Governing Body – In Public Date: 14 March 2019 Time: … › wp-content › uploads › 201… · 14-03-2019 · DR . Present Colin Seaton Lay Member, Patient and Public Involvement

Governing Body – In Public

Date: 14 March 2019 Time: 10.30–12:30 Venue: Jubilee Room, Aylesbury Vale District Council, the Gateway, Gatehouse Rd,

Aylesbury, HP19 8FF Chair – Dr Raj Bajwa

Link to papers published on the CCG website

No Agenda Item Action Lead Time Page Risk links

Welcome 1. Introductions, Apologies Chair 10:30 Verbal 2. Declaration of Interests in items for

items on this meeting’s agenda. Locations of public registers: https://www.buckinghamshireccg.nhs.uk/public/about-us/how-we-make-decisions/registers-of-interests/

For Noting & Mitigating Actions

Chair 10:30 Verbal n/a

3. Proposed changes to the CCG Constitution (from 1 April 2019) Recap aligned to LMC and locality engagement prior to formal virtual vote of member practices to adopt changes.

For Noting Chair 10:30 Paper n/a

4. Review and Approval of Minutes: a. Meeting minutes – 10/01/19 b. Action Log/Matters Arising

For Approval

Chair 10:35 Paper

n/a

5. Questions from the public For Discussion

Chair 10:40 Verbal n/a

6. Governing Body Assurance Framework (includes EU Exit Update) Members reminded to consider during meeting any points for consideration for recap (item 16).

For Assurance

Russell Carpenter, Board Secretary

10:50 Paper All

Decisions 7. Financial and Corporate Governance:

a) Buckinghamshire CCG 2019/20 Draft Budget Plan

b) Process for Approval of Annual Accounts and Annual Report

c) CCG/ICS Operating Plan 2019/20.

For Approval

Gary Heneage, Chief Finance Officer

11:05 Verbal Paper Link to website

GBAF 2,3,4

8. Annual Review of Terms of Reference and scheme of reservation and delegation – Primary Care Commissioning Committee

For Ratification

Graham Smith, Chair of PCCC

11:25 Paper n/a

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https://www.buckinghamshireccg.nhs.uk/public/about-us/how-we-are-doing/governing-body-meetings/20181920-meeting-papers/

https://www.buckinghamshireccg.nhs.uk/public/about-us/how-we-make-decisions/registers-of-interests/



https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2018/05/07c.-ICS-Ops-Plan-8-Mar-V1.0.pdf

Leadership reports 9. Chief Officers Report

For Assurance

Robert Majilton, Deputy Chief Officer

11:35 Paper

n/a

Assurance and Governance 10. Finance Report (Month 10) including

• ICS transformation funds report

• Risks and Mitigations • Discretionary spend

For Assurance

Gary Heneage, Chief Finance Officer

11:45 Paper

GBAF 2,3,4

11. Quality and Performance Report (Month 10)

For Assurance

Debbie Richards, Director of Commissioning and Delivery

11:55 Paper

GBAF 2,6

12. Governing Body Effectiveness Review – summary of results

For Assurance


12:20 Paper n/a

13. Governing Body Assurance Framework – recap

For Assurance


12:25 Verbal All

For Information 14. Approved Minutes For

Information Chair 12:30

Link to website

n/a

15. Safeguarding Adults Board – papers and minutes http://www.buckinghamshirepartnership.co.uk/safeguarding-adults-board/about-the-bsab/meetings/

For Information

Chair 12:30

See link

n/a

16. Public Sector Equality Duty (PSED) final report 18-19

For Assurance

Nicola Lester, Director of Transformation

12:30 Link to website

GBAF 2

17. Date and Time of the next meeting (in public): Thursday 13 June 2019 Bevan and Nightingale Rooms, 2nd Floor, Aylesbury Vale District Council, the Gateway, Gatehouse Rd, Aylesbury, HP19 8FF

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http://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2018/05/14.-Approved-minutes-1.pdf

http://www.buckinghamshirepartnership.co.uk/safeguarding-adults-board/about-the-bsab/meetings/



https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2015/11/Equality-Annual-Report-draft-30-Jan.pdf

https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2015/11/Equality-Annual-Report-draft-30-Jan.pdf

MEETING: Governing Body AGENDA ITEM: 3 DATE: 14 March 2019 TITLE: Proposed changes to the CCG Constitution (from 1 April 2019)

Recap aligned to LMC and locality engagement prior to formal virtual vote of member practices to adopt changes

AUTHOR: Russell Carpenter, CCG Head of Governance/Board Secretary LEAD DIRECTOR: Robert Majilton, Deputy Chief Officer LINK TO RISKS: Governing Body

Assurance Framework

No direct link to risks

Corporate Risk Register


Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information For Ratification

Summary of Purpose and Scope of Report:

The Constitution is the legal document sets out the way in which the CCG will fulfil its statutory responsibilities as set out in the 2006 Act.

The Governing Body is asked to: 1. RECEIVE for ASSURANCE attached member practice briefing pack on CCG

Constitution changes for adoption by the membership into effect as from 1 April 2019.https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2015/11/CCG-Constitution-amendments-proposed-to-membership-for-adoption-February-2019-V6-for-voting.pdf

2. NOTE that LMC has (a) been engaged in the pack that (b) it circulated to the countymeeting 8 February 2019 and (c) the following comments were received from Dr MattMayer, LMC Chief Executive Officer, on 15 February 2019: “There were no specificcomments from County or from me. The LMC notes almost all the changes seem to belogistical due to the merging of the two CCGs and changes to the election process inline with past events. If there is a particular item you want us to scrutinise then do letme know, but on the whole the LMC appears happy with this document.”

Authority to make a decision – process and/or commissioning (if relevant)

No decision required from Governing Body. Governing Body has previously agreed to changes to the Constitution on behalf of the membership on an interim basis. However, the CCG Scheme of delegation states that “Consideration and approval of applications to the NHS England on any matter concerning changes to the CCG's Constitution” is reserved to

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https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2015/11/CCG-Constitution-amendments-proposed-to-membership-for-adoption-February-2019-V6-for-voting.pdf



the Membership. This paper describes the process for this to take place, though a virtual vote following engagement with member practices through their locality meetings.

Conflicts of Interest: (please tick accordingly)

No conflict identified Conflict noted, conflicted party can participate in discussion and decision (see below) Conflict noted, conflicted party can participate in discussion but not decision (see below) Conflict noted, conflicted party can remain but not participate in discussion (see below) Conflicted party is excluded from discussion (see below) Governance assurance (see below) Governing Body Member GPs who have voting rights on Governing Body are directly conflicted in relation to changes to the Constitution which affects their role. However this process relates to the rules for appointment to roles rather than the appointment process itself, and there is no decision required at this meeting to adopt proposed changes as this is subject to a virtual vote of member practices.

Localities/virtual vote Clinical Locality Leads are directly conflicted in relation to changes that directly relate to their role. However this process relates to the rules for appointment to roles rather than the appointment process itself, and there is no decision required at locality meetings to adopt the proposed changes. Member practices will need to discuss themselves prior to virtual vote. The virtual vote will be the decision to formally adopt the changes described.

In relation to the virtual vote, the “practice representative” would otherwise be referred to as the GP Lead/Senior Partner. However, another named individual can deputise for the member practice at their discretion for the purposes of decision required (e.g. a practice manager or another individual member of senior management). This will also be applied in respect of Clinical Locality Leads who are also the named GP Lead/Senior Partner for their practice, whereby another Senior Partner will cast their vote in their place.

Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all Better Care for Bucks – to commission personalised, high value integrated care in the right place at the right time Better Care for Bucks – to ensure local people and stakeholders have a greater influence on the services we commission Sustainability within Bucks – to contribute to the delivery of a financially sustainable health and care economy that achieves value for money and encourages innovation Leadership across Bucks – to promote equity as an employer and as clinical commissioners

Governance requirements: (Please tick each box as is relevant to the paper)

Governance Element Y N N/A Comments/Summary Patient & Public Involvement

Equality Quality

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Privacy Financial Risks Members do not agree to proposed changes to the

CCG Constitution. If this arises then proposed changes will need to be reviewed and further amended as required. A 70% majority will be required to adopt changes. The timing of the vote may be adjusted into April depending on whether member practices make any requests for further amendments in addition to those described within the appendices of the briefing pack. If so, the final version adopted will be back dated to 1 April 2019.

Statutory/Legal Prior consideration Committees /Forums/Groups

As described above

Membership Involvement

Through locality meetings as described in the briefing pack and Member GPs who are also members of the Governing Body.

Supporting Papers:

CCG Constitution changes for adoption by the membership – briefing pack

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NHS BUCKINGHAMSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY (IN PUBLIC)

10 January 2019, 10:30am Jubilee Room, Aylesbury Vale District Council, the Gateway, Gatehouse Rd,

Aylesbury, HP19 8FF

1 Welcome & Apologies Lead The Chair Dr Raj Bajwa (RB) welcomed the Governing Body members to the meeting in public. Apologies noted as above.

Members (14) Name Title/Organisation Dr Raj Bajwa (Chair)

GP Clinical Chair RB Present

Tony Dixon Lay Member / Chair of Finance Committee TD Present Gary Heneage Chief Finance Officer GH Present Dr Graham Jackson Member GP and Clinical lead ICS GJ Present Crystal Oldman Registered Nurse CO Apologies Robert Majilton Deputy Accountable Officer RM Present Dr Rebecca Mallard-Smith

Member GP/Clinical Director Unplanned Community Care RMS Present

Louise Patten Accountable Officer LP Present Robert Parkes Lay Member / Vice Lay Chair / Chair of Audit Committee RP Present Debbie Richards Director of Commissioning and Delivery/Accountable

Emergency Officer DR Present

Colin Seaton Lay Member, Patient and Public Involvement CS Present Graham Smith Lay Member, Chair of Primary Care Commissioning

Committee GS Present

Dr Karen West Member GP/Clinical Director Integrated Care/Caldicott Guardian

KW Present

Dr Robin Woolfson Secondary Care Specialist Doctor RW Apologies Standing invitees (non-voting, subject to continual review): Name Title/Organisation Nicola Lester Director of Transformation NL Present Minute taker Name Title/Organisation Russell Carpenter Head of Governance/Board Secretary RC Present In attendance Name Title/Organisation Dr Stuart Logan Clinical Director Long Term Conditions RC Present

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2. Declarations of Interest in items on this meeting’s agenda The Chair Dr Raj Bajwa (RB) reminded the meeting of obligations to declare

any Conflict of interest they may have on any agenda items. RB noted that declarations previously made by members of the Governing Bodies are listed in the CCG’s Register of Interests published on the CCG website. https://www.buckinghamshireccg.nhs.uk/public/about-us/how-we-make-decisions/registers-of-interests/ Item 6 Primary Care Investments:

a) Primary Care Development Scheme 19-20 b) Locally Commissioned Services 19-20

Member GPs materially conflicted where partners in practices that financially benefit. Will remain present as meeting held in public but do not participate in discussion or decision. It is on this same basis that the financial detail described has not been withheld prior to decisions on both investments as it is already in the public domain. The Clinical Chair will hand over the chair of the meeting to his lay deputy for the duration of these items. . Both the Registered Nurse and Secondary Care Doctor are absent from the meeting, one of whom would ordinarily be required to ensure quorum (as one of two clinicians for quorum). Likewise one of the Accountable Officer, Chief Finance Officer or Deputy Accountable Officer would be required for quorum. To ensure a quorum for decision, the Accountable Officer as a registered nurse is counted as one of two clinicians required. The second clinician for quorum is the Director of Transformation, also a registered nurse, through enacting a CCG Constitution clause “The Director of Transformation will be co-opted as an additional voting member only in circumstances of conflict of interest material to member GPs/Chair which requires them not to count for quorum purposes.”

3. Review and Approval of Minutes: a. Meeting minutes – 13/12/18 b. Action Log/Matters Arising

DR commented as follows: • Page 6 Accountable Officer’s report; As regards access, the CCG has

invested into the MH standard this year and now ahead of trajectory on young people’s access to CAMHS, specifically wait times and prevalence.

• Page 8 Winter funding; Earlier in the year the CCG invested £1m at risk in discharge to assess. This was agreed at system level, with expectation from NHS England that some of this money is to come from winter money.

• Page 9 Quality and performance (RTT); this means we are confident our waiting list will end the year no greater than at the start.

The minutes were otherwise approved. Actions are updated separately in the log.

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4. Questions from the public RC confirmed none received in advance or tabled on the day.

5. Governing Body Assurance Framework (GBAF)

Governing Body was asked to RECEIVE FOR ASSURANCE the Governing Body Assurance Framework (GBAF) and Corporate Risk Register escalations (15+), whilst also discussing and commenting on control and assurances detailed. RB noted this item had come up the agenda following previous discussions so that Governing Body is fully energised when it is reviewed. RB also noted members are reminded to consider as the meeting progresses through the agenda any points for consideration for the recap (item 13). ICS Memorandum of Understanding and operating plan RC noted challenge previously in relation to the score for risk 1 regarding MOU for the ICS “IF the CCG is unable to deliver its commitments within the ICS memorandum of understanding and related operating plan”. This has since reduced to 12 on the basis that an appropriate governance framework is in place for the ICS reflective of it not having a legal status in its own right and the CCG Governing Body assured on its delivery (including copies of Partnership Board minutes for information). This was the only major change, with owners having reviewed in between. We are clear on our main risks, especially finance, which will be discussed further elsewhere on the agenda. EU Exit RC highlighted a risk identified and assurances provided within the report on the possibility for a no deal EU Exit and local impact. Our current risk is scored at 12 and so does not technically meet criteria for escalation (GBAF details risks at 15 and above), but members can be assured we do have a risk especially in relation to stockpiling in primary care. Materials previously circulated by the Department of Health and Social Care have been circulated to primary care practices in partial mitigation of this risk. RP queried if was any sign of movement from staff from the NHS affected by EU Exit. DR replied that there is in place a system Brexit planning group; with Natalie Fox (Chief Operating Officer at Buckinghamshire Healthcare NHS Trust) as the nominated ICS lead for this with constituent partners of the ICS all members of the group which meets fortnightly. The CCG is not anticipating any specific workforce threats. We are discussing with primary care on their impacts, with provider trusts looking at this in some detail. Where support from HR can be given to people to remain in post, this is being offered. We are not anticipating any further CCG issues that those we are not already aware of. GS queried, following the successful motion to prevent a no deal scenario ahead of further vote on the Prime Minister’s plan, would that mean the current risk would need to increase. RC replied the risk as currently defined would be eliminated if a no deal scenario was legislatively prevented, however that does not mean impact is eliminated and so the risk would need to be re-defined accordingly. Once we know the outcome of the subsequent vote on the Prime Minister’s plan the risk would be reviewed, and if the score changed and it met GBAF threshold it would escalate. DR pointed out all providers are undertaking detailed work on supply chain including equipment contract. We are supporting this rather than leading the process.

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Looked After Children health assessments TD raised concern in relation to the escalated corporate risk on Looked After Children (LAC) assessments. Current compliance 50% with 81 outstanding review health assessments for Looked After Children (as at 9 November 2018). This breaches statutory timescales of 100%. DR replied that she shared this concern; such were these that at the end of last year she now co-ordinates two weekly system escalation calls. There have been improvements. In relation to health summaries, we have now confirmed that all children who left care in 2018 have received a health summary, and later today we will receive a trajectory for the 2016 and 2017 backlog. In terms of the initial health assessments, October 2018 was a challenging month. We have actions in place for both in and out of county. We are continuing to work really hard to ensure that, even if the 20 day target for initial assessment is not met, we are doing everything we can to achieve on days 21 and 22 given recognition of complexities associated with this process. We are working to avoid every avoidable breach. In terms of the reviews, our next step is a trajectory to ensure compliance. Our provider is taking this very seriously and has introduced additional administrative and clinical resource in place to address this. The Local Authority has reviewed its systems and processes to ensure better communication between the two organisations in order to minimise any delays in the process. TD noted this has been picked up in a previous inspection report. DR went one stage further and noted a series of Ofsted monitoring visits which takes place. The next visit is anticipated to take place in February 2019. There is system commitment to ensure that during December 2018 and January 2019 this will have focus to ensure assurances can be given when inspection takes place. Accident and Emergency 95% target/Transforming Care Partnership LP noted A&E and transforming care partnership risks currently scoring above the escalation threshold. LP noted baselines of 16 and post mitigation scores also of 16. It is difficult to understand this if mitigations are expected to bring risk score down. This looks as if we haven’t got any interventions in place and she didn’t feel this was correct. If we removed all the controls we are pursuing, performance would be much worse. The risk score after mitigation isn’t looking at what has already been delivered. RC replied this is all dependent on the views of the risk owners on the impact they think controls and assurances in place are having; it is within their discretion. DR replied, in terms of A&E, DR agreed we have comprehensive performance management planning in place, We have not hit 95% target or Q3 trajectory, but we have made progress since last year and can review this risk. As regards transforming care partnership, this is much harder. We continue to escalate to NHS England that this is an unmitigated risk for us in terms of our financial exposure to very high cost packages. GH stated he is refusing to match fund until NHSE confirms capital. LP noted she understood this, but the risk currently reads as if there are no mitigations. GH replied there should be a transfer of allocation from NHS England to the CCG, which is why it continues to be high risk. DR noted we

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have control in terms of oversight of all named individuals, where they are and future expectations. But we are significantly disadvantaged in terms of resource as we have no beds to close to transfer funds from elsewhere. TD queried if we obtained funding the risk would be eliminated. GH replied in theory yes. LP added it is unlikely it would ever fully be eliminated but the score would reduce below threshold. RB that discussing this item higher on the agenda is effective.

Decisions 6. Primary Care Investments:

a) Primary Care Development Scheme 19-20 b) Locally Commissioned Services 19-20

RB handed over chairing of the meeting to RP. RP invited SK to describe the paper provided to the Governing Body.

(a) Approval of Recommendations for Primary Care Development Scheme (PCDS) 2019/20

The Governing Body is asked to agree the following recommendations for the PCDS (as described in the attached paper) Recommendations

1. Update the scheme elements with new specifications reflecting changes.

2. Update and simplify templates for the scheme and update the dashboard to reflect new elements and requirements.

3. Recommend for the PCDS that no further financial investment made until existing funding justified through review of outcomes.

SK introduced the item; discussions with clinicians have been ongoing since May 2018 to inform 19/20 plans. It is also clear that CCG’s nationally have been waiting for further guidance from NHS England on the Quality and Outcomes Framework (QOF) before taking local commissioning decisions. It is now expected to review this at end of 19/20 in line review of the GP contract. It is expected in 19/20 therefore to proceed with a third year of the current scheme. It is delivering on many areas linked to patient outcomes, especially heart failure, Atrial Fibrillation (AF) where the CCG is leading nationally, and diabetes care and support planning. There is further work to do on end of life care and links with secondary care on advanced care planning. The CCG is seeking longer term outcomes for long term conditions and self-care initiatives, which are known to feature in the NHS ten year plan. We are also developing primary care networks, so this scheme is a key part of this. The scheme is also being re-written to help the patient as a whole rather than in piecemeal. Prescribing elements of the scheme have also been tweaked; LMC have positively endorsed this. SL was permitted to speak (directly conflicted as a partner in a practice that would benefit from the scheme), highlighting that the aims seek to minimise hospital admissions, especially for more frail patients, through ensuring adequate care plans are in place. He stated a need to focus on risk stratification – both the top 10-15% of patients who are co-morbid with numerous long term conditions, and the base of the pyramid where patients do

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not have long term conditions with the aim to prevent them being diagnosed in future. We are aiming for good, holistic care which involves relatives and good outcomes. LP noted support in principle and its contribution to the long term plan. LP noted paper states “Recommend for the PCDS that no further financial investment made until existing funding justified through review of outcomes”. LP sought to confirm that this was beyond what is currently being requested as this was not clear in the paper circulated. SK replied that historically there is a budget which combines QOF (which moves as population and achievement increases) and a CCG investment element. The recommendation indicates no further investment from the CCG above that already budgeted for. RM noted that existing funding needed to be linked to outcomes (as the recommendation states) and believed that this has not yet taken place. SK confirmed it. LP asked that the recommendation be extended to “outcomes or evaluation”, as we always struggle with outcomes. LP also asked that in circumstances such as this, where clinicians are unable to participate in elements of scheme development due to conflicts of interest, we need absolute clarity on what the clinical involvement has been. LP asked to hear from SL that there has been sensible clinical involvement, despite conflicts of interest (SL directly conflicted as a partner in a practice that would benefit from the scheme). SL replied that regular meetings have taken place. RC raised on behalf of Dr. Robin Woolfson (not present) who had asked for clarity as to how progress was going to be monitored and reported to the GB throughout the year. SK replied that there is a comprehensive monitoring regime for the existing scheme, including monthly emails to all practices and monthly meetings with locality and portfolio clinicians. RM suggested we look at how this is incorporated into the quality and performance report. ACTION. Decision: The proposed recommendations were agreed.

(b) Locally Commissioned Services 19-20 (previously known as Direct Awards)

NL set the context; the CCG on an annual basis commissions practices to participate voluntarily in improvement schemes/enhanced services which are in addition to the core GMS contract. These were previously known as Direct Awards. SK described the national context in that all CCGs to some extent invest in local services that are above core GMS contract. Locally the CCG compares well with its neighbours, with close partnership with Oxfordshire to align specifications, with two services added that Oxfordshire had previously introduced, namely health checks for patients with serious mental illness (SMI) and prophylaxis for care home staff in the event of a flu outbreak. In year a dashboard had been developed to give all practices visibility of delivery, with aim now to automate this process so practice administration for their quarterly claims is seamless. This has been a key element in discussions with practice managers. RP asked if this scheme commissioned as one service or a number of

RM (SK)

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services. SK replied the whole list is 10 services; in Aylesbury 6 are bundled and contracted as one service for option of sign up (100% of practice have signed up), for the rest they are individual. When the CCG requests and sends out information each March, practices are asked to indicate which they are prepared to deliver. The aim is for as high sign up as possible as these are services people should be getting. Some practices will judge they don’t have capacity or capability. For some areas, these services are not being automatically delivered by their local practice. It is hoped to change this as primary care networks develop further and deliver these to cover patients not part of individual practice catchments so all patients have access. This is why the recommendations are as they are. Networks are not yet mature to offer this; this is expected to be in place in the next year. Meanwhile the scheme continues with the existing Aylesbury bundle and Chiltern individual based on activity. The scheme will be subject to ongoing monitoring as primary care networks develop. TD noted estimated spend on the scheme exceeds the allocated budget, and asked what assurances are in pace to no further overspend if further practices sign up to services. SK replied the scheme is monitored closely to balance demand and capacity and that budget can be exceeded. LP added that this cannot happen. GH agreed; we budget QOF at 100% delivery but we are often slightly under budget which largely mitigates overspend on enhanced services. We need a fixed budget given the financial position. We know from the beginning of the year the rate of take up with payment based on activity. RP raised concern that patients across the county have different levels of service and whether this is fair. SK replied to some extent they will still get the service, but may be through another local practice rather than their own. LP noted that the CCG has a responsibility to ensure equitable access. As part of ongoing evaluation, LP requested an assessment of equality impact in different communities as patients do have choice of GP practice. RP added if we are running different schemes through different practices that increases administration, and one of our drivers is to cut back on this encourage as many practices to drive to higher standard so we get more consistency. LP noted this as a clear message from Governing Body. LP noted clearly the paper doesn’t reflect PCN networks description in the long term plan. CCGs have a responsibility to understand what the ten year plan means and share that work with providers, so there is that work still to be done locally. LP further queried the difference between options 1 and 2 indicated within the paper as the disadvantages of both options appear to be the same. SK replied that option 1 bundles all the services, with option 2 retaining bundling 6 services for Aylesbury Vale practices and expending this to also cover Chiltern practices. LP noted that the table does not describe member practice push back as a disadvantage; we have to accept why this is a sensitive subject and we must take time to do this properly. SK added if you ask Chiltern practices about the bundle approach, their feedback is they prefer the current position. LP noted there is divided opinion which is not detailed in the disadvantages. There are sensitives, which mean

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more time is needed to ensure equitable access for specific communities and equitable contracting. The concern around the 10 year plan is that it is moving us away from principle of items of service and bundling at practice level to payment at primary care network level, which reduces costs for individual practices. SK replied that during 19/20 there would be thorough review to determine if this is the right package, with delivery at practice, network level or in hubs will be considered. Recommendation 1 – Current list of LCS services continues into 2019/20.

