can make a complaint. You

can complain to the organisation that you have been dealing with or you can make a complaint to

your local clinical commissioning group. Clinical commissioning groups must publish their

complaints procedure. If they agree with your complaint, the clinical commissioning group must make

sure that you are offered a choice for that health service.

To contact your local clinical commissioning group:

• Ask your GP practice, they can tell you how to contact your local clinical commissioning

group; or

• Visit NHS Choices, www.nhs.uk click on the ‘Health services near you’ section on the

homepage. You cIf you are unhappy with the decision from the clinical commissioning group,

NHS England or Monitor you have the right to complain to the independent Parliamentary

and Health Service Ombudsman. The Ombudsman is the final stage in the complaints

system. To contact the Ombudsman:

• visit www.ombudsman.org.uk;

• call the Helpline: 0345 015 4033;

• use the Textphone (Minicom): 0300 061 4298;

• text ‘call back’ with your name and your mobile number to 07624 813 005; you will be called

back within one working day during office hours (Monday to Friday, 8.30am - 5:30pm).

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You can also contact an NHS complaints advocacy service if you have concerns regarding your right

to choose. Contact your local Healthwatch to find out your local advocacy service.

• visit http://www.healthwatch.co.uk/find-local-healthwatch. an search for your clinical commissioning

group by your postcode or location.

Choosing to have a personal health budget

Is this a legal right? You have a legal ‘right to have’ a personal health budget (with some

exceptions) from October 2014, for people receiving NHS Continuing

Healthcare (including children).

NHS Continuing Healthcare is a package of care arranged and funded solely

by the NHS and provided free to the patient. This care can be provided in

any setting – including an individual’s own home. An assessment is carried

out by the clinical commissioning group using a multi-disciplinary team of

health and social care professionals.

You can find more about NHS Continuing Healthcare at NHS Choices:

www.nhs.uk.

Clinical commissioning groups will also be able to provide personal health

budgets to other groups of patients on a voluntary basis, if they recognise

that there is a benefit to the patient and the NHS from offering packages of

care in this way.

What choices do I have? For some NHS services (including Continuing Healthcare provided at

Home), you can choose to have a personal health budget if you want one.

A personal health budget is an amount of money and a plan to use it. The

plan is agreed between a patient and their health care professional or clinical

commissioning group. It sets out the patient’s health needs, the amount of

money available to meet those needs and how this money will be spent.

With a personal health budget, you (or your representative) can:

• agree with a health care professional what health and wellbeing outcomes

you want to achieve;

• know how much money you have for this health care and support;

• create your own care plan if you wish, with the help of your health care

professional or others;

• choose how to manage your personal health budget;

• spend the money in ways and at times that makes sense to you, in line with

your care plan.

Once you have a care plan agreed, you can manage your personal health

budget in three ways, or a combination of these:

• a ‘notional budget’: the money is held by your clinical commissioning

group or other NHS organisation who arrange the care and support that you

have agreed, on your behalf;

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• a ‘third party budget’: the money is paid to an organisation which holds

the money on your behalf (such as an Independent User Trust) and

organises the care and support you have agreed;

• direct payment for health care: the money is paid to you or your

representative. You, or your representative, buy and manage the care and

services as agreed in your care plan.

In each case there will be regular reviews to ensure that the personal health

budget is meeting your needs.

You do not have to have a personal health budget if you do not want one.

When am I not able to

make a choice?

You will not be able to have a personal health budget for all NHS services

(for example, acute or emergency care or visiting your GP).

A few individuals or groups of people may not be eligible for a personal

health budget or a direct payment.

Who is responsible for

giving me choice?

Your local clinical commissioning group is responsible for giving you choice.

Where can I get

information and support to

help me choose?

If you would like to manage your own personal health budget:

• contact your local clinical commissioning group.

You can find out more about personal health budgets from:

• NHS England ‘Personal health budget learning network’, at:

http://www.personalhealthbudgets.england.nhs.uk/index.cfm

• NHS Choices: www.nhs.uk

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Appendix 3

Wandsworth CCG Exceptions Funding Request Panel

Terms of Reference

1. Constitution

The Exceptions Funding Request Panel will be a subcommittee reporting to the


2. Membership

Clinical Lead (Chair)CommissionerFinance ManagerAdditional members as required by the Chair

3. Quoracy

At least one clinical representative and one commissioner/finance lead

4. Frequency

The panel will meet as and when required in order to respond to urgent requests

5. Duties

To consider individual funding requests that are an exception to the CCGs internal CHC policy.

These may include but are not restricted to:

Cases requiring a complex or atypical package of care

Exceptional cases which breach the WCCG CHC Commissioning and Equity and Choice Policy thresholds in terms of costs of care

6. Underpinning principles of decision making process

Commissioning decisions will be considered in light of the WCCG Commissioning and Equity and Choice Policies

All decisions will be recorded, evidenced and communicated to all stakeholders

The process will seek to ensure consistency and fairness

7. Review

Terms of reference will be reviewed annually.

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London Health DevolutionAuthor: Sponsor: Sandra Iskander Date: 14 December 2016

Executive Summary

Context

In December 2015, a London devolution agreement was signed which let to five pilot

areas working on how aspects of devolution would work in practice. This work has led to a

number of proposed devolution ‘asks’ related to integration, estates and prevention.

These proposals are being consulted on with business cases for specific proposals in

development.


1. What progress has been made on devolution to date?

2. What is the thinking on the most appropriate approach for individual proposals?

3. What is the timeline and process for the next steps?

Conclusion

Wandsworth currently does not have any devolution plans, and so is not directly affected

by the proposals. However, we will follow developments to determine whether any of the

devolution models offer opportunities in the future to support delivery of our priorities.

Input Sought

The Board is asked to:

1. Note progress and the forward timescales to the next Devolution agreement for London, building on the commitments and priorities agreed in December 2015.

2. Review and provide any comments on the current proposals as they support specific Devolution Pilot requests and enable the potential to devolve certain powers across London partners, including CCGs.

3. Support the development of the final Devolution agreement(s) and delegate authority to a named individual (e.g. CCG Chair) to agree and sign off the agreement on behalf of the CCG.


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The Report

London is on a journey to become the healthiest city in the world. Over the past few years,

our health and care system has made significant strides to organise services around the

changing needs of our city’s growing and diverse population. In support of this progress,

the Government recently invited London to explore whether devolution could make these

improvements go further and faster.

In December 2015, all 32 Clinical Commissioning Groups (CCGs), London Councils on

behalf of the 32 London boroughs and the City of London, the Mayor of London, NHS

England and Public Health England came together as ‘London Partners’, and signed the

London Health and Care Collaboration Agreement. Through this, the Partners committed

to work more closely together to support those who live and work in London to lead

healthier independent lives, prevent ill-health, and to make the best use of health and care

assets.

Central government and national bodies backed this vision through the London Health

Devolution Agreement, and invited London to explore devolution – the transfer of powers,

decision-making and resources closer to local populations – as an important tool to

accelerate transformation plans and respond to the needs of Londoners more quickly.

Many decisions about health service planning and budgets are taken at national level. This

can sometimes create unintended barriers to delivering the connected and tailored local

services that Londoners want. London has already made significant progress in integration

and collaboration within the current system through: co-commissioning in almost all CCGs; cross-borough STPs; pooling budgets through the Better Care Fund; joint decision-making

by health and wellbeing boards; and innovative transformation through NHS vanguards

and integration pioneers.

Devolution aims to allow us to go even further by enabling health and care decisions to be

made for London, in London.

Through the devolution agreements, London Partners aim to minimise unnecessary

bureaucracy, and provide new opportunities for CCGs and boroughs to support Londoners

to be as healthy as possible and to ensure that the health and care system is on a

sustainable footing.

London’s health and care landscape contributes significantly to the rest of the UK: a

quarter of NHS doctors and more than half of England’s nurses are trained in the capital,

and London is a centre of excellence for health training, education and specialist care.

London’s health and care system is also very large, with hundreds of organisations and a

considerable proportion of the NHS budget. Given this size and complexity, we are

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https://www.london.gov.uk/sites/default/files/london_health_and_care_collaboration_agreement_dec_2015_signed.pdf

https://www.gov.uk/government/publications/london-health-devolution-agreement/london-health-devolution-agreement#parties

https://www.gov.uk/government/publications/london-health-devolution-agreement/london-health-devolution-agreement#parties

exploring how devolution could work in practice through five pilots. These pilots have

focused on our three priorities - prevention, health and care integration and making best

use of health and care buildings and land - and are exploring decision-making at the most

appropriate and local level.

When developing their proposals, pilots have been exploring what is possible within the

current system and what explicit devolved powers are sought. It is clear that much can be

done within existing powers, but that by overcoming some specific challenges, efforts to

transform health and care could go further and faster. Pilots are setting out their

transformation vision, ‘offers’ by the local system to accelerate action and devolution ‘asks’

to overcome identified barriers to progress.

This paper aims to update CCG governing bodies on the progress of the London Health

and Care Devolution Programme as we move towards a second devolution agreement

and to confirm ongoing support.

We are keen to ensure the asks are coproduced and are reflective of the London-wide

system’s thinking. As we draft the final agreement and shape our final asks, CCG

governing bodies are asked to:

1. Note progress and the forward timescales to the next Devolution agreement for London, building on the commitments and priorities agreed in December 2015.

2. Review and provide any comments on the current proposals as they support specific Devolution Pilot requests and enable the potential to devolve certain powers across London partners, including CCGs.

3. Support the development of the final Devolution agreement(s) and delegate authority to a named individual (e.g. CCG Chair) to agree and sign off the agreement on behalf of the CCG.

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https://www.london.gov.uk/what-we-do/health/london-health-and-care-devolution/testing-health-and-care-devolution

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The risks [Yes]

Impact on our reputation [No]

Impact on our patients [No]

Impact on our providers [No]

Impact on our finances [No]

Equality impact assessment [No]

Patient and public involvement [No]

The CCG has considered whether entering into devolution arrangements is a priority. However as we

have no direct plan, we have not considered the detailed impact on specific areas.



inequalities [Yes ]


statutory responsibilities [No]


members, stakeholders and communities [No]




organisation [Yes /]

Please explain your answers:



[My paper does not comply]

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London Health and Care

Devolution

Enabling health and care

transformation through devolution:

Update and next steps

19 October 2016

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Background

•  This paper aims to update CCG governing bodies on the progress of the London Health and Care Devolution Programme as we move towards a second devolution agreement.

•  Following the devolution agreements in December 2015, London partners have been working with five local and sub-

regional pilots to support the development of business cases for devolution.

•  When developing their proposals, pilots have been exploring what is possible within the current system and what explicit

devolved powers are sought. It is clear that much can be done within existing powers, but that by overcoming some specific challenges, efforts to transform health and care could go further and faster. Pilots are setting out their transformation vision, ‘offers’ by the local system to accelerate action and devolution ‘asks’ to overcome identified barriers to progress.

•  The emerging work of the pilots has reiterated the need for multi-level action, based on the foundational principle of subsidiarity. The devolution agreement last year described three levels for devolved powers: borough-level, STP-level and London, with aggregation only where necessary.

•  This paper contains:

‒  A summary of current devolution proposals.

‒  This includes a description of the current thinking on the most appropriate approach for individual proposals (e.g. London level or voluntary draw-down by individual boroughs).

‒  These proposals continue to evolve as pilots finalise their business cases and with ongoing input from national

bodies and central government and wider engagement. As such, the detail of proposals and spatial levels is still evolving. The proposals are therefore draft and work in progress.

‒  Timeline and process for the next steps

2

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London already has a shared vision for better health and care

2012

London Health

Devolution

Agreement

2013 2014 2015

London Health Board

formed

London Health and

Care

Collaboration Agreement

London Health and

Care

Devolution Programme

established

Health and Social Care Act passed

Better Care Fund

Transformation in

integrated health

and social care

Better Health for London

64

recommendations

for London

Five Year Forward View the NHS’ strategy

Greater Manchester’s

health and

social care devolution

deal

Better Health for London: Next Steps

First collaborative

vision for London

2016

44 STPs under

development

Sustainability

and

transformation

plans (STPs)

announced

Healthy London

Partnership

established

Na

tio

na

l m

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sto

ne

s

Lo

nd

on

m

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sto

ne

s

Devolution pilots

underway

New Models of Care

Programme

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Transformation plans

Devolution aims to unlock barriers and enable transformation plans to go further and faster

Improving the

health and

wellbeing

of Londoners

Devolution

Learn more at: https://youtu.be/ir7oKEND9zs

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The devolution journey

Test how devolution

could work in five areas

of London

Secure devolution

based on robust

business cases

Devolution available

across London

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Key: type of pilot

Local prevention – note that this borough is also part

of the sub-regional estates pilot

Sub-regional care integration

Sub-regional estates

Local care integration

Integration in Lewisham: creating “One Lewisham Health and Social Care system” by combining mental and physical health

services and social care

Integration across Barking & Dagenham,

Havering and Redbridge:

delivering a personalised health and care

service focusing on self-care,

prevention and local services that enable the

sustainability of the health and care system

Prevention in Haringey: exploring licensing and

planning powers needed to ensure

that local environments support health, and

looking at early intervention to

support those who have fallen out of work due to mental

health issues

Integration in Hackney: Bringing together mental and physical health services, and health and social care budgets

Estates in Barnet, Camden,

Enfield, Haringey and

Islington (‘North Central London’):

making better use of health

and care buildings and land

London’s five pilots are exploring how devolution could work at different spatial levels

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01 Current status of proposals

If you have any questions on the following please contact the programme

team [email protected]

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Some asks are for the whole London system, others would be permissive, subject to local appetite and business cases

8

The terms of application of each proposed ask are specified in the pages below. These broadly fall into two categories:

-  ‘London level’ asks, which consist of the freedoms, powers and variations which, if granted, will apply to the London system as a whole; and

-  ‘Local/multi-borough draw-down’ asks are the freedoms, powers and flexibilities which, if granted, will be made available to sub-regional and local health economies to adopt should they so wish, subject to robust business cases.

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9

Integration: Summary of potential devolution asks

2c

Greater alignment between NHS England, NHS

Improvement and CQC for

regulatory functions in

London

The ability for an integrated / single delivery

system to be regulated as a

whole, despite underlying

distinct organisational operating units*

Supporting greater integration of the health and care

workforce and addressing

recruitment/retention

challenges (London, sub-regional/local)

Funding and governance to support workforce

transformation

(London/sub-regional)

Delegation / devolution of NHS England functions

including primary care

commissioning, capital and

transformation budgets

The ability for a joint local authority/CCG structure to

take on commissioning

functions, with pooling of

budgets*

Commissioning levers

and financial flows Regulation Workforce

DRAFT

Draft scope of ask

Local/multi-borough voluntary draw-down (with some functions initially devolved/ delegated from national to London)

London level

Other

*Note: Spatial level will depend on the design of any integrated system and also on agreed assurance / governance framework for re-designed regulatory framework

Freedoms and flexibilities during the development and

initial implementation stage of

the pilot

Supporting pilots to co-develop and adopt innovative payment

models

•  Enabling the delivery of integrated care and more consistent mental health and acute care; strengthening primary and community care, reducing hospitalisation and improving outcomes.

•  Thus, enabling people to live more independently and contributing to the financial sustainability of the system

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Estates: Summary of potential devolution asks

2c

Delegation of capital business case review and

approval functions

(sub-regional or London,

depending on the delegation limit)

Retaining the capital receipts generated by the London

system to enable investment in

health and care in London

Adoption of a commissioner capital control total

(London with sub-regional

draw-down)

A London estates board comprising local health

economies, London and

national partners to ensure

clarity on London’s assets, projects and capital needs,

building up from STP

estates strategies.

An estates delivery unit to consolidate existing

London-level and national

expertise to support local

areas to develop and deliver high-quality capital cases

London governance

and delivery Business case approval Capital

DRAFT

Draft scope of ask

Local/multi-borough voluntary draw-down (with some functions initially devolved/ delegated from national to London)

London level

Utilisation

*Note: Spatial level will depend on the design of any integrated system and also on agreed assurance / governance framework for re-designed regulatory framework

Accountability within London for utilisation of existing health and

care estates

•  Releasing capital from surplus estate to invest in primary, community and hospital estate •  Releasing surplus land for housing and wider public sector use

•  Accelerating estate transformation by streamlining decision-making

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London partners recognise significant opportunities to enable greater value for Londoners from the NHS estate. These form the basis of London’s devolution proposals. An estates board aims to directly solve some of the challenges of NHS estates approvals and disposals, by providing a single forum for NHS estate discussions in London and through early involvement

of London government partners and national bodies. As it matures, the Board would also provide a mechanism to administer devolved responsibilities, including delegated business case approvals.

The Board aims to enable strategic and decision-making functions to enhance efficiency, quality and transparency of discussions and decisions that are currently taken nationally. These functions would be phased over time, with the Board commencing with strategic and advisory role.

11

An estates board for London

The Board would aim to operate according to key principles: •  Subsidiarity, with decisions taken at the lowest appropriate level, and only taken at the London level when needed. •  Transparency – with all relevant discussions taking place at the London estates board

•  All partners bringing the collective expertise of their constituent organisations to achieve the greatest value for Londoners. •  Decision-making will seek to achieve consensus so far as is possible, while respecting the views and statutory

accountabilities of constituent organisations.