TD suggested this may mean the scheme may change part way through the year – is this sensible? LP suggested this should “continues for 19/20”. SK replied that 19/20 will be a year of change. Expectation is this scheme will be in place for full 19/20. What is offered to practices will include the word change. LP added, if anything, the contract may change but the list of services would remain the same. TD requested certainty. SK confirmed that at the moment, there were no more services expected to be added. Recommendation 2 – Existing specifications are consolidated into the current specification used by (former) Chiltern practices. LP referred to the recommendation. LP suggested the paper not clear on whether this is because it reflects best practice, if the proposal is consistent with best practice and links to academia/NICE guidance. It’s not a concern which prevents a decision, but still needs explanation. SK replied that because Chiltern practices have delivery based on individual services, all detailed specifications were reviewed last year. Aylesbury Vale specifications which indicate the bundling approach were less detailed and specific. They don’t fundamentally differ; rather the Chiltern specifications are better laid out. LP asked if there were administrative implications, SK confirmed there were not. Care Home Prophylaxis for Flu. DR noted, although we know people need a community based solution in 19/20, we need to evaluate success of the current winter scheme and ensure learning is built into subsequent schemes. What we commissioned this year may not be the same for next winter. LP clarified if this is covered by the recommendations. DR replied it t is vague hence the point made. This also needs to be linked to the evaluation. Conclusions RM recognised this is a holding position, and enhanced services are specifically mentioned in the long term plan as migrating to network level. So we must be clear about what capability, analysis and capacity we need to work through with practices/networks. It is tricky and sensitive. RM recommends that PCCC/PCOG have a detailed delivery plan to monitor and what co-production looks like, and how we provide skillset to support internal resource to deliver it. NL responded our main priority in 19/20 has to be to get networks established and so skills and capacity will be subsumed by this as a priority. RM acknowledged that we can’t do everything at once, but if we are doing this we have to be clear how it will be delivered. SK acknowledged a need for a robust mechanism. RM emphasised that we need a clear plan with timescales and milestones and to be monitoring it to ensure delivery through PCCC. LP noted networks will be held responsible for uniform coverage and addressing inequality.

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Decision: The proposed recommendations were agreed (with request that evaluation include equality impact assessment). RP handed back the Chair of the meeting to RB.

Leadership and Governance 7. Accountable Officer’s Report and System Working Update RM stated operational planning guidance was released 21/12/18, and the long

term plan had launched on the previous Monday. It contains many elements we have already been doing a system, with emphasis on commissioners working at scale with the STP. There are a number of areas we are waiting further detail. Thames Valley and Surrey Local Health and Care Record Exemplars (LCHRE) RM noted an update in the report provided. The matter was discussed at ICS Partnership Board last Tuesday; there is some additional assurance work required through Balvinder Heran before LP signs the partnership agreement. The recommendation (for delegated authority to LP to sign the Partnership agreement) still stands. And a recognition that the CCG signs on behalf of the system and therefore any costs is a call on system control total whatever the funding mechanism. Decision: this was agreed. Brexit RM noted previous discussion on this matter (under Governing Body Assurance Framework). RM asked Governing Body to not the CCG lead on Brexit is DR (as Accountable Emergency Officer). This was NOTED. LP added further comment to the report, In relation to ICS development, we are looking carefully at the form and function of the Clinical Senate; LP will be writing to organisations to request that it does meet on a regular day of the month, preferably Thursday, so that it can take commissioning work from the CCG. ICS Managing Director interviews will take place in a couple of weeks’ time, so LP hopes to report back on progress at the next meeting. CEO interviews for Buckinghamshire Healthcare NHS Trust are expected at the end of the month. RB commented that holding senate meetings on days which makes best use of clinical resources is essential. Brexit/medicines GS suggested it would appear odd the idea that patients may not have access to medicines with a no deal scenario, and queried (a) the CCG’s mitigations for risks in relation to administration and data sharing and (b) the risk of scaremongering which could lead to bad decisions. DR replied that a Brexit planning group meets fortnightly, with DR as the CCG SRO. The Brexit planning group is represented by directors of constituent organisations, with regional and national input through NHS England representation. In relation to nationally published guidance, we are using existing systems and processes for Emergency Preparedness, Resilience and Response (EPRR) and business continuity. Where business continuity plans are in place, providers and commissioners are revisiting those plans and will again in light of further guidance. Workforce issues are particularly concerning to providers who have contingencies.

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The Local Authority is working with the independent sector where it is harder to obtain situational reports. The CCG is also in discussion with primary care commissioning colleagues to understand the impact. We also have a system medicines optimisation board, of which clinical members are clear on their contingencies. Through NHS England they are liaising with community pharmacists and through the CCG to communicate with general practices. As system we have responsibility to provide public re-assurances not to stockpile; this behaviour could generate overreaction. Nationally demand is being tracked through the NHS supply chain; they know where every drug and medical device has come from, and we are supporting clear messages on this. GJ suggested that members of the public stockpiling is difficult as it’s not in public control, rather it is prescribers control. DR replied that we are re-assuring the public that they don’t need to ask for extra medication. LP added that this also relates to over the counter medications. RB concluded that this was another reason not to support third party ordering.

Governance and Assurance 8. Planning Framework – process and timescales

• 18/19 financial position update • 19/20 Planning Update

GH noted that 18/19 Month 8 is 32k favourable to plan. Expect to receive Q3 CSF in full, still forecast to hit year end plan but there is risk circa £5m. This is fully at this stage, but biggest risk is continuing healthcare and pressure on acute (Frimley and London providers). Attention will soon shift to year-end audit, and we anticipate take Audit Committee through the plan. As regards 19/20, we are still waiting for further balance of planning guidance, still unconfirmed on the control total and we still don’t have our allocations. Expecting some of that imminently, but we are unable to release first iteration of 19/20 plan without this. Given our financial challenges for next year, it is highly likely contract values will be reducing in 19/20. TD noted this as a difficult message and queried how we communicate it, especially with the general public. GH replied there is a clear need to communicate, internally, across the ICS and the public – as regards what is affordable for the Buckinghamshire pound once we understand our allocations. RB added that there is a dichotomy with national messages that the NHS is investing more. TD added it is one thing reducing contract value, another thing keeping an organisation to that. With Buckinghamshire Healthcare NHS Trust we could expect a block contract, but how will this work with other organisations? GH replied we will need to work together to do things differently and reduce costs. We have got good examples about what we can stop, especially elective activity, and we will need to send a clear message to the system. LP concluded that clinicians will also need to understand this message.

15

9. Finance Report (Month 8) including • ICS transformation funds report • Risks and Mitigations • Discretionary spend

Covered under above item.

10. Quality and Performance Report (Month 8)

DR apologies for the paper pack not having a report due to timing; it was not ready for the executive committee to be assured before it circulated to Governing Body. We do now have a report to be reviewed by the Quality and Performance Committee before release into the public domain. DR noted at the previous meeting we presented the winter plan, and reported on progress. The STP performance for December shows BHT performance for A&E did achieve 90%, and was best in STP and better than Frimley. Also borne by also best performance in bed day delays. Through Governing Body there has been concern about us needing to ensure we would get improved grip on reducing long LOS and driving out bed days. We have also been reducing ambulance handover delays. As regards this year to date, we have been improving capability for system forecasting demand and capacity across all elements of the system. In large part predicted pressure for the first two weeks of January has transpired. It came three days earlier, Friday 4 January rather than Monday 7 January. Further pressure this week is within expected levels with staff working hard to mitigate. We are maintaining OPEL3. CS queried why Friday 4 January was a pinch point. DR replied we are looking at this in terms of clinical presentation and trends to see what more we can learn. GS asked if next year it can be ensured members see data earlier. DR replied yes, on this occasion there was a timing issue. RMS suggested the pinch point is more closely related to where new year falls and that patients will wait until after when general practice becomes very busy. GJ added this this can also be affected by when the first day of the new school term also falls. GS further queried if Buckinghamshire is above average when compared nationally, and whether NHS England will be eliminating the 95% 4 hour target. DR replied we are in the middle of the pack and so we are not flagging as a challenged system. As regards the target, indications are we are not likely to see the target go, but there is national piece of work to ensure standards remain clinically appropriate. RM added that the model of care can move beyond what the original target was created for. . RB thanked all the people who worked on the winter plan. DR concluded that our new winter director has also brought in additional resilience with virtual system operations team on site at BHT, and they are having look forward meetings, managing multi-agency discharge beds and providing system challenges to improve discharge and drive out delays.

11. Inequalities Advisory Group (IAG): Update

CS talked Governing Body members through a supporting presentation published on the CCG website. https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2018/05/11.-IAG-presentation-CS.pdf

16

https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2018/05/11.-IAG-presentation-CS.pdf

https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2018/05/11.-IAG-presentation-CS.pdf

Data comes from public health, with clinicians attending to address specific priorities. Membership is based on the county’s community diversity. The group discusses strategies to address inequalities and engage communities with broad scope of ethnicity and culture with CCG messages on its behalf (e.g. winter pressures and what communities can do to help themselves). CS stressed independence of the group in both health and political terms. The benefits of a large membership outweigh the size of the group. CS noted CCG support to the group, facilitating clinical engagement and leadership in ensuring appropriate attendance. Their work is somewhat guided by this and the CCG’s priorities. CS noted having previously presented to the NHS Clinical Commissioners Lay Members Network about aims, from which a small amount of funding was provided by NHS England. Although is there is no further funding, the group is focused on its objectives with members willing to provide venues for meetings at no cost. As regards governance, the group is accountable to the engagement steering group on its objectives but with desire to be accountable and report to the CCG Executive Committee. In its next phase, CS thinks over the next six months the group will expand and allow greater reach, which needs continued support of the CCG. TD queried the amount of funding received. CS replied £2.5k. LP noted the great work of the group as a critical friend, which is the right way forward. Representation would always be difficult, but it looks representative. LP also welcomed links to public health especially with increased collaboration on population health management. LP noted a balance is needed between strategic and operational work (in a school for example). As regards funding, we need to work as a system to embed as all organisations have equality duties. The group could be a single entity for the system, linking to corporate social responsibility (CSR) activity and lottery funding. LP indicated looking at this as ICS lead. GS queried whether the success of the Chiltern house survey was entirely down to the group. CS replied not entirely, although a couple of group members are patients with group able to facilitate clarity on the long term plan and prevent unnecessary disquiet on an issue where public feeling can otherwise quickly become toxic. NL noted in terms of current and future accountability and reporting, the group currently reports through the engagement steering group, which feeds into the quarterly communications and engagement update reported to the Governing Body. The “getting Buckinghamshire involved” quarterly steering group met for the first time a few weeks ago, which in future will be its natural place. It is a system group chaired by Healthwatch with third party providers and community groups invited to be involved. They have yet to set their purpose with the first meeting more about introductions. LP queried whether reporting would be more effective to the Health and Wellbeing Board. NL replied the ICS would likely need its own engagement group of some sort. RB thanked CS for his role in this initiative, with a feeling that this is different to some other meeting with head teacher’s ability to reach

17

into families an aspect we can use better to address inequality gaps and financial challenges. Earlier on the agenda, we didn’t challenge how primary care investments (direct awards, primary care development scheme) would address the inequality gap. We should reflect on this and ensure this is part of our core challenge of business cases. Moving forward, RB expects to step aside with Dr Rashmi Sawnhey (Clinical Locality Director for Wycombe) expected to take a greater role.

12. Communications and Engagement Update

NL introduced the Q3 report and noted CS had previously referred to the survey of Chiltern House Medical Centre in which 1,124 members of the public took part to share views about the future of the practice. Overwhelmingly they wanted us to consider procurement for a new provider. That decision has subsequently been taken. This process had been supported by the Inequalities Advisory Group who handed out surveys at schools and mosques. A significant amount of work supporting it was also undertaken by the practice Patient Participation group (PPG). NL also noted the Equality and Diversity Annual Report is in its final stages before publication, seen by the Engagement Steering Group yesterday. Regards out of Hours provision in the south of the county, the survey referred to in the report was stated as closing on 25 January. And up until 2 December, the public was invited to comment on the CCG operational plan for last year to inform the plan we are now writing. We have also revised our engagement strategy to be published on our website. And a strategy for engagement was published alongside the town year plan this week, so patients and the public can understand it. We are working through what this means for Buckinghamshire. LP noted it useful to see all in one place.

13. Governing Body Assurance Framework – recap

There were no further comments.

14/15. Approved Minutes and reports as stated on agenda

Minutes provided for information were noted as received. Meeting closed 11:45.

16. Next meeting/AOB Date and Time of the next meeting: 14 March 2019

Jubilee Room, Aylesbury Vale District Council, the Gateway, Gatehouse Rd, Aylesbury, HP19 8FF

18

ACTION LOG

MEETING: Item 3b

DATE: 14/03/2019

TITLE: Action LogPrevious

Meeting

Date (or

Date

raised

/added)

Action

Number /ID

Minutes

Reference

Action Description Responsibility

/Owner

Target date Completed

date

Status Progress Details/Comments

10/01/2019 1 6; Primary Care Investments:a) Primary Care DevelopmentScheme 19-20b) Locally CommissionedServices 19-20

RC raised on behalf of Dr. Robin Woolfson (not present)who had asked for clarity as to how progress was going tobe monitored and reported to the GB throughout the year.SK replied that there is a comprehensive monitoring regimefor the existing scheme, including monthly emails to allpractices and monthly meetings with locality and portfolioclinicians. RM suggested we look at how this isincorporated into the quality and performance report.ACTION.

RM/DR 14/03/2019 14/03/2019 Closed Fed back to quality team for inclusion in future reports

Governing Body (in public)

19

MEETING: Governing Body AGENDA ITEM: 6 DATE: 14 March 2019 TITLE: Governing Body Assurance Framework – March 2019 AUTHOR: Russell Carpenter, Head of Governance/Board Secretary LEAD DIRECTOR: Robert Majilton, Deputy Chief Officer



Governing Body is asked to RECEIVE FOR ASSURANCE the Governing Body Assurance Framework (GBAF) and Corporate Risk Register escalations (15+), whilst also discussing and commenting on control and assurances detailed.


n/a paper for assurance, not decision


No conflict identified Conflict noted, conflicted party can participate in discussion and decision (see below) Conflict noted, conflicted party can participate in discussion but not decision (see below) Conflict noted, conflicted party can remain but not participate in discussion (see below) Conflicted party is excluded from discussion (see below) Governance assurance (see below) n/a.

Strategic objectives supported by this paper (please tick) 1. Better Health in Bucks – to commission high quality services that are safe,

accessible to all and achieve good patient outcomes for all

2. Better Care for Bucks – to commission personalised, high value integrated care inthe right place at the right time

3. Better Care for Bucks – to ensure local people and stakeholders have a greaterinfluence on the services we commission

4. Sustainability within Bucks – to contribute to the delivery of a financiallysustainable health and care economy that achieves value for money andencourages innovation

20

5. Leadership across Bucks – to promote equity as an employer and as clinicalcommissioners



Equality Quality As described within the attached Framework Financial As described within the attached Framework Risks As described within the attached Framework Statutory/Legal As described within the attached Framework Prior considerations GBAF is reported to the Governing Body

monthly with a deep dive quarterly. Membership Involvement Risks As described within the attached Framework Financial Consequences As described within the attached Framework Financial Approval As described within the attached Framework

Supporting Papers:

Appendix A: GBAF report March 2019 Appendix B: Corporate Risk Register escalations

21

Governing Body Assurance Framework – March 2019

Background The Governing Body Assurance Framework (GBAF) captures principal risks to the delivery of the CCG’s 5 strategic aims/goals, whilst also closely linked to the CCG’s corporate objectives.

These were agreed, for 2018/19, in public in July 2018 as: • Deliver the system FRP in 18/19 and achieve financial recovery and a sustainable

ICS by April 2020• Manage capacity, demand and clinical variation using a population health

management approach so that patient flow is safely optimised, equitable acrossboundaries and the NHS constitutional standards are met in accordance withplanning guidance

• Enable and support the component parts of the ICS and STP to delivertransformation of health and social care

• Support delivery of the Five Year Forward Views for New Models of Care, PrimaryCare and Mental Health for improved outcomes for patients

CCGs must have a robust risk management framework and have in place processes in place to identify emerging risks or issues.

Summary of GBAF report March 2019 (Appendix A). No risks are currently rated at 16. 6 of 17 risks are rated at 12; further details within the attached report.

Corporate Risk Register escalations – February 2019 (Appendix B) Alongside the GBAF are escalated risks from the Corporate Risk Register with a score of 15 and above in line with our Integrated Risk Management Framework.

Escalated risks relate to: 1. Completion of Looked After Children assessments,2. Transforming care cost pressures.3. Increased Non Elective short stay activity

The Corporate Risk Register was reviewed at the Executive Committee on 28 February 2019. The Committee reviewed the register, confirmed the corporate risks scores, including “new risks”.

EU Exit A previously reported and discussed risk on EU Exit remains at a corporate risk score of 12 and therefore falls below reporting threshold. The CCG Executive Committee has reviewed this risk and we have a system EU Exit group managing this risk closely alongside a detailed system action plan, linked to national and regional guidance.

System wide 4 hour national target -A&E IF Providers are unable to achieve the 4 hour waiting time target by 31st March 2019, THEN Unable to meet related statutory duty.

This risk was previously reporting above threshold but has been reduced to a corporate risk score of 12 and so falls below threshold of 15 for the Governing Body Assurance Framework. This is on the basis of being on track to reach 90% average by 31 March 2019.

22

Principal Risk Initial Current Acceptable Change Gap

IF THEN LEADING TO CORPORATE OBJECTIVE LINK

1The CCG is unable to deliver itscommitments within the ICSmemorandum of understanding andrelated operating plan

The outcomes andimprovement in patientservices may becompromised

(1) A disjointed approach to system delivery(2) Not delivering the benefits and improved outcomesset out in the system plans

Enable and support the component parts of theICS and STP to deliver transformation of healthand social care 12 12 8 -4 4

2If alternative care pathways areunable to impact on increasing non-elective demand by the end of thefinancial year

Activity run rates will notreduce to optimum desiredlevels against planningtrajectories informed bynational benchmarks

(1) Additional risk cost pressure through Frimley Healthwill materialise above existing forecasts(2) Further cost pressure on BuckinghamshireHealthcare NHS Trust through increased activity whichcould impact system partners(3) Further pressures from other acute providers(predominantly London, Oxford University HospitalsNHS Foundation Trust and Milton Keynes UniversityHospital NHS Foundation Trust)(4) non-compliance with statutory responsibilities(5) non-receipt of Commissioning Sustainability Fund(CSF) and Provider Sustainability Fund (PSF) moniesfrom NHS England(6) Implications for ICS system control total(7) Impact on Patient Experience(8) Potential for special measures

Deliver the system FRP in 18/19 and achievefinancial recovery and a sustainable ICS by April2020

Manage capacity, demand and clinical variationusing a population health management approachso that patient flow is safely optimised, equitableacross boundaries and the NHS constitutionalstandards are met in accordance with planningguidance

20 12 8 0 4

3The Quality, Innovation, Productivityand Prevention (QIPP) programme isunable to deliver its end of year costreduction estimates and further QIPPis not identified to meet furtherpressures

this will contribute to thedeficit outturn position forthe CCG resulting fromunaffordability

20 12 8 0 4

4Providers exceed activity run rateprojections incorporated into block orPBR contracts at end of the financialyear

this will contribute to deficitoutturn position for theCCG resulting fromunaffordability

20 12 8 0 4

5The CCG is unable to maintain itsoptimum staffing levels at any time

Capacity or capability todischarge itscommissioning functionswill be affected

(1) non-compliance with statutory responsibilities(2) Reduced motivations for remaining CCG staffthrough increased workload/pressure


9 9 6 0 3

6CCG Improvement AssessmentFramework standards (on quality andperformance) have not been metwhen measured at the end of thefinancial year

CCG rating would beaffected (likely reduced)

(1) non-compliance with statutory responsibilities(2) NHS England additional scrutiny.(3) Non-compliance with quality premium(4) Impact on Patient Experience


Support delivery of the Five Year Forward Viewsfor New Models of Care, Primary Care and MentalHealth for improved outcomes for patients

16 12 12 0 0

7The CCG is unable to deliver therequirements stipulated within theFive Year Forward View for NewModels of Care, Primary Care andMental Health

The expected benefits willnot be delivered

(1) A disjointed approach to system transformation anddelivery(2) Not delivering the benefits and improved outcomesset out in the system plans

Support delivery of the Five Year Forward Viewsfor New Models of Care, Primary Care and MentalHealth for improved outcomes for patients 12 12 8 0 4

Better Care for Bucks – to

commission personalised, high valueintegrated care in the right place at theright time

(1) non-compliance with statutory responsibilities(2) non-receipt of Commissioning Sustainability Fund(CSF) monies from NHS England(3) Implications for ICS system control total(4) Impact on planning a balanced outturn for futureyears(5) Potential for special measures

Deliver the system FRP in 18/19 and achievefinancial recovery and a sustainable ICS by April2020

(2) Manage capacity, demand and clinicalvariation using a population health managementapproach so that patient flow is safely optimised,equitable across boundaries and the NHSconstitutional standards are met in accordancewith planning guidance(3) Enable and support the component parts ofthe ICS and STP to deliver transformation ofhealth and social care

Sustainability within

Buckinghamshire – to contribute tothe delivery of a financially sustainablehealth and care economy that achievesvalue for money and encouragesinnovation

Better Health for Bucks – to

commission high quality services thatare safe, accessible to all and achievegood patient outcomes for all

NHS Buckinghamshire Clinical Commissioning GroupGoverning Body Assurance Framework

Strategic Aim/Goal

Leadership across Bucks – to

promote equity as an employer and asclinical commissioners

Mar-19

23

Managerial

Lead

(Delegated

Owner)

Robert

Majilton

IF

THEN

LEADING

TO

Date Opened Oct-18

Risk Cause: Financial Year End

Risk Rating Rationale for Current Score:

Likelihood Consequence

Initial 3 4 12Current 2 4 8Acceptable 2 4 8 Rationale for Acceptable Score:

Controls/dependencies (What are we currently doing about the risk?) (No. of controls and assurances must match) Gaps in controls (What additional measures should we seek?)

Internal or external Owner Owner Due By

Both ICS ManagingDirector / SystemSROs

Deputy Chief Officer Apr-19

Both CFOs group CFOs Apr-19

Both ICS ManagingDirector

Assurances (How do we know if the things we are doing are having an impact?) Gaps in assurance (What additional measures should we seek?)


Internal Director ofCommissioning &Delivery

ICS ManagingDirector / ICSPartnership board

Jun-19

Mitigating Actions (Controls - immediate) Mitigating Actions (Assurance - immediate - 0-3 or 3-6 months to reduce risk level)

Owner Due By Owner Due By

Directors On-going

b) System performance and financial reporting

c) System portfolio office

b) System financial plan and diagnostic still being finalised

Strategic Objective: Better Health in Bucks

(1) A disjointed approach to system transformation and delivery

(2) Not delivering the benefits and improved outcomes set out in the system plans

Clinical Lead

(Risk Owner)Dr Raj

BajwaTo commission high quality services that are safe, accessible to all and achieve good patient outcomes for allCorporate Objectives 2018/19:

Enable and support the component parts of the ICS and STP to deliver transformation of health and social care

a) Agreed ICS operating model including delivery infrastructure, implementation group and partnership board a) Framework for mapping commissioning functions and future state

Risk

Definition:The CCG is unable to deliver its commitments within the ICS memorandum of understanding and related operating plan Date last

reviewed

ICS MOU for 18/19 agreed by CCG Governing Body September 2018 with challenging deliverables; separate ICS and CCG operatingplans previously agreed for 2018/19.

Risk Proximity: (how soon

could it materialise?)

Description (new if red italics; must also indicate whether internal or external) Description (new if red italics)

March 2019

The outcomes and improvement in patient services may be compromised

Involvement in ICS groups and SRO leads from the CCG


a) Regular reporting on quality of services a) A number of ICS roles are temporary / secondments

Description (new if red italics) Description (new if red italics)

The system can demonstrate appropriate mitigation and oversight of key risks and issues and is escalating theseappropriately for resolution.

Whilst there continues to be progress on delivery of key areas of the system transformation and MOU and OperatingPlan deliverables there remain some areas of challenge particularly performance and system financial position.TheSystem has been improving performance and has developed a system operating plan for 2019/20. The financial part

0

5

10

15

20

25

Initial Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

AcceptableCurrent

24

Managerial

Lead

(Delegated

Owner)

Gary

Heneage

IF

THEN

LEADING

TO

Date Opened Oct-18







Internal CFO



Internal CFO



Internal CFO1) described within FRP - monthly re-forecasting with risks and mitigations refreshed


1) Finance Report, Finance Committee minutes, Executive Committee minutes, Audit Committeeminutes, further assurance with NHS England


1) Financial Recovery Plan with specific section on risks and mitigations

Risk Definition: If alternative care pathways are unable to impact on decreasing non-elective demand by the end of the financial

year

Date last

reviewed

ICS MOU for 18/19 agreed by CCG Governing Body September 2018 with challenging deliverables; separate ICS and CCG operatingplans previously agreed for 2018/19.

Risk Proximity: (how soon

could it materialise?)