The role and function of the board has significant interdependencies with wider devolution proposals. Detailed discussions

continue to clarify the proposed nature and scope of such devolved powers, and the board in its initial phase will be a valuable vehicle to collate expertise and streamline decision-making in this respect, allowing proposals to be developed at pace. The

board’s ability to fulfil the desired objectives would therefore be contingent on these devolved or delegated powers and resources being granted.

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12

Prevention: Summary of potential devolution asks

Devolution asks focusing on prevention have been progressed across three themes:

Powers to address problem gambling

Health as a fifth licensing objective for alcohol

(for local trial)

Powers to reduce tobacco consumption,

distribution and illicit

circulation

(some pan-London elements for illicit tobacco)

Devolve part of health and work budget to trial

initiatives tailored to

local needs (London ask with

funding devolved to local/multi-borough level)

Contractual variations to Fit for Work

service

Planning, licensing and fiscal powers to

encourage healthier

high streets

(London and local)

Use sumptuary tax revenue to invest in

London health

priorities

Tackling Obesity Healthier environments Health and Employment

DRAFT

Draft scope of ask

Local/multi-borough voluntary draw-down (commencing with Haringey prevention pilot)

London level

Complement individual Londoners’ efforts on staying healthy in their daily lives. Using devolution as a means to create better environments in which people can flourish

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Ongoing activity

13

Iterating proposals

Exploring governance and accountability

Engagement on devolution asks and

offers

Discussions re: legislative change

Sharing learning

•  Workshops with central government, national bodies, London partners and pilots to align objectives and test the appropriate devolution levers to bring about intended health outcomes

•  Maximising opportunities for alignment with STPs •  Supporting pilots to develop business cases by late October

•  To be developed based on emerging pilot governance proposals and engagement with constituent organisations and London partners.

•  Phased approach based on devolution requirements e.g. need for financial accountability

•  In partnership with DH, DCLG, NHSE and NHSI. London is examining amendments to existing legislation and considering additional legislative requirements

•  Engagement on and iteration of devolution offers and asks with the wider London system

•  Including shared learning from the pilots and development of a support package for non-pilot areas

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01 Shaping final asks and the

December agreement

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CCG involvement in shaping devolved health powers in London

•  Engagement has been key to developing the current set of asks and proposals. The high level proposals are subject to ongoing discussions with borough leaders, CCG Chairs and Chief Officers, LHCOG, BCF leads, London Prevention Board, LRET, HWBB chairs and the ADPH network.

•  These opportunities for engagement with the developing devolution propositions will be critical, but they will not by themselves offer the mechanism for propositions to be explored comprehensively in detail, nor will these opportunities allow

for the detailed and ongoing engagement likely to be required in the run up to December. For example, as pilot areas develop asks and discussions with London partners refine the detail, London’s health and care system leaders may wish to be able to offer engagement which can respond flexibly and in an iterative way.

•  The strategy for reaching agreement on London’s December asks will require an approach which recognises that decision making will be necessary for different asks at different spatial levels. For example, where asks are emerging which would not of themselves affect all of London if granted (i.e. they are permissive and discrete to local or sub-regional footprints)

then the appetite and support from a pan-London level would be beneficial but may not be essential to the case being made by the pilot area. However, where asks are emerging which would affect the whole of London if granted (i.e. where a pilot is

making the case for devolution which would impact on all boroughs), then broad agreement of the London system would be needed.

•  We are keen to ensure the asks are coproduced and are reflective of the London-wide system’s thinking. As we draft the

final agreement and shape our final asks, CCG governing bodies are asked to:

15

1.  Note progress and the forward timescales to the next Devolution agreement for London, building on the commitments and priorities agreed in December 2015.

2.  Review and provide any comments on the current proposals as they support specific Devolution Pilot requests and enable

the potential to devolve certain powers across London partners, including CCGs.

3.  Support the development of the final Devolution agreement(s) and delegate authority to a named individual (e.g. CCG

Chair) to agree and sign off the agreement on behalf of the CCG.

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Engagement with local government

16

Month Meeting or event

June Healthwatch Hackney

July London Councils and HSCIC Meeting

September Chief Executives (of local councils) of London Committee (CELC)

September Health and Wellbeing Board Chairs

October CELC

November CELC (TBC)

December Health and Wellbeing Board Chairs (TBC)

Local councils are engaged in discussions about health and care devolution. Illustrative engagement undertaken to date is described below:

In addition, significant engagement is underway at local level within pilots, among all stakeholders and political leadership.

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Key dates

CCG

engagement

Develop business cases and clarify asks and offers

Oct Nov Dec Jan Feb Mar April April June Aug Sept July

STPs submitted

LHB

Pilots Iterate business cases and negotiate

devolution

Menus of devolution developed for London

Implement shadow

arrangements

Develop business cases for devolution if locally desirable

London-wide

activity

Spreading learning

Sharing learning from pilots

Develop new working arrangements with phased implementation of activities within current powers

(TBC) Further devolution

announcement

2016 2017 2018

STP operational plans submitted

Non-pilot areas Engagement on devolution asks and offers

Implement shadow

arrangements

Implement devolved

arrangements

Develop London-level proposals Develop new working

arrangements with phased

implementation of activities within

current powers

Implement shadow

arrangements

Implement devolved

arrangements

Chief officers meeting London

Prevention Board

CCG chairs

12 14 14 15

29 27

19 Chief officers

LTG

LTG LTG 20

LTG

CCG CFO 17 Chief

officers & Chairs

CCG CFO

14 Chief officers

Themes, processes, timelines

Excerpts of

draft

agreement

and emerging

proposals

Updated agreement

and proposals

Final

agreement

Pilot OBCs developed

Current programme and engagement timeline

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01 Initial agreements published in 2015

Annex

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DRAFT

•  The London Health and Care Collaboration Agreement •  The London Health Devolution Agreement

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Two London agreements were signed in December 2015

Agreement to transform health and wellbeing outcomes and services, recognising:

•  the need to shift from reactive care to prevention,

early intervention, self-care and care closer to home

•  the scale and complexity of the health and care system

in London - transformation will be driven at three geographical levels

•  the need to tailor solutions to the different needs of

people and places and that locally shaped solutions will progress at different paces

•  The importance of enablers, including estates

Full report available here:

https://www.london.gov.uk/sites/default/files/london_health_and_care_collaboration_agreement_dec_2015_signed.pdf

The London Health and Care Collaboration Agreement

Commitment by government and national bodies to work with London to explore:

•  aligning capital programmes and removing barriers to make

best use of the NHS estate

•  flexibility of payment mechanisms

•  developing place-based provider regulation

•  workforce planning and delivery of education and training

•  devolving transformation funding

•  using planning & licensing to support prevention

•  joint working on employment and health.

Full report available here: https://www.gov.uk/government/publications/london-health-

devolution-agreement/london-health-devolution-agreement#parties

The London Health Devolution Agreement

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Summary of agreements

The key elements of the agreement are: i) Multi-level action: Given the size of the London system three levels of action will be needed: borough (local); multi-borough

(sub-regional); London-wide (regional).

ii) Underpinned by the principle of subsidiarity: This means that decisions should always be taken at the most local appropriate level and aggregated up to multi-borough or London-wide only as needed.

iii) London’s health and care system is highly complex. We have a large number of health and care organisations and population and patient flows occur with frequency across local boundaries. For these reasons London will be running pilots to test

different elements of health and care devolution at different spatial levels. iv) Focus on integration, prevention and estates

What does it mean for London?

Through Better Health for London, our city already has a plan making it fairly unique in England. All organisations have committed to delivering on the 10 aspirations to promote health and wellbeing set out in Better Health for London: Next Steps and in doing so, deliver on the NHS Five Year Forward View.

If decisions about London are made within the London system, they will respond more closely to the challenges and

opportunities of our city and population. We plan to test how this works in practice through devolution pilots with the ambition to scale up across the city. For Londoners we expect this to mean a more effective, streamlined health and care service, greater support to stay as healthy as possible for as long as possible and ensuring health and care resources are used most efficiently.

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Aspirations and objectives of London devolution (from 2015 agreements)

The parties have a shared commitment to deliver on the 10 aspirations to promote health and wellbeing set out in Better Health for London: Next Steps and, in doing so, deliver on the NHS Five Year Forward View and secure the sustainability of health services and social care.

21

To meet these aspirations, the parties share the following objectives:

•  To achieve improvement in the health and wellbeing of all Londoners through a stronger, collaborative focus on health promotion, the prevention of ill health and supporting self-care

•  To make rapid progress on closing the health inequalities gaps in London

•  To engage and involve Londoners in their health and care and in the health of their borough, sub-region and city including

providing information so that people can understand how to help themselves and take responsibility for their own health

•  To improve collaboration between health and other services to promote economic growth in the capital by addressing factors that affect both people’s wellbeing and their wider economic and life opportunities, through stronger partnerships

around housing, early years, employment and education

•  To deliver integrated health and care that focuses on maximising people’s health, wellbeing and independence and when

they come to the end of their lives supports them with dignity and respect

•  To deliver high quality, accessible, efficient and sustainable health and care services to meet current and future population needs, throughout London and on every day.

•  To reduce hospitalisation through proactive, coordinated and personalised care that is effectively linked up with wider services to help people maintain their independence, dignity and wellbeing.

•  To invest in fit for purpose facilities for the provision of health and care services and to unlock the potential in the health

and care estate to support the overall sustainability and transformation of health and care in the capital

•  To secure and support a world-class workforce across health and care

•  To ensure that London’s world-leading healthcare delivery, academic and entrepreneurial assets provide maximum benefit for London and the wider country and that health and care innovation is facilitated and adopted in London.

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All parties agreed to the following principles

22

•  Improving the health and wellbeing of Londoners will be the overriding driver for reform and devolution.

•  We will work to secure a significant shift from reactive care to prevention, early intervention, self-care and care close to home that supports and

enables people to maximise their independence and wellbeing.

•  London will remain part of the NHS and social care system, upholding national standards and continuing to meet and be accountable for statutory

requirements and duties, including the NHS Constitution.

•  Joint working will improve local accountability for services and public expenditure. Where there is local agreement to change accountability

arrangements, accountability to NHS England will be maintained – in relation to issues including delivery of financial requirements, national

standards and the NHS Constitution. Changes to current accountabilities and responsibilities will be agreed with government and national bodies as

necessary and may be phased to balance the pace of progress with ensuring a safe transition and strong governance. We commit to fulfil the legal

requirements for making significant changes to commissioning arrangements.

•  Decision-making will be underpinned by transparency and the open sharing of information between partners and with the public.

•  Transformation will be locally owned and led and will aim to get the widest possible local support. We will ensure that commissioners, providers,

AHSNs, patients, carers, the health and care workforce, the voluntary sector and wider partners are able to work together from development to

implementation to shape the future of London’s health and care.

•  All decisions about London will be taken in or at least with London. Our goal is to work towards resources and control being devolved to and within

London as far as possible, certainly in relation to outcomes and services for Londoners.

•  Collaboration and new ways of working will be needed between commissioners, providers, patients, carers, staff and wider partners at multiple

levels. Recognising that the London system is large and complex, commissioning and delivery will take place at three levels: local, sub-regional or

pan-London. A principle of subsidiarity will underpin our approach, with decisions being made at the lowest appropriate level.

•  Given London’s complexity we recognise that progress will happen at different paces and in different orders across the different spatial levels. We

will ensure that learning, best practice and new models for delivery and governance are shared to support and accelerate progress in all areas.

Subsidiarity as a principle will extend to the adoption of ideas piloted in other areas to allow flexibility and adaptation to local conditions.

•  The people that work in health, health care and social care are critical to achieving London’s transformation goals. We will build on London’s position

as the home of popular and world-class health education, to develop new roles, secure the workforce we need and support current and future staff to

forge successful and satisfying careers in a world-class London health and care system.

•  We recognise that considerable progress can be made, building on existing foundations, with existing powers and funding – and we are committed to

doing so. But devolution is sought to support and accelerate improvements. A series of devolution pilots will be established through which detailed

business cases for devolution of powers, resources and decision-making can be developed in partnership with government and national bodies.

Through these, devolution may be secured both for the pilots themselves and also for other parts of London, contingent on these areas also

developing suitable plans, delivery and governance arrangements.

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Continued…

•  While embedding subsidiarity, we will ensure the strategic coherence and maximise the financial sustainability of the future health and care system

across London. Political support for jointly agreed change will be an important feature of the arrangements.

•  New London-level arrangements, including governance and political oversight, will be established to secure this. We commit to minimising bureaucracy

as much as possible to enable delivery of local innovation.

•  In 2016/17 - and drawing from the experiences of the pilots - sustainability and transformation plans for health and care will be developed as part of

NHS and local authorities’ planning arrangements. These will draw on learning from the devolution pilots, other transformation initiatives including the

Vanguard programme and any London-wide initiatives.

•  A London-level picture, drawn from sub-regional health economy plans, will enable oversight of the impact on health outcomes and financial

sustainability of the system across the capital.

•  We recognise that London provides expertise and services for people who live outside the capital and that benefit the country more widely. London will

work collaboratively with other regions and national bodies to consider and mitigate the impact of London decisions on surrounding populations reliant

on London-based services.

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Board Assurance FrameworkAuthor: Sandra Allingham Sponsor: Sandra Iskander Date: 14th December 2016

Executive Summary

Context

The Board Assurance Framework (BAF) has been developed to report on the principal

risks to the organisation’s corporate objectives, and is the main process through which the

Board receives assurance on the management of risks.


1. Does the BAF include sufficient information on the controls and actions required to

mitigate the risks?

2. Does the BAF provide sufficient assurance against the achievement of each objective?

Conclusion

1. The report includes information on controls that have been put in place, and actions

identified, in order to manage and mitigate the risks. The detailed review and scrutiny

of the BAF ensure that appropriate controls and assurances are in place to manage the

mitigation of these risks.

2. All risks and their actions are regularly reviewed and scrutinised. The scrutiny process

involves the Risk Review Group, the Integrated Governance Committee, and the CCG

Board. Risk scores are tracked during the year to enable monitoring of the

effectiveness of the actions, controls and assurances.

Input Sought

We would welcome the board’s input to:

Review the Board Assurance Framework as a whole and assess on whether the

principal risks are accurately reflected.

Consider whether any further actions or controls are required.

Note the level of risk detailed in the report.

Approve the report.


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The risks [Yes]





Equality impact assessment [Not applicable]





inequalities [Yes]








organisation [Yes]





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Page 1 of 38

BOARD ASSURANCE FRAMEWORK

INTRODUCTION

The Integrated Risk Management Framework was approved in June 2012 by the CCG Board and reviewed by the Integrated Governance Committee in July 2014. The Board Assurance Framework and Risk Management process were reviewed by Internal Audit in October 2014, with identified recommendations, which have been actioned.

The risk process and framework is fully established across the CCG. Risks at all levels are identified, assessed, scored, reported, owned and recorded. Some risks will be identified by the Board; others will be raised by managers and staff as part of their day-to-day work. Each risk is assessed in terms of both its potential likelihood and impact. Those two dimensions are each given a score between 1 and 5 (in line with the National Patient Safety Agency’s Model 2 Risk Matrix) - the risk score is then calculated by multiplying those two numbers. Controls are put in place to reduce the likelihood or the impact of each risk.

The Board Assurance Framework has been developed from the organisation’s key objectives and principal risks to those objectives (identified by the Board). The Board Assurance Framework is the main process through which the Board receives assurance on the management of risks to the achievement of the strategic objectives.

Higher scoring operational risks are also reported and escalated within the wider system of risk across the organisation. This provides the Board with an overview of the totality of the high level risks which face the organisation together with the action plans to address them. The detailed review and scrutiny of the Board Assurance Framework ensures that appropriate controls and assurances are in place to manage the mitigation of these risks. Analysis identifies any objectives that are at a greater risk and provides opportunities for remedial action which will increase the level of assurance.

The Board Assurance Framework outlines details of the principal risks as at October 2016 that may prevent the CCG from achieving its strategic objectives. Information included in the report identifies:

Controls that have been put in place to manage the risks;

Assurances that have been received to demonstrate if the controls are having the desired impact;

Performance against Key Performance Indicators;

Details of any gaps in the assurance; and

Comments and further actions required.

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There are currently fourteen BAF risks, six rated very high (15-25), six rated as high (8-12), and two moderate (4-6). The highest level individual risk is: (R99) ‘Challenges facing main provider’ with a risk score of 20.

All risks and their actions are regularly reviewed and scrutinised. The scrutiny process involves the Risk Review Group, the Integrated Governance Committee, and the CCG Board. Risk scores are tracked during the financial year, to enable monitoring of the effectiveness of the actions, controls and assurances.

The following operational risks scoring twelve and above are being reported by exception:

(R72) Failure to provide assurance that those most vulnerable in care homes and in the community are free from harm – risk score 12

(R77) Failure to reduce inequalities because of absence of specific focus – risk score 12

(R89) Financial distress of main provider – risk score 16

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The dashboard below summarises the Corporate Objectives and lists the relevant principal risks.