Feb-19

Activity run rates will not reduce to optimum desired levels against planning trajectories informed by national

benchmarks

(1) Additional risk cost pressure through Frimley Health will materialise above existing forecasts

(2) Further cost pressure on Buckinghamshire Healthcare NHS Trust through increased activity which could

impact system partners

(3) Further pressures from other acute providers (predominantly London, Oxford University Hospitals NHS

Foundation Trust and Milton Keynes University Hospital NHS Foundation Trust)

(4) non-compliance with statutory responsibilities

(5) non-receipt of Commissioning Sustainability Fund (CSF) and Provider Sustainability Fund (PSF) monies

from NHS England

(6) Implications for ICS system control total

(7) Impact on Patient Experience

(8) Potential for special measures

Strategic Objective: Better Health in Bucks Clinical Lead

(Risk Owner)Dr Raj

BajwaTo commission high quality services that are safe, accessible to all and achieve good patient outcomes for all

Corporate Objectives 2018/19:

Deliver the system FRP in 18/19 and achieve financial recovery and a sustainable ICS by April 2020

Manage capacity, demand and clinical variation using a population health management approach so that patient flow is safelyoptimised, equitable across boundaries and the NHS constitutional standards are met in accordance with planning guidance

There will always be an inherent risk of activity above projected levels given transient population and PBRcontracts with providers.

Outturn assumptions broadly agreed with Frimley. Significant progress in non-elective demandmanagement schemes. Ongoing review and mitigations, including with London providers.

0

5

10

15

20

25


AcceptableCurrent

25

Managerial

Lead

(Delegated

Owner)

Gary

Heneage

IF

THEN

LEADING

TO

Date Opened Oct-18







Internal Chief FinanceOfficer







Chief FinanceOfficer

Ongoing Chief FinanceOfficer

OngoingDescription (new if red italics) Description (new if red italics)

1) As described within QIPP Audit and Recovery Plan 1) As described within QIPP Audit and Recovery Plan

1) Routine ongoing monitoring through CCG committee structure including Finance Committee (risksand mitigations described within Finance Report)

2) Finance Committee minutes (reported in public)3) Internal audit of QIPP provided reasonable positive assurance

Description (new if red italics)

Financial deficit position with need to identify further QIPP savings to offset

Description (new if red italics)

1) CCG QIPP Audit and Recovery PlanDescription (new if red italics; must also indicate whether internal or external)

Risk Proximity: (how soon could

it materialise?)

Description (new if red italics; must also indicate whether internal or external)

Strategic Objective: Sustainability within Buckinghamshire



Manage capacity, demand and clinical variation using a population health management approach so that patient flow is safelyoptimised, equitable across boundaries and the NHS constitutional standards are met in accordance with planning guidance


Risk

Definition:The Quality, Innovation, Productivity and Prevention (QIPP) programme is unable to deliver its end of year cost

reduction estimates and further QIPP is not identified to meet further pressures

this will contribute to the deficit outturn position for the CCG resulting from unaffordability


(2) non-receipt of Commissioning Sustainability Fund (CSF) monies from NHS England


(4) Impact on planning a balanced outturn for future years


Date last

reviewed

Feb-19

To contribute to the delivery of a financially sustainable health and care economy that achieves value formoney and encourages innovation

Clinical Lead

(Risk Owner)Dr Raj

Bajwa

Consequence remains potentially high given the value but CCG can reduce likelihood through management of theQIPP programme.

QIPP reporting broadly on plan with regular QIPP clinics in place and detailed monthly reporting of QIPPdelivery.

0

5

10

15

20

25


AcceptableCurrent

26

Managerial

Lead

(Delegated

Owner)

Gary

Heneage

IF

THEN

LEADING

TO

Date Opened Oct-18







Internal Chief Finance Officer







Chief Finance Officer

Ongoing Chief Finance Officer

Ongoing1) As described within Financial Recovery Plan. Detailed sensitivity and run rate analysis undertaken on a monthly basis.

1) As described within Financial Recovery Plan


1) Routine ongoing monitoring through CCG committee structure including Finance Committee


2) Finance Committee minutes (reported in public)

1) CCG Financial Recovery Plan with specific section on risks and mitigations

Risk

Definition:Providers exceed activity run rate projections incorporated into block or PBR contracts at end of the financial

year

Date last

reviewed

Financial deficit position with need to identify further QIPP savings to offset Risk Proximity: (how soon could it

materialise?)


Feb-19

this will contribute to deficit outturn position for the CCG resulting from unaffordability


(2) non-receipt of Commissioning Sustainability Fund (CSF) and Provider Sustainability Fund (PSF) monies

from NHS England


(4) Impact on planning a balanced outturn for future years


Strategic Objective: Sustainability within Buckinghamshire Clinical Lead

(Risk Owner)Dr Raj

BajwaTo contribute to the delivery of a financially sustainable health and care economy that achieves value for money and encourages innovationCorporate Objectives 2018/19:


Manage capacity, demand and clinical variation using a population health management approach so that patient flow is safely optimised, equitable across boundaries and the NHS constitutional standards are met in accordance with planning guidance


Consequence remains potentially high given the value but CCG can reduce likelihood through management of the Financial Recovery Plan.

At Month 7 risks were in balance; and the CCG continues to forecast on plan. but has used a£0.5m of its contingency.

0

5

10

15

20

25

AcceptableCurrent

27

Managerial

Lead

(Delegated

Owner)

Nicola

Lester

IF

THEN

LEADING

TO

Date Opened Oct-18







Internal Director ofTransformation

Director ofTransformation

15th Feb 2019

15th Feb 2018

Ongoing

Ongoing

Ongoing



Internal Director ofTransformation


15th Feb 2019

15th Feb 2018

Ongoing

Ongoing

Ongoing




15th Feb 2019

15th Feb 2018

Ongoing

Ongoing


15th Feb 2019

15th Feb 2018

Ongoing

Ongoing

Ongoing

a) Matrix of all roles across the organisation ranked as those which are statutory, those which arebusiness critical and those which are key supporting roles, along with agreed principles for action ateach level should any of them become vacant.b) Succession plan for all statutory and business critical rolesc) Vacancy impact assessment as soon as notice is given for any roled) Review of Vacancy Impact Assessments by Directors

a) Matrix of all roles across the organisation ranked as those which arestatutory, those which are business critical and those which are keysupporting roles, along with agreed principles for action at each levelshould any of them become vacant.b) Succession plan for all statutory and business critical rolesc) Vacancy impact assessment as soon as notice is given for any roled) Review of Vacancy Impact Assessments by Directors


a) Review of Vacancy Impact Assessments by Directorsb) Monthly Workforce Performance Dashboard from ConsultHR to Director of Transformationc) Quarterly HR Report to Executive Committee



a) Matrix of all roles across the organisation ranked as those which are statutory, those which arebusiness critical and those which are key supporting roles, along with agreed principles for action ateach level should any of them become vacant.b) Succession plan for all statutory and business critical rolesc) Vacancy impact assessment as soon as notice is given for any role


Risk Definition: The CCG is unable to maintain effective staffing levels at any time Date last

reviewed

Financial deficit position with need to identify further QIPP savings to offset this. Subsequent to NHSE letter of 23rd Nov 2018,

further targeted reduction of management and administration costs of 20% are expected from all CCGs by 2020/21.

Risk Proximity: (how soon could it

materialise?)


Dec-18

Capacity or capability to discharge its commissioning functions will be affected


(2) Reduced motivation for remaining CCG staff through increased workload/pressure

Strategic Objective: Leadership across Bucks Clinical Lead

(Risk Owner)Dr Raj

BajwaTo promote equity as an employer and as clinical commissionersCorporate Objectives 2018/19:

Manage capacity, demand and clinical variation using a population health management approach so that patient flow is safely optimised,equitable across boundaries and the NHS constitutional standards are met in accordance with planning guidance

A risk of staff leaving remains, but controls and assurances will ensure effective contingency plans are in place,especially if holders of statutory roles were to leave the CCG

Named CCG HR Lead in place with an appropriate and effective series of controls and assurances in place

0

5

10

15

20

25


AcceptableCurrent

28

Clinical Lead

(Risk Owner)Dr Karen

West

IF:

THEN:

LEADING

TO:

Date Opened Oct-18

Risk Cause: Immediate



Red Initial 4 4 16Amber Current 3 4 12Amber Acceptable 3 4 12 Rationale for Acceptable Score:



InternalExternalInternal/External



Internal / external Ongoing

External

Internal



Ongoing Ongoing

Ongoing

Ongoing

Associate Directorsof Contracts &Performance /Quality andSafeguarding

Associate Directorof Quality andSafeguarding

c) Peer comparison against similar provider performance

d) Less direct influence on providers for whom we are not leadprovider and therefore reliant on assurances offered by leadcommissioners.


a) Delay in the provision of data to provide assurance due toprocesses and complexity for these to be completed

b) Updated quarterly reports received from NHSE b) Ensuring recovery plans are robust and delivering improvementsexpected.c) Sharing of good practice and identification of potential 'buddies' toenable improvement

d) Quality visits & audits 3) Undertaken in line with agreed annual programme and furtheradhoc activity when required


a) Focus on under performing indicators, where leads are responsible for developing b)Remedial Action Plan (RAP) with the appropriate provider

1) Monitor RAPs (Rapid Action Plans)

c) Request for support from NHS England 2) When required

Strategic Objective: Better Health in Buckinghamshire

To commission high quality services that are safe, accessible to all and achieve good patient outcomesfor all

a) Monitoring through Contract management and CQRM meetings with providers

Challenged performance against national constitutional standards. Providers have to still control. Consequencehigh.

Risk Proximity: (how soon could

it materialise?)

2) Reported to Quality & Performance Committee on a quarterly basis3) Assurance made to CCG Governing Body through Quality & Performance report


Director ofCommissioning &Delivery

1) Each indicator has a responsible lead

Managerial

Lead

(Delegated

Owner)

Debbie

RichardsCorporate Objectives 2018/19: Manage capacity, demand and clinical variation using a population health managementapproach so that patient flow is safely optimised, equitable across boundaries and the NHS constitutional standards are metin accordance with planning guidance, Support delivery of the Five Year Forward Views for New Models of Care, PrimaryCare and Mental Health for improved outcomes for patients

Risk

Definition:Mar-19

CCG rating would be affected (likely reduced)


(2) NHS England additional scrutiny.

(3) Non-compliance with quality premium

(4) Impact on Patient Experience

CCG Improvement Assessment Framework standards (on quality and performance) have not been met

when measured at the end of the financial year

Date last

reviewed



Ability to risk assess/analyse gap between current position andframework when issued by NHS England mid-year.

Director ofCommissioning andDelivery

Ongoing

Achievement of all standards and improvement against thresholds

Majority of IAF indicators are compliant, where performance or quality standards have not been achieved oroutside of the NHSE thresholds these are under focus of the appropriate CCG lead. Performance is reflected inthe monthly integrated Quality and Performance Report

0

5

10

15

20

25

AcceptableCurrent

29

Managerial

Lead

(Delegated

Owner)

Robert

Majilton

IF

THEN

LEADING TO Date Opened Oct-18

Risk

Cause:

Financial Year End



Initial 3 4 12Current 3 4 12Acceptable 2 4 8

Rationale for Acceptable Score:



Internal Relevant Director Deputy Chief Officer Apr-19



Internal Relevant Director Executive Mar-19




Regular monitoring of delivery and reporting on operating plan milestones Development of planning for 2019/20


Regular monitoring of delivery and reporting on operating plan milestones Quarterly report on progress against the operating plan delivery

Risk

Definition:The CCG is unable to deliver the requirements stipulated within the Five Year Forward View for New

Models of Care, Primary Care and Mental Health

Date last

reviewed

Operational plan agreed for 2018/19 which sets out delivery expected in year for the5YFV.

Risk Proximity: (how

soon could it

materialise?)


Mar-19

The expected benefits will not be delivered

(1) A disjointed approach to system transformation and delivery

(2) Not delivering the benefits and improved outcomes set out in the system plans

Strategic Objective: Better Care for Bucks Clinical Lead

(Risk Owner)Dr Becky

Mallard-

Smith, Dr

Karen West

To commission personalised, high value integrated care in the right place at the right time


Support delivery of the Five Year Forward Views for New Models of Care, Primary Care and Mental Health for improved outcomes forpatients

Operational plan delivery and link to system wide transformation is monitored. Key areas of the5YFV are progressing whilst there remain some on-going risks around implementation and the5YFV plan is being refreshed as part of the long term NHS plan for the next 5 years.

0

5

10

15

20

25

AcceptableCurrent

30

Risk Title Risk Causes Risk Description (IF) Risk Effect (THEN) Consequence (LEADING TO) Project Risk Owner

Delegated Risk Owner

Corporate Risk Owner RiskBaseline

Score

Risk Score After

Mitigation

Corporate Risk Score

Reasoning for Current Score Risk Proximity Controls & Assurances in Place Actions Required

Quality and safeguardingCompliance with statutory timescales for completion of Looked After Children (LAC) assessments

Current compliance with Initial Health assessments, review health assessments and health summaries for Looked After Children not meeting statutory timescales

At entry to care system, initial health assessments must be undertaken within 20 days of notification, and thereafter annual for over 5s, 6 monthly for under 5s)

A recent Ofsted inspection also identified the lack of evidence of statutory duty to supply care leavers (aged 16 and 17) with health summaries

the CCG is unable to evidence that its commissioned provider for Looked After Children health assessments has met statutory requirements

the CCG will be unable to provide assurance that the commissioned provider has met its statutory obligations

(1) Failure to deliver on keyrecommendations of Children’sServices Improvement Plan(given services under statutorydirection following Ofsted re-inspection and rating ofinadequate)(2) Poor patient experience(3) Unidentified health needs notaddressed in a timely andeffective manner(4) Increased scrutiny fromexternal stakeholders includingNHS England

Debbie Richards

Gilly Attree Debbie Richards 20 16 16 Performance recovery evident but needs to be maintained and sustained. IHAs Nov 83% (Oct 67%); RHAs - backlog clearance plan agreed and on track to be completed by March; Health summaries 100% completed for 18/19 and plan now being implemented for 16/17 & 18/19 care leavers to be completed by June

Immediate Controls:(1) Joint Action Plan in place with Director escalation calls when required(2) Regular meetings held to identify issues and resolutions (monthly operationaland monthly performance meetings), outside constituted committeearrangements).(3) Commissioner support provided - joint commissioners have worked with theLAC health provider to support improvements in the timeliness of meeting thestatutory requirements for health summaries and health assessments. Thecommissioners are also supporting the Local Authority to consider how theirinternal systems can be amended to ensure effective joint working.(4) Corporate Parenting Panel scrutinises the LAC activity data from both theLocal Authority and Buckinghamshire healthcare NHS trust and provides robustchallenge.

Assurances: (1) Two weekly activity reports submitted to monthly operational andperformance meetings.(2) Minutes from operational and performance meetings provided for assuranceto Corporate Parenting Panel via single assurance report(3) Minutes from Corporate Parenting Panel (accountable to the SafeguardingChildren's Board) are published online

None other than those already stipulated within the Joint Action Plan.

Buckinghamshire Transforming Care Partnership (TCP) Cost Pressures

The requirement of the TCP plan is that match funding for the transition and capital funding is made available from NHSE. The plan lists what funding we feel will be needed to deliver on all the components in the plan.

If NHS England do not transfer TCP funding (ongoing)

then annual costs:

• £1m additional costpressure to CCG

Increased cost pressure across the system - the costs of new individual packages of care will rise gradually, in line with the TCP’s inpatient trajectory, but with sharp increases when the longer stay patients are discharged into more complex care packages. This will result in a gap between savings from inpatient care on the one hand and new community investment on the other

Gary Heneage

Debbie Richards

Gary Heneage 16 16 16 Differences between additional costs for the new model, CLDT and care packages, and funds released from bed closures is understood. The difference will need to be met through a combination of national funding opportunities and reconfiguring existing local resources across the whole system to work more effectively.

However, NHSE are still to provide clarity on what monies will be released from spec com inpatient beds to support repatriation. There is no additional funds for investment and we have identified as a system a growing funding gap for this cohort. This will increase cost pressures on the system. Clarity from NHSE is being sought

Immediate Controls:The CCG, through the reduction of inpatient beds, funded the enhancements to the existing Community Learning Disability Team (CLDT). The enhancements are derived from the new service model, with more staff having been recruited to enable the delivery of increased and more robust community support.

We have set out controls that advise NHSE of the issues of Bucks TCP not getting any transformation funding. The assurances are the constant updating and reviewing of our finance plans to NHSE to highlight the issues that this programme of work is not cost neutral and will continue to be a cost pressure to the system. This is a national issue.

Control 1: The CCG and local authority have made plans/assumptions about the funding for individual packages of care for those long-stay and out of area patients, through an aligned S117 budget.Control 2: NHSE national LD programme team have requested that all TCPs submit revised finance plans January 2017 and the cost pressures have been included in the revised plan. Update 07/08 a revised plan was submitted in May and again in June and July 2017 following feedback from NHSE national team.Control 3: CCG/BCC will not sign off plan until funding is identified. CFO refuses to sign off the plan. EXECUTIVE COMMITTEE REVIEW COMMENT 28.02.19: Continued discussions with NHS England during early March 2019 as part of the annual planning round.

Assurances: Reporting to NHS England on position; flagged as a risk during planning process. Detail is also included in the Finance Report reported to the Governing Body and its committees.

No other than description under assurances

Increased Non Elective short stay activity

Increase in non-elective activity across all providers especially with regard to short stay admissions.

The CCG is unable to address the identified growth in Non Elective activity

Then we will have PbR over-performance on some contracts and may be unable to deliver QIPP saving targets for 18/19.

Leading to a follow on impact for 2019/20 QIPP targets.

The quality, safety and patient experience will be negatively impacted in relation to the appropriateness of short stay admissions, especially for those of less than 1 hours duration.

Debbie Richards

Gary Passaway

Debbie Richards 20 16 16 Activity levels to date in year this financial year have shown no decrease on 17/18 baselines; NEL Demand Management programme in place and monitored through UCDB. South-facing clinician and Project Manager now in post

Immediate Controls:1. Ongoing analysis of Non elective activity to identify themes and trends.2. The BCCG Associate Director Contracts and Performance- attends ContractsPerformance meetings and Finance activity meetings for Frimley NHSFT.3. NEL Delivery Group is in place with specific programme of work, providingweekly reporting to facilitate timely responsiveness to actions and data reported.

Assurances:1. Contract Management - weekly reporting from NEL Delivery Group.2. Clinical Management - a number of committees discusses the controls andassurances to mitigate this risk though standing items.

Clinical Management- A&E/UEC delivery board must discuss the controls and assurances to mitigate this risk.

EXISTING RISKS AT OR ABOVE ESCALATION THRESHOLD FOR CORPORATE RISK SCORE (12+)

CORPORATE RISK REGISTER: FEBRUARY 2019 Governing Body escalations only

31

MEETING: Governing Body AGENDA ITEM: 7b DATE: 14 March 2019 TITLE: Process for Approval of Annual Accounts and Annual Report for

the year 2018-19 AUTHOR: Alan Cadman, Deputy Chief Finance Officer LEAD DIRECTOR: Gary Heneage, Chief Finance Officer Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information For Ratification Summary of Purpose and Scope of Report: The purpose of this paper is to request the Governing Body to agree delegated authority to approve the Draft accounts and annual report to the Audit committee at their meeting on the 22 May 2019 and for final approval of any changes post Audit Committee to the Chairs, Chairs of the Audit Committee, Chief Officer and Chief Finance Officer on behalf of the Governing Body. Under the CCG’s Scheme of Reservation & Delegation approval of the annual report and accounts is delegated to the audit committee. Under the audit committee terms of reference the audit committee will review the annual report and financial statements before submission to the governing body. The National Annual Reporting guidance requires Governing Bodies to approve the final Annual Report and Accounts. This paper clarifies the process for approval of the annual accounts and report to be submitted by 9.00am on the 29 May 2019. Due to the deadline for the submission of the final accounts and annual report to the Department of Health (29 May 2019) and its proximity to the date by which the preparation and audit of these documents will be completed, it is proposed that the Governing Body agree to delegate authority to approve the final accounts and annual report to the Audit Committee at their meeting on the 22 May 2019. Given the tight timetable for auditing the accounts there may be a requirement for adjustments post review by the Audit Committee. It is proposed that any such changes be approved by the Chairs, Chairs of the Audit Committee, Chief Officer and Chief Finance Officer on behalf of the Governing Body taking advice from the Auditors and other members of the Audit Committee. Such approval may be made virtually.

32

There are specific Certificates and Statements which are required to be signed by the Chief Officer (as Accountable Officer) and Chief Finance Officer.

The Annual Report and Accounts are then published on the CCG website and presented to an Annual General Meeting to take place in September 2018.

Key dates By 9.00AM, Wednesday 24 April 2019 • Draft Annual report and accounts• ISFE consistency statement & supporting data collection templates• Head of Internal Audit Opinion

By 9.00AM, Wednesday 29 May 2019 • Full Audited and signed Annual Report & accounts, approved by the Governing Body• ISFE consistency statement & supporting data collection templates• External audit completion report•By 17.00 Noon, Friday 7 June 2019• Annual report and accounts in full on public website

By 30 September 2019 Hold a public meeting at which the Annual report & accounts are presented.


No conflict identified Conflict noted, conflicted party can participate in discussion but not decision (see below) Conflict noted, conflicted party can remain but not participate in discussion (see below) Conflicted party is excluded from discussion (see below) Governance assurance (see below)

Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all

Better Care for Bucks – to commission personalised, high value integrated care in the right place at the right time

Better Care for Bucks – to ensure local people and stakeholders have a greater influence on the services we commission

Sustainability within Bucks – to contribute to the delivery of a financially sustainable health and care economy that achieves value for money and encourages innovation

Leadership across Bucks – to promote equity as an employer and as clinical commissioners



Equality Quality

33

Privacy Financial Risks Statutory/Legal Prior consideration Committees /Forums/Groups

Executive Committee, Audit and Finance Committees


Not applicable

Supporting Papers: N/A

34

MEETING: Governing Body AGENDA ITEM: 7c DATE: 14 March 2019 TITLE: CCG/ICS draft Operating Plan 2019/20. AUTHOR: Dr Noel Burkett, Head of Portfolio Office, Buckinghamshire Integrated

Care System LEAD DIRECTOR: Robert Majilton, Deputy Chief Officer LINK TO RISKS: Governing

Body Assurance Framework

GBAF 3 The Quality, Innovation, Productivity and Prevention (QIPP) programme is unable to deliver its end of year cost reduction estimates and further QIPP is not identified to meet further pressures


No direct link



The Governing Body is asked to APPROVE the draft CCG/ICS Operating Plan for 2019/20.

We are required by NHS England to complete an operations plan by 4 April 2019. We have integrated the ICS and CCG Operations Plan into one plan for 19/20. Linked to this document is the plan for review and agreement at this point by the Governing Body.



Authority is held by the CCG Governing Body for: • Approval of the CCG's operating structure• Agree that the CCG's commissioning plans are aligned with the CCG's strategy• Approval of the CCG's commissioning plan

Source: CCG Constitution - APPENDIX F1 - Scheme of Reservation and Delegation - committees, Chair, Accountable Officer, Deputy Accountable Officer and Chief Finance

35



Officer. Conflicts of Interest: (please tick accordingly) No conflict identified Conflict noted, conflicted party can participate in discussion and decision (see below) Conflict noted, conflicted party can participate in discussion but not decision (see below) Conflict noted, conflicted party can remain but not participate in discussion (see below) Conflicted party is excluded from discussion (see below) Governance assurance (see below) Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all





Governance requirements: (Please tick each box as is relevant to the paper) Governance Element Y N N/A Comments/Summary Patient & Public Involvement

Equality Quality Privacy Financial Risks Statutory/Legal Prior consideration Committees /Forums/Groups


Supporting Papers: https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2018/05/07c.-ICS-Ops-Plan-8-Mar-V1.0.pdf

36



MEETING: Governing Body AGENDA ITEM: 09. DATE: 14 March 2019 TITLE: Annual Review of Terms of Reference and scheme of reservation and

delegation – Primary Care Commissioning Committee AUTHOR: Russell Carpenter, Head of Governance/Board Secretary LEAD DIRECTOR: Robert Majilton, Deputy Chief Officer



The Governing Body is asked to: 1. RATIFY reviewed and updated terms of reference for 2019/20 in line with governance

best practice.2. NOTE recommendation in relation to clinical membership and proposed amendments

to terms of reference.3. NOTE feedback from Primary Care Commissioning Committee in approving

amendments.


Governing Body ratifies the terms of reference for its sub committees


No conflict identified Conflict noted, conflicted party can participate in discussion and decision (see below) Conflict noted, conflicted party can participate in discussion but not decision (see below) Conflict noted, conflicted party can remain but not participate in discussion (see below) Conflicted party is excluded from discussion (see below) Governance assurance (see below) Not applicable for this paper


Better Care for Bucks – to commission personalised, high value integrated care in

37

the right place at the right time Better Care for Bucks – to ensure local people and stakeholders have a greater influence on the services we commission Sustainability within Bucks – to contribute to the delivery of a financially sustainable health and care economy that achieves value for money and encourages innovation




Equality Quality Financial Risks Statutory/Legal Committee must have terms of reference as a

constituted committee Prior consideration Committees /Forums/Groups

Review and approval by Primary Care Commissioning Committee 7 march 2019


Named member GPs who are standing invitees

Supporting Papers:

Appendix A – Terms of Reference as attached.

38

Annual Review of Terms of Reference and schemes of reservation and delegation

Introduction The Committee should consider if its terms of reference remain fit for purpose at least once a year. If Committee members agree that any changes to the Terms of Reference should be made, in line with the CCG’s Constitution these changes should be recommended to Governing Body for formal ratification.

Previous review Terms of Reference for the Primary Care Commissioning Committee were previously reviewed and approved by the Primary Care Commissioning Committee on 01/03/2018 and ratified by the Governing Body on 14/06/2018.

Current review and amendments proposed Annual review at February 2019 has prompted the following amendments:

1. Standing invitees of PCCC updated to include Associate Director of Digital andIM&T.

2. Clear instruction that quorum relates to delegated decision making only.3. Statement regarding quorum in the event of voting members being unable to attend.4. All previous members who have no voting rights referred to as “standing invitees”

rather than “members” – both in main body and appendix.5. Previous statement under membership removed: If GP members need to withdraw

from decision making for conflicts of interest reasons; the Committee would still bequorate with a Lay and executive majority. This is on the basis that these membersare standing invitees and have no voting rights for delegated decisions.

Additional proposed amendments in relation to clinical membership are described below.

Scheme of reservation and delegation The scheme previously cited a number of financial values, e.g. up to 100k, but it was not clear whether this relates to annual value, composite value over the length of the contract, or change in value on an annual or other timescale basis. This has been strengthened to state that authority is based on annual value.

Oxfordshire benchmark – award of primary care contracts GMS, PMS, APMS As part of the review, the scheme has also been benchmarked against NHS Oxfordshire CCG’s equivalent arrangements. It was identified that Oxfordshire has delegated authority based on change in value.

There remain some differences between the two CCGs in role titles and levels of authority between individuals and Committee authority. However we are now consistent on both the thresholds and intent that contract award decisions are based on change in annual contract value rather than cumulative or annual contract cost.

39

Changes to Buckinghamshire’s proposed CCG Constitution Appendix F1: Scheme of reservation and delegation - committees, Chair, AO, Deputy AO and CFO No Decision P7 Approve and ratify proposals for the procurement of primary care services under co-

commissioning arrangements: a. Procurement of new practice provision; (up to £100k only per annum) b. Discretionary payment (e.g. returner/retainer schemes); (up to £100k only per annum) c. Decisions in relation to the management of poorly performing GP practices and including, without limitation, decisions and liaison with the CQC where the CQC has reported non-compliance with standards (but excluding any decisions in relation to the performers list); (up to £100k only per annum) d. Premises Costs Directions functions. (up to £100k only per annum)

P7a Approve and ratify proposals for the procurement of primary care services under co-commissioning arrangements: a. The award of GMS, PMS and APMS contracts for primary care services to some or all of the CCG population where they are within CCG budgets (excluding GP contracts for which core contract approval/monitoring and appraisal sits with NHS England Area Team; This includes: the design of PMS and APMS contracts; and monitoring of contracts; taking contractual action such as issuing branch/remedial notices, and removing a contract); (over £50k per annum change +/-)

CCG Constitution Appendix F3 - individual delegations Non-Pay Revenue and Capital Expenditure (excluding leases) Requisitioning/Ordering/Payment of Goods and Services

Value limit Committee or other organisation

CCG Management Directors (*6) Relevant Associate Director or Head of

Chief Officer

Deputy Chief Officer

Chief Finance Officer

Director of Transformation

Primary Care contracts Notes: this authority relates only to: Approve and ratify proposals for the procurement of primary care services under commissioning arrangements within agreed and approved budgets: The award of GMS, PMS and APMS contracts for primary care services to some or all of the CCG population

Up to £50,000 per

annum change +/-

X AD Primary Care Commissioning

Between £50,000 per

annum up to

£500,000 per annum change +/-

(1) PCCC (2) Primary Care Operational Group

X X

X

Over £500,000 PCCC

Over £500,000

Governing Body (some decisions)*

40

*Reasons for escalation to Governing Body could relate to:• Conflicts of interest for member GPs, whilst noting that member GPs are standing

invitees to Primary Commissioning Committee as opposed on having voting rightson decision in which they may be materially financially conflicted.

• There may also be reasons of risk or reputation that might prompt escalation.

Recommendations 1. RATIFY reviewed and updated terms of reference for 2019/20 in line with

governance best practice.

Clinical representation within the membership As part of the Constitution approval process with NHS England leading to a formal membership virtual vote to adopt changes in March 2019, there has been a check and challenge in respect of clinical representation, both membership and for quorum purposes.

It was identified that the terms of reference could be strengthened in this respect, especially given member GPs as standing invitees only. It was identified that under the previous quorum, decisions could be transacted without any clinical involvement, depending on how quorum is reached.

It was initially considered that the terms of reference be strengthened under quorum to include “In order to ensure appropriate clinical involvement at least one voting member be a registered clinician”. This would therefore require either the Accountable Officer or Director of Transformation to be present to transact decisions based on current membership.

NHS England guidance specifies that the Committee must have a lay/executive majority, which it already does. At the time of the first primary care commissioning delegations, the then legal advisers to NHS England advised that the Secondary Care Doctor and Registered Nurse should be included in the clinical minority. Clinical involvement is not otherwise mandated. At present, neither role has membership, either majority or minority. It has been considered whether to expand the clinical membership on this basis. It is concluded there would be no need to do so.

Recommendations Taking into account the above, the following is recommended as a compromise arrangement (and rendering irrelevant the above point about at least one voting member as a registered clinician):

1. The Primary Care Commissioning retains a right to co-opt additional clinicalrepresentation with suitable skills and experience, either voting membership orstanding invitee, to provide objective input and ensure its delegated authority fordecision making is effective. Alternatively independent clinical opinion may besought (especially where conflicts of interest are identified) and will be specified inpapers accordingly.

2. Member GPs as standing invitees have a valued role in their clinical opinion ofproposals prior to decisions. Appropriateness of their input to be judged on a caseby case basis by the Committee Chair depending on whether they are materiallyconflicted in the outcome of a commissioning decision.

Recommendation 2. NOTE recommendation in relation to clinical membership and proposed

amendments to terms of reference.

41

Feedback from review and approval by Primary Care Commissioning Committee (PCCC) 7 March 2019. In approving amendments, the Sub-Committee has requested that “with suitable skills and experience” is added to ensure that any co-opted individual for purpose of discussion and decision on matters is appropriately qualified. The paper provided also referred to some decisions to award could be escalated to Governing Body for decision, though did not specify the type of decisions to which this could relate. It was discussed that this could relate to:

• Conflicts of interest for member GPs, whilst noting that member GPs are standing invitees to Primary Commissioning Committee as opposed on having voting rights on decision in which they may be materially financially conflicted.

• There may also be reasons of risk or reputation that might prompt escalation. It was agreed to further amend the scheme of delegation to reflect these points. Recommendation

3. NOTE feedback from Primary Care Commissioning Committee.

42

Appendix A – Primary Commissioning Committee Terms of Reference

Terms of Reference for Delegated Commissioning Arrangements including Scheme of Delegation and

Primary Care Commissioning Committee Document Version Date Version

Number Description of Changes Edited by

10.03.15 2.1 Watermark added Change to paragraph 13 regarding number of votes

Louise Smith

11.03.15 2.2 Reference to Thames Valley area team removed and replaced with NHS England. Full Acronyms explained Change to secretariat from NHSE to AVCCG Change to membership section to read Chief Officer or Chief Finance Officer

Louise Smith

Elaine Baldwin

11.03.15 NOTE Sent to Graham Jackson for Chairs action and full Governing Body for approval of sign off. Sent to NHS England (South) as final version.

04.03.16 3.0 Document updated to delegated commissioning arrangements including scheme of delegation and Primary Care Commissioning Committee.

Elaine Baldwin

22.06.16 4.0 Document updated to take account of joint working arrangements between Aylesbury Vale and Chiltern CCGs.

Helen Delaitre

30.8.16 5.0 Document amended to include draft scheme of delegation at Schedule 4

Helen Delaitre

7.11.16 6.0 Document amended to include list of voting members, their deputies and deputising rights.

Helen Delaitre

11.2.17 7.0 Document amended to reflect Committee in Common arrangements starting April 2017.

Helen Delaitre

03.05.17 8.0 Document amended to reflect changes to membership of PCCC and to include 2017/18 MOU for Primary Medical Services Support for Delegated CCGs. ToRs reflect arrangements to make a CCG specific decision.

Wendy Newton/ Helen Delaitre/ Russell Carpenter

21.02.18 9.0 Document amended to reflect the formal merger of NHS Aylesbury Vale CCG and NHS Chiltern CCG and the name of the newly merged organisation (NHS Buckinghamshire CCG) with effect from 1 April 2018.

NHS Buckinghamshire will have a sole PCCC and

Wendy Newton

43

therefore PCCC will no longer be “meeting in common”. Membership of PCCC updated to reflect change in roles. Named individuals removed with membership only identifiable via designation. Removal of Schedule 1 – MOU without Appendices – which details the transitional arrangements for delegated commissioning between NHS England and the CCG – the transitional year end on 31 March 2018.

2.3.18 10.0 Clarification of voting member job titles in Section 1.7, further correction of job titles

Helen Delaitre

22.02.19 11.0 Associate Director of Digital and IM&T to become a standing invitee. Clear instruction that quoracy relates to delegated decision making only. Statement regarding quoracy in the event of voting members being unable to attend the meeting. Removal of “if GP members need to withdraw from decision making for conflicts of interest reasons; the Committee would still need to be quorate with a Lay and executive” This is on the basis that those members are standing invitees and have no voting rights for delegated decisions.

Wendy Newton

44

Introduction Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014 that NHS England was inviting Clinical Commissioning Groups (CCGs) to expand their role in primary care commissioning and to submit expressions of interest setting out the CCG’s preference for how it would like to exercise expanded primary medical care commissioning functions. One option available was that NHS England would delegate the exercise of certain specified primary care commissioning functions to a CCG.

1. In accordance with its statutory powers under section 13Z of the National Health Service Act 2006 (as amended), NHS England has delegated the exercise of the functions specified in Schedule 1 to these Terms of Reference. The delegation is set out in Schedule 1.

2. The CCG has established the Primary Care Commissioning Committee (“Committee”). The

Committee will function as a corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers.

3. The Committee comprises representatives of the following bodies:

• The CCG • NHS England • Healthwatch Bucks • LMC • Health and Well Being Board

Statutory Framework

4. NHS England has delegated to the CCG authority to exercise the primary care commissioning functions set out in Schedule 1 in accordance with section 13Z of the NHS Act.

5. Arrangements made under section 13Z may be on such terms and conditions (including terms

as to payment) as may be agreed between the Board and the CCG. 6. Arrangements made under section 13Z do not affect the liability of NHS England for the

exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and including:

a) Management of conflicts of interest (section 14O);

b) Duty to promote the NHS Constitution (section 14P);

c) Duty to exercise its functions effectively, efficiently and economically (section 14Q);

d) Duty as to improvement in quality of services (section 14R);

45

e) Duty in relation to quality of primary medical services (section 14S);

f) Duties as to reducing inequalities (section 14T);

g) Duty to promote the involvement of each patient (section 14U);

h) Duty as to patient choice (section 14V);

i) Duty as to promoting integration (section 14Z1);

j) Public involvement and consultation (section 14Z2).

7. The CCG will also need to specifically, in respect of the delegated functions from NHS England,exercise those set out below:

• Duty to have regard to impact on services in certain areas (section 13O);• Duty as respects variation in provision of health services (section 13P).

8. The Committee is established as a committee of the Governing Body of the CCG in accordancewith Schedule 1A of the “NHS Act”.

9. The members acknowledge that the Committee is subject to any directions made by NHSEngland or by the Secretary of State.

Role of the Committee

10. The Committee is established in accordance with the above statutory provisions to enable themembers to make collective decisions on the review, planning and procurement of primary careservices under delegated authority from NHS England.

11. In performing its role, the Committee will exercise management of the functions in accordancewith the agreement entered into between NHS England and the CCG, which will sit alongsidethe delegation and terms of reference.

12. The functions of the Committee are undertaken in the context of a desire to promote increasedcommissioning to increase quality, efficiency, productivity and value for money and to removeadministrative barriers.

13. The role of the Committee shall be to carry out the functions relating to the commissioning ofprimary medical services under section 83 of the NHS Act.

14. This includes the following:

• GMS, PMS and APMS contracts (including the design of PMS and APMS contracts,monitoring of contracts, taking contractual action such as issuing branch/remedial notices,and removing a contract);

• Newly designed enhanced services (“Local Enhanced Services” and “Directed EnhancedServices”);

46

• Design of local incentive schemes as an alternative to the Quality Outcomes Framework(QOF);

• Decision making on whether to establish new GP practices in an area;

• Approving practice mergers; and

• Making decisions on ‘discretionary’ payments (e.g., returner/retainer schemes).

15. The CCG will also carry out the following activities:

a) To plan, including needs assessment, for primary care services in the CCG’s geographicalarea.

b) To undertake reviews of primary care services in the CCG’s geographical area.

c) To co-ordinate a common approach to the commissioning of primary care servicesgenerally.

d) To manage the budget for commissioning of primary care services in the CCG’sgeographical area.

e) To assist and support NHS England in discharging its duty under section13E of the NHS Act2006 (as amended by the Health and Social Care Act 2012) so far as relating to securingcontinuous improvement in the quality of primary medical services.

f) To undertake and deliver an estates strategy across the CCG’s geographical area.

Geographical coverage

16. The Committee will comprise NHS Buckinghamshire CCG. It will undertake the function ofNHS Buckinghamshire CCG commissioning primary medical services for theBuckinghamshire area, as defined within the Constitution.

Membership

The Chair of the PCCC should not also chair the Audit Committee.

The Chair of the Committee shall be a Lay member of the CCG Governing Body.

The Vice Chair of the Committee shall be a lay member of the CCG Governing Body and agreed by the Governing Body.

17. Voting Members of the Primary Care Commissioning Committee shall consist of:• Lay member (PCCC Chair)• Lay member (Deputy PCCC Chair)• Accountable Officer (Deputy is Deputy Accountable Officer)• Chief Finance Officer (Deputy is Deputy Chief Finance Office)

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• Director of Transformation (Deputy is Associate Director of Primary Care)• Associate Director of Quality and Safeguarding (Deputy is Head of Quality)

Standing Invittees • Invitation to a Healthwatch Bucks representative• Invitation to a Health and Wellbeing Board representative• Local Medical Committee representative• NHS England (South) representative• NHS Buckinghamshire CCG Clinical Director(s)• NHS Buckinghamshire CCG Clinical Chair• NHS Buckinghamshire CCG Associate Director of Primary Care• NHS Buckinghamshire CCG Associate Director of Digital and IM&T• Non-conflicted GPs from other CCGs• Additional Lay Members• Subject Matter experts (e.g. premises, workforce).

Provision will be made for the Committee to have the ability to call on additional lay members or CCG members when required, for example where the Committee would not be quorate because of a conflict of interest. It could also include GP representatives from other CCG areas and non-GP clinical representatives (such as the CCG secondary care specialist).

Meetings and Voting

18. The Committee will operate in accordance with the CCG’s Constitution, Standing Orders andPrime Financial Policies. The Secretary to the Committee will be responsible for giving notice ofmeetings. This will be accompanied by an agenda and supporting papers and sent to eachmember representative no later than 5 days before the date of the meeting. When the Chair ofthe Committee deems it necessary in light of the urgent circumstances to call a meeting at shortnotice, the notice period shall be such as s/he shall specify.

19. Each member of the Committee shall have one vote. The Committee shall reach decisions by asimple majority of members present, but with the Chair having a second and deciding vote, ifnecessary. However, the aim of the Committee will be to achieve consensus decision-makingwherever possible.

20. The Committee has delegated authority to take decisions in accordance with standing ordersand schemes of delegation (Schedule 4).

Quorum

21. Five members of the Committee must be present for the quorum to be established including:• At least two lay members or one lay member and the Associate Director Quality &

safeguarding; and• Either the Accountable Officer (AO) / Deputy Accountable Officer or the Chief Finance

Officer (CFO).

Quorum only relates to delegated authority for decision making.

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The Primary Care Commissioning retains a right to co-opt additional clinical representation

with suitable skills and experience, either voting membership or standing invitee, to provide

objective input and ensure its delegated authority for decision making is effective.

Alternatively independent clinical opinion may be sought (especially where conflicts of

interest are identified) and will be specified in papers accordingly.

Member GPs as standing invitees have a valued role in their clinical opinion of proposals prior to decisions. Appropriateness of their input to be judged on a case by case basis by the Committee Chair depending on whether they are materially conflicted in the outcome of a commissioning decision.

Where quorum may be affected by availability of voting members a pre-decision in advance is

preferable in order to minimise potential delay in decision making.

Frequency of Meetings

22. Meetings will take place in public on a quarterly basis.

23. Meetings of the Committee shall: a) be held in public, subject to the application of 23(b);

b) the Committee may resolve to exclude the public from a meeting that is open to the public

(whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.

24. Members of the Committee have a collective responsibility for the operation of the Committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view.

25. The Committee may delegate tasks to such individuals, sub-committees or individual members

as it shall see fit, provided that any such delegations are consistent with the parties’ relevant governance arrangements, are recorded in a scheme of delegation, are governed by terms of reference as appropriate and reflect appropriate arrangements for the management of conflicts of interest.

26. The Committee may call additional experts to attend meetings on an ad hoc basis to inform

discussions. 27. Members of the Committee shall respect confidentiality requirements as set out in the CCG’s

Constitution and relevant policies.

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28. The Committee will present its minutes to NHS England and to the Governing Body of the CCG each quarter for information.

29. The CCG will also comply with any reporting requirements set out in its constitution.

30. The terms of reference will be reviewed at least annually with final approval being sought from

the Governing Body. Amendments will be made, where appropriate, to reflect any updated national model terms of reference and local need.

Accountability of the Committee

31. The Committee to have delegated authority from the Governing Body: • To carry out the functions relating to the commissioning of primary medical services under

section 83 of the NHS Act. • To assist and support NHS England in discharging its duty under section 13E of the NHS

Act 2006 (as amended by the Health and Social Care Act 2012) so far as relating to securing continuous improvement in the quality of primary medical services.

• To work with NHS England to agree rules for areas such as the collection of data for national data sets, equivalent of what is collected under QOF and IT inter-operability.

• To comply with public procurement regulations and with statutory guidance on conflicts of interest.

• To consult with Local Medical Committee and demonstrate improved outcomes reduced inequalities and value for money when developing a local QOF scheme or DES.

• To approve the arrangements for discharging the group’s statutory duties associated with its GP practice commissioning functions, including but not limited to promoting the involvement of each patient, patient choice, reducing inequalities, improvement in the quality of services, obtaining appropriate advice and public engagement and consultation.

Procurement of Agreed Services The below is taken from the Next Steps in Primary Care Co-commissioning document for further guidance on this please see link below. https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/11/nxt-steps-pc-cocomms.pdf 32. The Committee must comply with public procurement regulations and with statutory guidance

on conflicts of interest. The committee may vary or renew existing contracts for primary care provision or award new ones, depending on local circumstances. If the committee fails to secure an adequate supply of high quality primary medical care, NHS England may direct the CCG to act.

33. If the Committee is found to have breached public procurement regulations and/or statutory guidance on conflicts of interest, Monitor may direct the CCG or NHS England to act. NHS England may, ultimately, revoke the CCG’s delegation. Any proposed new incentive schemes should be subject to consultation with the Local Medical Committee and be able to demonstrate improved outcomes, reduced inequalities and value for money.

Consistent with the NHS Five Year Forward View and working with CCGs, NHS England reserves the right to establish new national approaches and rules on expanding primary care provision – for example to tackle health inequalities.

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https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/11/nxt-steps-pc-cocomms.pdf

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/11/nxt-steps-pc-cocomms.pdf

Review of Terms of Reference

34. These terms of reference will be formally reviewed by the CCG in April of each year, following the year in which the Committee is created, and may be amended by mutual agreement at any time to reflect changes in circumstances which may arise.

35. The Committee will make decisions within the bounds of its remit.

36. The decisions of the Committee shall be binding on NHS England, and the CCG within the

scope of these TOR and the CCG’s Standing Orders.

Schedule 1 – List of Committee Members Schedule 2 – Primary Care Commissioning Committee Guidance Schedule 3 – Extract from Scheme of Delegation relating to Primary Care

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Schedule 1 List of Committee Members.

Voting members per CCG = 6. Each CCG has a separate deputy. ROLE Lay CCG NHS

England Voting Rights

CCG Accountable Officer (Deputy Accountable Officer)

X YES

Director of Transformation (Deputy – Associate Director of Primary Care)

X YES

Lay Member - PCCC Chair (Deputy Chair - Lay Member)

X YES

Lay Member (not including PCCC Chair)

X YES

Associate Director of Quality and Safeguarding (Deputy – Head of Quality)

X YES

Chief Finance Officer (Deputy – Deputy Chief Finance Officer)

X YES

Chief Executive Officer Local Medical Committee

NO

CCG Clinical Chair X NO Clinical Director X NO Associated Director of Primary Care X NO Health & Well Being Board Representative

NO

Healthwatch Bucks Representative X NO Contracts Manager - NHS England (South)

X NO

Assistant Head of Finance - NHS England (South)

X NO

Assistant Director of Digitalisation and IM&T

X NO

Non-conflicted GP’s from other CCG’s

NO

Additional Lay Members

X NO

Subject Matter experts (e.g. premises, workforce)

NO

Additional input ad hoc (e.g. data analyst, contracting etc.)

NO

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Schedule 2 – Primary Care Commissioning Committee Guidance “It is for CCGs to agree the full membership of their primary care commissioning committee. CCGs will be required to ensure that it is chaired by a lay member and have a lay and executive majority. Furthermore, in the interest of transparency and the mitigation of conflicts of interest, a local Health Watch representative and a local authority representative from the local Health and Wellbeing Board will have the right to join the delegated committee as standing invitees. Health Watch and Health and Wellbeing Boards are under no obligation to nominate a representative, but there would be significant mutual benefits from their involvement. For example, it would support alignment in decision making across the local health and social care system. CCGs will want to ensure that membership (including standing invitees) enables appropriate contribution from the range of stakeholders with whom they are required to work. Furthermore, it will be important to retain clinical involvement in a delegated committee arrangement to ensure the unique benefits of clinical commissioning are retained.”

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Schedule 3 – Extract from Scheme of Delegation Points to note:

• This set of reservations and delegations was ratified by the Governing Bodies on 22 May 2017

• Approval is limited to £100k for all decisions listed and delegated. Any decision above that threshold would need to be escalated to the Governing Body with a recommendation from the Primary Care Commissioning Committee.

• Where a decision relates to either an individual practice or award, or more than one practice or award, a separate decision would otherwise need to be taken and managed accordingly on when the delegated limit of £100k comes into effect. E.g. a decision to approve/award affecting 3 practices at £50k each is under the delegated limit individually, but over the delegated limit as a collective at £150,000k.

• However, for the avoidance of doubt, the approval limit of £100k will apply irrespective of the number of contracts or awards underneath.

• In relation to P8 below, most QOF payments are likely to routinely fall above the stated threshold, though this delegation gives a flexibility and opportunity for primary care commissioning committee decisions where it is deemed to be relevant.