Corporate Objective Potential Principal Risk Initial Score

Current Score

Tolerance Score

Movement from previous

review

Date of last

Review

Risk 16 – Failure to receive the appropriate level of funding allocation. 20

(5x4)16

(4x4)9

(3x3)↔ 04/10/16

Risk 33 – Failure to have sufficient plans to cater for surges in activity and growth in population caused by local community developments.

9(3x3)

9(3x3)

6(3x2)

↔ 04/10/16

Risk 47 – Failure to have a shared understanding with providers of what safe high quality care looks like and how to recognise failure of care in light of the Francis, Keogh and Berwick reviews.

16(4x4)

8(4x2)

8(4x2)

↔ 04/10/16

Risk 50 – Failure to commission services in a way that delivers integrated and sustainable models of care.

16(4x4)

2(2x1)

8(4x2)

↓(3x2)

04/10/16

Objective 1:Commission high quality services which improve outcomes and reduce inequalities

Risk 99 – Challenges facing main provider20

(5x4)20

(5x4)New 04/10/16

Risk 7 – Financial pressures across the health and social care economy. 16

(4x4)16

(4x4)9

(3x3)↔ 04/10/16

Risk 9 – Failure to plan expenditure to reflect budget and maximise use of resources. 16

(4x4)16

(4x4)6

(3x2)↔ 04/10/16

Risk 68 – Failure to achieve performance ambitions set out in the 2015/16 Assurance Framework and the 2015/16 Operating Plan.

16(4x4)

16(4x4)

8(4x2)

↔ 04/10/16

Objective 2:Make the best use of resources, continually improve performance and deliver statutory responsibilities

Risk 75 – Sustainable health economy16

(4x4)12

(4x3)9

(3x3)↔ 04/10/16

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Risk 95 – 1% non-recurrent uncommitted reserve16

(4x4)

12(3x4)

↔

Risk 97 – Primary Care Commissioning20

(5x4)

12(4x3)

6(3x2)

↔ 04/10/16

Objective 3:Continually improve delivery by listening to and collaborating with our patients, members, stakeholders and communities

No corporate risks currently highlighted

Objective 4:Transform models of care to improve access, ensuring that the right model of care is delivered in the right setting

Risk 29 – Failure to reshape the local out of hospital and urgent care services to respond to local system.

20(5x4)

16(4x4)

6(2x3)

↔ 04/10/16

Risk 65 – Failure to develop and improve the CCG as an organisation. 9

(3x3)4

(2x2)1

(1x1)↔ 04/10/16

Objective 5:Develop the CCG as a continuously improving and effective commissioning organisation Risk 102 – New operational model 20

(4x4)12

(4x3)8

(4x2)New 01/12/16

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BAF Risk Profile Summary October 2016

5Moderate High Very

High1 Very

High

4 Moderate 1 2 6 Very High

3 Low Moderate 1 1 Very High

21 1 Moderate High High

IMP

AC

T

1 Low Low Low Moderate Moderate

1 2 3 4 5LIKELIHOOD

Objective Low Moderate

High Very High

1: Commission high quality services which improve outcomes and reduce inequalities 1 0 2 2

2: Make the best use of resources, continually improve performance and deliver statutory responsibilities 0 0 3 3

3: Continually improve delivery by listening to and collaborating with our patients, members, stakeholders and communities

0 0 0 0

4: Transform models of care to improve access, ensuring that the right model of care is delivered in the right setting 0 0 0 1

5: Develop the CCG as a continuously improving and effective commissioning organisation 0 1 1 0

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The table bellows identifies whether risks are influenced by Internal or External factors and whether risks are stable or changing:

External factors

Internal

Stable/known Unstable/new

St George’s Hospital

challenges (No.99, 5x4)

Funding

allocation(No.16, 4x4)Surges in activity &

growth in population(No.33, 3x3)

Financial pressures

across SWL(No.7, 4x4)

NHS Constitutions

domains(No.68, 4x4)

Quality of care within

commissioned services(No.47, 4x2) Sustainability and

Transformation Plan(No.75, 4x3)

SWL Operating Model(No.102, 4x3)

Transition of Primary

Care Commissioning(No.97, 4x3) OOH and Urgent Care

Services(No.29, 4x4)

1% non-recurrent

reserve(No.95, 3x4)

QIPP(No.9, 4x4)

Commissioning of

integrated & sustainable

models of care(No.50, 2x1)

Organisation

Development(No.65, 2x2)

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Objective 1: Commission high quality services which improve outcomes and reduce inequalities

Director Lead: N McDowellRisk 16 (Finance) – If the Department of Health reduced the CCG’s allocation, this would impact on the CCG’s recurrent investments and ability to achieve business rules, eg deliver target surplus.

Date last reviewed: 01/12/2016

Risk Rating:(consequence x likelihood)

Initial: 5 x 4Current: 4 x 4Tolerance rating: 3 x 3

Risk History Rationale for current score: NHS England set Business Rules for CCGs to operate within. The implication of the rules will impact the budgets after CCG allocations have been confirmed.

There are a number of variables which need to be confirmed in order to plan appropriately, such as the way primary care services are commissioned/ contracted for.

National tariff for 2017/18 has now been issued but is draft and subject to change. Full impact overall will not be known until contracts are signed at the end of December.

Internal Assurances

Management Team

Finance Resource Committee

Audit Committee

Finance Recovery Group

Board

Main controls in place: (What are we currently doing about the risk?)

Review of position and plans by monthly Finance Resource Committee.

Management Team receive regular reports on the financial plan.

NHS England Assurance meetings to review performance.

Reserves in place if adverse impact on financial position.

New Finance Recovery Group established to review the overall position including QIPP delivery and budget position.

External Assurances:

Internal Audit

External Audit

NHS England

Gaps in Assurances and Controls: (What additional assurances should we seek?) 1. Level of resources secured and plan for the year to be confirmed.2. QIPP plan assurance.3. Reserves analysis.

Further actions required: (What more should we do?) 1. Regular analysis of financial position at Finance Resource Committee

(31/03/2017).2. Monthly oversight at FRC of underlying recurrent financial position

(31/03/2017).

Additional comments: (With these actions taken, how serious is the problem?) If CCG allocations change without sufficient risk management then plans and targets will not be met. In addition, assumptions made in the Sustainability and Transformation Plan (STP) will be out of date and in need of refreshing which could increase the financial gap across SWL.

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Director Lead: A McMylorRisk 33 (Planning) – Rising population growth coupled with the projected increase in patients with long-term conditions places significant pressure on estates with primary and community services. If there is no coherent estates strategy factoring in the different health needs across Wandsworth, the population could suffer through unmet need or areas of the borough not having sufficient access to services.




Risk History Rationale for current score: The CCG’s current plans are based on a fundamental shift in setting of care (ie away from hospital) and there is a risk that these plans could be derailed if the increase in population, such as Nine Elms Vauxhall (NEV), or more patients being managed with a long-term condition are not able to access care in the appropriate out of hospital setting. This would drive up acute activity and spend.

This score remains the same as the CCG are planning a strategic response to the issues faced.

Internal Assurances:

Management Team

Estates Steering Group


An Estates Steering Group has been established, led by the CCG, bringing together partners from NHS England and NHS Property Services to maintain an overview of primary care estate within Wandsworth including opportunities for development.

Scoping work to identify MCP (Multi-specialty Community Provider) hub locations in light of expected population changes is on-going via the Estates Strategy Steering Group.

An Estates Strategic Framework has been developed and approved by Board in December, which detailed our broad approach to Estates Development in Wandsworth.

Joint Strategic Needs Analysis in place and referenced as part of the Estates and service development work.

All practice baseline surveys have been completed. These have been used to support practices in identifying potential opportunities to request IG funding as part of the next round of bids.

External Assurances

NEV Programme Board

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Gaps in Assurances and Controls: (What additional assurances should we seek?)

Review the outcomes of the Estates and Transformation Fund (ETTF) bid once known (11/16). Review options where we may not have been successful in funding specific schemes.

Further actions required: (What more should we do?)1. Continue to develop collaborative working to establish joint appointment

to develop Section 106 submissions. Additional resource identified to support development of joint process and delivery of Section 106 (01/01/2017).

2. Further meetings with SGH, NHSPS and Damson Health re potential to establish a Multi-specialty Community Provider (MCP) hub at Doddington (01/01/2017).

3. Review outcomes of ETTF bid once these become available (01/12/2016).

4. Review practice surveys and identify any priority areas that will affect practice capacity and report back to the Estates Working Group (31/12/2016).

Additional comments: (With these actions taken, how serious is the problem?) Monitoring arrangements are currently being put in place to work with Lambeth and Wandsworth Public Health departments to create a clear review process of the impact of the incoming population. The changes to the development will be reviewed either six monthly or annually as the development progresses. The on-going monitoring plans will directly involve LCCG and WCCG members of the Health Project Board.

Follow-up Health Input Assessment for Nine Elms Vauxhall being developed to be reviewed at the Project Board.

Estates and Technology Transformation Fund submission completed on 30th June; this includes bids that support the growth in West Wandsworth and other wards, as well as better use of Queen Mary’s Hospital (QMH).

All practices have the opportunity to bid in the new round of Improvement Grant (IG) funding. Applications from practices require support from the CCG in order to ensure that there are no revenue implications associated with any bids and that these align with our Estates Strategic Framework. Deadline for applications is 30/09/16.

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Director Lead: S IskanderRisk 47 (Quality) – Failure to develop effective early warning systems to monitor soft intelligence will hinder the early detection of poor, or potentially poor, quality of care within commissioned services.



Initial: 4 x 4 Current: 4 x 2 Tolerance rating: 4 x 2

Risk History Rationale for current score: The impact of failing to detect quality failures can be very severe both to patient safety and the reputation of the CCG/NHS. Learning from the Francis report shows that quality deterioration is more likely during periods of financial challenge. Although the CCG has monitoring systems and processes in place to triangulate hard and soft data, further developments can be made.

Enhanced surveillance process established with St George’s Hospital as part of the lead commissioner role to monitor current financial and quality concerns.


Integrated report to the Integrated Governance Committee.

Board receives summary minutes from Integrated Governance Committee.

Key indicators tracked through Quality Monitoring System.

Quality Group monitors Serious Incidents.

Safeguarding Committee monitors Safeguarding Key Performance Indicators.

Pressure sore incidents monitored through Quality Group.

Review of themes from complaints and patient feedback.


CCG leading at monthly Clinical Quality Review Groups (CQRGs) with the main providers, Quality Surveillance Group (QSG), and Professional Standards Board (Local Authority – Quality Surveillance).

Board and Integrated Governance Committee receive copies of reports and high level summaries from all Quality meetings (including CQRGs, Quality Group, Safeguarding Committee and other Task and Finish groups).

Programme of commissioner-led quality visits (quality walkabouts) at St George’s Hospital have been established to provide an opportunity to listen to patients, families, service users and staff during the visits.

Quality alert systems in place (‘Make A Difference’ at practices for healthcare professionals to raise quality concerns; Care Connect at St George’s Hospital; Google alerts; Twitter).

Monthly CCG Integrated Governance report details clinical quality concerns and actions to address highlighted issues.

Quarterly Quality and Patient Safety Report provided to Integrated Governance Committee providing details of clinical quality concerns and mitigations with a monthly highlight exception summary report.

Enhanced quality surveillance measures implemented for SGH during period of financial recovery.

Quality Group established to undertake more in-depth analysis of systems including for small contracts.

External Assurances

CQC Inspections and Reports

Quality Risk Summits

Healthwatch Reports

Provider Quality Accounts and quality / performance dashboards

Clinical Quality Review meetings with providers

Clinical Senates / Networks

Monthly meeting of NHS England London Quality Surveillance Group.

Friends and Family Test scores

Quarterly Assurance meetings with NHS England

Overview and Scrutiny Committee

Local Adults Safeguarding Board and the Local Safeguarding Children’s

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Clinical Reference Groups report quality issues to the Integrated Governance Committee.

Clinical commissioning representation on SGH quality inspection visits.

Clinical Harm Group set up to oversee clinical impact on patient care from delays in treatment – represented by CCG Clinical Quality Leads.

Board

Patient Experience reports (complaints, surveys, compliments) Care Quality Commission Reports

Gaps in Assurances and Controls: (What additional assurances should we seek?)1. Data on quality comprises some hard data (e.g. on HCAIs) and also soft intelligence

and is in disparate places and multiple formats, and collating a holistic view of quality across a provider is challenging, and assuring quality across a pathway across multiple providers is highly challenging.

2. The CCG commissions from a number of small providers including non-NHS providers, which do not have formal CQRG meetings.

Further actions required: (What more should we do?)1. Use Quality Group to triangulate data and review processes

(31/03/2017).2. Consider escalation of quality concerns through Management Team and

Integrated Governance Committee (31/03/2017).3. Develop action plan to address concerns raised in CQC reports

(31/03/2017).4. Roll-out quality dashboard to monitor smaller contracts (31/03/2017).5. Quality Oversight Group to be set up (31/01/2017).

Additional comments: (With these actions taken, how serious is the problem?) There continues to be a balance between developing trusting relationships with our main providers and establishing systems of control. Whilst the controls in place provide good assurance, risks of quality failures are exacerbated by financial pressures and also challenges in recruiting permanent staff to some roles.

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Director Lead: R WellburnRisk 50 (Commissioning) – If collaborative and partnership working with the Local Authority, NHS England and other CCGs does not secure the intended joined up approaches, this will impact on the CCG’s ability to achieve the transformational change necessary to improve the quality, value and viability of commissioned services. Date last reviewed: 01/12/2016



Risk History Rationale for current score: Responsibility for health has been split between CCGs, Local Authorities (Public Health) and NHS England. The complexity of this arrangement has the potential to lead to fragmented pathways across the wider health and social care landscape if there is no effective engagement, or alignment of health priorities.

A Health and Social Care Integration Group has been established by the CCG and Wandsworth Borough Council to oversee delivery of integrated commissioning programmes for Older People, Mental Health, Learning Disabilities, Children and Public Health.

WCCG is an integral partner of the South West London Five-Year Strategic Plan ensuring aligned CCG work plans and working within the SW London Sustainability and Transformation Planning Group.


Management Team

CCG Board

Delivery Group


Proposed single leadership model across the five CGs (Kingston, Merton, Richmond, Sutton and Wandsworth) to work collectively under one Accountable Officer to deliver the ambitions set out in the Sustainability and Transformation Plan (STP).

The move towards deeper collaborative working will include optimising governance arrangements to ensure streamlined and efficient decision making.

SRG (System Resilience Group) established with Merton CCG, Local Authorities and SGH to deliver the transformation and integration of services at local level.

The commissioning programmes are aligned to commission services that will deliver integrated and sustainable models of care. Joint programmes established with Merton CCG for urgent and planned care.

Cross CCG meetings established (Chief Officers, Finance, Commissioning) to take forward areas of shared interest. Monthly Joint Executive Committee established.

Two-year plan for integrated services within Better Care Fund owned by Health and Wellbeing Board.

WCCG is an integral partner of the South West London Five-Year Strategic Plan ensuring aligned CCG work plans and working within the SWL Sustainability and

External Assurances

Health and Wellbeing Board.

Overview by Joint Commissioning Executive, and Health and Wellbeing Board.

Better Care Fund Working Group

System Resilience Group

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Transformation Planning (STP) Group.

Health and Social Care Integration Steering Group established. Joint Commissioning Programmes agreed, with joint governance framework.

Lead provider commissioning arrangements in place.

Gaps in Assurances and Controls: (What additional assurances should we seek?)None currently identified.

Further actions required: (What more should we do?) 1. Continue to monitor. (31/03/2017)

Additional comments: (With these actions taken, how serious is the problem?) Effective joint working is likely to remain an area of significant risk, but shared governance arrangements and mutually agreed commissioning programmes will contribute to risk reduction during 2015/16.

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Director Lead: S IskanderRisk 99 (Delivery) – As lead commissioner the CCG has to give assurance to associate commissioners of services at St George’s Hospital about the management of risks relating to the significant challenges currently faced by the Trust. Date last reviewed: 01/12/2016



Risk History Rationale for current score: The main provider for health services for Wandsworth residents is St George’s University Hospital NHS Foundation Trust which is facing a number of significant challenges currently, including a large number of changes to the Board and senior leadership team, a sizeable savings programme in 2016/17 to deliver its financial control total, ongoing performance and quality issues including estates issues, workforce recruitment and retention issues, particularly in community services, and data quality and reporting issues linked to IT implementation and staff training, which has resulted in the Trust temporarily suspending national reporting of RTT (Referral To Treatment) waiting times. The contract with the Trust is the largest the CCG holds, the Trust is by far the largest provider of acute care, and is the CCG’s main provider of community services.

Any provider facing all of these challenges at the same time will be at greater risk of performance failures, and potentially of experiencing a delay in identifying significant performance or quality.


Management Team

Quality Group

Integrated Report to Integrated Governance Committee


CEO/CO regular meetings (as well as at executive level).

Continued quality oversight through Clinical Quality Review Group and Integrated Governance Committee.

Revised governance arrangements in place with the Trust and major associate commissioners, including with NHS Improvement and NHS England. External Assurances

System Resilience Group

Clinical Quality Review Group oversight of quality and review of Trust Cost Improvement Programmes

CQC Inspection undertaken 15th June 2016

Joint governance structure with NHS Improvement and NHS England

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Significant leadership changes at the Trust, with high number of roles filled by Interims. This impacts on the extent of assurance that can be given by the Trust

The normal contractual levers in the standard NHS Contract are not available in 2016/17 where providers are in receipt of Sustainability and Transformation Funding, which includes St George’s.

Further actions required: (What more should we do?)

Potential Board to Board, once new permanent Trust senior leadership team is in place. (31/03/2017)

Additional comments: (With these actions taken, how serious is the problem?) Given the range of factors applying at the same time and the gaps in assurance the risk level remains well above the tolerance rating, and some of the challenges facing the Trust do not have short term fixes.

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Objective 2: Make the best use of resources, continually improve performance and deliver statutory responsibilities

Director Lead: N McDowellRisk 7 (Finance) – If one or more SWL CCGs experience financial and performance difficulties, this would impact on Wandsworth’s ability to deliver statutory functions and responsibilities.




Risk History Rationale for current score: Most of the acute providers in SWL are experiencing financial distress. For 2016/17 a number of CCGs in SWL are also reporting a deficit position.

WCCG’s main provider is experiencing significant financial pressure for 2016/17.


Management Team


Board


Assurance meetings established with NHS England – triangulation of plans between providers and commissioners.

Monthly South West London Chief Finance Officers’ meetings in place.

Monthly South West London Finance Review Group meetings set up across SWL to monitor the on-going position – reports provided to Finance Resource Committee.

Regular finance reports to Management Team, Finance Resource Committee, and Board – reports detail risks and mitigating action, including utilisation of reserves.

Trust and Commissioner Assurance Board (TCAB) in place with main provider to review financial position.

External Assurances

Internal Audit review that budgets have been set appropriately

NHS England Assurance meetings.

Finance Review Group

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Gaps in Assurances and Controls: (What additional assurances should we seek?)1. Impact of in-year over performance on the STP.2. Review main provider financial turnaround plan.3. CCG plans to be shared and discussed through Finance Review Group.

Further actions required: (What more should we do?)1. To review South West London financial and performance issues in year

(31/03/2017).

Additional comments: (With these actions taken, how serious is the problem?) Provider and CCG’s financial challenge could impact ability to meet clinical performance targets and general stability in the health economy.

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Director Lead: N McDowellRisk 9 (Finance) – If the CCG does not deliver QIPP (Quality, Innovation, Productivity and Prevention) savings, this will jeopardise delivery of the financial control total, which would impact on the opportunity to improve quality and innovation Date last reviewed: 01/12/2016



Risk History Rationale for current score: CCG QIPP has areas which are high risk such as reduction in non-elective activity.

Historic performance has shown some schemes failed to deliver due to over optimistic savings and delays in delivery.

No significant new transformation programme implemented.

New schemes developed and implemented during the year.


Delivery Group

Finance Recovery Group

Management Team


Board


Business Intelligence Group (BIG) established, which will review any opportunities for establishing new QIPP schemes either in-year or subsequent years.

Finance Recovery Group established, chaired by Chief Officer, to oversee and ensure that QIPP schemes are managed in line with the project initiation documents and that performance is as expected. Where performance is not being delivered actions are agreed with Director responsible for that area.

Monthly Delivery Group meetings to review progress of delivery against Quality, Innovation, Prevention and Performance (QIPP) schemes reporting to Management Team.

All QIPP schemes have detailed plans, which where appropriate have been agreed with providers

2016/17 QIPP plan approved by the Board following Finance Resource Committee scrutiny.

Performance reported in finance report to Management Team, Finance Resource Committee, and Board.

NHS England assurance process monitors financial performance.

Internal Audit planned on the overall QIPP process from planning to monitoring.

External Assurances

Internal Audit

NHS England

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Further actions required: (What more should we do?)1. QIPP plan for 16/17 to be monitored monthly with a new Director level

Financial Control Group, reporting to CCG Finance Resource Committee (31/03/2017).

2. Continual development of schemes throughout the year – no investment released until risks are fully mitigated (31/03/2017).

Additional comments: (With these actions taken, how serious is the problem?) CCG holds a small contingency reserve but this might be utilised by other cost pressures emerging.

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Director Lead: S IskanderRisk 68 (Performance) – Failure to deliver performance improvements in commissioned services, resulting in non-delivery of the NHS Constitution Domains, core standards, targets, Quality Premium, or planned health outcomes. Date last reviewed: 01/12/2016



Risk History Rationale for current score: The CCG has faced a number of performance pressures over recent years. It has proved challenging to deliver some of the NHS Constitution standards, such as A&E four-hour maximum wait, RTT (Referral to Treatment) waits, cancer waits, and IAPT (Improving Access to Psychological Therapies). The standard on A&E four-hour maximum wait is unlikely to be achieved in 2016/17. Performance on the two-week urgent outpatient cancer wait, and sixty-two day maximum wait for treatment has been below the standard in 2015/16, but a recovery plan has been agreed with St George’s. There are significant issues with data quality of RTT waiting times information and St George’s has temporarily suspended national performance reporting.


Integrated report to the Integrated Governance Committee (IGC). The Board receives copies of the minutes from IGC.

Performance alerts and risks are reported to Management Team by exception.

Delivery Group gives detailed scrutiny of performance plans and 15/16 performance.

Commissioning Reference Group and CQRG monitor and report Acute Provider performance to the CCG.


Performance reporting mechanisms are in place for all the main providers and cover achievement against key performance measures as well as highlighting risks. Issues highlighted through Contract monitoring and CQRG meetings.

Minutes of Clinical Quality Review Groups are reported to the Integrated Governance Committee.

Dashboards for Clinical Reference Groups developed to enable progress to be tracked.

Performance reporting is a standing item on the Board and Integrated Governance Committee agenda. Board receives regular updates on areas of under-performance.

Assurance reviews with NHS England are scheduled to review current performance.

New governance structure now in place on performance at St George’s with NHS Improvement and NHS England.

Clinical harm review meeting in place.

Internal escalation process agreed and intensive support in place for high risk targets.

Following the One Version of the Truth diagnostic review a Flow Programme is in place for the emergency and urgent care system.

A remedial action plan is in place for Cancer access.

External Assurances

NHS England Assurance monitoring (face-to-face meetings/telephone calls).

NHS England Performance Improvement Forum.

A&E Delivery Board focus on urgent and emergency care across the system.

Joint governance arrangements in place with NHS Improvement (NHSI) and NHS England (NHSE).

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Gaps in Assurances and Controls: (What additional assurances should we seek?)1. Performance position on RTT waiting times and size of backlog is uncertain due to

data quality issues identified.2. Recovery plan for RTT from St George’s will be dependent on issues with the quality

of performance reporting being resolved, which is likely to take some time.3. The normal contractual levers in the standard NHS Contract are not available in

2016/17, where providers are in receipt of Sustainability and Transformation Funding, which includes St George’s.

Further actions required: (What more should we do?)1. Continued scrutiny from Delivery Group (31/03/2017).2. Implementation of new governance framework with NHS England, NHS

Improvement and St George’s (31/01/2017).3. Given the extent of the RTT waiting time issues additional capacity is

being sourced in other local providers, both NHS and independent sector. (31/03/2017)

Additional comments: (With these actions taken, how serious is the problem?) The CCG is commissioning providers to deliver the NHS Constitution standards, and is commissioning sufficient activity to do so. The CCG is performing a leadership role in improving patient pathways on a system-wide basis. However, performance is clearly not entirely within the influence of commissioner actions.

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Director Lead: G MackenzieRisk 75 (Delivery) – The SWL Sustainability and Transformation Plan (STP) sets out the financial case for change as well as the non-financial. If the programme does not deliver or proceed, there is a risk that the financial pressures set out would appear across the health economy. This would result in some providers not being financially viable as well as CCGs having a shortfall in delivery of shifts of care (impacts delivery of QIPP).




Risk History Rationale for current score: The System Transformation Plan (STP) has been developed by the CCGs and provider organisations and highlights the risks facing SWL if transformational change is not undertaken.

The 5 year plan is driven by reductions in acute activity and more activity taking place in the community along with general efficiencies brought about by collaborative working. Therefore if the SWL plans do not deliver this will put the strategy at risk. Plans so far such as QIPP across SWL have not been fully delivered and as a result acute activity continues to grow.

Financial position for providers is deteriorating faster than expected and the need for change is greater. CCG positions are also under significant pressure.


Delivery Group


Management Team

Board


The STP has been developed to resolve the financial gap across the SWL economy. WCCG play a significant role in supporting the delivery of the programme and lead in a number of areas.

WCCG has significant clinical and non-clinical input to ensure the priorities of the CCG are represented.

Investment fund created to implement changes required to transform services.

Financial performance is monitored through Finance Resource Committee, Management Team, and Board.

External Assurances

NHS England

SWL Programme Board

SWL Finance and Activity Committee

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Gaps in Assurances and Controls: (What additional assurances should we seek?)1. Contingency plan2. Understanding provider position on a regular basis.

Further actions required: (What more should we do?)1. CCGs reviewing the operational model for 2017/18 onwards to ensure

delivery of the STP (31/03/2017).2. Securing contracts with providers for 2017-19 that reflect STP planning

and financial requirements (31/12/2016).

Additional comments: (With these actions taken, how serious is the problem?) Risk is still high as programme develops.

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Director Lead: N McDowellRisk 95 (Finance) – The impact of central policy restricts CCG decisions regarding application of the 1% NR reserve, which reduces the potential for investment in services.



Initial: 4 x 4Current: 3 x 4Tolerance rating: TBC

Risk History Rationale for current score: Currently, the CCG has to report the reserve as uncommitted but has to assume for reporting purposes it is available to the wider NHS system.



Management Team

Board


Delivery of 0.5% surplus instead of 1% surplus was agreed by the Board.

Reduced level of planned investments.

No contribution to SWL risk pool agreed by the Board.


NHS England

Gaps in Assurances and Controls: (What additional assurances should we seek?)Can we make a case for this funding to be retained by commissioners either locally or across SWL?


On-going review to identify any in-year slippage (31/12/2016)

Review of all recurrent budgets (31/12/2016).

Additional comments: (With these actions taken, how serious is the problem?) No additional comments at this time.

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Director Lead: A McMylorRisk 97 (Primary Care Development) – Risks associated with the transition of functions associated with taking on Delegated Commissioning responsibilities




Risk History Rationale for current score: The CCG took on fully delegated Primary Care Commissioning functions from 1st April 2016. Since taking on these responsibilities, we are working closely with NHS England colleagues to understand the functions in more detail and work through the transition process.

A number of risks were identified as part of the due diligence exercise conducted prior to taking on delegated responsibilities, therefore, the CCG has already begun to implement a number of strategies to mitigate against those risks.


Primary Care Committee

CCG Board

Primary Care Operational Group

Finance Resources Committee

Primary Care Quality Review Group

Primary Care Quality Tracker


A Primary Care Commissioning Committee has been established to oversee the management of the delegated functions.

A Primary Care Operational Group has been established to support the day to day management and decision making process.

A Primary Care Quality Review Group has been established.

A Quality Contract is in place, which identifies gaps in quality across the borough and within individual practices, as well as providing a mechanism to support practices with any issues.

Practices have submitted their questionnaires as part of the baseline audit (deep dive) programme. These will be used to highlight any immediate areas of concern, and focus practice visits where additional information is required or area of support highlighted.

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NHS England

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A more detailed risk register to be developed for Primary Care Commissioning to include quality, finance and commissioning.

An integrated Primary Care Commissioning report will be developed, that will provide the Primary Care Committee with oversight of the management of primary care contracts and quality. This will be taken to the Primary Care Committee in December.


Finalise operating model which will detail the on-going processes and arrangements for the day to day management of the delegated functions (31/03/2017).

On-going transition process in place with NHS England (31/03/2017).

Weekly meetings taking place with NHS England colleagues to support the transfer and management of the delegated functions (31/03/2017).

Primary Care Commissioning risk register to be developed which combines both performance, contracting and quality areas (311/8/2016).

Individual practice ‘deep dive’ visits to take place to identify any legacy issues and to identify any possible issues, concerns or achievements. Key themes to be identified from the practice deep dive questionnaire; follow-up visits to take place where specific areas of concern are raised (01/12/2016).

Additional comments: (With these actions taken, how serious is the problem?) We continue to work with NHS England colleagues to manage the day-to-day activities associated with Primary Care Commissioning, and as such are in a position to better understand the current risks associated with these new functions. These additional assurances now in place, including a robust governance structure, ensure that risks can be identified earlier and any mitigating controls/actions can be put in place. We continue to monitor the various aspects of Primary Care Quality through our PCQRG; this includes any issues raised as a result of practice CQC visits, or infection control audits.

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Objective 4: Transform models of care to improve access, ensuring that the right model of care is delivered in the right setting

Director Lead: R WellburnRisk 29 (Planning) – If the CCG does not engage with the Collaborative Commissioning programme and the drive for integrated commissioning, or react to the call to action for transforming primary care and make robust plans in relation to the change in financial allocation, this will put the CCG at financial risk and impact on the ability to commission high quality services for patients in Wandsworth in the future.



Initial: 5 x 4 Current: 4 x 4Tolerance rating: 2 x 3

Risk History Rationale for current score: If the CCG does not engage with the South West London Collaborative case for change and the drive for integrated commissioning, or react to the call to action for transforming primary care and implement robust plans to address the change in financial allocations, this will put the CCG at financial risk, and impact on our ability to commission high quality services for patients in Wandsworth in the future.

Although we have robust plans in place for delivering the required shift to out of hospital care and are monitoring them closely, we are in the early stages of implementation and therefore are yet to see whether we will continue to deliver the reductions in activity expected in the longer term and therefore the risk score remains.

The Planned Care Programme has been established and the Programme Lead appointed. The objective will be to focus on areas where the CCG can reduce outpatient attendances using the Right Care approach through better care pathways and alternatives to hospital attendance.

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Out of Hospital Programme monitoring and evaluation overseen by the Delivery Group.

Regular reports from the Delivery Group to Management Team

Progress on out of hospital initiatives being monitored and evaluated by the Business Intelligence Team.


Focus on Right Care programme embedded within commissioning programmes and regular scrutiny on progress through Delivery Group.

Monthly reports to the Delivery Group on progress against overarching key performance indicators and secondary care activity trajectories.

Significant two year non-recurrent funding invested in Out of Hospital initiatives, which are monitored and evaluated by the Business Intelligence Team to ensure they are delivering on the Key Performance Indicators set out in the original plan and in QIPP.

A Primary Care Transformation Group has been established to oversee development of the Multi-specialty Community Provider (MCP) model and the wider primary care work programme.

Funding has now been agreed to continue successful programmes into 2016/17.

Sub-regional STP in place.

External Assurances

South West London Collaborative Out of Hospital Clinical Design Group.

Gaps in Assurances and Controls: (What additional assurances should we seek?)1. Further work required on the evaluation of the programme via the work commissioned from GE

Finnamore.2. Whilst activity for NELs has reduced, we have seen an increase in cost and the reasons for this

need to be understood.

Further actions required: (What more should we do?)1. Multi-speciality Community Provider (MCP) procurement –

new provider in place October 2017 (31/10/2017)

Additional comments: (With these actions taken, how serious is the problem?) Although a large number of out of hospital initiatives have already been developed and implemented, significant challenge remains, most notably around ensuring delivery of the ambitious targets identified for the remainder of year one and year two of implementation.

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Objective 5: Develop the CCG as a continuously improving and effective commissioning organisation

Director Lead: S IskanderRisk 65 (Organisation Development) – If there was not an effective workforce and strong leadership in place, it would be difficult for the CCG to be a high performing organisation, and undertake strategic plans to deliver on corporate objectives. Date last reviewed: 01/12/2016



Risk History Rationale for current score: The CCG continues to have a stable executive team with good clinical succession planning. The CCG continues to provide significant leadership to the SWL Collaborative Commissioning and across other London-wide programmes.

Although the risk is low, there are some challenges in management and clinical capacity.


Annual Staff Survey results.

Appraisal process and regular reviews of individual performance in place.


Structure and functions regularly reviewed by Executive Directors.

Workforce Committee maintains an overview of workforce related issues.

Aligned organisational objectives with team and individual objectives.

Regular staff Away Day sessions (three per year) and bi-monthly Team Briefing sessions.

Training sessions delivered as part of Board Seminar sessions.

Flexible working arrangements available for staff.

All staff have set work objectives and PDPs (personal development plans) which are reviewed regularly with their line manager to ascertain progress against the actions they have set themselves.

Coaching sessions for all Board members are on-going.

Workforce Committee agreed the action plan to implement the staff survey results including further training on objective setting.

External Assurances

Annual 360o survey of key CCG stakeholders.

CCG Assurance Framework.

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Gaps in Assurances and Controls: (What additional assurances should we seek?)1. Management and clinical capacity reviews needed.

Further actions required: (What more should we do?) 1. Contribute to the design and implementation of a new operating model for

five CCGs in SWL; refresh the CCG organisational development plan in accordance with the new operating model (31/12/2016).

Additional comments: (With these actions taken, how serious is the problem?) Reduction in management running costs may place additional pressures on workforce.