No Policy Area Decision P1 PRIMARY CARE

COMMISSIONING Approve arrangements for the review, planning, and procurement of primary care services under delegated authority from NHS England. (up to £100k only)

P2 PRIMARY CARE COMMISSIONING

Approval of the arrangements for discharging the CCG’s responsibilities and duties associated with its primary care commissioning functions, including but not limited to promoting the involvement of each patient, patient choice, reducing inequalities, improvement in the quality of services, obtaining appropriate advice and public engagement and consultation, obtain advice from persons who taken together have a broad range of professional expertise and acting effectively, efficiently and economically. (up to £100k only)


Day to day decisions on provider performance management and risk management associated with Primary Care to provide robust assurance to the Governing Body and NHS England. (up to £100k only)


Approve and ratify Direct Awards (up to £100k only)

P5 STRATEGY AND PLANNING

Approve and ratify practice incentive schemes, having regard to guidance by the Secretary of State. Monitor and review any such schemes. (up to £100k only)


Approve the following primary care services: a. Primary medical care strategy; (up to £100k only) b. Planning primary medical care services (including needs assessment); (up to £100k only) c. Primary Care Estates Strategy; (up to £100k only) d. Premises improvement grants and capital developments; (up to £100k only) e. Practice mergers (up to £100k only)

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No Policy Area Decision P7 PRIMARY CARE

COMMISSIONING Approve and ratify proposals for the procurement of primary care services under co-commissioning arrangements: a. Procurement of new practice provision; (up to £100k only per annum) b. Discretionary payment (e.g. returner/retainer schemes); (up to £100k only per annum) c. Decisions in relation to the management of poorly performing GP practices and including, without limitation, decisions and liaison with the CQC where the CQC has reported non-compliance with standards (but excluding any decisions in relation to the performers list); (up to £100k only per annum) d. Premises Costs Directions functions. (up to £100k only per annum)

P7a PRIMARY CARE COMMISSIONING

Approve and ratify proposals for the procurement of primary care services under co-commissioning arrangements: a. The award of GMS, PMS and APMS contracts for primary care services to some or all of the CCG population where they are within CCG budgets (excluding GP contracts for which core contract approval/monitoring and appraisal sits with NHS England Area Team; This includes: the design of PMS and APMS contracts; and monitoring of contracts; taking contractual action such as issuing branch/remedial notices, and removing a contract); (over £50k per annum change +-)


Advise on or approve matters relating to primary care contracting within agreed levels, specifically in relation to commissioning Locally Commissioned Services, Quality Outcomes Framework (QOF - subject to allowances within NHS England's legal framework), Out of Hour services, Walk-in Centres (including home visits as required and for out of area registered patients); (up to £100k only)


Approval proposals for primary care support and development and any associated plans in connection with commissioning and performance monitoring and development within the remit of the CCG. (up to £100k only)

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MEETING: Governing Body AGENDA 9 DATE: 14 March 2019 TITLE: Chief Officer’s Report AUTHOR: Robert Majilton, Deputy Chief Officer LEAD DIRECTOR: Lou Patten, Chief Officer Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information For Ratification Summary of Purpose and Scope of Report: Update to Governing Body members Authority to make a decision – process and/or commissioning (if relevant) Not applicable – paper for assurance and not decision Conflicts of Interest: (please tick accordingly) No conflict identified Conflict noted, conflicted party can participate in discussion and decision (see below) Conflict noted, conflicted party can participate in discussion but not decision (see below) Conflict noted, conflicted party can remain but not participate in discussion (see below) Conflicted party is excluded from discussion (see below) Governance assurance (see below) Not applicable – paper for assurance and not decision Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all





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Equality Quality Privacy Financial Risks Statutory/Legal Prior consideration Committees /Forums/Groups


Supporting Papers: None

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Chief Officer Report and System Working Update – February 2019 1. Change of Commissioning Locality - Move of Waddesdon Surgery from Aylesbury

South Locality to Aylesbury North Locality. On the 24 January 2019 the Executive Committee was notified of this proposed move and notice given by the practice partners. The Executive Committee was minded to support it, as was the CCG Chair, subject to the localities themselves approving it. Approval by the localities took place at their meetings during February 2019, and so the move will take effect as of 1 April 2019. 2. National Leads day This took place w/c 4 February 2018 for the ten integrated care systems across England – this learning set will continue to give the national team good insights. There was a lot of discussion about primary care networks to introduce provider led leadership and deliver out of hospital services that we know we need. 3. STP & Commissioning development

There are ongoing discussions about which commissioning activities should be undertaken at different population sizes. We are reviewing what would be undertaken at county, across Buckinghamshire, Oxfordshire and Berkshire West (STP) scale and through specialist commissioning. A steering group has been established, chaired by Lou Patten and 3 workstreams to cover:

• Primary Care Services Commissioning – including areas not already delegated such as dentistry and pharmacy

• Specialist Services Commissioning • CCG Commissioning

For the first 2 the purpose is to determine how these function should be aligned to the STP and interface with county based commissioning For CCG commissioning there will be a focus on Buckinghamshire and Oxfordshire to determine what level commissioning and functions are undertaken, with Berkshire West CCG joining any arrangement that would benefit from being STP wide. The proposal is to use models elsewhere, particularly on a function basis, and to test these out with local commissioners (both clinical and managerial) and then use to test against a pathway approach (e.g. how it would work for Unplanned care or mental health). This will supported by a series of workshops with the first one planned for the 28th March. Locally we want this to be co-production with CCG staff (recognising their will be other stakeholders in this). To go alongside this we are in discussion with Thames Valley Leadership Academy on some development / OD support to staff to help with development personal and team resilience and leading through system change. An independent STP Chair one day a week is also being recruited. 4. ICS/NHSE Assurance meeting The meeting was positive with strong representation from across the ICS. As expected there were challenges around performance however the improvement in performance was recognised.

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NHSE articulated we are moving in a good direction but caveated that there was a lot of work ahead and we needed to ensure we are focused on key priorities / interventions that will make a difference. NHS offered additional support in conducting a system. In addition the CCG had its Q4 Integrated Assurance Framework assessment call on the 7 March including against the Quality of Leadership domains and is also submitting evidence around Engagement activities. 5. Planning, System & Place The first draft ICS Operating plan for 2019/20 was submitted on the 19th February (copy as item 7C) and this incorporates the CCG Operating plan, this was accompanied by a number of returns covering finance, activity and performance. A set of Key Lines of Enquiry have been received from NHSE and are currently being reviewed. The plan has been developed and will continue to be reviewed through system meetings (as it is the system wide plan).

6. Aylesbury Vale Garden Town & Planning – Update

Development of the thinking behind the Aylesbury Garden Town continues and a Health and Wellbeing work stream has been established. There was a workshop in January by Dr Gillman and the initial conclusions were:

• Public Health priorities should be considered when planning the Garden town • A number of research areas were identified which would enhance the current

evidence base and facilitate the planning of future activities and projects including: o Enhanced analyse of movement patterns and potential for new connections o Understanding why people don’t use facilities o Learning lessons from recent developments to identify what has and hasn’t

worked The workshop findings will be taken forward to identify a number of principles and future

projects for Health and Wellbeing for each of the 6 placemaking elements. The CCG continues to actively engage in a number of planning related matters,

particularly on primary care premises given its responsibilities as a delegated commissioner and has secured additional Primary Care estates expertise. The business case for Berryfields is continuing through the NHS England approval process.

It is recognised that there is an opportunity to better link our understanding of population

health and care needs both now and in the future with the planning of care and delivery, including infrastructure requirements, for that population and we are developing this approach to planning for future health and care needs with partners and through the Health and Wellbeing Board.

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MEETING: Governing Body AGENDA ITEM: 10 DATE: 14 March 2019 TITLE: Finance Report AUTHOR: Alan Cadman, Deputy Chief Finance Officer LEAD DIRECTOR: Gary Heneage, Chief Finance Officer Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information For Ratification Summary of Purpose and Scope of Report: The purpose of this report is to INFORM the Governing Body of the financial position for the Buckinghamshire CCG to the end of January 2019 (M10). The summary for M10 financial performance is as follows: At Month 10 the forecast position is an in year breakeven, after forecasting full receipt of CSF, plus the brought forward deficit from 17/18 of £3.3m. The CCG received an allocation of £5.4m in M7, and a further £4.6 in M10 for Q3 relating to CSF, reducing the in year deficit from £15.5m. The CCG has reflected risks of £16.0m into the FOT positions which are fully mitigated including the release of £2.4m contingency. The reported position is that the CCG is to achieve the plan deficit of £15.5m but has additional risks of £2.3m of which are fully mitigated to report a balanced net risk position. The CCG is reporting an YTD underspend of £31k and forecasts underspend of £3k. The reported forecast position reflects pressures that have developed in the Acute and Independent sectors - Frimley Health due to increased NEL activity, Oxford University Hospital due to high cost patient activity, and other providers (including the Independent sector) due to Elective activity (significant T&O pressure), SCAS relating to coding issues, and acuity of patients. The CCG submitted a £21.4m QIPP target to NHSE England on 30 April. At the end of Month 10 CCG is forecasting 95% on the QIPP delivery before the application of mitigations. The CCGs continues to explore avenues to generate savings and to ensure that the CCG maximises it opportunities to deliver against its targets. Conflicts of Interest: (please tick accordingly)

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No conflict identified N/A Conflict noted, conflicted party can participate in discussion but not decision (see below) Conflict noted, conflicted party can remain but not participate in discussion (see below) Conflicted party is excluded from discussion (see below) Governance assurance (see below) Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all






There has been no direct PPI, however, lay members sit on Executive Team, Governing Body and Finance committee at which these are reviewed.

Equality Equalities screening/full impact assessment - results should be incorporated into the report.

Quality As above in relation to the three domains of quality (patient safety, clinical effectiveness/patient experience)

Privacy As above in relation to any change planned to the collection, use, disclosure and disposal of information for the work as is described within the summary or supporting papers.

Financial Risks Statutory/Legal Prior consideration Committees /Forums/Groups

This update has/will also reported to Programme Boards and Finance Committee.


There has been no direct membership involvement, however, members representatives in the form of Clinical and portfolio leads sit on Executive Team and Governing Body at which these are reviewed.

Supporting Papers: Finance report M10

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Finance Report for Month 10 – January 2019

1. Dashboards

The following dashboard shows the CCG performance against key financial indicators:

NHSE dashboard – run rate and QIPP

2 Issues and actions

The CCG has identified the following issues at M10 and the actions being taken to mitigate as shown in the following table:

Table 1 - Issues and actions

Issue Action Action Owner When Non Elective Activity is showing a month on month increase that is unaffordable

Move at pace with the South Bucks solution

Debbie Richards On Going

Eligibility risk on CHC resulting in increased costs

Weekly monitoring of activity through the Broadcare database

Gary Heneage On Going

High level of one off episodes in contracts

Robust contract challenges to ensure appropriate CCG spend

Helen Powell On Going

Change in Risk share arrangements for S117 budget

Carry out due diligence on the arrangement – draft report due March 2019

Gary Heneage March 2019

Indicator Target Actual Actual RAG£'000 %age

Financial Position YTD Planned Monthly Deficit 0.0 √Financial Position forecast outurn Planned Annual Deficit 0.0 √Running Costs forecast outturn Underspend 0.8 √QIPP forecast outturn Variance to plan before mitigations (1.1) !Risks & Opportunities Net risks of £0 0.0 √Creditor - Better Payment Practice Code Target 95% in value 97% √Monthly cash drawings Bank Balance 1.25% of drawings 0.33% √

KeyOn plan √Take note !Action Required X

Month

Actual Spend vs Planned

Spend Variance YTD >1% (adverse)

FOT Spend vs Runrate spend >1% (adverse)

QIPP Achievement

YTD <95%

Risks & Mitigations

change vs plan (increase)/decreas

e >£100k

Acute Performance below target

Creditors > 10% of

spend YTD

Debtors >10% of

spend YTD

10 0.01% 12.94% 106.43% 0 YTD Over £0.5m 4% 0.3%

At Month 10 the In-Year forecast position was a £3k underspend after allowing for the full receipt of CSF of £15.5m. This results in a deficit of £3.3m which relates to the brought forward deficit from 17/18. The CCG has received an allocation of £10.1m in year relating to 65% of CSF. NHSE manage the performance of the CCG on the in year position. The CCG is reporting an YTD underspend of £31k. The CCG has reported being on plan, and reported a further £2.3m of risk above plan which the CCG has mitigations in place to cover these risks.

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3. Executive summary including YTD and Forecast Outturn

The following table shows the reported position at M10

Table 2 – M10 position

The summary for M10 financial performance is as follows:

• At Month 10 the forecast position is an in year breakeven, after forecasting full receipt of CSF, plus the brought forward deficit from 17/18 of £3.3m.

• The CCG received an allocation of £5.4m in M7, and a further £4.6 in M10 for Q3 relating to CSF, reducing the in year deficit from £15.5m. The CCG has reflected risks of £16.0m into the FOT positions which are fully mitigated including the release of £2.4m contingency. The reported position is that the CCG is to achieve the plan deficit of £15.5m but has additional risks of £2.3m of which are fully mitigated to report a balanced net risk position.

• The CCG is reporting an YTD underspend of £31k and forecasts underspend of £3k.The CCG has accrued the YTD CSF received and 1 month of Q4 CSF unto the position.

• The reported forecast position reflects pressures that have developed in the Acute and Independent sectors - Frimley Health due to increased NEL activity, Oxford University Hospital due to high cost patient activity, and other providers (including the Independent sector) due to Elective activity (significant T&O pressure), SCAS relating to coding issues, and acuity of patients.

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• Movement in CHC following a detailed review of the forecast to ensure correctness (ensuring all savings, RIPs and new cases are accounted for correctly) in M10 has resulted in a forecast overspend of £1,852k – a movement in month of £3,382k. This movement is the result of the risk now being crystallised covering backdated costs of packages, the resolution of a FNC claim and the inclusion of an allowance for outstanding packages being brokered.

• Actions being taken to address the pressures – Frimley - South Bucks solution underway and programmes put in place to limit activity e.g. Roll out Airedale to 11 Care Homes, STP funded project to support SCAS shift to CATS and UCC, linking with East Berkshire on development of community Respiratory service, Cardiology workshop with BHT outreach arranged, initial proposal for Enhanced recovery at home model. BHT Drugs and Devices - use of Biosimilar. Challenging high cost episodes of activity at OUH and London Providers to ensure appropriate charging. IS – Ongoing reviews of referral patterns and look out how the contracts/activity can be managed more robustly. London Providers – review referrals into London providers and if any can be re directed for future activity. S117 – Review the proposed change in pool contributions – internal audit review due in January. CHC – Weekly monitoring of activity through the Broadcare database to understand impacts on the forecasts.

• The CCG submitted a £21.4m QIPP target to NHSE England on 30 April. At the end of Month 10 CCG is forecasting 95% on the QIPP delivery before the application of mitigations.

• The reported variance across planned and unscheduled care for Buckinghamshire CCG has been based on Month 9 SLAM flex position.

• The CCGs continues to explore avenues to generate savings and to ensure that the CCG

maximises it opportunities to deliver against its targets.

CSF (Commissioner Sustainability Fund)

The CCG has secured CSF of £15,500k, subject to a number of conditions mainly around hitting in year plan and FOT, which will offset the in year deficit to enable a final in year position of breakeven. Q1 and Q2 CSF of £5.4m has been received within M7, and a further £4.7m received within M10. The remaining CSF will be recognised in the accounts on receipt of the allocation.

The quarterly phasing of the CSF is shown below. For reporting purposes the phasing of the CSF is assumed to be equal between each quarter.

In terms of CSF available:

Quarters 1+2 has been achieved in full, £5,425k (35%) received in M7 Quarter 3 - £4,650k (30%) received in M10 Quarter 4 - £5,425k (35%)

Total £15,500k available

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The in year position including CSF at M10 is a deficit of £5,425k including the £31k YTD underspend. The CCG has received the Q1, Q2 and Q3 CSF allocation of £10.0m. The CCG is forecasting to meet the requirements and achieved Q4 CSF of £5,425k which should be received next month.

4. Risks and Mitigations

The CCG has reviewed the risks and mitigations and reflected appropriately within the financial position. The table below details those risks and mitigations which remain. The main risks relate to activity growth within Acute and CHC.

Table 3 – Summary of Risks and Mitigations

The above indicates that the risks the CCG has identified can be covered by mitigations.

For the CCG to maintain this position it is vital that QIPP schemes and other saving plans take grip and start delivering cash releasing benefits to offset the over performance issues in the acute sector.

The CCG has prepared a forward monthly forecast view based on M10 actuals extrapolated covering the remainder of the year as shown in the table below. This shows the CCG achieving breakeven against in year plan and should be able to achieve CSF in full.

` TotalRisk

Assessed M10£m RAG % £m £m

RisksAcute activity - sensitivity 1.000 R 100 1.300 1.300FNC Legancy Claims 0.500 R 100 0.150 0.150London Providers 0.600 R 100 0.600 0.600Lincolnshire patient 0.500 A 50 0.250 0.250S117 Rent Provision 0.065 R 100 0.065 0.065BHT - Credit note from 16/17 1.000 TBC 0 0.000 0.000

Total Risks 9.926 2.365 2.365MitigationsContingency 1.572 G 100 1.072 1.072Running Costs 0.288 A 75 0.216 0.216Programme Slippage 0.527 A 100 0.527 0.527Investment relating to IR Rules 0.550 G 100 0.550 0.550Total Mitigations 3.426 2.365 2.365

Net risks before External funding 6.500 0.000 0.000

External fundingTotal External funding 0.425 0.000 0.000

Net Risks After External Funding 6.075 0.000 0.000

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5. QIPP

The table below shows that the CCG`s QIPP delivery before mitigations. The current shortfall is £1.1m; biggest risk is NELs over activity, London and S117.

Table 4 - QIPP performance

The CCG has forecast QIPP delivery of 95% as at M10.

6. Acute Activity

Table 5 – Spend by Contract

QIPP - Delivery Status - 2018/19

Annual Target

£k

RAG YTD Target M10

YTD Actual M10

YTD Variance

£k

BEST MOST LIKELY

WORST

ORIGINAL QIPP TARGET TOTAL 21,435 17,863 19,012 593 21,435 20,307 13,439Baseline Delivered: - CHC/Running Costs/Community 5,988 G 4,990 4,990 0 5,988 5,988 5,988 - Targeted investments to must do only 3,028 G 2,523 2,440 (83) 3,028 2,728 3,028 - Budget Star chambers - agreed 480 G 400 317 (83) 480 380 380 - Release of NR primary care reserves (£1m of £1.7m held following review) 1,000 G 833 833 (0) 1,000 1,000 500Target - Baseline delivered 10,496 8,747 8,580 (167) 10,496 10,096 9,896 - Investments held 2,273 G 1,894 1,894 (0) 2,273 2,273 2,273 - Arden & Gem (part of £450k agreed) 150 G 125 150 25 150 150 150Target - Other delivered 12,919 10,766 10,624 (142) 12,919 12,519 12,319Activity required - some risk: - Acute contract QIPP (OUH, MK) 170 A 142 121 (21) 170 141 0 - Reduced London Capacity plan for high cost patient 1,400 A 1,167 129 (1,038) 1,400 154 700 - Risk share agreed with Frimley 1,927 G 1,606 835 (771) 1,927 1,000 0 - Prescribing assumed underspend 600 G 500 3,343 2,843 600 3,146 282 - CHC balance 2,200 G 1,833 1,833 (1) 2,200 2,200 0Target - including activity base 19,216 16,013 16,884 871 19,216 19,160 13,301Activity required - high risk: - Budget star chambers action required to deliver - Uptitration, PI, S117, diabetic pumps 399 A 333 58 275 399 69 69 - Frimley QIPP 1,000 A 833 0 833 1,000 0 0 - Other potential investments/budgets to hold 820 A 683 2069 (1,386) 820 1077 69Target - including activity base 21,435 17,863 19,012 593 21,435 20,307 13,439

0 (1,128) (6,868)

66

The main areas of contract over performance in Month 10 are as follows. Note that all figures quoted for the Acute and Independent Providers section below are those from the unadjusted Month 9 SLAM, which is the latest available information. To report the Month 10 position as per the above table, the SLAM values are uplifted.

Acute and Independent Providers:

• For 2018/19, Buckinghamshire CCG has agreed a block value of £245.7m with Buckinghamshire Hospitals. The overspend against High Cost Drugs and Devices before applying the risk share is £42k, which would give a year to date bottom line overspend of £21k after applying financial adjustments. Key drugs and devices drivers remain AMD/ DMO (Age-related Macular Degeneration / Diabetic Macular Oedema), and Arthritis / Psoriasis related drugs.

Uncoded activity has risen to £1.3m this month from a low of £0.26m in Month 8 SLAM. Previous values are £2.6m in Month 5 flex and £1.6m in Month 6 flex. Note: £212k worth of activity remained uncoded at Month 8 SLAM freeze.

• Frimley Health has reported a position of £2.6m over plan (6.7%), after the application of national adjustments, (last month £2.4m / 6.7%). NEL remains the single largest element of the over performance at £1.658m. The other key elements are CCU £289k, A&E £262k and NEL Short Stay £166k.

• Of the £1.6m Month 10 YTD over-performance balance in Other Planned and Urgent Care NHS Contracts, the most significant element continues to be at Oxford University Hospitals, which is seeing an over performance in M9 of £760k (5%), with activity over by 1,571 (2.6%), a favourable movement of £172k since last month, also with a reduced run rate.

The favourable movement has been driven by an increase in the underperformance of NEL, with it now under performing by £219k (7.9%). This is an in month favourable movement of £106k. Critical Care remains the highest over performing POD (£493k / 151%), however, the over performance has reduced by £21k in month.

• The other key over-performances in Other Planned and Urgent Care Contracts are Milton Keynes, and Luton and Dunstable. For Milton Keynes, the overall overspend is £626k in the Month 9 SLAM, compared to last month’s £548k. The key areas of over performance are Outpatient Firsts (£218k), Day cases (£165k) and Non-Elective Inpatients (£161k). Outpatient Follow ups and Procedures are over by a further £87k and £31k respectively. Luton and Dunstable is overspent £258k YTD. Non Elective areas account for £223k of this, predominately NEL, and within that General / Geriatric Medicine.

• The Independent Sector Acute providers are currently over-performing year to date by £578k (14.8%), up from Month 8 (£464k / 13.4%), and Month 7 (£350k / 11.6%). The main contributor to the over-performance is BMI, The Chiltern Hospital accounting for £495k (29.7%), followed by BMI Princess Margaret Hospital £55k (21%) and Spire Thames Valley £42k (10.7%, slightly down on last month).

• Ambulance Services: The position is driven by increased levels of activity and acuity in the 999 service. Pressure included due to tolerance levels on the contract along with future impact of “missed” calls.

• Other: release of NCA accruals from 17/18

67

The following information shows the comparison for activity and finance against plan for all main contracts. This information is direct from SLAM and not adjusted for risk share etc. This table shows activity across all providers as at Month 9 SLAM:

7 ICS Summary Buckinghamshire CCG is part of an Integrated Care System comprising of the Clinical Commissioning Group, Buckinghamshire Healthcare NHS Trust, Oxford Health Foundation Trust, South Central Ambulance Service, the countywide GPs federation, and Buckinghamshire County Council. The purpose of the ICS is to drive closer working which was first set out in a five-year plan for health and social care through to 2020 which called for better integration of GP, community health, mental health and hospital services, as well as more joined-up working with local government. The new approach is intended to: •provide care closer to home to reduce the length of stay in hospital •enable GPs and mental health teams to work alongside hospital teams in A&E, and •streamline care for people with long-term conditions Currently the finances reported relate to the CCG and Buckinghamshire Healthcare Trust and are shown in the following tables; this is 1 month in arrears, so M9 position: Table 6 – ICS Income and Expenditure (M9)

Within the CCG allocation there is a budget of £2.8m which the authority to spend against has been delegated to the Managing Director of the ICS. Predominately the spend is covering running costs and transformation programme spend – this covers various programmes to initiate change and are approved on a business case basis by the systems Director of Finance group chaired by the CCG CFO. The current M10 position is in the following table: Table 7 – ICS internal budget

68

Abbreviations and acronyms used:

2018/19 Financial Year from 1 April 2018 – 31 March 2019 k Thousand

ICS Budget M10Income

Annual Budget Budget Actual Variance Budget Forecast Variance

Total Income 2,940 1,134 1,134 0 2,940 2,940 0

ExpenditureICS Management Team/PMO Delivery 457 386 307 79 457 457 0

Price Waterhouse Coopers 17/18 103 103 103 0 103 103 0

Population Health Management 123 0 0 0 123 123 0Citizen Panel 40 0 0 0 40 40 0Aspirant (Transformation/Leadership) 100 0 0 0 100 100 0

Meeting rooms/other 5 4 2 2 5 5 0

Investments

CommittedMental Health 262 100 262 (162) 262 262 0Consultant Connect 156 156 0 156 156 156 0NEL Capacity/Demand 200 200 65 135 200 110 90Community Care Model 80 80 41 39 80 80 0Transformation Team 531 0 0 0 531 531 0

Total Committed 1,229 536 368 168 1,229 1,139 90

Awaiting Business caseSystem Development (OD) 300 0 0 0 300 122 178

Total awaiting Business Cases 300 0 0 0 300 122 178

Ringfenced FundingTransformation Team (part of £900k) 289 0 0 0 289 0 289Contingency @ 10% 180 0 0 0 180 0 180Other 49 0 0 0 49 0 49Unallocated 65 65 0 65Total Ringfenced Funding 583 0 0 0 583 0 583

Total Investments 2,112 536 368 168 2,112 1,261 851

Total Expenditure 2,940 1,029 780 249 2,800 2,089 851

Expected Underspend / (Overspend) 0 105 354 (249) 140 851 (851)

YTD Full Year

The CCG is treating this ICS Transformation Budget as a "Ring Fenced Budget" and as such will carry forward to 19/20 any underspend.