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Objective 5: Develop the CCG as a continuously improving and effective commissioning organisation

Director Lead: G MackenzieRisk 102 (Delivery) – A new operating model for CCGs is currently in development across SWL. This risks staff losing focus on operational priorities and key staff may leave the organisation.




Risk History Rationale for current score: Whilst the broad framework of the proposed operating model across SWL is described, some areas of the proposals remain subject to further development. Staff engagement and discussion is strongly encouraged about the detailed design of the proposals during the consultation period. During the period of consultation, staff will be given the opportunity to discuss the plans in team meetings and, where requested in 1:1 meetings.


Management Team

CCG Board


Formal HR process beginning shortly

Regular briefings from Chief Officers

Affected staff have had the opportunity to comment on proposalsExternal Assurances

SWL Chief Officers Group


Further actions required: (What more should we do?) 1. Further opportunities to comment provided through consultation period

(31/12/2016).2. Regular 1:1s to be held with affected staff through the process

(31/03/2017).3. Posts to be appointed to as quickly as possible to provide staff with

certainty (31/01/2017).4. Informal support to be offered from staff side / HR (31/03/2017).

Additional comments: (With these actions taken, how serious is the problem?) This would remain a serious issue as a degree of staff disruption is unavoidable until the formal HR process is completed.

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The following detailed Operational Risks are currently rated 12 or above and have been included for information:


Director Lead: S IskanderRisk 72 (Quality) – If the CCG is unable to provide appropriate oversight, scrutiny and assurance within the care home setting, this increases the risk of potential harm to vulnerable clients/service users.




Risk History Rationale for current score: Care homes care for some of our most vulnerable groups of patients. There is limited capacity available with several homes having closed in Wandsworth over the last two years and some patients are placed out of area. Systems for monitoring the quality of care homes are not as well developed as for other sections. Further work with the Local Authority and with Healthwatch is on-going.


Review of progress at Safeguarding Sub-committee (action plans, work plans in place and monitored).

Oversight at Integrated Governance Committee through Integrated Report.

Service Standards Board created to provide strategic direction to improving care home quality.

Feedback from health professionals working in care homes (BACS and GPs).

Quality Review Committee led by Local Authority in place with health involvement.


Adult Safeguarding Nurse in place enabling close working relationship with the Continuing Health Care team. Also attends contract monitoring meetings.

Executive Board Safeguarding lead in post.

Partnership working with Local Authority Safeguarding team and Local Adult Safeguarding Board membership.

Liaison Nurse post in place to support quality in care homes.

Quality Board with Wandsworth Healthwatch to focus on quality in care homes.

Joint Quality Dashboard to monitor key quality indicators.

External Assurances

Local Adult Safeguarding Board (SAPB).

Serious Incidents reported and reviewed.

CQC and Healthwatch reports.

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Gaps in Assurances and Controls: (What additional assurances should we seek?)A number of issues with the database of the previous support supplier were identified, which are in the process of being rectified in the move to the new supplier. This has highlighted that we are not able to be assured at this time that all funded patients have received their six-monthly reviews and therefore their circumstances or needs may have changed and not been actioned.

Further actions required: (What more should we do?) 1. Continue to share information with key partners (31/03/2017).2. Develop frailty work stream to support better commissioning for

vulnerable patients (31/03/2017).3. Implement quality dashboard for smaller contracts for Care Home Select

(CHS) (31/03/2017).

Additional comments: (With these actions taken, how serious is the problem?) Requires constant review and scrutiny to ensure service continues to meet requirements.

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Director Lead: G MackenzieRisk 77 (Quality) – If the CCG does not have robust data to guide understanding of health inequalities, or a strategy in place to address them, there is a risk that inequalities will continue or worsen.




Risk History Rationale for current score: Health inequalities are increasing across most London Boroughs.

Analysis based on the Joint Strategic Needs Assessment (JSNA) defines the Wandsworth population and sets out the challenge.

Differential health benefits across Wandsworth have been identified.

Health and Wellbeing Board strategy in place.


Management Team


Equality Impact Assessments when completed identify equalities impact used to measure outcomes.

Joint Strategic Needs Assessment has identified some areas of inequalities.

Corporate Objectives are monitored through the Board Assurance Framework (BAF).

Annual Equalities training delivered to staff.

Regular updates to Management Team.

Actual measure of life expectancy across Wandsworth used as a control to monitor achievement.

External Assurances

Health and Wellbeing Board

Gaps in Assurances and Controls: (What additional assurances should we seek?)1. Differential commissioning.2. Joint approach with Local Authority (H&WB)3. Regular updates to Board.

Further actions required: (What more should we do?) 1. Equality Impact Assessment process to be strengthened, with additional

scrutiny by the Patient and Public Involvement (PPI) team to ensure that strategies and policies take into account CCG priorities for reducing inequalities. Part of Board reporting review (31/12/2016).

2. Health inequalities project worked through Thinking Partners Group (31/12/2016).

Additional comments: (With these actions taken, how serious is the problem?) Making a difference in health inequalities is a long term issue.

Addressing health inequalities will require all partners to work together.

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Director Lead: N McDowellRisk 89 (Quality) – The main provider for health services for Wandsworth residents is St George’s Hospital Foundation Trust who are reporting a significant financial deficit for the year 2015/16. There are a number of risks which impact the CCG as a result of the financial position, such as quality, workforce levels, capacity, focus on delivery, waiting times etc.



Initial: 5 x 4Current: 4 x 4Tolerance rating: TBC

Risk History Rationale for current score:

Trust under review with turnaround plan in place.

Large deficit forecast for 16/17.

Performance targets proving to be challenging.

Staffing gaps appearing.



Quality Group



Enhanced quality surveillance in place to include increased walk rounds, close monitoring of Cost Improvement Programmes, encouragement of further GP alerts, and dedicated Director role.

Chief Executive Officer/Chief Officer regular meetings (as well as at executive level).

Monitoring performance against existing quality indicators and dashboards.

Continued quality oversight through Clinical Quality Review Groups and Integrated Governance Committee.

Tripartite analysis and meetings – regulatory bodies exchanging views.


Tripartite meetings – Monitor, NHS England, Wandsworth CCG


Turnaround plan.

Meetings with Regulator.

Further actions required: (What more should we do?) 1. Review by external assessors – Finance Resource Committee to assess

impact (31/03/2017).

Additional comments: (With these actions taken, how serious is the problem?) Financial challenges faced by SGUFT will see the Trust providing a different range of services which will impact CCG’s commissioning priorities.

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Financial PoliciesAuthor: Sandra Allingham Sponsor: Neil McDowell Date: 14/12/16

Executive Summary

Context

Following an initial review earlier in the year prompted by the introduction of Primary Care

co-commissioning it was identified that a full review of all financial polices was required to

ensure the CCG has a set of policies which together could be viewed as a complete

package.


1. Is the delegation of primary care commissioning reflected in the Standing Orders?

2. Do the documents accurately reflect the CCG Constitution?

3. Do the Prime Financial Policies provide sufficient information on financial governance

processes?

Conclusion

1. The amended Scheme of Reservation and Delegation reflects Primary Care co-

commissioning and amended job titles in partner organisations.

2. Standing orders have been reviewed and minor changes incorporated to reflect links

to the CCG constitution. A review of the policies has been undertaken to ensure

they align with the constitution where appropriate and integrated in a coherent way

with appropriate cross referencing.

3. The Prime Financial Policies have been significantly expanded to assist in clarity and

coverage.

4. A summary of the changes are set out in the report.

Input Sought

The Board is asked to approve the amendments to the Prime Financial Policies, Standing

Orders, and Scheme of Reservation and Delegation. Comments raised during the

discussion at the Finance Resource Committee meeting have been taken into account

during the review.


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The ReportA summary of the changes to the policy are listed below:

Standing Orders:

Section Title Amendments

1. Introduction 1.1.2 Reference to appointment of the Governing Body included.

2. CCG Composition of Membership, key roles and appointment process

Information updated for Board roles and inclusion of Primary Care Committee.

3. Committees and Sub-Committees

Information updated to accurately reflect the Constitution and CCG Conflicts of Interest policy.

Inclusion of new section (3.7) relating to Primary Care Committee meetings.

4. Conflicts of Interest No changes made.

5. Emergency Powers and Urgent Decisions

No changes made.

6. Suspension of Standing Orders Additional information included.

7. Duty to report non-compliance with Standing Orders and Prime Financial Policies

No changes made.

8. Use of Seal and Authorisation of Documents

Additional information included.

9. Overlap with other CCG policy statements/procedures and regulations

No changes made.

Prime Financial Policies:


1. Introduction 1.1.3 New paragraph re Shared Service provider.

2. Internal Control Expanded section clearly setting out relevant responsibilities.

3. Audit Expanded section setting out responsibilities for individual roles.

4. Fraud and Corruption Section expanded to include more detailed information including Security Management.

5. Expenditure Control No changes made.

6. Allocations No changes made.

7. Commissioning Strategy, Budgets, Budgetary Control and Monitoring

Expanded section to provide more detailed information on processes including Budgetary Delegation, Budgetary Control and Reporting, and Capital Expenditure.

8. Annual Accounts and Reports No changes made.

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9. Information Technology Section expanded to include Freedom of Information Publication Scheme, and assurance around corporate financial systems.

10. Accounting Systems No changes made.

11. Bank Accounts Section expanded to provide more detailed information on processes.

12. Income, Fees and charges and security of cash, cheques and other negotiable instruments

Expanded section to include more information on fees and charges, debt recovery, and security of cash, cheques and other negotiable instruments.

13. Tendering and Contracting Section expanded substantially to include comprehensive information relating to formal competitive tendering.

14. Commissioning Section expanded to include responsibilities for individual roles.

15. Risk Management and Insurance

Expanded section to provide further detailed information.

16. Payroll Section expanded to include line management responsibilities.

17. Non-Pay Expenditure Section expanded to include responsibilities of individual roles, duties of managers and officers, and joint finance arrangements.

18. Capital Investment, fixed asset registers and security of assets

Section expanded to include private finance, asset registers, security of assets, and NHS Local Investment Finance Trusts (LIFT).

19. Disposals and Condemnations, Losses and Special Payments

New section included.

20. Retention of Records Section of expanded.

21. Trust Funds and Trustees Section expanded.

Scheme of Reservation and Delegation:

The Scheme of Reservation and Delegation has been revised to reflect the delegation of

Primary Care Commissioning in April 2016. Information relating to GMS and PMS

Expenditure has been included in section 9 (h) of the Detailed Scheme of Delegation.

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The risks [Yes]


Impact on our patients [Not applicable]

Impact on our providers [Not applicable]

Impact on our finances [Not applicable]


Patient and public involvement [Not applicable]




inequalities [Not applicable]




members, stakeholders and communities [Not applicable]


is delivered in the right setting [Not applicable]


organisation [Yes]





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Conflicts of Interest PolicyAuthor: Sandra Allingham Sponsor: Sandra Iskander Date: 14/12/16

Executive Summary

Context

Following on from the publication of the revised Conflicts of Interest guidance in June,

work has been done to review the CCG’s Conflicts of Interest policy to ensure that the

guidance is appropriately reflected. The revised policy has been reviewed at the

Integrated Governance Committee and by Internal Audit.


1. What changes have been required?

2. Does the revised policy adequately reflect the new guidance?

Conclusion

1. A summary of the changes are set out in the report.

2. The revised policy encompasses all of the recommendations from the guidance.

Input Sought

The Board is asked to approve the revised version of the policy. Comments raised during

the discussion at the Integrated Governance Committee meeting have been addressed.


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The ReportA summary of the changes to the existing policy are listed below:


1. Introduction Revised wording (paragraphs 2, 3, and 4)

2. Definitions Conflicts of Guardian role included

3.3 Interests redefined3. What are Conflicts of Interest?

Paragraph relating to the Bribery Act 2010

removed – link to the Act included in Section 18

4. Principles Content reformatted

5. Identification and Management

of Conflicts of Interest

5.2 Appointment to Conflicts of Interest Guardian

role

6. Declaration of Gifts and

Hospitality

New section

7. Appointments, Roles and

Responsibilities in the CCG

New section

8. Managing Conflicts of Interest

at meetings

8.1 List of Committees included

8.4 Waiver – section removed as covered in

previous paragraphs

9. Preserving Integrity of Decision

Making Process when all or

most GPs have an interest in a

decision

No changes made

10. Procurement and Competition Section updated

11. Managing Conflicts of Interest

throughout the Commissioning

Cycle

New section

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12. Contract Monitoring New section

13. Raising Concerns and

Breaches

New paragraphs 13.1 and 13.2 included

14. Impact of Non-Compliance New section

15. Record Keeping No changes made

16. Reporting and Assurance New section

17. Conflicts of Interest Training New section

18. Linked Policies/Guidance Additional links included

Appendices 1-5 Revised

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The risks [Yes]


















organisation [Yes]





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Part C: Management Reports

Page

3. Part C: Management Reports 136

3.1. C01 Executive Report 137

3.2. C02 Performance Report 150

3.3. C03 Finance Report 158

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W A N D S W O R T H C C G P A G E 1 O F 1 3

Executive ReportAuthor: Sandra Allingham Sponsor: Nicola Jones / Graham Mackenzie 14/12/2016

Executive Summary

Context

The report provides information on the following items for information:

Management Team Summary

Sustainability and Transformation Plan

Lay Member Recruitment

SWL Operating Model

Off-Payroll Policy

Merton CCG Quality Function

Talking Therapies Contract

Children and Adolescent Mental Health Services

Input Sought

The Board is asked to note the content of the report.


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The Report

Management Team SummaryA summary of the main issues discussed by the Management Team in the period following the previous Board meeting is outlined below:

Performance

Serious Incidents and ‘Make A Difference’ Alerts

St George’s University Hospital Foundation Trust

Procurement

Quality and safety issues

Financial recovery

Personal Health Budgets

Safeguarding

Planning Round

Multi-specialty Community Provider

Continuing Health Care

IT

Effective Commissioning Initiatives

Sustainability and Transformation Plan (STP)

SWL CCGs submitted a revised Sustainability and Transformation Plan (STP) at the end of October in line with the national timetable. WCCG Governing Body reviewed the revisions before submission. Content has not changed significantly from the earlier version, however additional detail has been added to describe delivery, particularly in relation to Right Care Best Setting which describes new models of integrated out of hospital care.

The SWL STP has been published on the CCG and council websites and is now subject to wider engagement including presentations to the Health and Wellbeing Board, Wandsworth Healthwatch Alliance and at the CCGS annual equalities (EDAY) event.

The STP can be accessed via the following link: http://www.swlccgs.nhs.uk/documents/our-plan-for-south-west-london/

CCGs Operating Model

The six CCGs in SWL, together with partner organisations, have recently submitted the

SWL Sustainability & Transformation Plan (STP). The scale of the challenge ahead, as

described in the STP, has led the leaders of the CCGs in SWL to consider whether current

commissioning arrangements are sufficient to enable the delivery of the change

programme ahead.

A proposal for the consolidation of senior leadership roles and accountability amongst

local CCGs has been developed and is currently the subject of a formal consultation with

CCG staff that concludes on 21st December.

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http://www.swlccgs.nhs.uk/documents/our-plan-for-south-west-london/


Two organisational diagrams that illustrate the proposed future structures across CCGs in

SWL are attached for reference.

A key element of the proposals is for the creation of a single Accountable Officer post to

operate across 5 CCGs in SWL (in full by 2018). This post is currently subject to open

recruitment and it is hoped that an appointment will be made in the near future.

Final decisions on the overall structure and implementation arrangements will be taken in

the early New Year.

Operational Plan 2017-19The planning and contracting timetable has been brought forward this year, to ensure that contracts are agreed and in place prior to the new financial year. The planning round covers a two year period, 2017-19, and Operational Plans are expected to be based on delivering progress on the Sustainability and Transformation Plan for South West London. The national timetable for submission of final Operational Plans and contract signatures is 23 December, which is extremely challenging. In practice commissioners and providers are aiming to have the baselines and the principles agreed for the 2017-19 contract by that date, with further work on QIPP and closing any financial gaps to be concluded in the New Year. Contract offers were made to providers on 2 November, in line with the national timetable. These incorporated the QIPP savings identified at that time, with corresponding reduced activity levels, and also a level of yet to be identified transformational QIPP which is required to achieve the SWL CCG control total. The current requirement for QIPP savings for 2017/18 is £20.1m, which is significantly greater than the level of QIPP savings the CCG has needed to realise in previous years. At the time of writing c. £5m of transformational QIPP initiatives were still unidentified. Options for the further QIPP savings required are being explored, including further analysis of RightCare opportunities and through a comprehensive review of all budget lines with Directors and budget holders. Options for innovative contract models are being explored with acute providers in South West London, including St. George’s, with the objective of sharing the responsibility for managing risks around activity and finance variances between commissioners and providers, and enabling a greater focus on implementation of the strategic transformation as described in the South West London Sustainability and Transformation Plan.

Negotiations are progressing with South West London and St. George’s Mental Health Trust, with the main outstanding issue relating to the cost of living supplement. The Operational Plan comprises a finance plan, a QIPP programme, activity trajectories, Improvement and Assessment Framework trajectories and a Quality Premium submission. A draft plan was submitted to NHS England on 24 November, and the CCG is awaiting any feedback. Activity trajectories have been submitted incorporating growth in line with the Sustainability and Transformation Plan assumptions for 2017-19. The trajectories will need to be refreshed for the 23 December submission to incorporate the agreed position with providers on QIPP programmes.

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Improvement and Assessment Framework trajectories were also submitted which demonstrated that the performance standards will be achieved in 2017-19, with two significant exceptions. A trajectory for performance on the A&E 4-hour waiting time standard has been jointly submitted by both St. George’s and the CCG, which shows achievement of the 95% standard in three months in 2017/18 but an overall aggregate performance of 93.1% based on the expected improvements from the existing work programme mapped onto the historical seasonal activity and performance trend. The national expectation is that 80% of GP outpatient referrals will be made through the E-referral system by the end of Q2 in 2017/18 which is not expected to be achieved pending St. George’s making substantial progress with its outpatient transformation programme to make capacity available for appointment slots within reasonable timeframes. The biggest risks remain the unidentified QIPP savings gap and the financial gap between St. George’s starting position and SWL commissioners. The main performance risk, which also impacts on activity, relates to RTT at St. George’s, given that the Trust ceased national reporting from May 2016 due to the extent of the data quality issues the extent of the actual RTT backlog and any mis-match between available capacity and demand is impossible to quantify with any degree of confidence. Full reports on both the Finance Plan and Budgets and also the Operational Plan will come to the March 2017 Board meeting.

Lay Member Recruitment

As agreed at the Board meeting in October, the recruitment process for the three Lay

Members with specific responsibility for Governance, Patient and Public Involvement, and

Finance respectively, has been put in place, with the closing date for applications being

15th December. The periods of appointment for the current Lay Members are due to end

on 31st March 2017 (Governance) and 31st August 2017 (PPI) respectively. Appointment

of the third Lay Member (Finance) will be taken forward as priority, with the additional

appointments further into the year.

Merton CCG Quality Function The Director of Quality at Merton CCG will be leaving for a new role. Given the current

proposals to work collaboratively across SWL, the post will not be recruited to. We have

therefore agreed that Sandra Iskander will provide Director level support to the quality

team at Merton one day a week. Chris Clarke, the Merton Director of Performance will

provide some backfill support in return. This arrangement will begin in the New Year and

is expected to continue until the end of the financial year.

Concurrently, Wandsworth and Merton CCGs are consulting with staff about a proposal to

share safeguarding nursing teams. The proposal is to create three new posts (Head of

Safeguarding, Designate Nurse for Safeguarding Adults, and Designate Nurse for Looked

After Children) who would work across both CCGs providing a more resilient service.

Designate Doctor roles would remain unchanged. The staff consultation will end on 28th

December and the Board will be updated on the final proposal.

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Talking Therapies Contract Contract negotiation and mobilisation of the new Integrated Wandsworth Talking

Therapies have commenced. The Wandsworth CCG IAPT Transition and Mobilisation

Project Board has been established to manage existing IAPT performance in Quarter 3

and Quarter 4 of this financial year and oversee delivery of the mobilisation plan for the

new service. It is anticipated that contract will be signed before the 31 December 2016.

Children and Adolescent Mental Health Services (CAMHS)Local Implementation - Wandsworth CAMHS transformation plan was submitted in

October 2015 to deliver the Future in Mind recommendations to deliver the following

themes;

Promoting Resilience

Prevention and early intervention

Improving access to effective support

Care for the vulnerable children sexually abused / Edge of Care

Developing the workforce Eating Disorders

We were allocated transformation funding of £422,000 for general CAMHS service and

£168,000 for Eating Disorder Services from 2015/16 onwards.

Some of the achievements for Wandsworth over the last year have included:

CAMHS Access Service continues to perform well working to 2 -4 week target for waiting times for first appointments and has reduced referrals to Specialist T3 CAMHS by 33%.

We have increased P2B counselling services in Primary schools to 5 more primary schools in Sept 16.

An evidenced based parenting programmes has been developed to build self-esteem , attachment and emotional resilience.

We have developed a transition service model for children with neuro developmental disorders 18-25 the service is being implemented.

2016 Update - In February The Five Year Forward View for Mental Health set out a

roadmap for delivering the commitments made in the Mental Health Taskforce report.

The NHSE sets out a range of objectives to achieve by 2020/21 including:

A significant expansion in access to high-quality mental health care for children and young people

At least 70,000 additional children and young people each year to receive evidence-based treatment

To support this CCGs were given additional funding of £281,000 from 2016/17 in addition

to the £592,000 from last year.

CCGs were written to in Summer 2016, advising that we would need to submit a refresh update of our original CAMHS Transformation Plan by 31st October 2016. The plan articulated our progress in delivering the plan since last year, as well as how we work in

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the coming year on delivering broader transformational programme linked to the STP programme.

The local Wandsworth strategy is:

Our ambition is to give every child the best start in life and help them develop into healthy and resilient adults. Families will receive a rapid response to their needs, have access to information and advice that is high quality and evidenced based. The support they receive will be flexible, person centred, convenient and promotes their wellbeing and improved mental health.

Wandsworth CCG have identified the following priorities and are working together at an STP level to determine how we will implement these including:

Access to appropriate beds locally thus not having to travel long distances, face long waiting times, or disconnect from family and their local community

Availability of services out of hours

Support for young people when they return home after Specialised CAMHS admission

Consistent commissioning arrangements between community and Specialised CAMHS

Consistency in care and discharge plans

More multi-agency support to help children and young people with mental health problems to stay in community and prevent hospital admission

The plan was submitted to agreed deadline set and was endorsed by Wandsworth Health

and Wellbeing Board.

Future implementation - We are now working on a detailed implementation plan of how we

will deliver these programmes locally in Wandsworth. The detailed plans for the use of the

additional funding and increased KPIs will be brought to the CCG Board in January 2017.

Use of the Seal

The corporate seal has not been applied since the previous report.

Conclusion

The Board is asked to note the information on the items above.

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The long-term implications [Not applicable]

The risks [Not applicable]

Impact on our reputation [Not applicable]







The content included in the report relates to items for information only.





statutory responsibilities [Not applicable]






organisation [Not applicable]


The content included in the report relates to items for information only.




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Operating Model at April 2018

7

Croydon CCG Chair

Accountable Officer

CroydonLocal Delivery

Unit(incl CFO)

(Functions by MoU)

Sutton MDLocal Delivery

Unit

Chief Finance Officer

Director of Quality &

Governance

Director of Contracting

Accountable Officer

Merton CCG Chair

Merton & Wandsworth MD

Local Delivery Unit

Wandsworth CCG Chair

Kingston CCG Chair

Richmond CCG Chair

Kingston & Richmond MD

Local Delivery Unit

Sutton CCG Chair

Director of Performance

AcutePrimary

Care

Mental Health

Wandsworth Clinical Commissioning Group

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W A N D S W O R T H C C G P A G E 1 0 O F 1 3

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Operating Model at April 2018

7

Croydon CCG Chair

Accountable Officer

CroydonLocal Delivery

Unit(incl CFO)

(Functions by MoU)

Sutton MDLocal Delivery

Unit

Chief Finance Officer

Director of Quality &

Governance

Director of Contracting

Accountable Officer

Merton CCG Chair

Merton & Wandsworth MD

Local Delivery Unit

Wandsworth CCG Chair

Kingston CCG Chair

Richmond CCG Chair

Kingston & Richmond MD

Local Delivery Unit

Sutton CCG Chair

Director of Performance

AcutePrimary

Care

Mental Health


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Performance Report Author: Iain Rickard Sponsor: Sandra Iskander Date: 14 December 2016

Executive Summary

Context

This paper details the current and year-to-date performance against all NHS Constitution and Improvement and Assessment Framework (IAF) indicators (subject to available data). NHS England have not yet published a methodology for determining overall CCG performance for the ED 4-hour target, therefore this report focuses slightly more on the performance of our local providers and, in particular, St. George’s progress against its Sustainability and Transformation Plan trajectories. As of 8th July 2016, St. George’s have suspended formal national reporting against the 18 week RTT target until further notice, although St. George’s will continue to informally report some data locally. The CCG is working with the Trust, other commissioners and the regulators to ensure that the improvement plans will result in recovery of both data quality and performance delivery as soon as practically possible, although this is expected to take many months.

Clinical Priority Area: Mental Health

NHS England has published assessments of the mental health clinical priority area under the Improvement and Assessment Framework for all CCGs. The CCG has been rated as “Needs Improvement”. IAPT recovery rate is improving. We achieved 50.9% in July 2016, but this needs to be sustained. We are supporting practice based counsellors to improve collection of recovery data. The Children and Young People’s Mental Health indicator has been marked down in Q1 due to a reporting error on the finance return, which indicated that we were not planning to sufficiently increase spending on CYPMH. This has been corrected and subsequent quarterly ratings will show CYPMH as being fully compliant.


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Clinical Priority Area: Maternity

The CCG has been assessed as performing well against the maternity indicators.

Although a high score out of 100, our score for women’s experience of maternity services is in the lowest 25% of CCGs nationally.

Our score for choices in maternity services is similar most other CCGs in England.

The rate of stillbirths and deaths within 28 days of birth for Wandsworth CCG is among the lowest in

the country.

Looking Back

W H A T H A S G O N E W E L L ?

C. Difficile & MRSA Infection Rates

No cases of MRSA reported in September. 6 C. Difficile cases reported in September,

equalling 19 in the year to date, although this is well within the expected upper limit of 25

cases.

6-Week Diagnostics Waiting Time

Diagnostic 6-week wait performance remains at 99.3% in October and we are now

meeting the year-to-date target.

IAPT Waiting Times

6 and 18 week waiting time targets for IAPT continue to be met and were consistently

achieved during 2015/16.

Early Intervention in Psychosis 2-week Wait Target

This target is being met, although performance is sensitive to small numbers of patients.

Ambulance Response Times

London Ambulance Service has met response time targets for Wandsworth patients.

Maternity Clinical Priority Area

Rated as “Performing Well” although there is room for improvement around choice and

experience.

Improvement and Assessment Framework Indicators

We have improved against a number of Improvement & Assessment Framework

indicators and we have reduced the number of indicators in the lowest 25% of CCGs from

9 to 3.

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W H A T H A S N O T G O N E W E L L ?

ED 4 Hour Waiting Time

Performance is below 95% at all 5 of our main providers. However, St. George’s have achieved their STF trajectory target in October.

18-Week Referral to Treatment Waiting Time (Incomplete Pathways)

With St. George’s temporarily not reporting national data Chelsea and Westminster is now the biggest driver of the CCG’s 18-week performance. It has been achieving the 92% target

as a Trust, but has specific capacity issues at the Chelsea site, which are affecting waiting

times for Wandsworth patients.

52-Week Waiters

Provisional data shows 5 52-week waiters for October. 4 at Imperial (ENT x 2, Plastic

Surgery and T&O) and 1 at King’s in General Surgery. These are currently being investigated.

Cancer Waiting Times

We have not met the 2-week, 31-day (surgery) and 62-day cancer targets according to

the provisional data for October. St. George’s have met all the targets and are achieving their STF trajectory.

Mental Health Clinical Priority Area

Rated as “Needs Improvement”. However, Children and Young People’s services is now assessed as fully compliant, therefore the overall assessment of mental health is

expected to improve.

Looking Ahead

O P P O R T U N I T I E S ?

We continue to see the following positive trends:

Zero MRSA infections

Diagnostic waiting times consistently being met and YTD performance improving.

Maintenance of IAPT waiting times

Continued high levels of dementia diagnosis rates.

Improvements in ambulance response times.

R I S K S O R C O N C E R N S ?

18-Week Waits at St. George’s

Due to the data quality issues, we cannot know with certainty the length of time patients

are waiting for outpatient appointments and for operations at St. George’s. The Trust is supplying regular updates on waiting list size and activity, but due to the data quality

issues identified that information is not necessarily a reliable indicator of actual

performance.

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ED Performance at St. George’s

Much of the recent improvement in performance has been supported by bed availability.

Looking ahead to the winter period and based on historical experience, there is unlikely to

be excess bed capacity to support initiatives that have improved ED performance.

IAPT Access and Recovery

There is a risk that performance against these targets will reduce while the current

service is redesigned. Additionally, there is an indication that the prevalence of anxiety

and depression has increased by up to 25% nationally, which will mean that the access

target is more challenging as well as being increased in 2017/18 and 2018/19.

Dementia Diagnosis Rates

From 2017/18, Dementia prevalence will be calculated using registered patient population

instead of resident population. This will increase the potential number of patients with

Dementia by approximately 9% and cause a drop in our current performance. However,

we expect to continue to meet the 66.7% target in 2017/18.

In Conclusion C O NF I DE NC E ? I M P L I CAT I O NS ?

We have seen improvements in a number of

the NHS Constitution indicators in recent

months, although we need to work to ensure

these are sustained as winter approaches. The

greatest risk is around the uncertainty around

18-week RTT performance at St. George’s.

There are a small number of indicators which

are not supported by work programmes or

which have determinants that are difficult for a

CCG to influence, certainly in the short term.

It will be difficult for us to assure ourselves on

performance and progress towards resolving

18-week RTT data quality issues without robust

data.

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NHS Constitution Scorecard

Jul-16 Aug-16 Sep-16

Summary EAS04 MRSA - Incidence of HCAI YTD 0 0 0 0 (YTD) Sep-16 0 0 0 ▼Summary EAS05 C. difficile - Incidence of HCAI YTD 25 19 6 0 (YTD) Sep-16 5 3 6 ►

NHS Constitution

Summary EE001 RTT incomplete (Provisional) 92% 91.4% 90.6% 950 Oct-16 91.5% 91.0% 91.0% ▼Summary EBS04(3) RTT 52+ week waiters (Provisional) 0 22 5 5 Oct-16 3 1 3 ►Summary EE004 Diagnostics (Provisional) Diagnostics - 6 weeks + (Provisional) 99% 99.0% 99.3% 35 Oct-16 99.9% 99.3% 99.3% ▲Summary EB006 2 week wait 93% 91.1% 92.8% Oct-16 93.7% 94.5% 94.0% ▲Scorecard EB007 Breast symptoms 2 week wait 93% 92.7% 98.6% Oct-16 93.8% 93.3% 94.4% ►Summary EB008 31 day first definitive treatment 96% 97.9% 98.2% Oct-16 97.6% 98.2% 98.6% ►Scorecard EB009 31 day subsequent treatment surgery 94% 98.6% 90.0% Oct-16 100.0% 100.0% 100.0% ▲Scorecard EB010 31 day subsequent treatment drug 98% 99.4% 100.0% Oct-16 100.0% 100.0% 100.0% ▲Scorecard EB011 31 day subsequent treatment radiotherapy 94% 97.0% 96.8% Oct-16 93.8% 97.9% 100.0% ►Summary EB012 62 day standard 85% 84.5% 83.9% Oct-16 93.0% 79.3% 84.1% ►Scorecard EB013 62 day screening 90% 89.7% Oct-16 100.0% 50.0% ►Scorecard EB014 62 day upgrade 92.3% 100.0% 0 Oct-16 100.0% 80.0% ►Scorecard EBS01 Mixed-sex accommodation breaches 0 3 1 1 Oct-16 0 2 0 ►Scorecard Local9 Total number of Delayed Transfers of Care 0 592 97 97 Sep-16 87 102 97 ►CCG EBS03 CPA follow up within 7 days 95% 95.4% 95.1% 7 Sep-16 95.1% ►CCG EH01 IAPT 6 week target 75% 93.6% 94.2% 30 Aug-16 89.1% 94.2% ►CCG EH02 IAPT 18 week target 95% 98.5% 98.1% 10 Aug-16 96.6% 98.1% ►CCG EH03 IAPT in recovery 50% 46.3% 44.9% 190 Aug-16 50.9% 44.9% ▲CCG EH04 Early Intervention Psychosis 2 week target 50% 72.7% 80.0% 1 Sep-16 66.7% 81.8% 80.0% ►CCG EAS01 Dementia 67% 73.6% 75.7% 456 Oct-16 73.7% 73.7% 73.4% ▲

A&E 4 Hour Waits

Summary EB005 % within 4 hours ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 95% 92.8% 92.2% 1107 Sep-16 94.4% 92.7% 92.2% ▼Summary EB005 % within 4 hours CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST 95% 94.9% 93.8% 1437 Sep-16 95.0% 94.8% 93.8% ▼Summary EB005 % within 4 hours KINGSTON HOSPITAL NHS FOUNDATION TRUST 95% 92.7% 92.3% 760 Sep-16 93.8% 91.3% 92.3% ►Summary EB005 % within 4 hours KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST 95% 84.3% 82.0% 4292 Sep-16 83.5% 88.2% 82.0% ►Summary EB005 % within 4 hours GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 95% 90.0% 89.2% 1746 Sep-16 90.8% 89.0% 89.2% ▼Summary EBS05 Trolley Waits >12Hrs ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 0 1 0 0 Sep-16 0 0 0 ▼Summary EBS05 Trolley Waits >12Hrs CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST 0 0 0 0 Sep-16 0 0 0 ▼Summary EBS05 Trolley Waits >12Hrs KINGSTON HOSPITAL NHS FOUNDATION TRUST 0 0 0 0 Sep-16 0 0 0 ►Summary EBS05 Trolley Waits >12Hrs KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST 0 24 2 2 Sep-16 6 5 2 ►Summary EBS05 Trolley Waits >12Hrs GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 0 0 0 0 Sep-16 0 0 0 ►Scorecard EB015(1) Red 1 75% 78.5% 82.8% 5 Oct-16 84.6% 78.4% 82.4% ▲Scorecard EB015(2) Red 2 75% 73.5% 75.5% 325 Oct-16 72.2% 76.0% 73.2% ▲Scorecard EB016 Cat A19 95% 97.5% 98.1% 26 Oct-16 97.7% 97.3% 97.2% ▲

Latest Month data shows an increase over previous 12 months (using 6 sigma methodology), which is an Improvement in performance ▲Latest Month data shows an increase over previous 12 months (using 6 sigma methodology), which is a Deterioration in performance ▲

Latest Month data shows an Decrease over previous 12 months (using 6 sigma methodology), which is an Improvement in performance ▼Latest Month data shows an decrease over previous 12 months (using 6 sigma methodology), which is a Deterioration in performance ▼

Latest Month data is within normal variation of previous months data and is neither showing a statistical increase or decrease ►Achieving Target

Failing Target

LAS

Trust Measures

Previous MonthsPerformance

YTD

Performance

Month

Latest

Data

SEL/SWL/

KentCode Health Outcomes Framework / Every one Counts

Safe environment and protecting

from avoidable harm

A&E

Mental Health

RTT (Provisional)

Cancer - 2 weeks

Cancer - 31 days

Cancer - 62 days

Target Breaches 12M Trend

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Improvement & Assessment Framework Scorecard: October 2016 Update

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Sustainability & Transformation Programme Trajectories

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For Reference Edit as appropriate:


The long-term implications

The risks

Impact on our reputation

Impact on our patients

Impact on our providers

The performance report provides a view of current performance and, based on this and

wider intelligence, likely future trends. If future performance is expected to be below targets

or expected levels, then this is highlighted as a risk. Our performance relates to the work

of our providers in many areas and is a reflection of our reputation and the quality of care

our patients are receiving.



inequalities


statutory responsibilities


organisation

Our overall performance and performance in specific areas reflects how successfully we

are meeting these objectives.