Analysis of ringfenced Accruals

NEL Capacity/Demand 90System Development (OD) 178Transformation Team 289Consultant Connect 19/20 TBA 120

Total ringfenced accrual 677Balance accrued 174

Total Carry forward 851

69

2017/18 Financial Year from 1 April 2017 – 31 March 2018 m Million

A&E Accident and Emergency MSK Musculo-Skeletal

APMS Alternative Provider Medical Services MPIG Minimum Practice Income Guarantee

AT Area Team NHSE NHS England

BPPC Better Payment Practice Code- target (currently 95% of invoices to be paid within 30 days of receipt of invoice or goods/service. PBR

Payment By Results – payment system (based on Healthcare Resource Groups) used mainly in acute contracts

AVCCG Aylesbury Vale CCG OUH Oxford University Hospitals NHS Foundation Trust

Break-even Position where actual costs are same as planned i.e. not in deficit or surplus (loss or profit) POD Point of Delivery – area of acute care activity of

similar type (e.g. Inpatient or Outpatient)

Budget A sum of money allocated for a specific purpose PPD Prescription Pricing Department (central body that provides GP prescribing data)

CCG Clinical Commissioning Group PSF Provider Sustainability Funding

CAMH Child & Adolescent Mental Health Services QIPP Quality, Innovation, Prevention and Productivity –

plans and associated savings / changes in financial costs

CCGs Aylesbury Vale and Chiltern Clinical Commissioning Groups Reserves Monies set aside for a specific purpose e.g. Contingency reserves for unforeseen spend in year.

CHC Continuing Health Care RTT Referral to Treatment is the definition by which patients waiting to be treated are measured

CQUIN Commissioning Quality & Innovation Revenue Resource Limit (RRL)

Total funding allocated for the year set by the Department of Health

CSF Commissioner Sustainability Funding RBH Royal Berkshire Hospital

CSU Commissioning Support Unit QIPP Quality, Innovation, Prevention and Productivity –

plans and associated savings / changes in financial costs

CT Control Total SCAS South Central Ambulance Service

Deficit Financial variance where overall net costs are more than planned SLAM Service Level Agreement Monitoring – i.e. contract monitoring information

Excess Bed Days

Term used in acute contracts to describe days chargeable under PBR in excess of the standard tariff (for example a tariff might set 5 days as standard stay and days above this are charged to the CCG)

STP Sustainability and Transformation Plan (now Local NHS Plan)

FPH Frimley Health NHS Foundation Trust. Surplus Financial variance where overall net costs are less than planned

FOT Forecast Outturn (from 1/4/18 to 31/3/19) Variance (Adverse) Difference against plan (overspend)

FNC Funded Nursing Care Variance (Favourable) Difference against plan (underspend)

GP General Practice or General Practitioner YTD Year-to-date (from 1 April to the end of the reported month)

HR Human Resource department (part of CSU)

70

NHS Buckinghamshire CCG

Quality and Performance Report

‘Everyone working together so that the people of Buckinghamshire have happy and healthy lives’

February 2019

71

Report Highlights by Exception Indicator Target Position Summary Page

Cancer Page 4

31 Day – Subsequent Treatment - Surgery 62 Day – Screening Service 62 Day – Urgent GP referral to 1st treatment

BHT achieved: 86.4% (Target 94%) 66.7% (Target 90%) 86.18% (Target 85%) All long waiters and potential breaches are monitored on a weekly basis , and prevented where possible. Tertiary referrals to OUH continue to be a concern and will be addressed with the support of OCCG

12-13

RTT Page 4

Incomplete – percentage seen within 18 weeks Incomplete – 52+ week waiters

RTT and long waiters monitored on a regular basis with emphasis on admission dates allocated to patients. Overall RTT is stable and close to ops plan trajectory. There were no 52 week breaches at BHT and on track to deliver a lower waiting list in March 2019 compared to March 2018. The ICS has funded a Vanguard to treat the cataract backlog in Q4, thereby supporting the reduction in the waiting list and sustaining RTT at BHT.

14-15

Diagnostics Page 4

Less than 6 weeks wait for a diagnostic test. BHT achieved 0.13% with 3 breaches in December. The Trust monitors potential long waiters on a weekly basis, allocating dates to patients to avoid month end breaches. Closer scrutiny will be given to the Frimley and Diagnostic World performance, identifying the causes of the breaches and corrective actions will be taken as appropriate

16

A&E 4 hour waits Page 6

Buckinghamshire Healthcare Trust Milton Keynes Oxford University Hospitals Frimley Health

A&E Delivered sustained improvements towards the 4 hour standard. BHT performance for Q3 was 89.23%; December was improved on the previous month & 4.57% better than the same period last year. Typically delivering above regional and national average, the system is around 30th best nationally

18-19

Delayed Transfers of Care (DToC) Page 6

Rate of days of delayed transfers of care

The DToC performance significantly improved in December for the majority of providers including at BHT, Frimley, Oxford Health and MK. The Bucks system is currently adrift of meeting the agreed daily delay target . This is the 1st time that the BCF trajectory has been achieved

20

SCAS Page 6

Category 1 – Mean (7 minutes) Category 2 – Mean (18 minutes) Category 3 – 90th Percentile (120 minutes) Category 4 – 90th Percentile (180 minutes)

SCAS achieved 4 of the 6 primary targets at Thames Valley contract level, with 4 targets achieved for Bucks at CCG level. Work continues to overcome challenges, which include staffing levels

22-24

72

Report Highlights by Exception Continued Indicator Target Position Summary Page

Continuing Health Care Page 6

Assessments within 28 days Reduction of CHC assessments in acute hospitals

Performance declined in January for Assessment within 28 days. Performance for ‘Reduction of CHC assessments in acute hospitals improved slightly but is still above standard. An action plan is in place and progress is being closely monitored.

25

Dementia Diagnosis Rate Page 5

Two thirds of people with dementia to be formally diagnosed. (66.7%)

The Bucks, Oxford shire and West Berks (BOB) STP target was narrowly underachieved in January 66.3% , the CCG target was again underachieved with performance at 64.2% Work continues on the four priority areas identified for action to recover standard by year end with an additional 149 people are required to be diagnosed

26

Eating Disorders Page 7

Waiting time for routine referrals to CYP eating disorders - within 1 week (urgent) , within 4 weeks (routine)

Performance improved in December. Referral numbers to the service are low, subsequently if one referral is not assessed within the timeframe this significantly effects performance

29

Mixed Sex Accommodation Page 6

Zero patients Breaches reported at Frimley Health , London North West and Royal Berkshire. Frimley - these will occur until building works are competed in early 2019.. No breaches reported at BHT

32

BHT SSNAP Results Page 9

“A” Rating SSNAP results show that BHT are: • The top performer for the Thames Valley • In the top 5% of Trusts in the UK.

34

OUHFT Never Event – Feb 2019 Page 10

Zero Never Events OUHFT have reported a Never Event in February 2019 regarding a retained vaginal pack post surgery.

36

73

2018-19

INDICATORReferral to Treatment RTT Admitted % within 18 weeks 71.36% 71.73%RTT Non-Admitted % within 18 weeks 90.31% 91.11%RTT Incomplete % within 18 weeks 92% 91.00% 87.65% 89.27%RTT Incomplete 52+ week waits 0 4 5 113 OUH x 5 (Gynaecology x 4 & Urology x 1)Diagnostic test waiting timesDiagnostics % waiting over 6 weeks 1% 1% Dec 1.42% 0.73%Cancer patients Cancer - 2 week wait 93% 93.0% 96.6% 95.2%Cancer - Breast symptoms 2 week wait 93% 93.6% 97.9% 95.2%Cancer - 31 day first definitive treatment 96% 96.5% 97.1% 96.4%Cancer - 31 day subsequent treatment - surgery 94% 96.3% 91.4% 89.3% 32 out of 35 patients seen within target.Cancer - 31 day subsequent treatment - drug 98% 98.6% 100.0% 99.8%Cancer - 31 day subsequent treatment - radiotherapy 94% 94.3% 98.3% 96.4%Cancer - 62 day - Urgent GP Referral to 1st Definitive Treatment 85% 85.9% 86.4% 80.4%Cancer - 62 day - Screening 90% 95.2% 66.7% 85.9% 4 out of 6 patients seen within target.

CCG

No standard

Bucks CCG Operational

Plan

National Standard

Report Month

Report Period Actual Year to Date Commentary

Dec

Dec

BUCKINGHAMSHIRE CCG

Please note: RAG rating for all Monthly standards will be against Lead CCG Operational Plan if included/YTD RAG rating is against National Standard.

74

2018-19

INDICATORMental HealthCPA - Followed -up within 7 days of discharge (Qtrly) 95% Q3 18/19 98.2% 97.2%CPA - Followed -up within 7 days of discharge (mth) Adult 95% 100.0% 97.3%CPA - Followed -up within 7 days of discharge (mth) Older Adult 95% 100.0% 98.6%CPA - Documented Risk Assessment (Adult) 95% 95.0% 94.8%CPA - Documented Risk Assessment (Older Adult) 95% 100.0% 100.0%CPA - Crisis Contingency Plan (Adult) 95% 95.2% 95.7%CPA - Crisis Contingency Plan (Older Adult) 95% 98.1% 97.5%Mental Health - Improving Access to Psychological Therapy (IAPT)Access: The proportion of people with depression/anxiety that have entered psychological therapies.

19.5%Revised to 18% by Q4 24.1% 19.5%

Recovery: Proportion of people with depression/anxiety completing treatment and moving to recovery

53% 59.8% 59.3%

People that wait 6 weeks or less from referral to entering IAPT 75% 99.3% 99.1%People that wait 18 weeks or less from referral to entering IAPT 95% 100.0% 99.9%Transforming CareAdult Patients in secure hospitals (via NHS Specialist Commissioning Services) 2CAMHS Patients in secure hospitals (via NHS Specialist Commissioning Services) 4Current Inpatients - Specialist Hospital (Learning Disability - Dove Ward) 4Current Inpatients - Specialist Hospital (No Learning Disability) 0Current Inpatients - Out of Area LD Specialist hospitals (Forensic locked rehab). 3Current Inpatients - Out of Area Mental Health Specialist hospital 2Learning Disability Health ChecksProportion of people on the GP Learning Disability Register that have received an annual health check during the year

75% by 2020 65% Jan 29.3% 29.3% Target to be achieved by year-end.

Dementia DiagnosisDementia Diagnosis Rate 66.7% 66.0% Jan 64.20%

Jan

Jan


National Standard

Report Month

Jan

Jan

Commentary

CCG

Report Period Actual Year to Date


Plan

Please note that for both Access and Recovery published monthly data is provisional and subject to refresh the following month.

75

2018-19Report Period Actual

Q3 2018/19

Category A Ambulance CallsCategory 1 - Life-threatening injuries and illness ( MEAN) 7 Minutes 0:07:56 0:07:50Category 1 - Life-threatening injuries and illness ( 90th PERCENTILE ) 15 Minutes 0:14:50 0:14:44Category 2 - Emergency calls e.g. Stroke patients ( MEAN ) 18 Minutes 0:18:59 0:18:18Category 2 - Emergency calls e.g. Stroke patients ( 90th PERCENTILE ) 40 Minutes 0:38:18 0:36:15

Category 3 - Urgent calls ( 90th PERCENTILE )120

Minutes 2:34:09 2:18:36

Category 4 - Less Urgent calls ( 90th PERCENTILE )180

Minutes 4:16:37 3:11:52

2018-19INDICATORA&E 4 Hour WaitNHS England 84.38% 88.51%Buckinghamshire Healthcare Trust 92.65% 87.45% 88.49%Milton Keynes University Hospital 87.90% 86.98% 91.78%Oxford University Hospital 86.03% 87.89%Frimley Health 82.68% 88.11%

INDICATOR

Report Period Actual

Year to Date

Delayed Transfer of Care

Rate of Days Delayed Transfers of Care per 100,000 856.6 Q2 18/19 1103.9 Please see main report for monthly DToC performance

Continuing HealthcarePercentage of CHC assessments within 28 days 80% 25%Reduction in CHC assessments in Acute hospitals <15% 24%Mixed Sex AccommodationBreaches of Mixed sex accommodation 0 Dec 19 278 Frimley Health x 17/London NW x 1/Royal Berkshire x 1Infection Control

Incidence of healthcare associated infection - MRSA 0 (Year) 0 0 0

Incidence of healthcare associated infection - C.Difficile 108 (Year) 9 8 85Electronic Referral System (ERS)NHS e-Referral Service (eRS) for all consultant led first outpatient referrals. Dec 81% December figure is provisional and may be subject to chanVTE (Venous Throboembolism)Buckinghamshire Healthcare Trust 95.7% 95.8%Milton Keynes University Hospital 84.2% 80.2%Oxford University Hospital 97.3% 97.2%Frimley Health 96.7% 97.1%

National Standard

Report Month

CommentaryBucks CCG

Operational Plan

CCG

Dec

SCAS Thames Valley - Performance: Cat 1 both targets were met with a sl ightly improved performance in the 90th percentile category. Cat 2 both targets were met with a sl ight decrease in performance for both categories gainst November. Cat 3 90th percentile target was not met with performance at 2:16:59 Cat 4 90th percentile target was not met with a decrease in performance against November.Bucks CCG performance was worse than overall within Thames Valley

CommentaryStandard

December update: No reported MRSA cases . The CCG were below the monthly tra jectory for C.Di ffici le


95% Q2 18/19

Jan

CCG


Plan

Jan

National Standard

Report Month Commentary

Lead CCG Operational

Plan

Report Month


Year to Date

Provider

95.0% Of the local Providers all but Frimly Health were above the NHS England average performance in January.

Jan

76

2018-19

Other National ExpectatonsReport Period Actual

Year to Date

Mental Health

Early Intervention in Psychosis - Psychosis treated with a NICE approved care package within two weeks of referral

53% 77% Jan 86% 87%

National target i s at least 50% of people with a fi rs t episode of psychos is receive NICE concordat care package within 2 weeks of referra l (FYFV 2020/21 target). National guidance rates the CCG as EXCELLENT for this indicator

Waiting Times for Routine Referrals to CYP Eating Disorder Services - Within 1 week (Urgent).

95% 100% Q2 18/19 100.0% 88.9%

Waiting Times for Routine Referrals to CYP Eating Disorder Services - Within 4 weeks (Routine).

95% 73.7% Q2 18/19 64.7% 68.0%

Primary CareWheelchairChildren, whose episode of care was closed, who waited more than 18 Weeks for a Wheelchair Q3 18/19 0 7 0 breaches since Q1 and introduction of buggy clinic


Learning Disabilities/Autism Care - Reliance on Inpatient Care for People with LD or Au Please note: for all above tables the following applies.

National Standard

Report Month

CCG

CommentaryBucks CCG

Operational Plan

Septembers data from the trust shows YTD activi ty at 100% for urgent (1 week). There have been no urgent referra ls in Q2. The numbers of urgent referra ls are very low, therefore performance wi l l be adversely affected i f patient i s missed.

77

INDICATORReferral to Treatment RTT Incomplete 52+ week waitsDiagnostic test waiting times (DM01)Cancer Wait Times (CWT) Mental Health - CPA (monthly)Mental Health - Improving Access to Psychological Therapy (IAPT)Mental Health - CPA(Quarterly)Transforming CareLearning Disability Health ChecksDementia DiagnosisCategory A Ambulance CallsA&E 4 Hour WaitBuckinghamshire Healthcare TrustDelayed Transfer of CareRate of Days Delayed Transfers of Care per 100,000Continuing HealthcareMixed Sex AccommodationInfection ControlChildren/Young Persons Eating Disorder (CypEd)

CCG leadNHS DigitalSouth Central Ambulance Service (SCAS)NHS EnglandTrust

NHS England

CCG leadNHS Digital via TIBCO managed File TransferPublic Health England - HCAI Data Capture System (DCS)NHS Digital via TIBCO managed File Transfer

NHS Digital via TIBCO managed File Transfer

BUCKINGHAMSHIRE CCGGlossary of data sources

Data Source

Appropriate Trust via CSU Contract leadsNHS Digital via TIBCO managed File TransferNHS Digital (Strategic Data Collection Service (SDCS))

Oxford Mental Health

NHS Digital via TIBCO managed File TransferCCG lead

78

INDICATOR PROVIDER

FREQ

UEN

CY

THRESHOLDCURRENT PERIOD

CURRENT VALUE

TREND - 13mths rolling

STROKE

BHT M 90% Dec-18 98%

OUHFT M 85% Dec-18 92%

MKFT M 80% Dec-18 85%

BHT M 95% Dec-18 100%

OUHFT M 85% Dec-18 82%

MKFT M 65% Dec-18 80%

Thrombolysis Stroke - (door to needle) <60 minutes

BHT M 80% Dec-18 100%

MATERNITY TREND - 13mths rolling

BHT M 26.5% Dec-18 31.0%

MKFT M 26% Mar-18 26.0%

HWPH M 26% Oct-18 29.0%

BHT M - Dec-18 17.5%

MKFT M - Mar-18 15.0%

HWPH M - Oct-18 13.9%

BHT M - Dec-18 13.5%

MKFT M - Mar-18 11.0%

HWPH M - Oct-18 15.0%

C-Section Rate - Elective

C-Section Rate - Emergency

East Berkshire CCG have not realeased Maternity data for M08 for FHFT

MATERNITY

Trust is experiencing severe data extraction issues - MKCCG are following this up via contractual meetings with the Trust

7 of 7 patients received Thrombolysis within 60 minutes





Although BHT are breaching their threshold for C-Section, they are not considered an outlier either nationally or locally when the

national picture is taken into account

COMMENT

55 of 56 patients spent 90% of their time on SU



STROKE

% pts admitted to SU <4hrs

53 of 53 patients were admitted within 4 hours



% pts spent >90% of time SU

C-Section Rate - Combined

83%64% 65% 83% 73% 80% 71% 68% 70% 86%

62% 74% 75% 80%

89% 93% 88% 90% 98% 96% 98% 96% 98% 94% 97%100%100%

57% 75% 65% 62% 74% 89% 77% 87%67% 74% 67% 60% 82%

95% 98% 98% 98%100%100%98% 96% 98% 98% 99%100%98%

88% 89% 90% 64%100%93% 94% 98% 88% 78% 89% 89% 92%

96% 83% 83% 87% 85% 90% 83% 89% 90% 96% 92% 90% 95% 85%

31% 32% 30% 30% 29% 29% 30% 30% 31% 27% 30% 29% 28%

15% 16% 15% 15% 14% 15% 15% 14% 18% 13% 13% 13% 13%

28% 27% 27% 26% 33% 31% 28% 29% 33% 33% 33% 26%

19% 17% 16% 15%21% 17% 18% 17%

22% 22% 19% 15%

15% 16% 15% 15% 15% 14% 15% 16%13% 15% 17% 16% 15%

9%12% 12% 10% 10% 11% 10%

14%10%

14% 13% 13% 14%

9% 10% 12% 11% 13% 13%11% 12% 11% 12% 14%

11%

14% 17% 13% 15% 14% 16% 14% 16% 19% 19% 19% 17% 17%

23% 29% 25% 25% 24% 26% 23% 30% 29% 33% 32% 29% 31%

82% 73% 80% 75% 75% 83%100%

78% 75% 92% 83% 73%100%

30% 31% 27% 30% 29% 28% 31% 27% 28% 28% 30% 29%

14% 18% 13% 13% 13% 13% 15% 13% 15% 18% 15% 15%

29% 33% 33% 33% 26%

17%22% 22% 19% 15%

16%13% 15% 17% 16% 15% 16% 14% 14% 11%

15% 14%

10%14% 13% 13% 14% 12% 10% 12% 12% 10%

12% 12% 14%

12% 11% 12% 14%11%

19% 19% 19% 17% 17% 17% 17% 19% 20% 19% 18% 16% 18%

29% 33% 32% 29% 31% 29% 27% 31% 31% 28% 30% 27% 31%

79

INDICATOR PROVIDER

FREQ

UEN

CY


CURRENT VALUE


SAFETY THERMOMETER BHT M - Jan-19 8

OHFT M - Jan-19 1FPH M - Jan-19 0

HWPH M - Jan-19 0OUHFT M - Jan-19 9

BHT M 0 Jan-19 0OHFT M 0 Jan-19 0FPH M 0 Jan-19 0

HWPH M 0 Jan-19 0OUHFT M 0 Jan-19 1

BHT M - Jan-19 97.2%

OUHFT M - Jan-19 98.0%

FHFT M - Jan-19 98.0%

MKFT M - Jan-19 97.9%

BHT M - Jan-19 1.0%

OUHFT M - Jan-19 0.4%

FHFT M - Jan-19 1.2%

MKFT M - Jan-19 0.8%

WORKFORCE TREND - 13mths rolling

BHT MiA 3.5% Nov-18 3.8%

OHFT MiA 3.5% Nov-18 4.4%

BHT M - Nov-18 11.2%

OHFT M - Nov-18 11.6%

Statutory Training BHT Q 85% Dec-18 92%

All SIs logged

All Never Events Logged

New Pressure Ulcers -

% of patients with NEW Pressure Ulcers

Please see Quality Narrative section for further details

COMMENT

Vacancy Rate

Sickness(This figure is reported month in

arrears)

WORKFORCE

NEW Harm Free Care-

% of patients with no NEW harm

0

20

BHT OHFT FPFT HWPFT OUH

0

5


87% 88% 89% 88% 89% 89% 89% 89% 91% 93% 93% 93% 92%

4.5% 4.7% 5.2%4.2% 4.1% 3.9% 3.8% 3.6% 3.7% 3.5% 3.9% 4.4%

3.8% 4.3% 3.8% 3.7% 3.4% 3.2% 3.3% 3.4% 3.3% 3.7% 3.9% 3.8%

0.86% 0.95%

BHT OUHFTFHFT MKFTNational Average

97.86%

97.84%

BHT OUHFTFHFT MKFTNational Average

10% 10% 11% 10% 10% 10% 12% 12% 12% 16% 13% 12% 11% 11%

11% 11% 11% 14% 12% 12% 14% 13% 12% 13% 12% 12%

80

INDICATOR PROVIDER

FREQ

UENC

Y


CURRENT VALUE


COMPLAINTS

BHT M - Dec-18 51

HWPH M - Oct-18 33

OUHFT M - Dec-18 80

BHT MiA 85% Oct-18 92%

HWPH MiA 70% Sep-18 40%

BHT M - Dec-18 93%

FHFT M - Dec-18 98%

OUHFT M - Dec-18 95%

MKFT M - Dec-18 97%

BHT M - Dec-18 29%

FHFT M - Dec-18 25%


MKFT M - Dec-18 8%

BHT M - Dec-18 92%

FHFT M - Dec-18 95%


MKFT M - Dec-18 85%

BHT M - Dec-18 27%

FHFT M - Dec-18 13%


MKFT M - Dec-18 5%

OHFT - Dec-18 93%

National Average - Dec-18 89%

OHFT - Dec-18 8%

National Average - Dec-18 3%

Friends and Family Test% Recommended

Friends and Family Test% Response Rate

Friends and Family TestA&E

% Response Rate

Friends and Family TestA&E

% Recommended

Friends and Family TestIn Patients

% Recommended

Friends and Family TestIn Patients

% Response Rate

Total Number of Complaints Received

No M08 data has been collected by East Berkshire CCG

No M08 data has been collected by East Berkshire CCG

COMMENT

COMPLAINTS

Complaints responded to within Trust Policy (reported Month In

Arrears)

No explaination for the spike in response rate has been received from East Berkshire CCG - it is likely a data collection issue.

44 46 56 36 60 38 37 47 49 51 59 46 53 51

44 22 52 43 50 39 38 37 44 42 41 33

92% 80% 88% 78% 77%96% 89% 87% 95% 86% 93% 92% 79%

19% 23% 19% 27% 23% 20% 22% 26%56% 57% 57% 40%

98 65 86 63 84 83 64 77 93 103 98 111 97

95%95%

BHT FHFT

OUHFT MKFT

National Average

96%

86%

BHT FHFTOUHFT MKFTNational Average

21%

24%

BHT FHFTOUHFT MKFTNational Average

12%12%

BHT FHFT

OUHFT MKFT

National Average

3% 3%

OHFT National Average

88% 89%

OHFT National Average81

Cancer - 31 Day Waits Assessment: 31 Day Subsequent Treatment Surgery (Target 94%) – CCG Performance – 91.4% - 32 out of 35 patients seen within target. • 3 breaches at BHT within the skin pathway: 1 was a late referral from a tertiary centre, 2 were interface challenges between skin and plastics. Clinical

Director leads are supporting the improvement, resulting in a reduction in breaches, but is taking time to embed. • Due to the small numbers, 1 breach can adversely affect breach performance. • The issues in skin and plastics are recognised, but not supported through TVCA work (as does not feature on the TVCA prioritised programme) so being

reviewed separately.