3. Executive Summaries should not exceed 1 page. [My paper does not comply]



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Month 7 Finance Report Author: Peter Ifold, Deputy CFO Sponsor: Neil McDowell, Acting CFO Date: 12/2016

Executive Summary

Context

The Finance Team is responsible for reporting the financial position for the CCG each

month. This paper provides information on the month 7 financial position, highlighting key

issues and the forecast outturn. In addition, this paper updates the Board on the 2017-19

planning round and highlights key information from the recently published operating plan

guidance together with key points relating to the full draft submission at the end of

November

Questions addressed in this report

1. What is the CCG’s year to date financial performance against the approved budget?

2. Is the CCG on target to meet the planned 0.5% financial surplus at year end?

3. Implications around financial governance, strategy, performance and risk.

4. Can we keep running costs within the target set?

5. Are we meeting business rules in 2017/18 and is SWL achieving its control total set?

Conclusion

1. The CCG is on course to meet its target surplus of £2.08m.

2. We expect to meet the running cost target.

3. The CCG is only able to achieve an in year break even position as opposed to the

0.5% surplus required to meet business rules

4. In addition South West London as a whole based on the financial plan submission

made at the 24 November, 2016 is not achieving the control total set (£4.6m surplus)

W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [

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Input Sought

The decision we would like from the Board

is:

To note the contents of the report and the

current planning position for 2017/18

Input Received

This paper has been reviewed by the

Finance & Resources Committee in

November 2016 (apart from the key points

arising from the November 24 Plan

submission).

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The Report[Consider each question with reference to: (1) Strategy: progress towards our long-term goals

(2) Performance: delivery of this year’s results

(3) Governance: whether we are working in the ‘right way’]

Looking Back

W H A T H A S G O N E W E L L ?

The CCG is on course to achieve a balanced Financial Position and achieve the

planned 0.5% financial surplus at year end.

We are on course to meet the running cost target.

W H A T H A S N O T G O N E W E L L ?

At this point of the financial year The CCG are facing significant financial pressures

and we are forecasting a net overspend of £5.4m on operational budgets. Whilst this

may imply an improvement on the previously reported position this reflects the

treatment of reserves and excludes some potentially high level risks.

Potential unmitigated risks total £4m and a recovery plan is being developed to

ensure the achievement of financial targets.

As the financial year progresses achievement of this level of recovery plan

becomes more challenging and a greater cause for concern

Whilst the new provider for the management of Continuing Healthcare has made

good progress in identifying the financial pressures in this area, further financial

pressures have recently been identified which has put greater financial pressure on

the budgets than we had envisaged. For reporting purposes it is assumed that some

savings will still be implemented before year end.

The CCG continues to receive limited detailed information on Primary Care co-

commissioning budget from NHSE, in particular the lack of a forecast outturn, and we

are assuming an overall breakeven which is dependent on achievement of a £233k

QIPP which to date reflects no savings.

Looking Ahead

O P P O R T U N I T I E S ?

Investment in non-acute services that started in 2015/16

By investing in out of hospital services this should help manage demand and costs

around acute and other high cost services. Additional QIPP schemes are being

investigated to support the shortfall and whilst this will reduce the gap on the original

QIPP plan, the scale of impact will reduce as the year progresses.

CCG Directors have been asked to identify savings which would release 0.75% of

their budget responsibility

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To support this internal budget reviews are being held and underspend areas

“frozen” to support the position.

R I S K S O R C O N C E R N S ?

Further escalation of financial pressures will put increasing pressure within a

decreasing timescale and limit our ability to manage within the resource limit in 16/17

and meet the business rules set, Specific areas of concern are:

Managing acute performance, including acute QIPP phased in the 2nd half of the

year and managing the financial impact if Continuing Healthcare growth

continues.

Non delivery QIPP

QIPP delivery is essential for the future financial health of the CCG.

In ConclusionC O N F I D E N C E ? I M P L I C A T I O N S ?

I am confident that the financial position

outlined in this paper is accurate based on

available information and reflects the risks

moving forward.

Whilst the CCG is still on course to

achieve a balanced Financial Position

and achieve the planned 0.5% financial

surplus at year end, significant pressures

exist and unless further mitigations are

introduced immediately the CCG will have

difficulty maintaining this position.

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Data DashboardSee following PowerPoint slide pack.

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The long-term implications Yes

Ensuring that we understand cost drivers that will impact on future years

The risks Yes

Mitigations against a number of risks have been considered and implemented

where appropriate

Impact on our reputation Yes

By not achieving the targets set would have an adverse impact on our

Organisational reputation.

Impact on our patients Yes

Insufficient funding or poor planning would impact on our ability to commission

services in an efficient way.

Impact on our providers Yes

Prompt payment, accurate reflection of activity and finance

Impact on our finances Yes

Throughout the report

Equality impact assessment Not applicable

Patient and public involvement Not applicable




inequalities Yes


statutory responsibilities Yes


members, stakeholders and communities Not applicable


is delivered in the right setting Yes


organisation Yes

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Finance Report up to the end of October 2016

Presented by Finance –

December 2016

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Contents1. Month 7 Financial Position

2. Balance Sheet

3. 2017-19 Planning

4. Recommendations

Board December 20162 15 December 2016

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Finance Scorecard up to October 2016

Board December 2016

Financial Strategy Financial Performance• SWL Collaborative Commissioning programme

work is ongoing to deliver system transformation plan.

• Allocations have been published for the next 4 years from 17/18 with the next 2 years confirmed (hard) and the following 2 years indicative (soft)

• 1% non recurrent reserve cannot be committed in 2016/17

• Planning guidance for 2017-19 now issued• Contracts to be agreed by end of December for 2

years• CCG control totals have now been issued.

• Plan to achieve the target surplus of £2.08m (0.5%)• QIPP target is not forecast to be met but we are

forecasting to meet the running cost target• Action is being taken to manage Continuing Health

Care costs following concerns raised• Acute contracts are also over performing.• Overall there is no variance from plan at month 7 but

note the significant risks to this position.

Financial Governance Financial Risk• Annual internal audit plan is in place.• Board Assurance Framework has been updated in

October 2016.• Financial control environment assessment has

been submitted with action plan in place• Finance Recovery Group set up in September

2016 to oversee the QIPP programme and report into the Finance & Resources Committee.

• Financial ledger system has limited capability to do detailed analysis.

• Emerging issues around acute contracting and continuing care may impact on our ability to achieve the target surplus. Further mitigations are being developed to ensure that flexibility is built into the position.

• 2016/17 QIPP delivery represents a significant risk due to size of the programme and the level of reserves held to mitigate against performance.

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Month 7 – WCCG Key Messages

Board December 2016

• We still plan to achieve the target surplus set (£2.08m)

• The overspend on Continuing Healthcare has increased to £2.7m (year to date) and £3.3m (full year). As the database becomes more robust the true level of spend is being identified. Though there is still more work to be done on this, it is envisaged that the majority of the movements in the worsening outturn prior to the positive impact of savings plans have been identified.

• The overall full year forecast for the Acute SLAs has improved slightly this month, mainly in relation to Chelsea and Westminster. However, concerns remain as this position is dependent on the achievement of £1.6m QIPP at St George’s which is phased in the second half of the year.

• We are now forecasting a full year underspend of £1,365k on Prescribing due in part to a reduction in national pricing.

• Reserves are being used to support the £5.4m forecast overspend on operational expenditure.

• We expect to meet running costs.

• To ensure the target surplus is achieved the CCG is identifying and progressing mitigating actions with a view to implementing savings that will generate £4m in 16/17 to ensure financial targets are met.

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Month 7 – Revenue Resource Limit

Board December 2016

• The Resource Limit reflects the amount of money the CCG has available to commission services (programme) and to run the CCG (admin). At Month 6, the CCG received £150k for consultant support to the SWL Collaborative, and £74k for Children and Young People Mental Health.

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Month 7 Financial Position

Board December 201615 December 20166

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Month 7 Acute Analysis


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Month 7 – Acute Commentary• Overall we are reporting an adverse forecast outturn variance of £3.5m, compared to a £3.8m overspend

at month 6. The major improvement area is Chelsea and Westminster.

• The main areas of forecast overspend are focussed on St George’s (£2,153k), Guy’s & St Thomas (£695k), Chelsea & Westminster (£555k) and UCLH (£390k) offset by Kingston Hospital (£710k) and Elective Orthopaedic Centre (£639k).

• St George’s over performance is against Emergency, Out patient attendances and Direct Access partially offset by underspends on elective and maternity. Within the SLA there is a significant QIPP (£1.6m), which has not impacted on the year to date position and is phased to impact in the second half of the year.

• Chelsea & Westminster over performance has reduced and the major areas of overspend are focussed on emergency and 1st out patients, offset by an underspend on maternity.

• The Guy’s & St Thomas overspend is focussed on elective and drugs & devices whilst the UCLH overspend is widely distributed with the main focus on elective and emergency.

• Elective Orthopaedic Centre are the most significant under performer on elective and Kingston Hospital the most significant underperformer on emergency. Imperial Hospitals are showing an over performance on critical care.

• There is still pressure on the non contracted activity with acute providers

• Charge exempt overseas visitors expenditure is assumed to be within the allocation. However the allocation has not been confirmed yet (expected for month 8).


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Primary Care Month 7

Board December 2016

• The most recent report from NHSE for Primary Medical Care covers the M06 period so the figures have been extrapolated to M07 which may result in minor year to date variations when the M07 report is received. There is an overspend in the year to date position largely reflecting the under-achievement of QIPP. NHSE have not provided a forecast outturn and we are continuing to pursue this issue. Based upon our understanding of information received we have assumed for now that the delegated budget will break even at year end, e.g. because refunds relating to prior year business rates are expected to contribute towards the QIPP target. However, there remains a risk of an overall overspend on the delegated budget.

• Reflecting the recent Prescribing information, the Primary Care budgets are now forecasting an overall underspend of £1.179m being the Prescribing underspend (£1.365m mentioned above) offset by other small overspends elsewhere – APMS: Walk In Element and cost pressures on OOH, GP In hours, and SPA111.

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Month 7 – Other Commentary• Non-Acute Services are reflecting an overspend of £2.124m year to date and £3.426m full year, so there

has been an adverse movement from Month 6 of £0.677m YTD with a slight improvement of £0.062m in the full year.

• Continuing Healthcare and Free Nursing Care (combined overspend £3.823m) are offset by one or two areas of underspend (circa £0.4m) where it has been identified that spend is unlikely to be incurred. Whilst the new provider for the management of Continuing Healthcare has made good progress in identifying the financial pressures in this area, further financial pressures have recently been identified which has put greater financial pressure on the budgets than we had envisaged. For reporting purposes it is assumed that some savings will still be implemented before year end.

• Spend on the South London & Maudsley SLA and the s117 agreement with the Council continue to show an overspend though these have not changed since last month. These overspends are offset by an underspend on the Mental Health Placements line. Overall mental health expenditure is meeting the value to achieve parity of esteem.

• Running Costs are reflecting a year to date underspend of £133k, with a forecast outturn underspend of £115k. On Corporate Programme Costs, there is YTD overspend of £211k with a forecast underspend of £85k. This improvement in the forecast position reflects anticipated recharges on the Continuing Healthcare management budget.


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Running Costs at Month 7

Board December 2016

The forecast spend is within the CCG’s Running Cost resource allocation of £7,481k

15 December 201611

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CCG Risks and Mitigations


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CCG Underlying Recurrent Position• The CCG has always had a healthy

underlying recurrent surplus.

• This means that it always had funding it could commit non recurrently for pump priming, investments etc.

• However our financial position has meant that we have had to use more of this resource to prop up the recurrent pressures coming through

• This is not sustainable and needs to be addressed through a savings programme that slows current run rate below the level of growth in our allocation.

15 December 2016 Board December 201613

• The chart above shows the underlying recurrent surplus at a high of £11m in April 2015 with a projected £0.5m at March 2017.

• The increase to £6.8m at April 2017 is due to the growth allocation to the CCG in 2017/18• Reality is that most of this will be needed to fund contracts so the savings plan for 17/18 will

be key in addressing this issue.

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2. Balance Sheet

3. 2017-19 Planning

4. Recommendations


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Statement of Financial Position at Month 7

Board December 2016

• This balance sheet snapshot reflects payments to be made on 1st November (in month 8). Therefore cash position above is not correct. Real cash position is a surplus of £85k as per Cash Drawdown slide

15 December 201615

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Cash flow Statement at Month 7


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Cash Drawdown to Month 7


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Better Payment Practice Code

Board December 2016

• We are achieving the target, which is 95%

15 December 201618

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2. Balance Sheet

3. 2017-19 Planning

4. Recommendations


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Approach to 17/18 PlanningOverview

• The publication of the “Strengthening Financial performance and Accountability 2016-17” document recently has given added impetus to setting clear commissioning intentions early and moving the business cycle forward, to get contracts signed by the end of December 2016 that cover a two year period.

• All CCG’s are expected to have signed all NHS contracts by the end of December, and the tariff and business rules guidance will be brought forward to facilitate this. Formal guidance is yet to be issued but it is expected that contracts will be based on activity assumption with financial values based on the draft 17/18 tariff.

• NHSE have signalled a much more structural approach to linking STPs with and contracts. Tariffs will be set for two years and local systems will be incentivised to work together more collaboratively. It is clear there will need to be a radical change in the behavioural dynamic of planning/contracting towards a more collaborative process

Approach

• A contracting and financial framework is in the process of being agreed, which will outline the agreed core principles at an STP level with clear lines of accountability and delegation between CCGs at a sub-regional level and the parameters each sub region can negotiate within. Each sub regional lead CCG DoC will establish negotiation teams and negotiating mandates such that all contracts are set within the parameters defined by the CCGs. The CCG lead will negotiate and deliver specified contracts for 2017/18 18/19, on behalf of their own CCG, SWL CCGs and London CCGs.

• Formation of a SWL Contract Delivery Group formed of directors from each of the 6 SWL CCGs as well as senior representatives of the CSU.

• The role of this group is to provide assurance, direction and support to unblock challenges as required of the overall contracting round


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Planning Guidance – Headlines Updated2 year contracts signed by 23 December 2016

London CCGs are being held to a regional control total

For SWL this is across the 6 CCGs and is a £4.6m surplus.

This means for Wandsworth the expectation is that we deliver a 1% surplus (a 0.5% in year surplus) at the very least to contribute to SWL control total.

1% non recurrent reserve comprises:

0.5% uncommitted

0.5% invested in STP transformation

CQUIN – 1.5% for national initiatives, remaining 0.5% to providers for achieving 16/17 financial target and 0.5% linked to the STP objectives.

Control totals to be issued to all providers which will feed into CCG control totals noted above.

Sustainability and transformation funding available for 2 years to providers (subject to hitting agreed performance targets)

Commissioner allocations have been refreshed for identification rule changes with NHS England specialised and the impact of moving to HRG 4+.


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Business Rules - UpdatedTaken from the 2017-19 Planning Guidance:

• In year break even where organisations are already achieving 1% surplus.

• 0.5% contingency reserve.

• 1% non recurrent reserve but note the use as per previous slide

• 2.09% growth in our allocation.

• 0.1% net national tariff uplift but actual considerably higher.

• Separate growth assumptions to be planned for Prescribing and continuing health care.

• Mental health parity of esteem continues (links to allocation growth) but is now called mental health investment standard.

• No investments planned.

• Expectation that individual CCG and provider organisations as well as local systems overall need to deliver within a financial control total


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Looking Forward – Issues - Updated• Issues from 16/17 moving forward:

• Growth in continuing care has continued through 16/17 so will be a pressure moving forward together with the new rates for Free Nursing Care.

• Prescribing cost pressures appear to be less of an issue in 16/17 but we have to be mindful of price changes both up and down

• Acute contracts continue to over perform & given 2 year planning cycle will be critical that these exit at as close to plan as possible. Current offers are showing significant gaps which have been covered by unidentified QIPP.

• Making good the non achievement of 16/17 QIPP

• Ensuring that the deterioration in the underlying recurrent position is addressed.

• Into 17/18

• Another challenging year with a complex contracting round for the acute sector caused by control totals and the STP expectations.

• Minimal growth has been given to the CCG so will be key to understand those areas where we will be mandated to fund.

• QIPP ask is significant again for this year (current estimate is around £20m). This also includes where recurrent pressures in 16/17 were covered from non recurrent resources.


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Risk Analysis - UpdatedRisk BAF Ref

(likely x impact)

Detail / Mitigating Actions

Allocation is less than expected

Risk:16(5x4)

Current draft plans assume low growth. However any non discretionary allocations will further eat into the growth available. Specialist commissioning transfers are not fully funded.

Financial pressure in SWL economy

Risk:75(4x4)Risk: 7(4x4)

Providers and commissioners are working on delivering a sustainable health economy with improved quality health outcomes. Key will be to linking CCG QIPP initiatives with Provider cost improvement programmes.

Financial distress of main provider

Risk: 89(4x4)

CCG continues to work closely with St George’s and regulators on a recovery plan. This may impact the way some of the services are currently commissioned and the way we contract for services in 17/18

Deliver a balanced financial plan

Risk: 9(4x4)

Large QIPP challenge planned for 17/18 will put pressure on the plan to deliver a 1% surplus. Plans are currently being drawn with mitigating actions to manage the riskOther factors to note include the late issuing of the final tariff after contracts have been agreed.


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Financial Plan – Headlines (1 of 2)


For 2017/18 the CCG is planning for a 0.5% surplus which does is an in year break even position and is not meeting business rules.

The main risks to the CCG position in 16/17 relate to:

• Uncertainty around provider contracts given the very early stage of the year and the chance to get QIPP agreed and into contracts.

• Ensure that in setting contracts that we purchase enough activity to deliver all the core national standards of performance around A&E and RTT.

• Continuing healthcare continues to increase above the level of growth allocated to the CCG. However for 17/18 it is expected the investment in the new provider will start to have an impact and limit this growth.

• Whilst prescribing has been kept well within budget to note that some opportunities may have been brought forward early therefore limiting opportunity in 17/18.

• We are also mindful that as patients become aware of their right to a personal health budget there will be an increase in requests.

• There are very low levels of reserves to support in year over performance of contracts or to cover contracts that come in above the plan value.

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Financial Plan – Headlines (2 of 2)• We currently have a QIPP of £20.2m which is 4.3% of our allocation and this is above the

level that we have had in previous years. We are assuming an investment of £4m to delivery this programme.

• This year we are negotiating an acute contract with SWL providers which aligns Trust CIP and CCG QIPP schemes.

• Acute growth is in line with the STP (circa 2.3%)

• We have included an investment in primary care that is linked to the £3 per head of population. This has been assumed to be spent evenly across the 2 years i.e. £1.50 in each year.

• For mental health we have assumed a parity of esteem uplift in line with our growth. We will be working with mental health providers to determine how we use this additional funding, ensuring we are getting value for money/achieving outcomes and agreeing uplifts at least in line with demographic growth.

• The 1% non recurrent risk reserve has been reinstated with 0.5% released back to CCGs and 0.5% to remain uncommitted. The CCG will use this to fund the SWL collaborative and Health London Partnership contributions.

• We have assumed that the allocation received in 16/17 for the move to market rates for our properties is non recurrent which has created a cost pressure of £1.9m.


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Financial Summary 16/17 to 17/19


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Assumptions Underpinning The Submission


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Timetable

Board December 2016

Item Date

Provider Control Totals & STF Allocations published 30/09/16

Commissioner allocations published 21/10/16

Submission of STPs 21/10/16

National tariff section 118 consultation published 31/10/16

Final CCG & specialised service CQUIN scheme guidance published 31/10/16

Submission of summary level 17/18 and 18/19 operational financial plans 01/11/16

Issue initial contract offers to providers 04/11/16

Providers to respond to initial contract offers 11/11/16

Submission of full draft 17/18 to 18/19 operational plans 24/11/16

Submission of progress on contract negotiations (weekly from…) 21/11/16

Contract mediation advised and entered into. 05/12/16

Publish national tariff 20/12/16

National Deadline for Signing contracts 23/12/16

Submission of final 17/18 and 18/19 operational plans aligned to contracts 23/12/16

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2. Balance Sheet

3. 2017-19 Planning

4. Recommendations


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Recommendations

• The Board are asked to note the month 7 position and the risks contained within it

• The Board are also asked to note that the 2017-19 planning section has been updated to reflect the recently published operating plan guidance


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Part D: Board Governance

Page

4. Part D: Board Governance 196

4.1. D01 Summary Minutes: 197

4.1.1. Integrated Governance Committee 197

4.1.2. Finance Resource Committee 200

4.1.3. Audit Committee 202

4.1.4. Primary Care Committee 205

4.2. D02 AOB and Other Matters to Note

4.3. D03 Open Space

4.3.1. Members of the public present are invited to ask questions of the Boardrelating to the business being conducted. Priority will be given to writtenquestions that have been received in advance of the meeting.

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COMMITTEE FEEDBACK FORM

Committee: Integrated Governance Committee

Meeting date: 20th September 2016

Main items discussed: CSU Update

Continuing Health Care External Governance Report

Lay Member Board Roles

Conflicts of Interest Guidance

Record Sharing and Planning

Integrated Governance Report

Decisions: Lay Member Board Roles – In compliance with the new guidance published in June 2016, the Committee was asked to discuss and agree the proposal to recruit a third Lay Member to the CCG Board. The Committee approved the recommendation to the Board to increase Lay Member appointments to a total of three.

Particular points to note:

CSU (Commissioning Support Unit) Update – Two workshops had been held to identify any opportunities for synergies of services commissioned from the CSU and delivered in-house across the six CCG and through the SWL Collaborative; to identify any areas for improvement; consider and agree the process and options appraisal criteria; develop options. A further workshop was scheduled in September to finalise proposals. Following discussion, the Committee requested a further report to be brought back in a couple of months.

Continuing Health Care (CHC) External Governance Report – The Committee received the report from the assessment, undertaken by the Good Governance Institute, of Continuing Health Care arrangements in Wandsworth. A number of actions were identified, which would be taken forward. The recommendations from the report would be shared with the CHC provider. A redacted version of the document would be made available on the website.

Conflicts of Interest Guidance – An update was provided on the work required following publication of the latest guidance. The Conflicts of Interest policy will be taken to the October meeting for review and comment. Further work also remained to review Terms of Reference for all Committees and Sub-committees, and the Constitution.

Record Sharing and Planning – A number of issues were highlighted around IT, governance, and Information Governance, which, it was considered, were not being addressed within the existing CCG structures. A paper would be taken to the Management Team for further discussion.

Integrated Report - The report provided an update on performance with

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particular focus on the following areas: risks, Information Governance, finance, QIPP, A&E, Referral to Treatment, Cancer, Diagnostic Waits, CCG Assurance, and quality.

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Committee: Integrated Governance Committee

Meeting date: 18th October 2016

Main items discussed: Review of Conflicts of Interest Policy

Conflicts of Interest Self-Certification

Integrated Governance Report

Decisions: No decisions were required.


Review of Conflicts of Interest Policy – The Conflicts of Interest policy had been reviewed in light of the new national statutory guidance for CCGs issued in June. The main areas of change related to the third Lay Member, changes around governance, contract and procurement, and management of the process. A number of further amendments were highlighted during the discussion. The final version of the policy would be presented for sign off at the Board meeting in December.

Conflicts of Interest Self-Certification – The CCG was required, as outlined in the guidance, to submit quarterly self-certification returns starting with Q2 2016 onwards. A copy of the proposed submission was provided for comment. Currently the CCG was compliant with requirements.

Integrated Governance Report - The report provided an update on performance with particular focus on the following areas: risks, Information Governance, finance, QIPP, A&E, Referral to Treatment, Cancer, Diagnostic Waits, Infection Control, Improving Access to Psychological Therapies (IAPT), and quality.

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Committee: Finance Resource Committee

Meeting date: 18th October 2016

Main items discussed: Review of Financial Policies

2017/19 Operational Plan Guidance

Balancing the Finances

Financial Position

Month 4 QIPP

St George’s Position

Decisions: No decisions required.


Review of Financial Policies – A detailed review of the Prime Financial Policies (PFP) and Standing Orders (SO) had been undertaken. A number of the existing PFP sections were expanded to provide more comprehensive information and detail regarding process. This review has resulted in a more comprehensive and coherent document, with the proposal that this should be taken forward to the Board for approval. It was agreed that as a full review of the PFP had not been done for a while, an in-depth review would be included on the next meeting Agenda.

2017/19 Operational Plan Guidance – The main headlines from the planning guidance. It was expected that the position around the control total and allocation would be clearer. The content of the report outlining the current position was noted.

Balancing the Finances – The paper highlighted work being done to address the financial position and processes that have been put in place. Discussions have been held to consider potential options, which included clinical oversight. Some additional schemes were identified alongside those that could be delivered immediately. A series of clinical audits will be undertaken on ECI procedures but it was not expected that this would achieve significant gain. The content of the report was noted.

Financial Position - The current position was noted. Continued over-performance was noted around Continuing Health Care, which was currently covered in the overall position. The position at Month 6 was generally on track, due to a positive technical adjustment in prescribing, and some additional QIPP delivery. NHSE was now proposing that the 1% non-recurrent uncommitted reserve would remain in CCG positions if a break-even position was achieved. This was contrary to previous guidance which stated that this funding would be used to balance the national provider position. If available to the CCG, this funding would be used to cover recurrent pressures.

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Month 4 QIPP – Performance was in line with the previous forecast. There were some risks around schemes due to deliver in the second half of the year. It was assumed that the acute QIPP of £1.6m would be achieved, but there remained a high level of risk. The Committee continued to express concern regarding the forecast shortfall against target, with other proposals to bridge the gap to be considered.

St George’s Position – The latest report to the Trust Board reported an upper end forecast deficit position of £80m approximately. The Trust was currently reporting a £55m forecast over-performance. The Trust was expecting to address the current run rate and bring this back to £1m deficit per month.

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Committee: Audit Committee

Meeting date: 15th July 2016

Main items discussed: SBS Service Auditor Report

Internal Audit Update

External Audit – Annual Audit Letter

Counter Fraud Update

External Audit Procurement

Decisions: External Audit Procurement – The Committee was asked to review proposals submitted for the proposed procurement process. A recommendation was presented to all SWL CCG Audit Committees that this should be done as a collective process, but not as a collective appointment. The proposal was discussed and a number of comments were noted. Following on from the discussion, a revised proposal was recommended to be fed back to Merton CCG, as the lead organisation for the process.


SBS Service Auditor Report – The report covered the period to 31st March 2016. During the discussion a number of comments were noted.

Internal Audit Update – An update on work to date was received. No significant issues were highlighted from the reviews undertaken. The content of the report was noted.

External Audit – Annual Audit Letter – The letter provided a summary of all the work undertaken over the past twelve months. The content was noted.

Counter Fraud Update – An update was provided to the Committee including the Counter Fraud Annual Report. Some comments were noted regarding the self-review return to NHS Protect, which would be followed up. No reactive investigations had been undertaken over the past year. The content of the report was noted.

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Committee: Audit Committee

Meeting date: 21st October 2016

Main items discussed: Conflicts of Interest Stock-Take

Review of Prime Financial Policies

Internal Audit Update

External Audit Update

Counter Fraud Update

Future Operating Model for CCGs

External Audit Procurement

Decisions: No decisions were required.


Conflicts of Interest Stock-Take – An update was presented on the work to review the Conflicts of Interest policy to reflect the guidance published in June. The main updates to the policy were around procurement, gifts, and role of Conflicts of Interest Guardian. The updated policy has been reviewed at Integrated Governance Committee – the final version will be presented to the Board for sign off in December. An internal audit of Conflicts of Interests was required to be undertaken in Q4. It was noted that NHSE was undertaking a further review of the wider NHS conflicts of interest issue, which could result in further amendments to the policy being required.

Review of Prime Financial Policies – An update was provided for information. Details of the work had previously been discussed by the Finance Resource Committee. The detail in a number of sections have been expanded to provide further information and processes. The FRC will review the final documents, with recommendation to the Board for final approval.

Internal Audit Update – An update on work to date was received. No significant issues were highlighted from the reviews undertaken. The content of the report was noted.

External Audit – An update was provided to the Committee, including a comparison review of the risk register with a number of CCGs across London and the South East. It was agreed that the report would be taken to IGC for discussion and work would be considered to localise some of the recommendations from the review.

Counter Fraud Update – An update was provided to the Committee. The Committee was informed of a referral reported through the National Fraud Reporting Line. The content of the report was noted.

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Future Operating Model for CCGs – SWL CCGs have been engaged in a review process to fundamentally change lines of accountability and senior leadership. A new shared Executive Team would be put in place, and a change to local CCG team arrangements. The proposal in development is subject to consultation. Audit Committees governance was being reviewed, but these would remain local at the moment.

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Committee: Primary Care Committee

Meeting date: 6th September 2016

Main items discussed: Primary Care Commissioning – Update on decisions / Practice Baseline Reviews

Review of APMS Contracts

Primary Care Commissioning Intentions

Tuberculosis Local Incentive Scheme

Anticoagulation Local Incentive Scheme for Direct Oral Anticoagulant

Primary Care Quality Review Group Update

Estates Update

Finance Report

Decisions: Review of APMS Contracts – Information was received relating to two contracts that were coming to an end.

The Practice Furzedown – The CCG has been working with NHSE to review the options, which had also been reviewed by the Primary Care Operational Group. It was noted that the anticipated growth in list size had not materialised, with one-third of patients on the current list size being out of borough. The practice was only achieving 63% QOF compared on average to 92% for Wandsworth practices within a two mile radius. Engagement with stakeholders regarding potential dispersal of the list recommended this as the preferred option. Work has been done with other practices in the area regarding the potential list dispersal.

Following detailed discussion, the Committee agreed the preferred option, to close the practice and for dispersal of the patient list, subject to engagement, with the final decision to be made in December.

The Junction – The Committee was asked to review the recommendation for the practice to be extended. The practice has a current list size of 7300, with 96% QF performance. This was a high performing practice which meets the needs of the local population. Two contracts were in place at the practice – APMS and Walk-In – delivered by the same provider.

The Committee agreed the preferred option to extend the contract for a minimum of one year from 1st April 2017, with further discussion with the current provider. A paper for final decisions would be held in Part II at the December meeting of the Committee.

Primary Care Commissioning Intentions – Three main areas were identified which link with those set out in the STP around primary care transformation – London Strategic Commissioning Framework Specifications, Commissioning of MCP Model, Quality. An extensive

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programme of engagement with patients would be put in place.

Following on from the discussion, the Committee agreed the proposed Commissioning Intentions.

Anticoagulation Local Incentive Scheme for Direct Oral Anticoagulant (DOAC) – The paper outlined the proposal to address this urgent medical need for a streamlined pathway, through a procurement process, which would take up to nine months. The proposed scheme would relieve the pressure whilst long term options were considered. GPs were already managing patients and issues around capacity in secondary care.

The Committee agreed the proposal.


Primary Care Commissioning – Update on decisions – The paper provided an update on decisions taken by the Primary Care Operational Group, including NHS England, most of which related to contract variations.

Practice Baseline Reviews – An update was provided on the programme, which had been agreed as part of the due diligence exercise. Once completed the reviews will be used to inform discussions to be held with practices. Key findings would be brought back to the Committee for review.

Tuberculosis Local Incentive Scheme – This was a national scheme, with funding allocated. The paper was provided for information. Discussions had been held with GPs and the LMC – currently there was a high rate of cases in Wandsworth. The content of the report was noted.

Primary Care Quality Review Group Update – The report provided an update on work undertaken since the previous meeting, including Patent Engagement, GP patient survey, General Practice Resilience Framework and General Practice Development Programme, CQC reports. The content of the report was noted.

Estates Update – An update on the current position was noted.

Finance Report – The content of the report was noted.

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Part E: Meeting Close

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5.1. E01 Clinical Chair's Closing Remarks

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