Recommendation(s)/Recovery Trajectory: • The CCG continues to work across the system with partners to agree action plans and develop sustainable solutions to improve performance • A project manager in in post at BHT to support the redesign of critical pathways – Lower GI and Upper GI, as well as learning from transformation work

already completed on Urology and Lung • Bucks system commissioning are working with OCCG and OUH to understand the challenges and support improvement, from both Quality and

Performance perspectives • BHT business case been approved to upgrade MRI equipment that will provide greater capability locally. This is expected to be in place later in 2019 • Collaborative work is underway to understand patient flows through pathways and identification of opportunities to improve coordination and reduce /

alert breaches. The initial review is underway and expected to be completed in February • Work on pathway reviews and establishing the vague symptoms clinic is in progress, but experiencing a delay due to capacity, contributing to the sustained

performance of the 62 day standard as well as support the emerging 28 day standard. These programmes are a significant piece of work and will take time to implement and embed, being monitored directly by TVCA.

• Work with primary care is ongoing through the QIS scheme, supporting practices in areas of need and hosting community event(s)to improve engagement with communities.

104 Day Breaches • 3 104+ day breaches in December all at BHT and waiting at OUH a deep dive on these patients has been requested • Following review with quality colleagues, Clinical Harm Reviews are now underway. It has been identified that these breaches include inpatient stays. • PET scanning remains a challenge at OUH with a 4 week wait, rather than the required 2 weeks. This is being escalated across the system and is

compounded by contract changes at OUH of PET scan provider. BHT is seeking alternative centres, such as Northampton, to mitigate this. • Due to historical issues and work with tertiary centres, the CCG has seen a reduction breaches on the Gynae pathway as patients can elect to go to

Northampton sooner.

82

Cancer (All Wait Times) 31 DAY WAITS - Maximum 31 day wait – Subsequent Treatment - Surgery Target 94% December: CCG - 91.4% BHT – 86.4% Q3: 90.2% against 94% target Year To Date: 89.3%

62 DAY WAITS - Maximum 62 day wait – Screening Target 90% December: CCG - 66.7% BHT - 66.7% Q3: 81.1% against 90% target Year To Date: 85.9%

Other target not achieved in Quarter 3: • 62 Day GP Referral to First Treatment - Actual 80.8% against 85% target

Other target currently not achieved Year to Date: • 62 Day GP Referral to First Treatment - Actual 80.4% against 85% target

Overview: 62 day standard (Treatment) – There is continued sustained performance in the Bucks system with 4 out of 5 months achieving the standard. • Oxfordshire - Performance and recovery continues with performance closely monitored by commissioning and provider leads. A risk to Bucks CCG performance remains,

which is closely monitored with the support of OCCG. • Work continues in Bucks, as in other regional systems, to support delivery of TVCA MOU, seeking to implement numerous initiatives to deliver sustained 62 day

performance. Benefits of this work take time to be realised, as recognised there are no quick solutions. BHT remains confident that that local performance will be sustained. Continuation of the work programme is supported by and MOU and the release of half of FY18/19 funding .

Assessment: 62 Day Screening Standard (Target 90%) – CCG Performance – 66.7%, 4 out of 6 patients seen within target. • Due to small numbers, any breach adversely affects performance. In December there were 2 breaches; both caused by patients having MRIs at Northwick Park, which

will stop when local MRI is installed later this year. • Endoscopy service currently under review to improve flow and capacity through services. • FIT kits (as part of national screening) are done via MK and Guilford. Fit Testing for colonoscopy are expected to flow through SMH or MK and an increased demand is

expected.

2018-19Cancer - 31 day Subsequent Treatment - SurgeryTotal Patients Treated 35 327Number of patients treated after 31 days 3 35Performance 91.4% 89.3%

94%

StandardMonth Actual

DecemberYTD

2018-19Cancer - 62 day Screening StandardTotal Patients Treated 6 149Number of patients treated after 62 days 2 21Performance 66.7% 85.9%

YTD

90%

StandardMonth Actual

December

83

RTT – Incomplete pathways (patients to start treatment within a maximum of 18 weeks)

Situation: December Performance – 87.65% National Target: 92% not achieved Operating Plan trajectory: 91.0% not achieved

Background: • The Operating Plan trajectory or the national target were met in December. All providers are focusing on reducing the 18 week backlog in conjunction

with waiting list sizes, which remain above plan and due to the holiday period increased in December. • There is a requirement that the size of the waiting list at 31st March 2019 is the same as it was at 31st March 2018

Assessment: The CCG continues to work with BHT to reduce the number of duplicate patients identified, the cause of which is mainly due to administrative errors and change of the referral by the GPs.

Recommendation(s)/Recovery Trajectory: The continued pressure of non-elective and financial constraints continue to attract BHT board level scrutiny to the focus of elective activity. In Q4 the vanguard provides capacity to clear the cataract backlog, aiming to achieve improvements in the overall RTT performance and waiting list reduction, although this is not demonstrated by the December data. BHT continues to maintain zero 52 week waiters, with the focus on the limitation of breaches of the 40+ and 45+ week waiters in all specialties, which continue to be reviewed on a weekly and daily basis respectively. Monthly validation of the patients waiting is carried out, aimed at treating the long waiters and also reducing the waiting list size. Both BHT and OUH continue to monitor Remedial Action Plans (RAP) in conjunction with the lead CCGs, with an overview at Executive level. All providers continue to monitor the waiting list sizes to limit growth to meet the national requirement of no increase when the number of patients waiting at 31st March 2019 is compared to 31st March 2018.

2018-19Referral to Treatment Incomplete % waiting < 18 weeks (All Providers)Buckinghamshire CCG 91.0% 87.65% 89.27%Local Provider performance by CCGBuckinghamshire Healthcare NHS Trust 87.52% 89.43%Oxford University Hospitals NHS FT 79.20% 80.73%Milton Keynes University Hospital NHS FT 90.69% 89.91%Frimley Health NHS FT 91.35% 92.59%

92% Dec

RAG rating: CCG (monthly) rated against CCG Operational Plan/YTD is rated against National target

National Standard


Plan

Report Month


Year to

Date

84

RTT: Incomplete pathways - Over 52 week waiters

Situation: December: 5 over 52 week Incomplete pathways waiters, 0 occurred at BHT

The relevant lead CCG requests Clinical harm reviews for all breaches to ascertain the occurrence of any clinical harm as a result and the assurance for long waiters. Buckinghamshire CCG is also working with lead commissioners where clinical harm reviews are required for Buckinghamshire Patients.

Actions: • 4 of the 5 patients that were reported in December received treatment in January, with 1 patient waiting for a date for admission

(known as a To Come In (TCI) date). • BCCG is working closely with OCCG to gain the assurance that the issues causing the long waits for patients at OUH are being

addressed to resolve both short and long term concerns.

Provider Specialty Apr May Jun Jul Aug Sep Oct Nov Dec

MILTON KEYNES HOSPITAL Trauma & Orthopaedics 3 2 2 3 2 2 1 1 0Gynaecology 3 7 9 11 12 14 9 6 4Urology 0 0 0 0 0 0 1 1 1Other 0 0 0 0 0 0 1 0 0

ROYAL FREE LONDON General Surgery 0 0 1 1 0 0 0 0 0Ophthalmology 0 0 0 1 1 1 1 0 0Other 0 0 0 1 1 1 1 0 0Rheumatology 1 1 0 0 0 0 0 0 0Trauma & Orthopaedics 0 0 2 2 0 0 0 0 0

LONDON NORTH WEST General Surgery 0 0 0 0 1 1 0 0 0Total Breaches All Specialties 9 10 14 19 17 19 14 8 5

OXFORD UNIVERSITY HOSPITALS

WEST HERTFORDSHIRE HOSPITALS

Buckinghamshire CCG - Over 52 week waiters

Month: December OUH TotalTCI DateAwaiting TCI 1 1Status AwaitedAwaiting ReviewClock StoppedFollow Up bookedPatient now seen 4 4TOTAL 5 5

Buckinghamshire CCG - Over 52 week waiters

85

Diagnostics

Situation: Patients waiting 6 weeks or more for a diagnostic test. Target <1% December: CCG 1.42% BHT 0.13%

Background: The percentage of patients waiting 6 weeks or more for a diagnostic test. The waiting list data is a “snap shot” of the waiting list on the last day of the month in question.

Assessment: • 6 week breaches at all providers due to lack of resource over the Christmas period • BHT have identified longer waits for colonoscopy, flexi sigmoidoscopy and gastroscopy • Diagnostic World is a smaller provider and the contract is managed by the CSU • Providers are aware of capacity & demand issues within the services.

Recommendation(s)/Recovery Trajectory: • BHT provides a weekly report for patients waiting for diagnostics as above and continue to date patients in month to avoid month

end breaches • Closer scrutiny will be given to the Frimley and Diagnostic World performance, identifying the causes of the breaches and corrective

actions will be taken as appropriate • Any identified areas of clinical harm will be included in the next report.

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Y-T-DUnder 6 week waits 6321 6205 5781 5532 4776 4653 5521 6723 4167 49679Over 6 week waits 22 47 51 38 24 25 46 51 60 364Total Waiting List 6343 6252 5832 5570 4800 4678 5567 6774 4227 50043Performance 0.35% 0.75% 0.87% 0.68% 0.50% 0.53% 0.83% 0.75% 1.42% 0.73%

Buckinghamshire CCG

Diagnostics2018-19

86

Referrals (GP)

Situation: December 2018 - GP referrals were about 3.9% lower (9,001 per 1000 in 18/19 YTD) compared to 17/18 (9,366 per 1000 YTD)

Background: BHT and other providers should incur 0% growth in referrals from GPs.

Assessment: GP Referrals - pressures in Dermatology (up 8.3% compared with 17/18), Neurology (up 9.1% compared with 17/18) and Urology (up 28.3% compared with 17/18) GP referrals are being maintained below the 1.1k per 1000 per month average, however, referrals from all sources are also at a lower monthly average from 17/18. (-8.0%).

Recommendation(s)/Recovery Trajectory: The overall plans to reduce GP elective referrals carry over from 17/18, however , the CCG has plans for the improved management of elective care in Frimley Health facing practices. Actions include: • Planned care monitoring and review of all pathways involving intermediate triage (will include Ophthalmology, Gynaecology and ENT) • GP/Localities Reporting packs now in place with review at Clinical Leads Meetings and then update and actions at locality meetings • Advice and Guidance usage promotion with all practices (includes CVD, Haematology, Dermatology and Pain and this list is being increased by BHT from 1st July to cover

Urology, Neurology and ENT, usage of this service is monitored on a regular basis • Continued increased use of ERS and structured pathways by all practices • Sharing of clinical expertise across GP networks and Localities , creating greater emphasis on performance • Review and close management of Referral Levels and elective care spend by practices and localities • Greater control of First to Follow up ratios and C2C referrals through contract management. 87

A&E – Four Hour Waits Situation: Measure of the time that patients wait within an A&E department or other urgent care units (eg UTC) before being admitted, treated & discharged or transferred to another hospital. National target of 95%. January: • BHT Actual: 87.45% not achieved • MKUFT Actual: 86.98% not achieved • OUH Actual: 86.03% not achieved • Frimley Actual: 82.68% not achieved

BHT A&E Operating Plan trajectory, 92.65% for January was not achieved.

Buckinghamshire Healthcare Trust

Background: • 87.45% achievement in January, a 2.86% decrease compared to the 90.03% achieved in December • 87.45% represents an adverse position against 92.65% January 2019 local trajectory.

Assessment: • January performance - 87.45%; a 5.2% adverse variance to plan. BHT recognised as consistently delivering an improved performance compared to peers • 12 hour breach was declared in January - immediate review undertaken and learning shared

• The outbreak of Norovirus affected the patient flow therefore impacting on the Trust’s performance December Highlights & Achievements • Qtr. 3 performance (Oct – Dec 2018) - 89.28% • Current Qtr. 4 (Jan – March 2019) performance - 87.51% • Attendances were 2,059 higher than plan; ED experienced 2.1% more breaches than plan equating to 12.5% of attendances • Daily average of patients for January - 439, higher than December (413) • Best day performance - 95.42% on 27/01 • Busiest day for GP streaming – 70 patients were seen 3/01, compared to highest of 60 in December • Conversion rate (rate of attendance to admission): increase due to acuity of patients and cases of suspected flu & Noro-virus • Performance had improved all through the New Year, but dipped straight into January due to capacity & flow constraints on 4/01 with performance of

76.11%, which recovered to 91.54% on 6/01 2019 88

A&E – Four Hour Waits

Recovery actions & key areas of focus for February 2018:

• ICS Winter Director is leading the system response, including forward look meetings with all system partners where periods of pressure are predicted and additional mitigating actions agreed.

Key areas of focus for the coming month include:

Recommendation(s)/Recovery Trajectory:

• Use of ‘Consultant Connect’ to offer advice & guidance and assist General Practitioners in optimising the streaming of patients to appropriate services’ continues with ongoing monitoring Closer working with Paediatric clinicians to enable an increased number of conditions to be seen within GP Streaming

• Mental Health Audit – Escalation & Action working group – National recording of stranded MH patients. To assist with patients of MH disposition • Start of Elimination ‘Corridor Care’ programme and national recording • Maintain safe care and reduce footfall at the Emergency Department by providing alternative OOH services through Ambulance redirection also

general communications nationally of alternative service provision i.e. Pharmacy and use of 111 services • Weekly Look Forward meeting involving system partners continues to provide a system focus on key elements to support improved planning, gap

analysis and planning arrangements for the next 10 days

GP Service: • Service now embedded and BAU at SMH, seeing an increase of between 50-70 patients each day

• Fill-rate of shifts stabilising at about 80% with unfilled shifts occurring on evenings and weekends being the key risk

• Appropriate paediatric patients now seen by GP service

• Recruitment remains challenging, though most GP’s work via internal staff bank - experiencing difficulties in filling all weekend shifts regularly.

89

Delayed Transfers of Care (DToC) Situation: 22.3% reduction compared to the previous month, being the best reported performance of 18/19.

Background: DToC continues to be an area of focus for BHT and Bucks patients at neighbouring trusts particularly Frimley Health. DToC monitoring at BHT, Milton Keynes, Oxford University Hospital Trust and Frimley Health is managed on a daily basis. DToC is a key aspect of the 8 High impact change programme of work and the 7 Urgent & Emergency Care (UEC) domains within Hospital to home. Reducing the number of DToCs improves patient flow, creates capacity and reduces length of stay in the hospital.

Assessment: The DToC rate significantly decreased in December for the majority of providers including at BHT, Frimley, Oxford Health and Milton Keynes. The Bucks system is currently not meeting the agreed daily delay target . Key actions are identified below to support recovery.

Recommendation(s)/Recovery Trajectory: • Winter Director in post , who will be providing director led support and escalation where appropriate • Multi Agency Discharge Events (MADE) being planned (monthly) to support collective drive and ownership support improved patient flow across the system. The

exercise focuses on: o Recognising and unblocking delays o Supporting improved patient flow across the system o Challenge, improve and simplify complex discharge processes

APR MAY JUN JUL AUG SEP OCT NOV DECBUCKINGHAMSHIRE HEALTHCARE NHS TRUST 673 786 643 676 543 781 597 524 405 42% -23%FRIMLEY HEALTH NHS FOUNDATION TRUST 412 724 529 583 404 642 572 412 331 34% -20%MILTON KEYNES UNIVERSITY HOSPITAL NHS FOUNDATION TRUST 259 179 140 60 70 146 69 152 85 9% -44%OXFORD HEALTH NHS FOUNDATION TRUST 117 72 98 115 92 115 72 82 58 6% -29%OXFORD UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 56 136 68 57 60 62 34 24 44 5% 83%OTHERS 50 72 115 63 76 60 120 47 41 4% -13%Total 1567 1969 1593 1554 1245 1806 1464 1241 964 100% -22%

Provider% change from

previous month % of DToC

distribtion for Dec2018/19

90

GP Triage Situation: November Accepted percentage rate: 87%; a 2% increase compared to the previous month. An average acceptance rate of 84% for the financial year to date.

Background: SCAS crews attempt to hand over the care of the patient to their GP surgery to manage, resulting in the potential avoidance of an A&E attendance and non-elective admission. The definitions of the GP Triage measures are as follows: • GP Triage Attempted is the number of times SCAS has tried to contact the GP • GP Triage Accepted is the number of times a GP accepted the clinical responsibility for the SCAS patient

Assessment: • 1.6% increase in GP triaged accepted Bucks patients. 1% decrease in the southern locality with a 9% increase in the northern locality compared to the

previous month • BHT Clinical Director for unplanned care and SCAS lead continue to work with localities and GP practices to ensure messages continue to be conveyed

and identified how this can be effectively managed • Further areas for proposed improvements to be identified, agreed and monitored through the A&E Delivery Board at which there is a monthly update

provided by SCAS • Within Thames Valley as a whole an improvement continues to be noted in the number of GP Triage attempts where the call was accepted by service

contacted (i.e. GP, OOH, 111 , mobile directory)

Recommendation(s)/Recovery Trajectory: • The practice level detail is shared at locality meetings to increase awareness of performance achievement • SCAS provide performance updates to the A&E delivery Board

CCGGP Triage

AttemptedGP Triage Accepted Proportion

GP Triage Attempted

GP Triage Accepted Proportion Difference

Buckinghamshire CCG 451 384 85% 483 419 87% 2%

Last Month (Oct) Current Month (Nov)

91

SCAS - Ambulance Response Programme (ARP) Situation: December 2018 The following targets were not achieved: Category 1 - 7 minute response ‘mean’. Buckinghamshire CCG: Performance: 7.56 Category 2 - 18 minute response ‘mean’. Buckinghamshire CCG: Performance: 18.59 Category 3 -120 minute ‘90th percentile’. Buckinghamshire CCG: Performance: 2:34:09 Thames Valley: Performance: 2:16:59 Category 4 - 180 minute ‘90th percentile’. Buckinghamshire CCG: Performance: 4:16:37 Thames Valley: Performance: 3:08:26

Situation: Quarter 3 2018/19 The following targets were not achieved: Category 1 - 7 minute response ‘mean’. Buckinghamshire CCG: Performance: 7.50 Category 2 - 18 minute response ‘mean’. Buckinghamshire CCG: Performance: 18.18 Category 3 -120 minute ‘90th percentile’. Buckinghamshire CCG: Performance: 2:18:36 Thames Valley: Performance: 2:06:12 Category 4 - 180 minute ‘90th percentile’. Buckinghamshire CCG: Performance: 3:11:52

Category Cat 3 Cat 47 minutes 15 minutes 18 minutes 40 minutes 120 minutes 180 minutes

Mean 90th Percentile Mean 90th Percentile 90th Percentile 90th PercentileBuckinghamshire CCG 0:07:56 0:14:50 0:18:59 0:38:18 2:34:09 4:16:37

Performance to previous month Slightly Worse Slightly Worse Worse Worse Worse Significantly Worse

SCAS - Thames Valley 0:06:56 0:12:40 0:17:05 0:34:16 2:16:59 3:08:26

Performance to previous month Same Improvement Similar Slightly Worse Worse Worse

Month: December 2018

Cat 1 Cat 2

Target

SCAS ARP Standard Q1 Q2 Q3

Mean 00:07:31 00:07:49 00:07:50

90th Percentile 00:14:23 00:15:10 00:14:44

Mean 00:06:44 00:07:10 00:06:55

90th Percentile 00:12:29 00:13:13 00:12:53

Mean 00:15:10 00:17:03 00:18:18

90th Percentile 00:28:37 00:32:37 00:36:15

Mean 00:14:14 00:15:35 00:16:39

90th Percentile 00:27:39 00:30:32 00:33:12

Buckinghamshire CCG 90th Percentile 01:51:37 02:10:10 02:18:36

Thames Valley (North Cluster) 90th Percentile 01:46:43 02:00:06 02:06:12

Buckinghamshire CCG 90th Percentile 02:42:50 03:11:07 03:11:52

Thames Valley (North Cluster) 90th Percentile 02:37:08 02:48:39 02:55:46

Cat 1 response

Cat 2 response

Cat 3 response

Cat 4 response

BuckinghamShire CCG

Thames Valley (North Cluster)

Buckinghamshire CCG

Thames Valley (North Cluster)

92

SCAS - Ambulance Response Programme (ARP) Background: Ambulance Response Performance is reported against the Ambulance Response Programme (ARP) targets. Definition of these categories/targets: Category 1 – Life Threatening These should be responded to in a mean time of seven minutes and 90th percentile time of 15 minutes. Category 2 – Emergency These should be responded to in a mean time of 18 minutes and 90th percentile time of 40 minutes. Category 3 – Urgent These types of calls should be responded to at least 9 out of 10 times before 120 minutes. Category 4 – Non Urgent These less urgent calls should be responded to at least 9 out of 10 times before 180 minutes.

Assessment: • 4 out of 6 primary targets achieved at Thames Valley contract level • Buckinghamshire failed CAT 1 (7 minute ‘mean’), CAT 2 (18 minute ‘mean’) and Cat 3 & 4 ‘90th Percentile’ targets at CCG level • 1.5% increase in activity and 0.8% down against plan compared to last year • 51 hours of delays reported in December. Handover delays reporting at SMH continue to remain positive (SMH continues being identified as an exemplar)

following successful implementation of the new Rapid Assessment & Treatment (RAT) service at SMH. Although long waits have increased slightly month on month, there is a significant improvement over same period last year

• Reductions in CAT 3 and CAT 4 conveyances to SMH reported and alternatives in the community are signposted as appropriate, in line with the wider work to establish channel shift from the ED’s to alternatives in the community

• Non conveyance CQUIN – SCAS reported this is on track

Issues: • Performance against the 999 targets continues to be significantly below plan due to the shortfall in resourcing levels impacted by the low levels of

recruitment and workforce attrition being higher than planned • Recruitment shows an improved position but pressure remains in Dispatch and Clinical Advisors • Significant increase in sickness since November 2018 both short and long term • Shortage of private providers in the first half of the month but recovered significantly

Recommendation(s)/Recovery Trajectory: • SCAS continue to focus on Cat 1 mean performance and how to optimise fleet mix to support continual achievement of this target • Continued focus on channel shift of Cat 3 and Cat 4 conveyance, with Emergency Department alternatives being agreed by a working group, including

Wycombe UTC, CAT services in Marlow and Thame and the MUDAS service in Wycombe Hospital. Recent audit at SMH reported a reduction in the number of CAT 3, 4 and inappropriate conveyances

• A noted increase in Cat 2 Conveyances needs to be understood and will be incorporated in the Wexham Park Hospital audit • SCAS establishing MiDos (Directory of Services) as a key priority • Mental Health: aware of rising demand, with services focusing on review, development and exploration of support from the Thames Valley Integrated

Urgent Care service (TVIUC) • Handover delays continue to be stable. In December, handover delays remained low for the fifth consecutive month. BHT are currently regarded as an

exemplar in this area. 93

NHS 111 - The New Integrated Urgent Care Service - SCAS

Situation: Calls answered within 60 seconds : Target: 95% Actual: 66.63% not achieved Call abandonment: Target <3.5% Actual: 5.32% not achieved

Background: • Under performance of -9.72% at TV contract level compared to modelled activity in December. • 15,017 calls received by the Bucks Integrated Urgent Care service in December; -10.69% under performance for Buckinghamshire.

Assessment: • Main issues are:

o Changing peaks of when the calls are received o Staff sickness, recruitment and retention

• Despite a number of remedial actions being put in place SCAS has seen deteriorated performance over the last few months and has not achieved the call

answer target since October 2017. Commissioners have therefore issued a Contract Performance Notice. An initial remedial action plan has been submitted and is being reviewed with commissioners

• Through the Integrated Workforce Board SCAS is planning on an attrition rate of 67% for the year and claim to have a robust recruitment plan in place

based on this figure. Bank and overtime hours are offered to all employees. Since November 2018 SCAS has resourced additional time, over and above the contracted hours, from Conduit to assist in covering challenging hours between 2pm-5pm. SCAS will also profile in the call centre educational and audit staff over the Bank Holiday periods.

Recommendation(s): • SCAS has consistently failed to meet targets since the service commenced. For performance during the period 05/09/17 – 31/12/17 a penalty notice was

issued to the amount of £57,775. Four penalty notices, each of £48,950.81 (capped value in accordance with the terms of the contract), have been issued since

• Under the terms of the contract any penalties incurred within Year 1 – 2 will be reinvested. • Despite a number of remedial actions being put in place SCAS has seen deteriorating performance over the last few months and has not achieved the

call answer target since October 2017. Commissioners have therefore issued a Contract performance Notice. A remedial action plan has been submitted and additional workshops are planned to review staffing.

Dec-18 Name Threshold Bucks Abandoned calls <3.5% 5.32% Call waiting time >=95% 66.63% Transfer to 999 < 10% 11.58% Transfer to 999 (Cat 1 & 2) - 7.00% Attend Accident and Emergency Department Type 1 & 2 <5% 5.80%

94

Continuing Healthcare Situation: 80% of Continuing Health Care assessments completed within 28 days of checklist being accepted. January – Actual : 26% not achieved

Situation: Less than 15% of full NHS Continuing Health Care assessments to take place in an acute hospital setting by March 2018. January – Actual : 24% not achieved

Background: NHS Continuing Healthcare ("fully funded NHS care") is care outside of hospital that is arranged and funded by the NHS. A national framework mandates the process to be followed to identify whether a person meets the threshold for NHS CHC funding, or are the responsibility of the Local Authority or are self-funders.

Assessment: • Performance against the 28 day target deteriorated further to 26% in January. This can be attributed not only to ongoing recruitment and retention

challenges, but also high levels of sickness absence both of which are being actively managed with the support of HR.

• Performance against the assessments in acute hospital target has improved to 24% in January (25% in December). The number of Decision Support Tool assessments (DSTs) carried out in acute remains low compared to previous months with the high % attributable to a comparatively low total number of DSTs completed.

Recommendation(s)/Recovery Trajectory • Performance recovery of the 28 day standard is targeted for Q4 2018/19 although this currently looks like it will be a challenge to achieve. The existing

recovery action plan has been enhanced and shared with NHSE. The support of the NHSE regional CHC team is being drawn upon with a facilitated workshop to identify further improvement opportunities to be set up imminently.

• Discharge to Assess beds were re-introduced in November 2018. The last time the discharge to assess model was in place during winter 2017/18 the

assessments carried out in acute target was achieved. On this basis performance recovery had been targeted for the end of Q3. Whilst performance continues to improve this trajectory has been missed. The aforementioned action plans introduces further measures to meet this standard.

Target 80% April May June July August September October November December JanuaryBuckinghamshire CCG 47% 45% 42% 44% 44% 45% 56% 50% 40% 25%

2018/19Percentage of CHC assessments within 28 days

Target <15% April May June July August September October November December JanuaryBuckinghamshire CCG 32% 28% 26% 26% 26% 26% 36% 31% 25% 24%

CHC assessments carried out in Acute hospitals2018/19

95

Dementia Diagnosis Rate (DDR) Situation: January 2019 National Target: 66.7% Bucks, Oxfordshire and Berkshire STP Actual: 66.3% not achieved Buckinghamshire CCG Actual: 64.2% not achieved Buckinghamshire CCG revised Local Trajectory 66.0% not achieved

Background: The national target is for two thirds of people with dementia to be formally diagnosed. The Dementia 65+ estimated diagnosis rate indicator tracks this ambition by comparing the number of people thought to have dementia with the number of people diagnosed with dementia, aged 65 and over.

Assessment: • 64.7% - Slight decrease in performance compared to December 2018 • 149 people required to be diagnosed to reach target of 66.7% • OHFT - Clinics in South Bucks are experiencing issues with demand and capacity • Performance issues present in South Bucks Older Adult Mental Health Team due to workforce capacity and recruitment and retention • 60% - YTD (at month 8) performance of memory clinic for Buckinghamshire • 56% - Month 8 performance across both clinics • Self-assessment checklist completed • Buckinghamshire Corrective action plan in place • Oxford Health remedial action plan for memory clinic performance submitted December 2018

Recommendation(s)/Recovery Trajectory: The four priority areas for action to recover standard by year end: 1. Memory Support Service (MSS) contract to be extended for a further two years 2. Improve performance of South Bucks memory clinic - recruit to vacancies specifically Community Psychiatric Nurse dementia specialist 3. Care Homes to be targeted for screening /diagnosis have been identified. Memory support service agrees to deliver the targeted work. 4. Dementia Pathway workshop scheduled for the 20th February

96

Safeguarding Children – Looked After Children (LAC) Situation: The LAC service in Bucks continues to work to improve the timely review health assessments to LAC within Buckinghamshire. A number of meetings were held with the LA and health partners to consider what improvements can be made to the current system to facilitate health assessments taking place within statutory timescales. Current compliance: All Health Summaries 100% (as of 11/01/2019) Current compliance IHA’s 83%( November figures) Current compliance RHA’s 60% and 60% respectively for in county and out of county children (as of 22/02/2019)

Background: • BHT and the CCG work closely with the Local Authority to address the effectiveness of the current systems and aim to devise more efficient systems to

provide an improved service delivery for LAC as a whole.

Assessment: • The risk to LAC and the CCG is that the identified most vulnerable children are not receiving timely health assessments. • The Corporate Parenting Panel are robustly challenging the improvement for the LAC service, on a bi-monthly basis. Meetings have taken place with social

care to look at the current systems and how these could be improved to comply with national guidance. • Due to current performance, this has been flagged as Red on the Local Safeguarding Children’s Board’s (LSCB) risk register. • There is a recovery plan in place and this is being monitored via 2 weekly data submission by BHT, the operational LAC meeting and separately by the

monthly performance meeting. • Subsequent to the last report a series of escalation meetings have been held between senior leaders within the ICS, with the expectation of a series of

improvements over agreed trajectories

Recommendation(s): • Continue the escalation meetings and detailed monitoring of the trajectory plan • Report to Corporate Parenting Panel for challenge and scrutiny

97

Access Target - Children and Young People

Situation: Buckinghamshire CCG : As at Dec 2018 YDT 35% exceeding 32% year end target Nationally reporting 16.8%, but assurance from NHSE that locally over achieving on the 32% target

Background and Objective: 32% Access target for Children’s and young people’s mental health services

Assessment: • Data – following CCG merger a large number of Buckinghamshire YP unallocated to a CCG within the system. Provider & CCG worked with NHS Digital

to resolve issue - issue resolved but April to June will not be corrected in national reporting until Q4. 18/19 investment to support improved access; recruitment delay so impact of this to be fully realised in Q3/4

• 18/19 access figure has been revised to reflect 5-17 year old population; 17/18 figure was an over estimate • Reported Under-performance result of data issues following CCG merger and impact of Service model • Service Model was designed and commissioned to target prevention and offer consultation to reduce un-necessary assessments and facilitate

early/self management; contacts will be single contacts rather than two contacts as per the data requirement for this target • Data quality tightened to ensure 2 points of contact are captured to register on the system where this has occurred. Two points of contact reset from

01/04/18 so we anticipated performance would increase over Q1

Additional actions: Recommendation(s)/Recovery Trajectory: 1. Working with NHSI to ensure correct CCG data capture & to demonstrate 2 points of contact 2. To continue to work with OHFT and NHSI on data quality 3. OHFT commissioned online Counselling (Kooth) - now reporting directly into MHSDS 4. Confirmation received of successful bid for CYP Trailblazer

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Eating Disorders - Children & Young People Situation: Month 10 - December Data Percentage of Urgent Referrals assessed within 7 days – YTD performance 100% Percentage of Routine Referrals assessed within 4 week – YTD performance 84% (small number of patient breaches greatly reduce percentage achieved)

Background and Objective: Threshold for referral to assessment for both key performance indicators is 95%

Assessment: • 100% YTD for the urgent referral KPI • 84% YTD - under performance against routine referral KPI • Referral numbers to the service are low, subsequently if one referral is not assessed within the timeframe this significantly effects performance

Recommendation(s)/Recovery Trajectory: 1. Continue to monitor contract performance 2. Review activity across financial year to identify trends and build resilience where

required 3. Anticipated continued improvement in performance due to upwards trend, but not sufficient to recover and achieve 95% by year end due to low number of referrals

Urgent Referral to Assessment within 7 days

Quarter 18/19 Performance Number of referrals

Q1 100% 4

Q2 100% 0

Q3 100% 0

Routine Referral to Assessment within 4 weeks

Quarter 18/19 Performance Number of referrals seen within timeframe

Total number of referrals

Q1 82% 26 32

Q2 95% 9 10

Q3 100% 1 1

Routine Referral to Assessment within 4 weeks by month

Month Performance

May 67%

June 89%

July 91%

August 100%

September 100%

October 100%

November 100%

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Learning Disabilities Annual Health Checks (AHC) Situation: • Indicator measures the proportion of people over 14 years old with a learning disability on the GP register receiving an Annual Health Check • Buckinghamshire CCG local target for 2018/19 is 65%. • EMIS data showed that Buckinghamshire CCG had achieved 29.3% in January (number of people 14+ that have an annual health check compared to the

number of people 14+ registered on the LD register) Note: Historic trends show that more patients have health checks towards the end of the financial year and as such performance increases considerably later in the year. There is also large variation in performance between practices.

Background: • This indicator measures the proportion of people on the GP Learning Disability Register that have received an annual health check during the year,

measured as a percentage of the CCG registered learning disability population. • 2020 - National target = 75% Against which 2017/18 Buckinghamshire CCG local target = 55%, with achievement of 55.25% 2018/19 Buckinghamshire CCG local target = 65% (people aged 14+) The local target is used as a proxy to measure performance for the Operating plan measure for AHCs delivered by GPs for patients on the LD Register (total population) (Trajectory: Q1 = 0%, Q2 = 18.9%, Q3 = 28.3% , Q4 = 61.3%)

Assessment:

Recommendation(s)/Recovery Trajectory: Actions currently being taken to improve performance include:- • GP Practice training • Community specialist LD support • Regular bulletin of information • Links with Business Support Managers • AHC dashboard for practices and CCG to monitor progress against targets • Reminders to GPs of the incentive scheme in place to support increased numbers of AHCs being completed • Buckinghamshire CCG and Buckinghamshire County Council held a health and wellbeing event on 13th September to raise awareness about health checks

and all the support available locally. The event was really well attended by exhibitors, carers and people with a learning disability and/or autism. 100

Transforming Care – Out of Area Placements

The National Transforming Care Programme (TCP) (Building the Right Support) aims to improve services for people with learning disabilities and/or autism (including those without a learning disability), who display behaviour that challenges, including those with a mental health conditions. Monthly reporting to NHSE is through HSCIC and is used to monitor inpatient flow of this cohort. Inpatients that are included in the monitoring/reporting meet the definition above and are adults and children. The planning assumptions made by the NHSE and by which Buckinghamshire TCP is measured are:

• 10-15 inpatients per million population in clinical commissioning group (CCG) commissioned beds (such as assessment and treatment units) • 20-25 inpatients per million population in NHS England-commissioned beds (such as low, medium or high-secure services). Buckinghamshire Transforming Care Programme cohort is currently: Position as at January 2019: • 4 patient in Dove Ward, LD specialist hospital • 3 patients out of area, LD specialist hospital (Forensic locked rehab) • 2 patient out of area, MH specialist hospital Out of Area Placements: There are currently six patients placed via NHSE Specialised Commissioning Services in secure hospitals. These six patients comprise: • 2 adult patients in secure hospitals • 4 Child Adolescent Mental Health (CAMHS) patients in secure hospitals

April May June July August September October November December January6 6 5 5 5 8 9 9 9 9

5 5 6 5 6 5 6 6 7 6Out of Area Placements

Buckinghamshire Transforming Care ProgrammeCurrent inpatients

Patients placed via NHSE Specialist Commissioning Services (secure hospitals)

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Mixed Sex Accommodation December - 19 breaches were reported for Bucks CCG: Frimley Health – 17 (Frimley x 1 /Wexham x 16) , London North West x 1 and Royal Berkshire x 1. Frimley Health - Lead commissioner has indicated that the majority of breaches occur on the Day Surgery Units and that the situation will continue until the completion of the necessary building works scheduled for completion in the autumn.

MRSA Situation: As at 18th February - No MRSA cases were attributed to the CCG in January.

C. Difficile Situation: As at 18th February - Buckinghamshire CCG was within the monthly trajectory in January.

MRSAAssigned to: Apr May Jun Jul Aug Sep Oct Nov Dec Jan TotalBucks CCG's Total 0 0 0 0 0 0 0 0 0 0 0

2018-19

C.Difficile (2018-19) Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 TotalAll cases 10 7 7 5 10 8 13 9 8 8 85Monthly limit 9 9 9 9 9 9 9 9 9 9 90Cumulative Status

Buckinghamshire CCG

-5

Mixed Sex Accommodation Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 TotalNumber of breaches 21 29 25 22 56 47 34 25 19 278

Buckinghamshire CCG

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Electronic Referral System (ERS) Programme

Situation: December 2018 - Buckinghamshire CCG Actual: 81% usage. NB. December figure is provisional and may be subject to change

Background: • National requirement to move to the full use of the NHS e-Referral Service (eRS) for all consultant led first outpatient referrals. • From 1st October 2018 providers will not be paid for activity which results from referrals if the referral has not been made through eRS and will have the

right to return such referrals to GPs. (Exceptions apply)

Assessment: • Reasons for the performance below the planned trajectory are being identified • The reporting capability of eRS has not been fully explored • Currently no reports are produced from the eRS to monitor referrals by GP Practice and speciality.

Recommendations: • To explore and develop an appropriate set of reports from which to monitor referrals to assist the management of demand and levels of referrals

DecemberTrajectory 100%Actual (provisional) 81%

Buckinghamshire CCG

E-Referral Coverage

103

BHT SSNAP (Sentinel Stroke National Audit Programme) Results

Situation: Current reported performance for SSNAP.

Background: SSNAP measures the quality and organisation of stroke care in the NHS and is the single source of stroke data in England, Wales, and Northern Ireland.

Assessment: BHT perform better than any other trust in Thames Valley with regard to the metrics measured by the SSNAP and are in the top 5% of Trusts in the UK.

Recommendations: Continue oversight and monitoring and explore with BHT an improvement plan for D7/8/9/10 to achieve A rating.

104

Quality Oversight Arrangements Situation: Buckinghamshire Healthcare NHS Trust: Pathology delays, Lung Biopsy pathway, awaiting of confirmation for outcome of Business Case, resulting in delays in pathway and duplication of repeat test results. Dementia Screening planned for next BHT CQRM. Visit planned to A & E to observe cultural behaviours towards Mental Health Patients based on feedback from patients and or advocates. A Deep Dive analysis is being undertaken into the Ophthalmology Services in Buckinghamshire, the findings will be reported back at the next meeting. Milton Keynes Hospital NHS Foundation Trust: Adult Male Patients placed on an inappropriate ward, AD for Quality and Safeguarding has requested and agreed with the Quality Team at MK CCG they will review and feedback. Feedback has highlighted no concerns as patients have now been repatriated to appropriate environments. The CCG is also aware of on-going issues around VTE at MKUHFT and is following this up with MKCCG. Oxford Health NHS Foundation Trust: Looking into responsiveness of OHFT services (MH) with the voluntary sector, due to feedback suggesting this could be improved. To be discussed at next CQRM meeting. The Priory – High Wycombe This was a CAMHS LD facility with 12 beds. The unit opened in April 2018, the CCG undertook a site visit in September 2018 and noted areas to be monitored. This service was not commissioned by BCCG, NHSE commissioned the establishment as a Specialist Service. Bucks CCG provided statutory oversight relating to safeguarding matters. Professional concerns were raised in December 2018. Subsequent partner agencies provided advice, support, and input however The Priory were unable to provide the quality of care required; this resulted in the priory terminating their contract with NHSE. The unit closed in February 2019. None of the service users were Bucks registered patients.

Background: Following a series of reviews, patient feedback and attendance at key meetings the above quality concerns were identified.

Assessment: The CCG is working with the relevant providers or associate commissioners to address the identified quality concerns, they require varying approaches to understand fully the context and related responses required.

Recommendations: Buckinghamshire CCG to conduct follow up activities and report back to next planned committee.

105

Oxford University Hospitals Foundation Trust – Never Event Feb 2019 Situation: OUHFT have reported a Never Event in February 2019 involving a retained vaginal swab post colposcopy and vaginal biopsy. The patient involved was not registered to a Bucks GP Practice.

13 Months Rolling

Background: Never Events in the NHS are defined as: “…patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers.”

Assessment: This is the sixth Never Event reported by OUHFT in the 2018/19 Financial Year. OUHFT reported a similar incident in June 2018 which also involved the retention of a Vaginal Pack post surgery. OUHFT continue to receive support from NHS Improvement.

Recommendations: As this incident does not involve a BCCG patient, it is recommended to allow OUHFT to carry out their investigation and OXCCG to review the RCA.

0

2

4


106

MEETING: Governing Body AGENDA ITEM: 12 DATE: 14 March 2019 TITLE: Governing Body Effectiveness Review – summary of results AUTHOR: Russell Carpenter, Head of Governance/Board Secretary LEAD DIRECTOR: Robert Majilton, Deputy Chief Officer LINK TO RISKS: Governing Body

Assurance Framework No direct link to risks





The Governing Body is asked to: 1. NOTE purpose, plan and next steps for Sub-Committee effectiveness reviews and self-

assessments (Appendix A)2. NOTE summary findings and actions arising from its effectiveness review in February

2019 (Appendix B)

It is best practice that Committees and Sub-Committees in any organisation review at least annually their effectiveness. The CCG internal audit plan for 2019/20 also includes an audit to review the effectiveness of the CCG’s key committee’s with the particular focus to be agreed as part of the detailed scoping, including;

• Are committee roles and responsibilities appropriately defined;• Has the Governing Body defined its expectations for the committee;• Is the Governing Body receiving the right assurances at the right time to enable it to

discharge its responsibilities?

This paper and subsequent review of the results of a sub-committee self-assessment at the next meeting of the Governing Body in public on 13 June 2019 will inform this audit process. Purpose, plan and timescales are shown in Appendix A. The Governing Body has also recently undertaken its own self-assessment at a seminar held in February 2019, the summary results of which are appended (appendix B). The next meeting in public in 13 June 2019 will also be used to provide feedback on actions from this self-assessment.


Not applicable to this paper

107


No conflict identified Conflict noted, conflicted party can participate in discussion and decision (see below) Conflict noted, conflicted party can participate in discussion but not decision (see below) Conflict noted, conflicted party can remain but not participate in discussion (see below) Conflicted party is excluded from discussion (see below) Governance assurance (see below) Not applicable to this paper








Equality Quality Privacy Financial Risks Statutory/Legal No implications per se, but an annual

effectiveness review is best governance practice Prior consideration Committees /Forums/Groups


Member GPs as standing invitees to the Sub-Committee

Supporting Papers:

None

108

Appendix A: purpose, plan and next steps for Sub-Committee effectiveness reviews and self-assessments

Purpose of effectiveness review and evaluation • best practice to conduct at least annual review• Periodic reflection can improve function• Identifying areas of both good and not so good practice can be used to drive up

standards• Ensuring sound decision making• Reflect on and embed learning from elsewhere

– Long paper packs– Conflicts of interest– Decision making

All sub-committees briefed on findings from PWC review of Coastal West Sussex CCG: • This CCG has experienced similar financial circumstances with £21m deficit end

17/18).• PWC Coastal West Sussex CCG - Governance Review 2018 published 23 October

2018 (released January 2019)• Members to follow link and using the findings to inform self-assessment

Coastal West Sussex CCG - Governance Review 2018

Each Sub-Committee to facilitate review aligned to annual review of terms of reference, with use of equivalent self-assessment tool as used for Governing Body.

Timescales

Committee/Sub-Committee

Effectiveness Review scheduled/taken place

Terms of Reference Review due

Governing Body 14 February 2019 11 April 2019 Executive Committee

28 March 2019 25 April 2019

Finance Committee

27 March 2019 27 March 2019

Audit Committee 28 March 2018/25 July 2018 27 March 2019

27 March 2019

Remuneration Committee

TBC TBC

Quality and Performance Committee

28 March 2019 28 March 2019

Primary Care Commissioning Committee

7 March 2019/6 June 2019 7 March 2019

The results of effectiveness reviews and self-assessments to next Governing Body in public on 13 June 2019.

109

https://www.coastalwestsussexccg.nhs.uk/domains/coastal-west-sussex-ccg.org.uk/local/media/documents/misc/Final_CWS_CCG_report.pdf

Appendix B – CCG Governing Body Effectiveness Review – February 2019

It is best practice that Committees and Sub-Committees in any organisation review at least annually their effectiveness. This was facilitated in February 2019 for the Governing Body at an organisational development seminar. A contributory factor in undertaking the effectiveness review was an earlier Financial Governance Review, in July 2018, undertaken by internal auditors RSM.

This had identified: 1. There was a lack of evidenced escalation and/or increasing urgency during the

course of the year as the financial situation deteriorated.2. The Governing Body needs to have greater ownership and oversight of financial

performance to discharge its responsibilities.

Resulting action: 1. Embed ownership and oversight within governing body2. Ensure roles and responsibilities are clear3. Provide detailed explanation of governing body roles and responsibilities.

The above is already clearly described within the CCG’s Constitution; the legal document sets out the way in which the CCG will fulfil its statutory responsibilities as set out in the 2006 Health Service Act. However, it was considered that there was opportunity to identify what best practice looks like and whether the Governing Body can evidence it.

Self-assessment questionnaire

Seminar discussion was informed by a self-assessment questionnaire all members were asked to complete in advance, covering the following areas:

1. Composition, establishment and duties2. Meetings3. Compliance with the law and regulations governing the NHS4. Governing Body role specific criteria.

The self-assessment, covering 65 separate questions, was benchmarking from a number of sources:

1. NHS Audit Committee Handbook, HFMA, Third Edition 2014/Fourth Edition 20182. Audit and Risk Assurance Committee Effectiveness Checklist, National Audit Office,

November 20173. Financial Reporting Council, Guidance on Board Effectiveness, July 2018

Members were asked to reply “yes”, “no” or “not sure”/”not applicable” to the majority of questions, with a handful as free text only questions. A number of specific questions were then selected for further discussion based on these responses to maximise opportunity with the time available.

Key: NS = not sure, NA = not applicable

110

https://www.nao.org.uk/wp-content/uploads/2012/10/Self_Assessment_Checklist.pdf



https://www.frc.org.uk/getattachment/61232f60-a338-471b-ba5a-bfed25219147/2018-Guidance-on-Board-Effectiveness-FINAL.PDF

https://www.frc.org.uk/getattachment/61232f60-a338-471b-ba5a-bfed25219147/2018-Guidance-on-Board-Effectiveness-FINAL.PDF

Appendix B (continued) Note: follow up/deadline on all actions stated is 13 June 2019, date of next Governing Body meeting in public.

Question Yes No NS/NA Comments Actions COMPOSITION, ESTABLISHMENT & DUTIES 5 Does the Governing Body

report regularly to the membership? Does it provide an annual report? Is this timed to coincide with publication of the annual report and accounts? Has a members AGM been held?

67% 25% 8% We need to be clear on means of member communications – newsletters can lose impact. We can also call council of members.

Action 1: to consider how we best communicate with member practices on the direction of travel in a meaningful way. (Chair/Accountable Officer)

7 Does the Governing Body invite relevant CCG Management Directors/Senior Management Team to explain the issues at the earlier stages, enabling all directors to share concerns or challenge assumptions well before the point of commissioning decisions?

75% 17% 8% We can challenge more et earlier developmental stages within portfolios. We also have a sub-committee structure delegated responsibilities. It was noted that Individual Funding Requests (IFR) is not included in the Quality and Performance Report.

Action 2: Quality and Performance Committee to facilitate presentation from the IFR team about how it conducts its business. (Director of Commissioning and Delivery)

Action 3: Quality and Performance report template to be updated to include Individual Funding Requests alongside Continuing Healthcare. (Director of Commissioning and Delivery)

8 Does the Chair have regular meetings with the key attendees (E.g. the Accountable Officer, CFO)?

67% 8% 25% The Chair noted he could improve his means of engagement.

Action 4: Slots either side of Audit Committee for these discussions that could subsequently inform governing body agenda planning. (Board Secretary).

Action 5: ensure all lay members have at least annual appraisal. (Board Secretary)

21 Do the members of the Governing Body have a clear understanding of terms of appointment, including what is expected of us, how our individual performance will be appraised, the duration of our appointment, training required and how this will be provided?

67% 25% 8%

9 What evidence does the Governing Body have that very senior management is willing to listen, take criticism and let others make decisions?

Free text – generally positive that senior management does respond to challenge

Audits would likely look through previous minutes for evidence; we often have quite a robust discussion about finance which we often let run in confidential, but this is what we are audited on.

Action 6: limit confidential agenda item on Finance to only the key messages. (Board Secretary).

111

Question Yes No NS/NA Comments Actions 15 Does the Governing Body

review the work plans of its sub-committees at the beginning of each year and at each meeting thereafter?

25% 67% 8% Action 7: review priorities of the 19/20 operating plan and ensure there is evidence of inclusion on work plans where responsibilities have been delegated to sub-committees. (Deputy Accountable Officer)

GOVERNING BODY ROLE SPECIFIC CRITERIA 32 Does the Governing Body

review, evaluate and recommend to the Board for approval the guiding principles that govern the overall approach with respect to the CCG’s service investment and disinvestment plans and level of risk management?

33% 25% 42% Action 8: amendment to cover sheet template under authority for decision “Paper author to also include prompt that asks committee what feedback it requires and when in relation to the decision to be taken. (Board Secretary)

47 Does the Governing Body assure responsibility for value-for-money reviews?

67% 16.5% 16.5%

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Documents

Governing Body – In Public Date: 14 March 2019 Time: … › wp-content › uploads › 201… · 14-03-2019 · DR . Present Colin Seaton Lay Member, Patient and Public Involvement